Guideline-directed medical therapy for acute heart failure led to rapid symptomatic and radiographic resolution in a 69-year-old man whose initial imaging mimicked lymphangitic carcinomatosis.
Case Report (n=1)
Acute heart failure can closely mimic lymphangitic carcinomatosis on imaging, highlighting the importance of integrating clinical and echocardiographic findings to avoid unnecessary invasive testing.
Abstract Pulmonary imaging findings that resemble malignancy represent a difficult diagnostic challenge with major therapeutic implications. Lymphangitic carcinomatosis (LC) is among the most feared radiographic patterns, typically manifesting with progressive dyspnea, diffuse interstitial thickening, and nodular opacities in patients with advanced cancer. However, several benign cardiopulmonary conditions, including infection, inflammatory disease, and cardiogenic pulmonary edema, can produce nearly identical findings, risking premature diagnostic anchoring and unnecessary invasive testing. We describe a case of fulminant new-onset heart failure radiographically mimicking LC, emphasizing the importance of clinicoradiologic correlation and multidisciplinary evaluation. A 69-year-old man with longstanding hypertension (off medications for one year), prior parotidectomy (2022), and recent transsphenoidal surgery presented with several days of worsening dyspnea, orthopnea, abdominal discomfort, anorexia, and 10-pound weight loss. He denied cough, fever, or chest pain. On arrival, he was hypertensive (183/121 mmHg), tachycardic (129 bpm), and O2 saturation (SpO2 93% on room air). Laboratory testing showed troponin 1000 ng/L, pro-BNP 7971 pg/mL, mild acute kidney injury, and transaminitis. CTA of the chest, abdomen, and pelvis revealed scattered pulmonary nodules, interlobular septal thickening, bilateral pleural effusions, and mediastinal adenopathy initially interpreted as highly suspicious for LC, prompting urgent oncology and pulmonology consultation. Yet several features were discordant: an acute clinical onset, absence of cough or systemic symptoms, lifelong nonsmoking status, and a stable right-lung nodule (1.2 cm) unchanged from prior PET/CT imaging. Cardiac evaluation provided the unifying diagnosis: examination notable for an S3 gallop, markedly elevated natriuretic peptide, and echocardiogram demonstrating new severe HFrEF (ejection fraction 15-20%) with global hypokinesis and left-ventricular dilation. Guided diuresis and initiation of guideline-directed medical therapy led to rapid symptomatic and radiographic improvement. Follow-up CT showed near-complete resolution of nodularity and interstitial thickening, confirming cardiogenic pulmonary edema rather than metastatic disease. Right and left heart catheterization identified triple-vessel coronary artery disease with preserved cardiac output and wedge pressure of 15 mmHg. The patient was stabilized on sacubitril/valsartan, beta-blocker, spironolactone, loop diuretic, and high-intensity statin, with plans for coronary artery bypass grafting and outpatient pulmonary surveillance. This case highlights how acute heart failure can closely mimic lymphangitic carcinomatosis on imaging, particularly in patients with prior oncologic histories. Integrating clinical tempo, biomarker data, and echocardiographic findings prevented unnecessary biopsy and redirected therapy toward cardiac optimization. Recognizing cardiogenic mimics of malignancy is essential, as timely identification of these reversible patterns can spare patients invasive procedures, reduce risk, and expedite definitive management. This abstract is funded by: None
Chaney et al. (Fri,) conducted a case report in Cardiogenic pulmonary edema (n=1). Guideline-directed medical therapy was evaluated. Guideline-directed medical therapy for acute heart failure led to rapid symptomatic and radiographic resolution in a 69-year-old man whose initial imaging mimicked lymphangitic carcinomatosis.