Methods
Potential cardiac and pulmonary pathologies were considered for further
diagnostic workup, including infective endocarditis, mediastinal mass,
and lung or intrathoracic malignancy. These conditions were evaluated as
part of the differential diagnosis. Blood investigations were sent, and
Hemoglobin was found to be 11.78 g/dL (normal range: 13–18 g/dL), total
leukocyte count was elevated at 22,550 cells/µL (normal range:
4,000–11,000 cells/µL), with a differential count showing neutrophils
at 81% (normal range: 45–75%) and lymphocytes at 8% (normal range:
25–45%). The erythrocyte sedimentation rate (ESR) was significantly
elevated at 80 mm/hr (normal range: 0–12 mm/hr), but C-reactive protein
was in the normal range. The platelet count was 236,100 cells/µL (normal
range: 150,000–400,000 cells/µL). Prothrombin time (PT) was prolonged
at 18 seconds (normal range: 11–14 seconds). Serum sodium was slightly
low at 132 mEq/L (normal range: 135–145 mEq/L), and serum potassium was
notably reduced at 2.9 mEq/L (normal range: 3.5–5.2 mEq/L). Blood Sugar
level was in the normal range and was 77 mg/dl (Normal range: 74-130
mg/dl); hsTroponin I was significantly high and was 2904 pg/ml
(standard: less than 12 is negative). The patient’s liver function test
results were as follows: total protein was 6.4 g/dL (reference range:
6.4–8.2 g/dL), total bilirubin was 0.8 mg/dL (reference range: 0–1.1
mg/dL), direct bilirubin was 0.4 mg/dL (reference range: 0.0–0.4
mg/dL), alanine transaminase (ALT) was 34 U/L (reference range: 0–50
U/L), aspartate aminotransferase (AST) was 43 U/L (reference range:
0–45 U/L), alkaline phosphatase was elevated at 462 U/L (reference
range: 40–140 U/L), and serum albumin was slightly low at 3.3 g/dL
(reference range: 3.8–4.9 g/dL). Electrocardiography was sent and told
to have sinus rhythm along with left atrial abnormality and left
fascicular block. (Figure 1) Echocardiography revealed multiple
hyperechoic, hypermobile large mass (17x15 mm) attached to left
ventricle suggestive of embolized tumor mass.
After ruling out other pathologies based on the patient’s history,
physical examination, and initial investigations, intrathoracic
malignancy became the leading suspicion. An ultrasound of the abdomen
and pelvis was performed, revealing a mass in the left lower lobe of the
lung. To further confirm the diagnosis, a multi-detector computed
tomography (MDCT) scan was conducted, which demonstrated a mildly
heterogeneously enhancing hypodense lesion in the left lower lobe,
suggestive of a malignant lung mass. Additionally, the MDCT identified
metastatic lymph nodes and mild pleural effusion. Ultrasound-guided
Tru-cut needle biopsy was sent from the left lung mass, and it revealed
multiple cores of necrotic tissues composed of small areas of the viable
tumor with a sheet of fascicles of spindle cells with a diagnosis of
Spindle cell Tumor.