Fluctuating Cutaneous Varices as a Diagnostic Clue for a Huge Right Atrial Mass in a Dialysis Patient

Keywords: cutaneous varices, right atrial mass

A 72-year-old man presented with altered consciousness. His past medical history included left renal cell carcinoma status post nephrectomy 3 years earlier, end-stage renal disease with regular hemodialysis, and central venous obstruction with stenting at the right subclavian vein and superior vena cava 8 months earlier. He was intubated and placed on a mechanical ventilator and inotropes for managing respiratory failure and shock. Physical examination revealed jugular vein enlargement and cutaneous varices over the chest wall (Figure 1A, arrow). The varices were engorged and then vanished during the respiratory cycle (Video Series). Transthoracic echocardiography revealed a 4.5- × 5.7-cm2 heterozygous mass in the right atrium (Figure 1B and Video Series). Computed tomography showed a large, calcified thrombus from the central veins to the right atrium (Figure 1C). During the inspiratory phase, the mechanical ventilator inflated the lung, resulting in positive pressure in the right ventricle that limited ventricular dilation during diastole. The right atrial mass also hindered blood flow into the right ventricle and caused blood to flow back into the peripheral venous system. This could cause obstructive cardiogenic shock and fluctuating cutaneous varices (Video Series). The patient refused further intervention and died from multiple organ failure. The unusual phenomenon provided a clue for a huge right atrial mass in dialysis patients.

Affiliations and Disclosures

From the ¹Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan; ²Cardiovascular Center, MacKay Memorial Hospital, Taipei, Taiwan; ³Division of Nephrology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan; and ⁴Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei City, Taiwan.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted April 8, 2022.

Address for correspondence: Yen-Yu Liu, MD, Department of Critical Care Medicine, MacKay Memorial Hospital, 92, Sec 2, Zhongshan North Road, Taipei 10449, Taiwan. Email: yenyu1012@gmail.com

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