Epstein-Barr Virus: From Kissing Disease to Broken Heart

We present a case of a 59 year old female patient that presented with exertional chest pain and palpitations. A workup revealed an EKG with signs of right ventricular hypertrophy, a high Pro-BNP and 3 sets of negative troponin levels. A CT scan of the chest was negative for pulmonary embolism (PE) but revealed a nodular thickening of the atrial septum with right atrial extension encasing the right coronary artery. A CT scan of the abdomen and pelvis with IV contrast revealed several nodular foci scattered in the subcutaneous fat of the abdominal wall bilaterally. An initial transthoracic echocardiogram (TTE) revealed thickening of the interatrial septum with a mass protruding from the interatrial septum into the left atrium and a secondary pedunculated mass protruding from the interatrial septum into the right atrium with significant obstruction within the right atrium. An ultrasound-guided biopsy of the soft tissue nodule in the right anterior abdominal wall and subcutaneous tissue showed the classical starry sky appearance pattern confirmed later to be a Burkitt lymphoma. The patient received chemotherapy and follow up CT of the abdomen and pelvis reported resolution of the soft tissue density involving the partially visualized portions of the heart. Although rare, cardiac lymphomas should be considered in the differential diagnosis of patients with identified cardiac masses. As the initial presentation is usually composed by non-specific symptoms, a detailed clinical history can identify certain constitutional symptoms and a thorough physical exam can lead to the suspicion of cardiac structural pathology prompting the need for the appropriate chest imaging. Further characterization may need TTE or TEE which are more sensitive and specific due to the tri-dimensional and temporal quality of the imaging. Appropriate biopsy with pathology and molecular studies are of utmost importance in making an accurate diagnosis in order to select the best management for this highly aggressive malignancy.