Case Report: A 73 year old female was admitted to our hospital with complaints of acute shortness of breath on exertion and chest tightness accompanied with non-exertional left arm pain. Her prior history was significant for hypertension. Vital signs were significant for tachycardia. EKG revealed sinus tachycardia and low voltage QRS complexes. Cardiac Biomarkers were negative. CXR on admission showed massive cardiomegaly. (A) Echocardiography, Off Axis, Apical long axis view showing a large mass attached to the LV apex surrounded by large pericardial effusion. Pericardiocentesis was performed and 1200ml of bloody fluid was removed. (B) Cardiac MRI was performed which revealed a mass arising from the inferolateral wall of Left Ventricle measuring 6.5x4.9x6.2 cm Left thoracotomy, wedge biopsy of left ventricular mass was performed. (C, D)Pathological analysis confirmed well differentiated Leiomyosarcoma (grade 1 of 3) FNCLCC grading system. Tumor was strongly positive for vimentin, smooth muscle myosin and desmin.

Case Presentation: 47-year-old Liberian woman with a history of latent TB and no prior cardiac history presented with dyspnea, palpitations, and weight loss. She had fevers, tachycardia, and cervical lymphadenopathy. Cardiac exam showed widened pulse pressure, systolic and diastolic murmur, and features of heart failure. TTE showed dilated left ventricle with preserved ejection fraction, aortic root aneurysm compressing left atrium, severe aortic and mitral regurgitation, and moderate pericardial effusion with no tamponade. CT angiogram of neck, chest and abdomen showed right subclavian artery mycotic aneurysm, large left supraclavicular lymphadenopathy, multiple aortic arch, and descending thoracic aorta mycotic aneurysms. She underwent emergent surgical intervention. Intraoperative TEE revealed rupture of aortic root aneurysm into left ventricular outflow tract causing a fistula, perforated anterior mitral leaflet, and distortion of the left atrial wall. She underwent mitral and aortic tissue valve replacement, aortic root replacement, and a pericardial patch repair of the left atrial wall. Subsequently, she underwent right subclavian artery aneurysm resection, right carotid axillary bypass, and vertebral artery reimplantation. Aortic valve pathology was suggestive of endocarditis with negative cultures. Lymph node biopsy revealed non-necrotizing granulomatous inflammation with no evidence of acid-fast bacilli, fungi, and malignancy. Autoimmune workup was negative. A PET CT showed post-surgical inflammatory changes with no evidence of malignancy. Discussion: We describe an unusual case of multiple large arterial aneurysms causing severe valvular insufficiency requiring emergent surgical intervention. The patient underwent extensive workup which was unrevealing. She was treated for subacute bacterial endocarditis and suspected Bechet’s disease. Thus, the quest for a definitive diagnosis continues to elude us.