Intended for healthcare professionals

Endgames Picture Quiz

A collapse with hypertension and hypokalaemia

BMJ 2014; 349 doi: (Published 04 November 2014) Cite this as: BMJ 2014;349:g6582
  1. Hannah Pintilie, core medical trainee12,
  2. William Petchey, specialty registrar in nephrology and general medicine1,
  3. Ketan Dhatariya, consultant in diabetes and endocrinology and general medicine2,
  4. Mahzuz Karim, consultant in nephrology and general medicine1
  1. 1Department of Renal Medicine, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
  2. 2Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospital, Norwich, UK
  1. Correspondence to: M Karim mkarim{at}

A 60 year old white man was admitted from the emergency department after an unwitnessed collapse and generalised weakness and malaise. He had no medical history of note and was taking no drugs. On clinical assessment he had hypertension, which had not previously been documented, with a blood pressure of 187/91 mm Hg. Blood tests showed severe hypokalaemia (2.1 mmol/L (reference range 3.6-5.0), having been normal (4.7) nine months earlier) and metabolic alkalosis (bicarbonate 38 mmol/L, 22-30). Random blood glucose was 6.0 mmol/L (3.5-7.8).

On the post take ward round, he was noted to have clubbing of the nails and a tanned appearance. A 60 pack year smoking history was elicited. Further biochemical tests were requested and, because his chest radiograph was abnormal, chest computed tomography was performed (fig 1).


  • 1. What does this axial computed tomogram through the chest show?

  • 2. What is the unifying diagnosis?

  • 3. What is the underlying pathophysiology?

  • 4. What tests would you use to confirm the diagnosis?

  • 5. How would you manage this condition?


1. What does this axial computed tomogram through the chest show?

Short answer

A large mass in the right hilar and posterior lower lobe with confluent hilar lymphadenopathy.

Long answer

A large soft tissue mass is seen in the right hilum and posterior lower lobe with confluent hilar lymphadenopathy (fig 2). It encases the segmental bronchi of the …

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