Triple trouble: rheumatic heart disease, infective endocarditis, atrial myxoma

A young college-going male presented with worsening dyspnoea and palpitations for 6 months. He was diagnosed with rheumatic heart disease. The patient’s echocardiogram showed not only rheumatic affection of the mitral valve with restricted leaflet movements, but there was also a calcified hyperechogenic mass attached to the atrial aspect of the anterior mitral leaflet, which signified a probable calcified thrombus or an organised vegetation; and a heterogenous, low-attenuating mass attached to the interatrial septum characterised as an atrial myxoma. Considering the gravity of the situation, the patient underwent a successful removal of intracardiac masses with a bioprosthetic mitral valve replacement urgently. Although reported, the occurrence of atrial myxoma with rheumatic heart disease is a rare phenomenon. Left atrial thrombus and myxoma can mimic each other and pose a diagnostic challenge even in today’s era of multimodality imaging.