A Case of Acute Cerebral Infarction Caused by Myxoma of the Left Atrium

Introduction

This case report describes a 42-year-old male patient who presented with acute cerebral infarction caused by left atrial myxoma. The patient’s journey from initial symptoms to diagnosis and treatment provides valuable insights into this rare but significant condition. The case highlights the importance of considering cardiac sources in young patients presenting with stroke-like symptoms, even in the absence of overt cardiac manifestations.

Patient Presentation and Initial Management

The patient, a 42-year-old male with a height of 178 cm and weight of 70 kg, was admitted to the emergency department on July 4, 2018, with a 5-day history of dizziness and left limb weakness. His symptoms began during an intensive surfing activity in Sanya, southern China, where he experienced nausea and vomiting of gastric contents. Over time, he developed left-sided weakness, including difficulty raising his left arm above his head and walking steadily. Notably, he did not experience vertigo, blackouts, or loss of consciousness.

Initial evaluation at a local hospital in Sanya revealed hypotension (90/60 mmHg) and normal blood glucose (5.0 mmol/L). He was treated with glucose, vitamin C, and potassium chloride, which resulted in slight improvement of his symptoms. Upon returning to Beijing, he sought further evaluation at Dongzhimen Hospital.

Diagnostic Workup and Findings

Cranial MRI with diffusion-weighted imaging (DWI) revealed multiple acute and subacute cerebral infarctions in various brain regions, including the bilateral frontal lobe, right parietal lobe, lateral ventricle, basal ganglia, thalamus, and temporal parietal lobe. This led to the diagnosis of acute cerebral infarction.

Physical examination at Dongzhimen Hospital showed normal vital signs: temperature 36.3°C, pulse 76 beats/min, respiratory rate 18 breaths/min, blood pressure 124/78 mmHg, and oxygen saturation 97%. Neurological examination revealed grade IV muscle strength in the left arm and leg, with normal muscle tone and positive palsy test in the left arm. The right side showed normal strength (grade V) and negative palsy test. Other findings included normal heart boundaries, regular heart rate, and absence of pathological murmurs.

Further investigations included a 24-hour ECG monitoring, which showed sinus rhythm with premature ventricular contractions. Echocardiography revealed left atrial enlargement and the presence of a left atrial myxoma. Interestingly, serological testing showed a positive result for syphilis-specific antibody (TP) with a titer of 4.75.

Medical History and Risk Factors

The patient’s medical history included cholecystectomy seven years prior and a history of obesity four years ago, when he weighed 95 kg (BMI 30). Through dietary control and regular running, he had successfully reduced his weight to 70 kg (BMI 22) at the time of presentation. His parents were healthy, and there was no significant family history of cardiovascular disease.

Treatment and Outcome

Based on the findings, the patient was diagnosed with left atrial myxoma and acute cerebral infarction secondary to cardiogenic embolization. He underwent successful myxoma resection at FuWai Hospital in August 2018. Pathological examination confirmed the diagnosis of left atrial myxoma, with no evidence of tumor cell infiltration into the pedicle heart wall. At follow-up, the patient reported complete resolution of his neurological symptoms and no further complications.

Discussion

Cardiac myxoma (CM) represents the most common primary cardiac tumor, accounting for more than 50% of all cardiac tumors. Other primary cardiac tumors include papillary elastic fibroma (26%), fibroma (6%), and lipoma (4%), with rhabdomyoma and atrioventricular node tumors being relatively rare. Left atrial myxoma is particularly significant as it accounts for approximately 2% of cerebral infarctions in young patients. Notably, cerebral embolism often precedes cardiac symptoms in these cases, with about 55.6% of patients presenting with cerebral embolism as their initial manifestation.

The pathophysiology of myxoma formation remains incompletely understood. Current evidence suggests that myxoma tumor cells originate from primitive multipotent mesenchymal stem cells capable of differentiating into myocardial cells, neuroendocrine cells, and endothelial cells. This case illustrates the often subtle presentation of CM, where patients may lack overt cardiac symptoms or signs. The absence of pathological murmurs and normal cardiac examination findings in this patient underscore the importance of maintaining a high index of suspicion in young stroke patients.

The relationship between CM and obesity remains unclear. This patient had a history of obesity (BMI 30) and reported dietary habits that included fried and spicy foods, coupled with physical inactivity. His successful weight loss through dietary control and regular exercise raises interesting questions about the potential impact of rapid weight loss on cardiovascular health. Some studies suggest that rapid weight loss may have detrimental effects on the body, potentially making patients more vulnerable to certain conditions.

This case is particularly noteworthy for several reasons. First, the patient’s symptoms were precipitated by intense physical activity (surfing), which may have contributed to emboli dislodgement. This observation aligns with literature suggesting that vigorous exercise can, in rare cases, lead to sudden cardiac events. Second, the positive syphilis serology represents an intriguing finding, as there is no established literature linking CM with syphilis. This may represent the first reported case of CM in a TP-positive patient.

The patient’s successful outcome following myxoma resection underscores the importance of timely diagnosis and appropriate surgical management. The absence of tumor cell infiltration in the pedicle heart wall suggests a favorable prognosis, and the patient’s complete recovery of neurological function further emphasizes the benefits of prompt intervention.

Clinical Implications

This case highlights several important clinical considerations:

The importance of considering cardiac sources of embolism in young patients presenting with stroke-like symptoms, even in the absence of overt cardiac manifestations.
The need for thorough investigation, including echocardiography, in cases of unexplained cerebral infarction, particularly in younger patients.
The potential role of intense physical activity in precipitating embolic events in patients with cardiac tumors.
The importance of maintaining a high index of suspicion for CM in patients with cerebral embolism, as it may be the first manifestation of the disease.
The need for further research into potential associations between CM and other conditions, such as syphilis and rapid weight loss.

Conclusion

This case of acute cerebral infarction secondary to left atrial myxoma serves as a valuable reminder of the diverse presentations of cardiac tumors. The patient’s initial neurological symptoms, absence of cardiac findings, and eventual diagnosis underscore the diagnostic challenges posed by CM. The successful outcome following surgical intervention highlights the importance of early recognition and appropriate management of this condition. This case also raises interesting questions about potential associations between CM and other factors such as intense physical activity, rapid weight loss, and syphilis, warranting further investigation in future studies.

doi.org/10.1097/CM9.0000000000000111

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