Testicular torsion in Henoch--Schonlein syndrome.

Harvey (1968) used the term "wreck.ing ball" to describe the movements of a calcified pedunculated right atrial myxoma, likening it to the swinging iron ball suspended from a crane used for demolishing buildings. In the patient he described the tricuspid valve had been almost completely destroyed by the movemen,ts of the tumour. Similar patients with incompetent tricuspid valves damaged by calcified right at,rial myxoma have been reported by Oliver and Missen (1966) and Fluck and Lopez-Bescos (1968). Predominant mitral regurgitation, though unusual, has been descibed in a few patients with myxoma of ithe left atrium (Cohen et al., 1963; Penny et al., 1967; Wittenstemn et al., 1959). It was attributed to partial herniation of the tumour through the mitral valve interfering with valve closure. Ruptured chordae tendineae were not seen. The present patient, unlike most others with left atrial myxoma, presented with a sudden onset of severe mitral regurgitation and pulmonary oedema. Probably the chordae tendineae ruptured at that time and the rupture was related to ithe "wrecking ball" effect of the heavily calcified, mobile tumour. The sudden onset of mitral regurgitation suggested ruptured chordae tendineae but atrial myxoma was not considered. A variety of auscuktatory findings have been described in patients with left atrial myxoma, including systolic and diastolic apical murmurs, accentuated pulmonary valve closure sounds, ejecion sounds and diastolic filling sounds (Goodwin, 1963; Greenwood, 1968; Harvey, 1968). The diastolic filling sound, the so-called "tumour plop," occurs earlier in diastole than the usual third heart sound, near the timing of the opening snap of the mitral valve with which it is sometimes confused (Greenwood, 1968; Abbott et al., 1962; Pi-tt et al., 1965). This early diastolic sound is thought to be produced by the sudden deceleration of the tumour on its pedicle as it enters the left ventricle (Pitt et al., 1965). The "third heart sound" heard in our patient was quite early and may have been produced in this way. Though the combination of ruptured chordae tendineae and left atrial myxoma has not been previously reported the association should not be unexpected, especially when the tumour is calcified. While some miitral regurgitation can be caused by a left atrial myxoma, the sudden appearance of severe regurgitation would be unusual and misleading. The presence of an early third heart sound ("tumour plop") may be a clue in this situation, but it is difficult to distinguish from the usual third heart sound heard in some cases of nitral regurgiltation.