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An unusual left ventricular mass.

CASE A 58-year-old man presented to the ED with complaints of worsening shortness of breath and lower extremity swelling over the past 2 to 3 months. The patient has a past medical history of hypertension managed with carvedilol and lisinopril. He experienced a myocardial infarction 5 years ago that was treated medically without surgery or stenting. He recently emigrated to the United States and 2 weeks ago was treated for an upper respiratory infection with no relief in his symptoms. The medications used by the clinic in that treatment were not known. Physical examination The patient appeared well developed and nourished and in mild respiratory distress. His vital signs were unremarkable. He had bibasilar lung crackles and a cardiac examination showed normal fi rst and second heart sounds without murmur, rubs, or gallops. Neck examination showed moderate jugular venous distension. The extremity examination revealed bilateral 2+ pitting lower extremity edema. His peripheral pulses were intact. Diagnostic studies The patient’s cardiac troponin level was 0.12 ng/mL (normal range, 0.04 ng/mL or less) and pro brain natriuretic peptide (proBNP) was 18,000 pg/mL (normal range, 100 pg/mL or less). His liver enzymes were mildly elevated. An ECG showed normal sinus rhythm with moderate left ventricular (LV) hypertrophy and incomplete left bundle branch block. A two-dimensional transthoracic echocardiogram (TTE) revealed dilated cardiomyopathy with an estimated LV ejection fraction of 25% to 30%. A large (3.3 cm x 3.5 cm [1.3 in × 1.4 in]) cystic-appearing mobile mass was noted in the apex of the left ventricle with areas of hyperand hypoechogenecity and distinct circumferential hyperechogenecity. He was diagnosed with heart failure and initially treated with IV furosemide, an oral angiotensin-converting enzyme inhibitor, and an oral beta-blocker. The differential diagnosis of the LV mass was broad given its appearance, and it was diffi cult to determine the exact identity from the echocardiogram alone despite the use of a contrast agent. WHAT IS YOUR DIAGNOSIS? • echinococcus granulosus • LV thrombus • hydatid cyst • bronchogenic cyst • cardiac hemangioma