Medical Mystery of the Week

      You have received your COVID19 immunizations but continue to practice some Telemedicine. You are shown the chest x-ray and given a heart recording of a 45-year-old man who is complaining of intermittent episodes of shortness of breath while sitting or standing which are relieved by lying down. You are given no other information.
       What is your diagnosis, what test(s) do you advise to substantiate your suspicions, and what treatment, if any, do you advise? 
DIAGNOSIS: Left atrial myxoma causing a "tumor plop" sound as the tumor enters and exits the left ventricle. In the sitting and standing positions, the tumor may block the mitral valve causing both a mitral stenosis-like murmur and dyspnea; this does not occur in the supine or prone positions.
      75-85% of myxomas arise in the left atrium, 10-20% in the right atrium, and 5% in the ventricle. The tumors may be solid or papillary and are more common in women and in persons 30-70 years old. Systemic embolization, usually from thrombi on the tumor, occurs in ˜35% of cases. Sudden death may occur due to acute obstruction of the mitral valve. Patients often have signs of chronic inflammation including fever and elevated levels of IL-6 and CRP. Patients with small tumors are treated with anticoagulants and/or thrombolytic agents; large tumors are removed surgically.