Heart of the Matter: Syncope as a Rare Presentation of Lung Cancer Invading\nthe Heart
A 65-year-old Caucasian man with a history of tobacco dependence presented with a brief\nepisode of dizziness while standing in line at the bank, which was immediately followed by\nwitnessed loss of consciousness for 30 seconds. The dizziness was only “seconds-long” and\nimmediately preceded “passing out.” He reported one previous episode of syncope last summer\nwhile “walking in the heat,” which also was sudden without any prodromal or other associated\nsymptoms. His review of systems was negative for seizures, angina, orthostatic hypotension,\nstroke, or trauma. Over the past 3 months, he experienced an 18.1 kg weight loss with\nanorexia and constipation. The patient was a retired construction worker, had smoked 50\npack-years, and drank alcohol, but denied intravenous drug use.\nOn physical examination in the emergency department (ED), the patient was afebrile, with a\npresenting heart rate of 63 beats per minute (bpm), blood pressure range of 134/73,\nrespiratory rate of 20 breaths per minute, and normal oxygen saturation of 98% on room air.\nThere was no evidence of orthostatic hypotension based on blood pressure and heart rate\nmeasurements in the supine, sitting, and standing positions. The patient appeared thin and\nchronically ill with temporal-wasting, barrel chest, mild egophony of the right lung base,\nand a scaphoid abdomen. There was no evidence of dry mucus membranes, delayed capillary\nrefill, heart murmur, jugular venous distension, lymphadenopathy, clubbing, cyanosis, edema,\nor neurological deficits. In addition, there was no evidence of gastrointestinal bleeding,\nscleral icterus, or jaundice.\nLaboratory studies were notable for white blood cell count of 16.9 K/mm3,\nhematocrit of 28% with normal mean corpuscular volume (MCV), platelets of 650\nK/mm3, albumin of 2.6 g/dL, normal glucose and corrected calcium, and negative\ncardiac enzymes. There were no other electrolyte or biochemical laboratory abnormalities\nwith respect to liver and renal function. A chest radiograph showed a right peri-hilar\nmass-like dense opacity concerning for malignancy (). Electrocardiogram (ECG) revealed\nbradycardia, variable junctional and ectopic atrial rhythms, ventricular bigeminy, QT\nprolongation, low voltage, T-wave abnormalities, and short PR interval (). Additional rhythm strips in the ED showed\nventricular bigeminy followed by a witnessed episode of worsening bradycardia (heart rate in\nthe range of 30-35 bpm) with associated near syncope.\nChest computed tomography (CT) revealed a large cavitating necrotic mass in the right\nmiddle lobe contiguous with the mediastinum, invading the superior vena cava and right\natrium with surrounding patchy consolidation (). Echocardiogram showed an extrinsic\npericardial mass at the right atrial roof () with an atrial mass measuring 5.0 × 4.4 cm (). Bronchoscopy showed erythema and\ncompression within the right bronchus intermedius and external compression of the right\nupper lobe bronchus ().\nEndobronchial biopsy revealed invasive well-differentiated squamous cell carcinoma and a\nclinical picture consistent with stage IIIB disease ().\nUnfortunately, the patient missed several chemotherapy appointments to treat his lung\ncancer. He did not maintain regular follow-up and we do not know whether he had recurrent\nepisodes of syncope. On hospital readmission 6 months later, the patient developed atrial\nfibrillation and flutter (with frequent ventricular ectopy) and electrocardiographic\nevidence of right atrial enlargement (, ), a right\npleural effusion, and hypoxemic respiratory failure. The patient eventually expired from\nprogressive lung cancer opting for comfort care rather than continued medical treatment.