3. 30 year old female no DM,HTN mother of 3
childrens, last child one and half year old .
She was transferred to KAMC ICU on 23rd
March 2019 ,in state of cardiogenic/septic
shock ,on evaluation discovered to have
classical Hodgkins Lymphoma
( nodular sclerosing type stage 1V B.
KAMC,
Cardio-oncological syndromes
4. Two Echo before chemotherapy on 24th march/& 25th April 2019
showed mildly dilated LV with severe global LV systolic dysfunction
EF 25 - 30%,moderate to severe MR, no pulmonary hypertension,
small pericardial effusion. BNP was 1810/1264, troponin
0.178/0.115.Mild passive liver congestion Bil 2.3/2.6,renal function
normal, septic work up were negative. Thyroid profile was normal
,ESR 100,CRP 29,Hb 7.4,Wbc 21.5,S Lactate 2.2.
( Rare clinical manifestation of Hodgkins lymphoma ).
She received chemotherapy ( without ABVD )and tolerated very well
without worsening of heart failure and LV ejection fraction.
KAMC,
Cardio-oncological syndromes
5. We saw her in screening clinic ( post discharge HF
review) ,monitored her throughout chemotherapy and
in addition to chemotherapy, we gave her bisoprolol,
,furosemide, valsartan, & spironolactone .She regularly
followed at HF clinic ,and remain compensated .
Her echo repeated after 6 months in September 2019
EF improved to 35%,mild MR. Subsequently her last echo
done after around one year in Feb 2020.
Normal LV size EF 50-55%,no valve regurgitation.
KAMC,
Cardio-oncological syndromes
6. This is a classical reversible heart failure and rare clinical
manifestation of Hodgkins lymphoma.
In fact chemotherapy cured heart failure ( From Stage C
to stage A HF )
We deliberately did not switched her on sacubitril
,because she was compensated in FC 1, despite low EF
,she was closely followed by cardiologist and oncologist
during and after chemotherapy course with simple
biomarkers. she is now only on bisoprolol.
KAMC,
Cardio-oncological syndromes
7. Family need a son and she want to
become pregnant .
Can She
??
KAMC,
Cardio-oncological syndromes
8. Brief Discussion
Primary and secondary cardiac involvement in lymphoma are
extremely rare .Little attention has been directed towards
cardiac involvement in lymphoma.
Careful screening for myocardial dysfunction in patients with
primary or secondary cardiac lymphomas is of utter
importance, since it can limit the use of several chemo
therapeutic agents including anthracyclins commonly used in
lymphoma. In this case probably echo was done at right time in
right case because of suspected cardiogenic/septic shock
KAMC,
Cardio-oncological syndromes
9. Brief Discussion
Lymphoma account for 55.6% of hematological malignancies and
Hodgkins lymphoma represent 30% of total lymphoma cases.
Pulmonary, hepatic,cerebral and testicular are among the most
common extranodal determination.
Cardiac involvement is rarely described in the literature .
Our case was classical Hodgkins nodular sclerosing type stage 1V B
( on left cervical lymph node biopsy) .She presented with severe LV
systolic dysfunction, with raised BNP and troponin at admission
before chemotherapy ,unable to receive ABVD,however She
completed 6 cycles of chemo ( GDP ) under close follow up.
KAMC,
Cardio-oncological syndromes
10. Primary oncologist did not opted ABVD , may be
cardioprotective therapy was not available or indvidual
decision . Nonethless no acute cardiac adverse events
were noted throughout chemotherapy .
Cardiac function and valve regurgitation markedly improved
and normalized indeed with normal biomarkers on post
discharge heart failure follow up after chemo.Post therapeutic
imagistic evaluation revealed complete remission and
reversal of cardiac dysfunction.
KAMC,
Cardio-oncological syndromes
11. THANK YOU dear oncologist
For such a wonderfull case referral.
This heart failure is not a tigerneither a elephant heart
So we consider it Horse:
