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Left Ventricular Thrombus and Embolic Stroke Caused by a Functional Paraganglioma

CASE HISTORY A 49-year-old Caucasian man was admitted for elective transesophageal echocardiography to examine whether he had a patent foramen ovale. One month before this admission, the patient had flulike symptoms, left upper quadrant abdominal pain, and constipation for 2 weeks. He then developed a 1-minute episode of garbled speech and left upper extremity weakness that lasted for 24 hours. He was admitted into another hospital. An abdominal computed tomography (CT) scan revealed a large left retroperitoneal mass and multiple left renal infarcts. A head CT suggested stroke. Since the renal and brain infarcts suggested an embolic etiology, transthoracic echocardiography was performed, which detected a 1.3 1.9 cm mobile mass in the mid left ventricle apparently attached to the interventricular septum (Figure 1, Left). Also noted was reduction of left apical wall motion. Transesophageal echocardiography was performed at the other hospital without complications and confirmed the transthoracic findings. On electrocardiography (ECG), the patient exhibited a prolonged QT interval and diffuse T-wave abnormalities especially on the precordial leads without evidence of atrial fibrillation (Figure 1, Right). Troponin levels were mildly elevated to 0.07 ng ⁄mL (normal <0.05 ng ⁄mL). Coronary angiography revealed normal coronary arteries. He was anticoagulated with heparin, then warfarin and enoxaparin, and was treated with metoprolol due to the abnormal ECG findings. On repeat echocardiography and cardiac magnetic resonance imaging (MRI) 2 to 3 weeks later, the left ventricular (LV) mass was not seen, but LV systolic function was still abnormal, with an ejection fraction of 47%. The distal left ventricle and apex thickened during diastole but moved dyskinetically during early systole. From the Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA; Division of Endocrinology and Carcinoid and Neuroendocrine Tumor Center, Cedars-Sinai Medical Center, Los Angeles, CA; Division of Hematology and Oncology, Cedars-Sinai Medical Center, Los Angeles, CA; Private Practice, Bakersfield, CA; and the Robert J. and Suzanne Gottlieb Endowed Chair in Surgical Oncology, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA Address for correspondence: Run Yu, MD, PhD, Division of Endocrinology and Carcinoid and Neuroendocrine Tumor Center, Cedars-Sinai Medical Center, B-1318700 Beverly Boulevard, Los Angeles, CA 90048 E-mail: run.yu@cshs.org Manuscript received July 7, 2009; accepted July 20, 2009