Difficulty Breathing

Authors:
William K. Mallon, MD, FACEP
Moustafa H. Moustafa,MD, MS

Affiliations:
Associate Director of Residency Training
Assistant Professor of Medicine
University of Southern California
School of Medicine (WKM)

PGY III, Department of Emergency Medicine
Los Angeles County and
University of Southern California Medical Center (MHM)

Chief Complaint:

Difficulty breathing

History of present illness:

A 27 year old male presents to the emergency department with increasing shortness of breath and a dry cough. His difficulty breathing increases when he lays flat, and recently he has been unable to sleep fully recumbent. He was seen 2 weeks previously with similar symptoms at an outside clinic. The patient was diagnosed with the "flu" and was started on amoxicillin and albuterol by metered dose inhaler. There was no improvement of his symptoms with this therapy. He also describes some recent voice changes with intermittent hoarseness. The patient is no longer able to work as a waiter because of the shortness of breath. A 20 pound weight loss is noted over the past 6 months. There is no history of fever or night sweats. He has a 13 pack year smoking history but denies intravenous drug use and homosexual activity. The patient takes no medications and has no allergies. An inguinal hernia repair occurred at age 14 years.

Physical Examination:

The patient is an alert, ambulatory male, cooperative with a mildly hoarse voice. Vital signs are pulse: 90 beats/minute, blood pressure: 132/50 torr, respirations: 18 breaths/minute, temperature: 37.3 C (oral), and pulse-oximetry 97% on room air.

The HEENT examination is normal. Inspection of the neck reveals dilated, vertically oriented superficial veins (figure 1) which extend to the anterior upper chest wall. Palpation of the neck reveals bilateral lower anterior cervical adenopathy and supraclavicular adenopathy. The cardiac examination is normal. Auscultation of the lungs reveals a prolonged expiratory phase, mild expiratory wheezing, and apical rhonchi. Inspection of the abdomen reveals a fine lattice of small veins of the right costal margin. The rest of the examination is normal.

Laboratory Analysis:

Complete blood count: white blood cells, 9.7 x 109/L;
hematocrit, 37.7%; hemoglobin, 13.2 g/dL;
platelet count, 320 x 109/L.
Chemistry: sodium, 141 mmol/L; potassium, 4.4 mmol/L; chloride, 104 mmol/L;
C02, 22 mmol/L; BUN, 2.9 mmol/L (8mg/dL); creatinine, 80 umol/L (0.9 mg/dL).

Emergency Department Course:

The chest radiograph reveals a large anterior mediastinal mass extending into the neck and involving the thoracic outlet (Figures 2 and 3). A contrasted CT scan of the chest was obtained and is shown in Figure 4. Note that the lesion extends anteriorly to the sternum and to the trachea posteriorly where mild compressive changes can be seen. Decadron 10mg IVP was given to decrease any edema associated with the lesion. Emergent consultation with hematology - oncology and radiation oncology were obtained.

The patient course, diagnosis and discussion

Prior Presentations:
This series of photographs was presented at the 1995 SAEM Annual Meeting
Clinical Photography Competition and was the first place winner of the clinical category.

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