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Why does this man have dyspnoea and a swollen face?

Dr Mike Wyndham on how he uncovered the cause of this elderly man’s symptoms

 

The patient

This 73-year-old man was well known to us at the practice. He was the longstanding carer of his wife who suffers from multiple sclerosis.

She was now confined to a wheelchair and depended heavily on her husband.

He presented one morning with a complaint of shortness of breath, which was beginning to interfere with his ability to care for her.

People had started to comment that his face looked swollen and he wondered if this was linked to the headaches he was suffering from.

He had always enjoyed good heath and the only thing he was taking was lactulose for occasional constipation. He rarely drank alcohol and had been a 20-a-day smoker before giving up eight years previously.

First instinct

Observation of the chest identified two key physical signs. Firstly, the JVP was elevated and did not pulsate and secondly there were prominent dilated veins on the chest wall, which, on questioning, had appeared in recent weeks. This made the likely diagnosis superior vena cava obstruction (SVCO). The question was what was the underlying cause.

Differential diagnosis

•‘Foreign bodies'

• Lymphoma

• Other malignancy (excluding lymphoma)

In the past, diseases such as tuberculosis or syphilis were a common cause of SVCO. Although these may still be common in some parts of the world, they are uncommon in the UK. Interventional medicine has meant that blood vessel access is required more often – such as dialysis catheters or pacemaker insertion. These may result in SVCO.

In view of this patient's medical history, this was not the problem. Lymphoma is the cause of SVCO in about 15% cases. There were certainly no abnormal glands to be felt and so this made the diagnosis less likely.

The vast majority of cases will be caused by bronchogenic carcinoma but metastatic lymph nodes pressing on the superior vena cava may always be a possibility. The smoking history made lung cancer most likely.

Getting on the right track

A chest X-ray showed a superior mediastinal mass. The biggest clue to the diagnosis came with the result of the renal function, which showed his sodium to be 126. This suggested a possible diagnosis of inappropriate ADH secretion. Small cell lung cancer may be associated with this biochemical change. This diagnosis was confirmed in hospital and treatment commenced.

Dr Mike Wyndham is a GP in Edgware, north London

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