ABSTRACT

Metastastic Mediastinal Lymphoma Mimicking STEMI in a Physically Fit Young

Army Force: A Case Report
L T Ratana MD, A Setyasari MD
Dustira Army Hospital, Cimahi, West Java

Introduction
While caused by vast cardiac pathology, ST-elevation and cardiac marker elevation often
narrowly viewed by physicians as a result of acute coronary syndromes. Other causes of
ST-elevation, such as early repolarization, pericarditis, cardiac mass, and secondary ST-
abnormalities due to conduction disturbance are frequently overlooked, although
occurring infrequently in young patients.

Case Report
We present a case of 22 year-old army force came to the ER with chief complain of
intermittent pressuring chest pain radiating to left arm area since 5 months before
admission. The complain worsened in last 3 days after a parachute jumping session,
accompanied with nausea, vomiting, and cold sweating. Physical examination revealed
an otherwise healthy young man with normal vital signs. Chest examination revealed
symmetrical chest wall movement, widened cardiac border, pericardial friction rub and
wide fixed splitting of second heart sound with loud P2, and apical systolic murmur of 4th
grade with no radiation. ECG displayed 3-mm ST-elevation at 2,3,avF, V4-V6 and
CKMB value of 74 U/L. 6-hour post admission ECG showed evolution of the ST-
elevation, confirming the diagnosis of STEMI. He was treated as STEMI with no
significant clinical improvement. Upon follow-up in cardiology ward, pathologic Q wave
was not found, emergency echocardiography was performed and an extra-cardiac mass
compressing pulmonary artery, pericardial effusion, and mitral regurgitation were found.
After patients clinical condition improved, chest X-ray was performed and a mediastinal
mass and pulmonary metastases were found, indicating poor prognosis. The patient was
then referred to Gatot Subroto Central Army Hospital with suspected primary mediastinal
lymphoma with pulmonary and pericardial metastasis. Before further examination was
performed, the patient experienced cardiac tamponade and died in the ICU. Autopsy was
not performed due to familys objection

Discussion
Diagnosis of secondary cardiac cancer is very intriguing. Half of the patients with cardiac
malignancy was misdiagnosed at first hospitalization. As far as authors concern, there
are 19 international case reports of cardiac malignancy misdiagnosed as STEACS, 4 of
which exhibits ST-elevation and elevation of cardiac marker. Features triggering
physicians suspicion in these case reports are non-improving chest pain and absence of
pathologic Q wave in serial ECG.

Conclusion
ST-elevation in ECG is not merely caused by ACS. Other differential diagnosis, have to
be cautiously considered especially in young patients. Simple measures and high index of
suspicion towards alternative diagnosis, such as chest X-ray and echocardiography could
guide the diagnosis.
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