Clinical Case Report Painful multiple mononeuropathy as a first symptom of cardiac myxoma: an unusual clinical presentation Maude Michaud a , Valérie Wolff b , Sébastien Pelletier c , Philippe Evon c , Sébastien Richard a, ⁎ a Department of Neurology, CHU Nancy, Hôpital Central, 29 avenue du Marechal de Lattre de Tassigny-CO n° 34 54035 Nancy Cedex, France b Department of Neurology, CHU Strasbourg, Hôpital de Hautepierre, 1 avenue Molière 67098 Strasbourg Cedex c CH Bar le Duc, 1 boulevard d’Argonne 55012 Bar le Duc Cedex, France abstract article info Article history: Received 16 July 2014 Received in revised form 29 August 2014 Accepted 10 September 2014 Keywords: Atrial myxoma Cardiac surgery Multiple neuropathy Purpura Background: Atrial myxoma (AM) is responsible for multiple serious complications, such as ischemic stroke, and requires cardiac surgery. However, diagnosis and, thus, treatment may be delayed by an initial misleading clinical presentation including nonspecific extracardiac symptoms. Involvement of the peripheral nervous system as a first symptom of AM has been reported only once before and never in the form of multiple mononeuropathy. Case: We report the case of a 51-year-old woman who had suffered from pharmacoresistant neurological pain sequentially in several peripheral nerve territories for more than a year before the appearance of purpuric mac- ules on the palms and soles and emergence of a biological inflammatory syndrome. Cardioembolic disease was suspected after radiological examination detected multiple asymptomatic renal and splenic infarctions and a small right frontal cortical ischemic stroke. Transoesophageal echocardiography revealed an atrial mass which was removed by surgery. AM was confirmed after histopathological analysis. The neurological pain resolved along with embolic and systemic signs of AM, and the patient has since been free of pain. Conclusion: Multiple mononeuropathy is a possible symptom of AM and may precede onset of other embolic or systemic signs by several months. © 2014 Elsevier Inc. All rights reserved. 1. Introduction Involvement of the peripheral nervous system in patients with atrial myxoma (AM) has rarely been reported before and only with symmet- ric neuropathy [1]. We present the case of a patient with AM who had suffered from painful multiple mononeuropathy for more than a year before the onset of other systemic and embolic symptoms. 2. Case report A 51-year-old woman with a past medical history of hypertension and osteopenia was admitted because of persistent and insomnia-related burning dysaesthesia for more than 1 year. The patient had experienced neurological pain—resistant to analgesics and pregabalin—sequentially in different sensitive territories for several weeks before regression: first in the left sural territory and then in the right before recurrence in both radial and right ulnar territories. Clinical examination a year later during hospitalization revealed purpuric macules on both palms (Fig. 1A) and soles (Fig. 1B) which had appeared within the previous week. Blood tests showed a platelet count of 267G/L, an inflammatory syndrome with a C-reactive protein level of 27mg/L and a high erythrocyte sedimen- tation rate of 53mm/h. There was no indication of any autoimmune ab- normality: testing for complement, antinuclear antibody, antineutrophyl cytoplasmic antibody, and anticardiolipin antibodies was negative. Elec- tromyography, performed at the onset of symptoms, was normal. As the neurological pain was associated with systemic signs, the physicians de- cided to perform a thoracoabdominal computed tomography (CT) scan which revealed multiple infarcts of kidneys (Fig. 2A) and spleen (Fig. 2B) and a brain MRI revealing a small recent frontal cortical ischemic stroke (Fig. 2C). The electrocardiogram and cervical ultrasonography were normal. These findings were suggestive of an embolic mechanism, and a transoesophageal echocardiography (Fig. 2D) was subsequently performed revealing a left atrial mass of a mobile polypoid tumor aspect compatible with AM. This diagnosis was confirmed after removal of the tumor (Fig. 1C) on histopathological analysis (Fig. 1D). The neuropathy was relieved as well as the systemic and cutaneous symptoms, and the patient has been free of neurological pain since the surgery 1 year ago. 3. Discussion Cardiac myxoma is the most frequent primary tumor of the heart, and 75% are located in the left atrium [2]. AM may be responsible for Cardiovascular Pathology 24 (2015) 121–123 Abbreviation: AM, Atrial myxoma. Funding: A case of neuropathy treated by cardiac surgery: A novel clinical presenta- tion of cardiac myxoma. There was no financial support from any funding source for the conduct and the prep- aration of this work. Conflict of interest: none. ⁎ Corresponding author at: Department of Neurology, CHU Nancy, Hopital Central, 29 avenue du Marechal de Lattre de Tassigny-CO n° 34 54035 Nancy Cedex, France. Tel.: +33-3-83-85-16-56; fax: +33-3-83-85-11-59. E-mail address: s.richard@chu-nancy.fr (S. Richard). http://dx.doi.org/10.1016/j.carpath.2014.09.005 1054-8807/© 2014 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Cardiovascular Pathology