A 46-year-old female presented to our hospital emergency room with the chief complain of acute onset of chest pain for 8 hours. She described pain as pressure like, constant and was progressively worsening. The pain was present in substernal area and was non radiating. Patient denied fever, chills, shortness of breath, palpitations, nausea, vomiting or dizziness.

The patient had a past medical history significant for squamous cell carcinoma of left tongue diagnosed three years ago status post left hemi-glossectomy with reconstruction, adjuvant radiation and chemotherapy. Two years after the initial diagnosis, on surveillance positron emission tomography (PET) scan she was noted to have hypermetabolic lesions in the left neck, right thigh, left scapula and posterior right rib concerning for metastatic disease. Also, she had left apical lung mass, biopsy proven as squamous cell carcinoma consistent with metastasis. She had past surgical history of cesarean section, right ovarian cyst rupture status post laparoscopic ovarian cystectomy and left hemi-glossectomy with reconstruction. She had smoking history of 15 packs per year. She denied alcohol or recreational drug use. His family history included breast cancer in the mother. Physical examination revealed a thin female in mild distress. Her vitals were within normal limits. Lungs were clear to auscultation bilaterally. Heart sounds, rate and rhythm were regular. No murmur was heard. No reproducible chest pain was noted. Abdomen was soft, non-tender and non-distended with no hepatosplenomegaly. Cranial nerves 2-12 were grossly intact. No edema or cyanosis noted in extremities bilaterally.

On admission, electrocardiogram (ECG) showed sinus rhythm, rate 97 beats per minute, ST segment elevation in leads II, III and avF and diffuse T- wave inversions (Figure 1). On admission, troponin-I 4 was 0.124 ng/mL. Based on the above symptoms and ECG abnormalities, there was a concern for inferior wall ST elevation myocardial infarction (STEMI). She underwent emergent coronary angiography. Angiography showed mild non-obstructive coronary artery disease. Transthoracic echocardiography (TTE) with contrast was performed. It showed thickened and hypokinetic inferoseptal, inferior and inferolateral walls with a round echo density present in the left ventricular (LV) cavity arising from the thickened infero-lateral wall measuring 1.8x1.5 cm2 (Figure 2). The biventricular systolic function was normal with no significant valvular abnormalities. There was a concern for metastatic intramyocardial tumor. For further evaluation, she underwent cardiac magnetic resonance imaging (MRI). It revealed 3.9 x 2.3 x 3.4 cm mass with imaging findings suggestive of malignant tumor attached to and infiltrating LV inferior myocardium, epicardial fat and pericardium. It also revealed 1.2 x 0.8 x 0.9 cm mobile mass in the mid- LV cavity, possibly attached to posteromedial papillary muscle with imaging findings consistent with a thrombus. In the light of the angiographic, echo and cardiac MRI findings, her symptoms and ECG abnormalities were attributed to the cardiac mass causing infiltration or displacement of the myocardium. The patient was started on apixaban for LV thrombus. On day 2 of hospitalization, her chest pain was controlled with tramadol. Repeat ECG showed persistent ST elevation in leads II, III and avF and T wave inversions. She has persistent elevation in troponins ranging 0.16 to 0.20 ng/mL. Our report highlights a rare case of cardiac metastasis in a patient with tongue cancer presenting as STEMI.