Images in Cardiovascular Medicine Myocardial Infarction With Intracardiac Thrombosis as the Presentation of Acute Promyelocytic Leukemia Diagnosis and Follow-Up by Cardiac Magnetic Resonance Imaging

29-year-old woman presented in February 2010 withacute-onset severe chest pain. This radiated to the leftshoulder and was associated with breathlessness. She wasafebrile, her saturations were 100% on air, and her clinicalexamination was entirely normal. An electrocardiogram showeddiffuse 2- to 3-mm ST-segment elevation. At presentation,troponinIwaselevatedat2.4ng/mL(normal 0.1ng/mL).Fullblood count, chest radiograph, arterial blood gas, and bedsideechocardiogram were unremarkable. She was diagnosed withmyopericarditis and discharged from the accident and emer-gency department with nonsteroidal anti-inflammatories.Two days later, she returned with worsening chest pain andwas admitted for investigation. She had a full blood count,and urea and electrolytes were within the normal range.Troponin I was significantly elevated at 15.2 ng/mL,C-reactive protein was 160 mg/L (normal 10 mg/L), andD-dimer was 20 000 g/L (normal 0 to 500 g/L). Herelectrocardiogram showed further widespread ST elevation,and repeat bedside echocardiogram demonstrated a mass atthe left ventricular apex, with apical hypokinesis (Figure 1and online-only Data Supplement Movie I). A cardiac mag-netic resonance scan revealed apical scarring consistent witha small myocardial infarct, with adherent apical thrombus inboth the left and right ventricles (Figures 2 and 3 andonline-only Data Supplement Movies II and III).Coronary angiography showed no evidence of coronaryartery disease. To exclude paradoxical embolism, a bubbleechocardiogram was performed, which was normal. In viewof her intracardiac thrombus, therapeutic dose low–molecular-weight heparin was commenced.Over the 3 days after admission, she developed an isolatedneutropenia, with her neutrophil count dropping to 0.9210