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Endgames

Case Report

Acute dyspnoea, dysphagia, and non-specific chest pain in a smoker

BMJ

2008; 337 doi: 10.1136/bmj.a2678 (Published 29 December 2008)

Cite this as: BMJ 2008;337:a2678

Case history

A 59 year old man with a history of heavy smoking presented to casualty with two days of acutely worsening shortness of breath on a background of progressive breathlessness over three months. He had noticed his voice becoming hoarse and a lump appearing above his left clavicle, with worsening dysphagia and non-specific chest pain. On examination he had no fever, blood pressure 97/64 mm Hg, and regular heart rate of 105 bpm, with oxygen saturation of 92% on air. He had clubbing with generalised facial and neck swelling, with suffused conjunctivae and a jugular venous pressure to the jaw raised to 15 cm. Bilateral supraclavicular lymphadenopathy was noted. His heart sounds were muffled and, apart from a hyperexpanded chest, his lungs were clear to auscultation. Abdominal examination showed no organomegaly. A 12 lead electrocardiogram showed sinus tachycardia with low voltage complexes, and a chest radiograph showed a widened mediastinum with an enlarged globular cardiac silhouette.

Questions

1 What is the differential diagnosis?
2 What investigation is most urgent?
3 What is the most likely underlying cause for this man’s presentation?

Answers

Short answers

1 Pericardial effusion or tamponade; obstruction of the superior vena cava
2 Echocardiograpy
3 Primary lung malignancy

Long answer

Outcome

Urgent echocardiography showed a large pericardial effusion causing haemodynamic compromise, shown by diastolic collapse of the right ventricle in diastole and greater variation in speed of blood flow across the mitral valve with respiration. On pericardiocentesis, 1 litre of blood stained fluid was aspirated and a percutaneous catheter drain inserted; symptoms improved somewhat but the jugular venous pressure remained high.

Analysis of the pericardial fluid showed an exudative effusion. No malignant cells were seen.

Computed tomography showed extensive bilateral lymphadenopathy extending retrosternally into the superior mediastinum, causing superior vena cava obstruction, with right basal lung field opacity consistent with primary lung carcinoma. The patient …