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.