New onset facial swelling

A 64 year old woman presented to her general practitioner with a one week history of cough with green sputum. These symptoms were preceded by a two month history of worsening shortness of breath and swelling of her face, arms, neck, and breasts. Her family reported her face becoming “purple . . . like she’s going to burst.” Her medical history included hypertension and an episode of pneumonia four years earlier, and she had a smoking history of 40 pack years.

She was referred to the medical assessment unit. On examination, she had oedema and plethora of her face, arms, and upper chest, but no jugular venous distension or collateral vessels. There was no jaundice, anaemia, clubbing, cyanosis, or lymphadenopathy. Observations were unremarkable. Her airway was patent and the trachea central, with a respiratory rate of 17 breaths per minute (range 12-20 breaths per minute) and saturations of 98% on air. There was decreased air entry and dullness to percussion throughout the whole right lung. Cardiovascular examination was normal. Bloods on admission were white cell count 13.7×10⁹/L (4.0-11.0x10⁹/L), haemoglobin 112 g/L (115-165g/L), C reactive protein 139 mg/L(0-10mg/L). Urea and electrolytes, liver function tests, and bone profile were normal. Chest radiography showed a large pleural effusion on the right. Urgent computed tomography (CT) with contrast showed a large mass lesion involving the mediastinum, which was completely compressing the diameter of the superior vena cava to a slit (fig 1⇓). …