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Лимфома Ходжкина — редкая причина полной атриовентрикулярной блокады (клинический случай)
Лимфома Ходжкина — редкая причина полной атриовентрикулярной блокады (клинический случай)
Правкина Е.А., Синицын Д.С., Викулова П.С., Глуховец И.Б., Субботин С.В. Лимфома Ходжкина — редкая причина полной атриовентрикулярной блокады (клинический случай) // CardioСоматика. 2025. Т. 16, № 2. С. 176–187. DOI: 10.17816/CS641936 EDN: XQRANE
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Аннотация
Обоснование. Полная поперечная блокада — опасное состояние, требующее неотложной помощи и установки кардиостимулятора. При этом ключевой элемент успешного лечения — выявление причины блокады. В статье описан редкий клинический случай, при котором атриовентрикулярная блокада III степени была вызвана лимфомой Ходжкина.
Описание клинического случая. 14.01.2023 пациентка, 81 год, экстренно госпитализирована в районную больницу с жалобами на одышку, слабость, отёки ног, кашель и лихорадку. На электрокардиограмме ритм расценен как фибрилляция предсердий, на рентгенограмме описаны патологические изменения. Поставлен диагноз «пневмония», начата терапия антибиотиками, антиаритмиками и антикоагулянтами. За время лечения регистрировался синусовый ритм с наджелудочковой экстрасистолией с диффузными изменениями миокарда. Клинического улучшения не наблюдалось. 31.01.2023 зафиксирована полная атриовентрикулярная блокада, пациентка экстренно переведена в кардиологический стационар, где установлен временный электрокардиостимулятор. При дифференциальной диагностике причин блокады обсуждались побочные эффекты препаратов и инфаркт миокарда. Эхокардиография выявила образования в правом предсердии, утолщение листков перикарда, жидкость в полостях и дискинез межжелудочковой перегородки. Компьютерная томография, запланированная для исключения ТЭЛА, не выполнена по техническим причинам. Спустя 29 ч пребывания в стационаре пациентка скончалась. Патологоанатомическое исследование выявило лимфому Ходжкина с поражением средостения, сосудов и всех оболочек сердца. Также обнаружены тромботические наложения и тромбоэмболия с опухолевыми клетками в мелких ветвях лёгочных артерий. Старческий возраст, неспецифические жалобы, отсутствие подозрения на В-симптомы и редкие причины блокад привели к несвоевременной диагностике.
Заключение. Онконастороженность врачей-кардиологов в отношении пациентов с атриовентрикулярными блокадами весьма низкая, что может приводить к диагностическим ошибкам, иногда фатальным для пациента. Поражение сердца может быть первым проявлением медиастинальной лимфомы. В описанном случае компьютерная томография могла бы направить врачей к верному диагнозу. Данная статья публикуется с целью повышения уровня осведомлённости врачей в отношении лимфом с поражением сердца для ранней диагностики и успешного лечения пациентов.
Ключевые слова: лимфома Ходжкина, клинический случай, лимфома с поражением сердца, лимфома средостения, атриовентрикулярная блокада
CASE DESCRIPTION: On January 14, 2023, an 81-year-old female was urgently admitted to a district hospital with dyspnea, generalized weakness, lower extremity edema, cough, and fever. The rhythm on electrocardiography was interpreted as atrial fibrillation, and chest radiography demonstrated pathologic findings. Pneumonia was diagnosed, and treatment with antibiotics, antiarrhythmic agents, and anticoagulants was initiated. During treatment, sinus rhythm with supraventricular extrasystoles and diffuse myocardial changes was recorded. No clinical improvement was observed. On January 31, 2023, complete atrioventricular block was documented. The patient was urgently transferred to the inpatient cardiology department, where a temporary pacemaker was implanted. Differential diagnosis of the conduction disturbance included drug-induced atrioventricular block and myocardial infarction. Echocardiography revealed masses in the right atrium, thickening of the pericardial leaflets, fluid accumulation in the cavities, and interventricular septal dyskinesia. Computed tomography planned to rule out pulmonary embolism (PE) was not performed because of technical limitations. After 29 hours of hospitalization, the patient died. Postmortem examination revealed Hodgkin lymphoma involving the mediastinum, blood vessels, and all layers of the heart. Thrombotic deposits and tumor emboli containing lymphoma cells were identified in the small branches of the pulmonary arteries. Advanced age, nonspecific symptoms, lack of suspicion for B symptoms, and the rarity of such a cause of atrioventricular block contributed to the delayed diagnosis.
CONCLUSION: Oncologic vigilance among cardiologists regarding patients with atrioventricular block remains low, which may result in diagnostic errors and, in some cases, fatal outcomes. Cardiac involvement may be the first manifestation of mediastinal lymphoma. In the present case, computed tomography might have guided physicians toward the correct diagnosis. This article aims to raise awareness among physicians about lymphomas with cardiac involvement, thereby facilitating earlier diagnosis and more effective treatment.
Keywords: Hodgkin lymphoma, case report, heart neoplasms, mediastinal neoplasms, atrioventricular block
Описание клинического случая. 14.01.2023 пациентка, 81 год, экстренно госпитализирована в районную больницу с жалобами на одышку, слабость, отёки ног, кашель и лихорадку. На электрокардиограмме ритм расценен как фибрилляция предсердий, на рентгенограмме описаны патологические изменения. Поставлен диагноз «пневмония», начата терапия антибиотиками, антиаритмиками и антикоагулянтами. За время лечения регистрировался синусовый ритм с наджелудочковой экстрасистолией с диффузными изменениями миокарда. Клинического улучшения не наблюдалось. 31.01.2023 зафиксирована полная атриовентрикулярная блокада, пациентка экстренно переведена в кардиологический стационар, где установлен временный электрокардиостимулятор. При дифференциальной диагностике причин блокады обсуждались побочные эффекты препаратов и инфаркт миокарда. Эхокардиография выявила образования в правом предсердии, утолщение листков перикарда, жидкость в полостях и дискинез межжелудочковой перегородки. Компьютерная томография, запланированная для исключения ТЭЛА, не выполнена по техническим причинам. Спустя 29 ч пребывания в стационаре пациентка скончалась. Патологоанатомическое исследование выявило лимфому Ходжкина с поражением средостения, сосудов и всех оболочек сердца. Также обнаружены тромботические наложения и тромбоэмболия с опухолевыми клетками в мелких ветвях лёгочных артерий. Старческий возраст, неспецифические жалобы, отсутствие подозрения на В-симптомы и редкие причины блокад привели к несвоевременной диагностике.
Заключение. Онконастороженность врачей-кардиологов в отношении пациентов с атриовентрикулярными блокадами весьма низкая, что может приводить к диагностическим ошибкам, иногда фатальным для пациента. Поражение сердца может быть первым проявлением медиастинальной лимфомы. В описанном случае компьютерная томография могла бы направить врачей к верному диагнозу. Данная статья публикуется с целью повышения уровня осведомлённости врачей в отношении лимфом с поражением сердца для ранней диагностики и успешного лечения пациентов.
Ключевые слова: лимфома Ходжкина, клинический случай, лимфома с поражением сердца, лимфома средостения, атриовентрикулярная блокада
________________________________________________
CASE DESCRIPTION: On January 14, 2023, an 81-year-old female was urgently admitted to a district hospital with dyspnea, generalized weakness, lower extremity edema, cough, and fever. The rhythm on electrocardiography was interpreted as atrial fibrillation, and chest radiography demonstrated pathologic findings. Pneumonia was diagnosed, and treatment with antibiotics, antiarrhythmic agents, and anticoagulants was initiated. During treatment, sinus rhythm with supraventricular extrasystoles and diffuse myocardial changes was recorded. No clinical improvement was observed. On January 31, 2023, complete atrioventricular block was documented. The patient was urgently transferred to the inpatient cardiology department, where a temporary pacemaker was implanted. Differential diagnosis of the conduction disturbance included drug-induced atrioventricular block and myocardial infarction. Echocardiography revealed masses in the right atrium, thickening of the pericardial leaflets, fluid accumulation in the cavities, and interventricular septal dyskinesia. Computed tomography planned to rule out pulmonary embolism (PE) was not performed because of technical limitations. After 29 hours of hospitalization, the patient died. Postmortem examination revealed Hodgkin lymphoma involving the mediastinum, blood vessels, and all layers of the heart. Thrombotic deposits and tumor emboli containing lymphoma cells were identified in the small branches of the pulmonary arteries. Advanced age, nonspecific symptoms, lack of suspicion for B symptoms, and the rarity of such a cause of atrioventricular block contributed to the delayed diagnosis.
CONCLUSION: Oncologic vigilance among cardiologists regarding patients with atrioventricular block remains low, which may result in diagnostic errors and, in some cases, fatal outcomes. Cardiac involvement may be the first manifestation of mediastinal lymphoma. In the present case, computed tomography might have guided physicians toward the correct diagnosis. This article aims to raise awareness among physicians about lymphomas with cardiac involvement, thereby facilitating earlier diagnosis and more effective treatment.
Keywords: Hodgkin lymphoma, case report, heart neoplasms, mediastinal neoplasms, atrioventricular block
Полный текст
Список литературы
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6. Sakaeva DD, Raevskaya TV, Valiakhmetova ChKh, Iskhakova AI. Specific Myocardial Lesion in a Patient with Diffuse Large B-Cell Lymphoma (a Case Report). Creative Surgery and Oncology. 2018;8(4):316–323. doi: 10.24060/2076-3093-2018-8-4-316-323 EDN: ZABANN
7. Demina EA, Tumyan GS, Moiseeva TN, et al. Hodgkin Lymphoma. Clinical recommendations. J Modern Oncol. 2020;22(2):6–33. doi: 10.26442/18151434.2020.2.200132
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9. Zhuang S, Chang L, Feng X, et al. Primary cardiac lymphoma: a clinicopathological study of 121 cases. Front Oncol. 2025;14:1509100. doi: 10.3389/fonc.2024.1509100 EDN: QLWTGE
10. Gadaev IYu, Ershov VI, Bochkarnikova OV, et al. Cardiac involvement in lymphomas. Review of literature and case report of the clinical course of B-large-cell lymphoma. Rational Pharmacotherapy in Cardiology. 2015;11(6):610–617. doi: 10.20996/1819-6446-2015-11-6-610-617 EDN: VJGIFZ
11. Vatrasova SI. Primary lymphoma of the heart masked by myopericarditis: a clinical case. Bulletin of Medical Internet Conferences. 2019;9(8):338. (in Russ.) EDN: LBYYGZ
12. Chen CF, Hsieh PP, Lin SJ. Primary cardiac lymphoma with unusual presentation: A report of two cases. Mol Clin Oncol. 2017;6(3):311–314. doi: 10.3892/mco.2017.1131
13. Liu J, Zheng Y, Zhang W, et al. Case Report: A case of third-degree atrioventricular block associated with primary cardiac lymphoma. Front Cardiovasc Med. 2024;11:1356134. doi: 10.3389/fcvm.2024 EDN: JAQDQL
14. Kinoshita S, Ando J, Ando M, Komatsu N. Primary Lymphoma of the Pericardium. Intern Med. 2021;60(24):4005–4006. doi: 10.2169/internalmedicine.7643-21 EDN: TLVDZM
15. Sekar B, Swami G, Ibrahim A, et al. 76-year-old Gentlemen with primary cardiac lymphoma presenting as acute coronary syndrome and atrioventricular block. BJR Case Rep. 2016;2:20150466. doi: 10.1259/bjrcr.20150466
16. Volkov AV, Poletaeva MP, Eshmotova GK, Chupyatova EA. Morphological characteristics of primary b-cell lymphoma of the heart (case study). Selected Issues of Forensic Medical Examination. 2021;(20):33–36. (In Russ.) EDN: NLEJQQ
17. Visker YaYu, Kovalchuk DN. Clinical case of Burkitt lymphoma with primary heart disease. Vestnik SurGU. Meditsina. 2020;3(45):49–52. doi: 10.34822/2304-9448-2020-3-49-52 EDN: DBNKZS
18. Penyaeva EV, Petrosyan AD, Kovrigina AM. Primary cardiac lymphoma. a case from practice. Creative Cardiology. 2018;12(1):70–75. doi: 10.24022/1997-3187-2018-12-1-70-75 EDN: YWEZPE
19. Aleksandrov SS, Rednikov AA, Aleksandrov SA. A case of diffuse b-cell large cell lymphoma with heart involvement. Almanac of Young Science. 2014;(2):32–39. (In Russ.) EDN: UHKHDR
20. Koh YW, Kang HJ, Park C, et al. Prognostic significance of the ratio of absolute neutrophil count to absolute lymphocyte count in classic Hodgkin lymphoma. Am J Clin Pathol. 2012;138:846–854. doi: 10.1309/AJCPO46GFKGNXCBR
21. Uryasyev OM, Solovyeva AV, Korshunova LV, et al. Peculiarities of Exudative Pericarditis in Cardiac Metastasis. Science of the young (Eruditio Juvenium). 2023;11(4):563–572. doi: 10.23888/HMJ2023114563-572 EDN: FNARSB
22. Yakushin SS, Nikulina NN, Terekhovskaya YV. Clinical Manifestations and Diagnosis of Pulmonary Embolism in Routine Clinical Practice: Data from the Ryazan Regional Vascular Center. I.P. Pavlov Russian Medical Biological Herald. 2022;30(1):51–62. doi: 10.17816/PAVLOVJ85405 EDN: XUSJCB
2. Shan R, Ning Y, Ma Y, et al. Prevalence and risk factors of atrioventricular block among 15 million Chinese health examination participants in 2018: a nation-wide cross-sectional study. BMC Cardiovasc Disord. 2021;21(1):289. doi: 10.1186/s12872-021-02105-3 EDN: KEKEHQ
3. Kashou AH, Goyal A, Nguyen T, et al. Atrioventricular Block. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2024.
4. Lukianova IYu. Atrioventricular conduction disorders (a literature review). Juvenis Scientia. 2018;(10):17–23. doi: 10.32415/jscientia.2018.10.03 EDN: PIBGMH
5. Hoffmeier A, Sindermann JR, Scheld HH, Martens S. Cardiac tumors — diagnosis and surgical treatment. Dtsch Arztebl Int. 2014;111(12):205–211. doi: 10.3238/arztebl.2014.0205
6. Sakaeva DD, Raevskaya TV, Valiakhmetova ChKh, Iskhakova AI. Specific Myocardial Lesion in a Patient with Diffuse Large B-Cell Lymphoma (a Case Report). Creative Surgery and Oncology. 2018;8(4):316–323. doi: 10.24060/2076-3093-2018-8-4-316-323 EDN: ZABANN
7. Demina EA, Tumyan GS, Moiseeva TN, et al. Hodgkin Lymphoma. Clinical recommendations. J Modern Oncol. 2020;22(2):6–33. doi: 10.26442/18151434.2020.2.200132
8. Abdurakhmanov DT, Abuzarova GR, Ageeva TA, et al. Russian clinical guidelines for the diagnosis and treatment of lymphoproliferative diseases. Poddubnoi IV, Savchenko VG, editors. Moscow: Rossiiskoe professionalnoe obshchestvo onkogematologov, 2018. (In Russ.)
9. Zhuang S, Chang L, Feng X, et al. Primary cardiac lymphoma: a clinicopathological study of 121 cases. Front Oncol. 2025;14:1509100. doi: 10.3389/fonc.2024.1509100 EDN: QLWTGE
10. Gadaev IYu, Ershov VI, Bochkarnikova OV, et al. Cardiac involvement in lymphomas. Review of literature and case report of the clinical course of B-large-cell lymphoma. Rational Pharmacotherapy in Cardiology. 2015;11(6):610–617. doi: 10.20996/1819-6446-2015-11-6-610-617 EDN: VJGIFZ
11. Vatrasova SI. Primary lymphoma of the heart masked by myopericarditis: a clinical case. Bulletin of Medical Internet Conferences. 2019;9(8):338. (in Russ.) EDN: LBYYGZ
12. Chen CF, Hsieh PP, Lin SJ. Primary cardiac lymphoma with unusual presentation: A report of two cases. Mol Clin Oncol. 2017;6(3):311–314. doi: 10.3892/mco.2017.1131
13. Liu J, Zheng Y, Zhang W, et al. Case Report: A case of third-degree atrioventricular block associated with primary cardiac lymphoma. Front Cardiovasc Med. 2024;11:1356134. doi: 10.3389/fcvm.2024 EDN: JAQDQL
14. Kinoshita S, Ando J, Ando M, Komatsu N. Primary Lymphoma of the Pericardium. Intern Med. 2021;60(24):4005–4006. doi: 10.2169/internalmedicine.7643-21 EDN: TLVDZM
15. Sekar B, Swami G, Ibrahim A, et al. 76-year-old Gentlemen with primary cardiac lymphoma presenting as acute coronary syndrome and atrioventricular block. BJR Case Rep. 2016;2:20150466. doi: 10.1259/bjrcr.20150466
16. Volkov AV, Poletaeva MP, Eshmotova GK, Chupyatova EA. Morphological characteristics of primary b-cell lymphoma of the heart (case study). Selected Issues of Forensic Medical Examination. 2021;(20):33–36. (In Russ.) EDN: NLEJQQ
17. Visker YaYu, Kovalchuk DN. Clinical case of Burkitt lymphoma with primary heart disease. Vestnik SurGU. Meditsina. 2020;3(45):49–52. doi: 10.34822/2304-9448-2020-3-49-52 EDN: DBNKZS
18. Penyaeva EV, Petrosyan AD, Kovrigina AM. Primary cardiac lymphoma. a case from practice. Creative Cardiology. 2018;12(1):70–75. doi: 10.24022/1997-3187-2018-12-1-70-75 EDN: YWEZPE
19. Aleksandrov SS, Rednikov AA, Aleksandrov SA. A case of diffuse b-cell large cell lymphoma with heart involvement. Almanac of Young Science. 2014;(2):32–39. (In Russ.) EDN: UHKHDR
20. Koh YW, Kang HJ, Park C, et al. Prognostic significance of the ratio of absolute neutrophil count to absolute lymphocyte count in classic Hodgkin lymphoma. Am J Clin Pathol. 2012;138:846–854. doi: 10.1309/AJCPO46GFKGNXCBR
21. Uryasyev OM, Solovyeva AV, Korshunova LV, et al. Peculiarities of Exudative Pericarditis in Cardiac Metastasis. Science of the young (Eruditio Juvenium). 2023;11(4):563–572. doi: 10.23888/HMJ2023114563-572 EDN: FNARSB
22. Yakushin SS, Nikulina NN, Terekhovskaya YV. Clinical Manifestations and Diagnosis of Pulmonary Embolism in Routine Clinical Practice: Data from the Ryazan Regional Vascular Center. I.P. Pavlov Russian Medical Biological Herald. 2022;30(1):51–62. doi: 10.17816/PAVLOVJ85405 EDN: XUSJCB
2. Shan R, Ning Y, Ma Y, et al. Prevalence and risk factors of atrioventricular block among 15 million Chinese health examination participants in 2018: a nation-wide cross-sectional study. BMC Cardiovasc Disord. 2021;21(1):289. doi: 10.1186/s12872-021-02105-3 EDN: KEKEHQ
3. Kashou AH, Goyal A, Nguyen T, et al. Atrioventricular Block. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2024.
4. Lukianova IYu. Atrioventricular conduction disorders (a literature review). Juvenis Scientia. 2018;(10):17–23. doi: 10.32415/jscientia.2018.10.03 EDN: PIBGMH
5. Hoffmeier A, Sindermann JR, Scheld HH, Martens S. Cardiac tumors — diagnosis and surgical treatment. Dtsch Arztebl Int. 2014;111(12):205–211. doi: 10.3238/arztebl.2014.0205
6. Sakaeva DD, Raevskaya TV, Valiakhmetova ChKh, Iskhakova AI. Specific Myocardial Lesion in a Patient with Diffuse Large B-Cell Lymphoma (a Case Report). Creative Surgery and Oncology. 2018;8(4):316–323. doi: 10.24060/2076-3093-2018-8-4-316-323 EDN: ZABANN
7. Demina EA, Tumyan GS, Moiseeva TN, et al. Hodgkin Lymphoma. Clinical recommendations. J Modern Oncol. 2020;22(2):6–33. doi: 10.26442/18151434.2020.2.200132
8. Abdurakhmanov DT, Abuzarova GR, Ageeva TA, et al. Russian clinical guidelines for the diagnosis and treatment of lymphoproliferative diseases. Poddubnoi IV, Savchenko VG, editors. Moscow: Rossiiskoe professionalnoe obshchestvo onkogematologov, 2018. (In Russ.)
9. Zhuang S, Chang L, Feng X, et al. Primary cardiac lymphoma: a clinicopathological study of 121 cases. Front Oncol. 2025;14:1509100. doi: 10.3389/fonc.2024.1509100 EDN: QLWTGE
10. Gadaev IYu, Ershov VI, Bochkarnikova OV, et al. Cardiac involvement in lymphomas. Review of literature and case report of the clinical course of B-large-cell lymphoma. Rational Pharmacotherapy in Cardiology. 2015;11(6):610–617. doi: 10.20996/1819-6446-2015-11-6-610-617 EDN: VJGIFZ
11. Vatrasova SI. Primary lymphoma of the heart masked by myopericarditis: a clinical case. Bulletin of Medical Internet Conferences. 2019;9(8):338. (in Russ.) EDN: LBYYGZ
12. Chen CF, Hsieh PP, Lin SJ. Primary cardiac lymphoma with unusual presentation: A report of two cases. Mol Clin Oncol. 2017;6(3):311–314. doi: 10.3892/mco.2017.1131
13. Liu J, Zheng Y, Zhang W, et al. Case Report: A case of third-degree atrioventricular block associated with primary cardiac lymphoma. Front Cardiovasc Med. 2024;11:1356134. doi: 10.3389/fcvm.2024 EDN: JAQDQL
14. Kinoshita S, Ando J, Ando M, Komatsu N. Primary Lymphoma of the Pericardium. Intern Med. 2021;60(24):4005–4006. doi: 10.2169/internalmedicine.7643-21 EDN: TLVDZM
15. Sekar B, Swami G, Ibrahim A, et al. 76-year-old Gentlemen with primary cardiac lymphoma presenting as acute coronary syndrome and atrioventricular block. BJR Case Rep. 2016;2:20150466. doi: 10.1259/bjrcr.20150466
16. Volkov AV, Poletaeva MP, Eshmotova GK, Chupyatova EA. Morphological characteristics of primary b-cell lymphoma of the heart (case study). Selected Issues of Forensic Medical Examination. 2021;(20):33–36. (In Russ.) EDN: NLEJQQ
17. Visker YaYu, Kovalchuk DN. Clinical case of Burkitt lymphoma with primary heart disease. Vestnik SurGU. Meditsina. 2020;3(45):49–52. doi: 10.34822/2304-9448-2020-3-49-52 EDN: DBNKZS
18. Penyaeva EV, Petrosyan AD, Kovrigina AM. Primary cardiac lymphoma. a case from practice. Creative Cardiology. 2018;12(1):70–75. doi: 10.24022/1997-3187-2018-12-1-70-75 EDN: YWEZPE
19. Aleksandrov SS, Rednikov AA, Aleksandrov SA. A case of diffuse b-cell large cell lymphoma with heart involvement. Almanac of Young Science. 2014;(2):32–39. (In Russ.) EDN: UHKHDR
20. Koh YW, Kang HJ, Park C, et al. Prognostic significance of the ratio of absolute neutrophil count to absolute lymphocyte count in classic Hodgkin lymphoma. Am J Clin Pathol. 2012;138:846–854. doi: 10.1309/AJCPO46GFKGNXCBR
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Авторы
Е.А. Правкина*1, Д.С. Синицын1, П.С. Викулова1, И.Б. Глуховец1, С.В. Субботин2
1Рязанский государственный медицинский университет им. акад. И.П. Павлова, Рязань, Россия;
2Областной клинический кардиологический диспансер, Рязань, Россия
*vikont313arbus@yandex.ru
1Ryazan State Medical University, Ryazan, Russia;
2Regional Clinical Cardiology Dispensary, Ryazan, Russia
*vikont313arbus@yandex.ru
1Рязанский государственный медицинский университет им. акад. И.П. Павлова, Рязань, Россия;
2Областной клинический кардиологический диспансер, Рязань, Россия
*vikont313arbus@yandex.ru
________________________________________________
1Ryazan State Medical University, Ryazan, Russia;
2Regional Clinical Cardiology Dispensary, Ryazan, Russia
*vikont313arbus@yandex.ru
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