Sore throat turned to be a bronchogenic carcinoma with super
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Superior vena cava (SVC) syndrome is a group of symptoms caused by complete or partial obstruction of the flow of blood through the SVC. The obstruction is, in most cases, caused by the formation of thrombus or infiltration of a tumour through the vessel wall. The result is venous congestion that creates a clinical situation relating to increase in the venous pressure in the upper part of the body. Symptoms commonly associated with vena cava syndrome include cough, dyspnoea, swelling of the neck, face and the upper extremities and dilation of the chest vein collaterals. To understand better we have discussed a case of a 50-year-old man who presented to the emergency department with ‘sore throat’ which can be easily misdiagnosed as a case of uncomplicated acute pharyngitis. It was a real challenge to diagnose this patient as SVC syndrome caused by bronchogenic carcinoma.

On the first presentation to the primary health centre, the patient had a sore throat, a change of voice and a mild cough. He received a course of amoxicillin and the cough improved.

The patient later developed puffiness of the neck and face and shortness of breath, mostly at night. He was admitted to a private clinic where he received another course of antibiotics. However, this treatment did not yield any improvement. He then presented to the emergency department of this facility with the sore throat, a puffy face (figure 1), swelling of the neck and shortness of breath. He denied bleeding and vomiting, fever, neck pain, syncope and seizure. He also denied palpitation, chest pain, dizziness, abdominal pain, diarrhoea and dysuria.

There were enlarged tortuous superficial veins over the chest wall (figure 2). The inferior vena cava was mildly dilated. Chest X-ray showed an enlargement of right hilum with added density within it representing a hilar mass. There is also an ill-defined perihilar opacity noticed on the right side and a widening of the right paratracheal stripe (figure 3).

CT thorax, abdomen and pelvis with contrast showed a large lobulated mediastinal mass, with extension to the right hilum, measuring 8×9×8 cm in anteroposterior (AP), transverse and craniocaudal (CC) dimensions, respectively, showing minimal enhancement (figure 4). The mass lesion was compressing the SVC, causing occlusion of the right main pulmonary artery and partial occlusion of the right upper lobe bronchus.

The right supraclavicular lymph node incisional biopsy was done & the diagnosis of a metastatic small cell carcinoma is confirmed and most likely of lung origin. After the diagnosis of SVC syndrome caused by bronchogenic carcinoma was confirmed, the multidisciplinary treatment plan was explained to the patient. Unfortunately, he travelled home to start the treatment in his country, and he was lost to follow-up.

Learning points:-
1. Sore throat is a common presentation in most emergency departments. The condition can be challenging to diagnose and treat because it is not always easy to get the diagnosis right the first time.

2. The physician should keep a high index of suspicion of other causes of; ‘sore throat’ especially when there are no local signs of pharyngitis like tonsillar–pharyngeal oedema, uvular oedema, patchy tonsillar exudates, cervical lymphadenitis or strawberry tongue.

3. A bronchogenic carcinoma complicated with a superior vena cava (SVC) syndrome can be presented primarily with sore throat. History taking, meticulous physical examination and relevant investigations are the proper way to reach the correct diagnosis.

4. Chest X-ray is the accepted first imaging that can show the hilar mass.

5. CT chest with contrast is the best imaging to illustrate the actual size of the mass and the compression of the SVC.

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