Education And Debate

Grand Rounds—Nottingham City Hospital: A rare cause of superior vena cava obstruction

BMJ 1996; 313 doi: (Published 23 November 1996) Cite this as: BMJ 1996;313:1324

A rare problem presenting in an unusual way

Since the first description of the superior vena cava syndrome in 1757 the causes of the syndrome have shifted dramatically. Granulomatous and infective causes, such as syphilitic aortic aneurysm and tuberculosis, have been replaced by malignant tumours, which now account for over 80% of cases. Lung cancer, followed by lymphoma, is the most frequently associated tumour, with the syndrome resulting from external compression of the superior vena cava.1 We discuss the investigations performed over three days to establish a diagnosis in a 64 year old man with the classic superior vena cava syndrome.

Case history

A 64 year old white man was referred to our hospital from his general practitioner with a five day history of frontal headache, facial swelling, dizzy spells, and collapse without loss of consciousness. He had a complicated medical history dating back to 1973, when he had the first of 15 acute admissions with severe, left sided, pleuritic-type chest pain associated with shortness of breath. On most admissions chest radiograph, electrocardiogram, and arterial blood gas pressures were normal, but during his second admission a repeat lung perfusion scan showed bilateral filling defects compatible with the clinical diagnosis of pulmonary emboli, and treatment with warfarin was started. The patient continued taking warfarin until 1980, but during these six years he continued to have episodes of severe chest pain and was frequently admitted to hospital. In 1980 during an episode of pain a pulmonary angiogram failed to show any evidence of emboli; anticoagulation was therefore stopped and the patient not seen again until the present admission.

On admission he looked unwell. His face and neck were noticeably swollen with facial plethora. There were prominent tortuous veins over the upper trunk and appreciably distended, but compressible, external jugular veins. There …

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