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A 9 year old boy presented to our paediatric emergency department with a three week history of breathlessness, generalised body swelling, and an abdominal mass (fig 1⇓). On examination he had signs consistent with right heart failure and a smooth, non-tender epigastric mass separate from his liver. Ultrasound examination of the abdomen suggested this mass to be nodal Burkitt’s lymphoma, which was later confirmed by histology. Echocardiography revealed a 3.94 cm diameter mobile solitary intra-cavitary homogeneous mass, which appeared to be arising from the postero-medial wall of the right atrium, and prolapsing in and out of the right ventricle in addition to a global moderately sized pericardial effusion (fig 2⇓). The mass impaired right ventricular diastolic filling and right ventricular outflow tract ejection.
Clinical improvement was rapid and dramatic following chemotherapy for Burkitt’s lymphoma (fig 3⇓). Repeat echocardiography four weeks after initial presentation showed the intra-cardiac mass had become much smaller and was no longer impairing right ventricular haemodynamics (fig 4⇓). Our patient had been referred to us as a case of congestive cardiac failure, which is common in sub-Saharan Africa and often secondary to rheumatic heart disease, where symptomatic control with diuretic therapy is the mainstay of treatment. Diuretic therapy in our patient could have worsened his symptoms and caused a delay to diagnosis. Although a rarity outside Africa, Burkitt’s lymphoma is the most common childhood malignancy in sub-Saharan Africa. Early recognition of its varied presentation is essential if avoidable morbidity and mortality is to be prevented.