January 2022

A 34-year-old female with a left atrial mass and multiple acute brain infarctions*

Contributor: 

Sampson Kwabina Boham, MD

AP/CP Scheduling and Education Chief Resident -PGY4

Department of Pathology and Laboratory Medicine

Indiana University School of Medicine

Chen Zhang, MD, PhD

Associate Professor of Clinical Pathology & Laboratory Medicine

Department of Pathology and Laboratory Medicine

Indiana University School of Medicine

*This case has been peer reviewed

Clinical history:

The patient is a 34-year-old female with a history of type 1 diabetes mellitus who presented to the emergency room with sudden onset of worsening migraine, lethargy, vision changes, confusion, and agitation. She gets occipital migraines about once a month with associated vision changes, word-finding difficulties, and dizziness. MRI showed multiple small (largest measuring 1.4cm) acute infarctions in the posterior circulation territory involving the left cerebellum, bilateral occipital lobes, posterior right parietal lobe, and right thalamus.

Of note, the patient also complained of chronic shortness of breath, and laboratory findings showed markedly elevated d-dimer. CT scan showed a large 5.1 x 2.9cm filling defect in the left atrium. Echocardiography showed a large approximately 7.0 x 2.6cm left atrial mobile mass protruding into the left ventricle through the mitral valve with each systole.

Gross Examination of Left Atrial Mass:

Fragmented yellow-tan to red-brown, lobulated, and gelatinous mass with aggregate dimensions of 5.1 x 4.9 x 3.1 cm. Sectioning revealed tan, lobulated, gelatinous, and focally hemorrhagic cut surfaces.

Microscopic examination 

Upon histological review, the left atrial mass was noted to comprise of bland spindle cells with eosinophilic cytoplasm occurring singly and in small cords residing in a myxoid background with scattered small blood vessels. The most striking feature was the presence of prominent mucinous glands in one section of the mass. No significant pleomorphism or increased mitotic figures were present.

For PC users, right click to open image in a new window, then zoom to enlarge.

 Figure 1a. Gross image of left atrial mass showing yellow-tan to red-brown, lobulated, and gelatinous mass with hemorrhagic areas.

Figure 1b: Bland spindle cells occurring singly and in cords residing in a myxoid background. H&E, 100X

Fig. 1c: One focus showing prominent mucinous glands. H&E, 100X

Fig. 1d: High magnification view of prominent mucinous glands. No significant pleomorphism or increased mitotic activity is seen. H&E, 200X