AIDS and Non-Hodgkin's lymphoma: cardiac symptoms as first manifestation of a highly malignant B-cell lymphoma 18 years after HIV infection

History and findings: A 35-year-old man who, as a result of intravenous dru g abuse, had become infected with HIV 18 years previously, was admitted wit h signs of right-heart failure. Three months earlier a systolic murmur had first been heard in the 5th intercostal space parasternally. Investigations: Transesophageal echocardiography (TEE) demonstrated a 3 x 2 cm right atrial tumour, moderate to severe tricuspid regurgitation and pulm onary hypertension. Blood cultures grew Streptococcus. Diagnosis. treatment and course: Endocarditis with atrial thrombi and recur rent pulmonary emboli was diagnosed and treated with antibiotics and antico agulants. Three weeks later the TEE showed an increase in the atrial tumour . Computed tomography of skull, thorax and abdomen did not demonstrate any significantly enlarged lymph nodes. Exploratory thoracotomy revealed an inf iltrating highly malignant centroblastic non-Hodgkin's lymphoma (NHL) of al most the entire free wall of the right atrium. After two courses of chemoth erapy (CHOP protocol) the size of the tumour had significantly decreased. Conclusion: The differential diagnosis of a right atrial tumour can be diff icult in patients with HIV or AIDS. Even if the site is atypical and there is no lymphadenopathy, a lymphoma should be considered. In case of doubt a histological diagnosis via an exploratory thoracotomy should be performed.