CRA20 IS IT JUST TUBERCULOSIS? A CASE REPORT OF SUPERIOR VENA CAVA OBSTRUCTION SECONDARY TO SMALL CELL CARCINOMA WITH CONCURRENT TUBERCULOSIS INFECTION

Boon Tung Low¹, Samuel Desmond¹, Siew Teck Tie²
1. Internal Medicine Department, Hospital Miri, Miri, Sarawak, Malaysia
2. Divisions of Respiratory Medicine, Department of Medicine, Sarawak General Hospital. Kuching, Sarawak, Malaysia

This is a case of 47 years old gentleman who is an active smoker complained of cough for 3 months associated with loss of appetite and weight. His chest X-ray revealed right upper lung opacity which was later proven to be enlarged mediastinal lymphadenopathy with superior vena cava obstruction (SVCO) based on the computed tomography. He was started on anti-tuberculous based on his sputum GeneXpert which was positive for Mycobacterium tuberculosis and he had history of tuberculosis contact before. The biopsy of the mass was done which later revealed granulomatous inflammation. His sputum mycobacterial culture later grew pansensitive Mycobacterium tuberculosis. Despite 2 months of intensive phase with anti-tuberculous, he did not showed a significant clinical improvement as he develop pericardial effusion and unilateral exudative pleural effusion despite been compliant to his medication. A repeated CT scan done showed there is worsening SVCO.  Due to the fact that he did not respond well with anti-tuberculous treatment, another biopsy was conducted which later proven to be metastatic small cell carcinoma. Patient was started on chemotherapy but he was later succumbed to death. Superior vena cava obstruction  is commonly due to malignant cause (70%) such as lung malignancy, lymphoma and others. Benign causes (30%) include device related SVCO, radiation fibrosis and infection such as syphilis or tuberculosis. SVCO management is based on its aetiology hence correct diagnosis is of utmost importance.  SVCO due to tubercular mediastinal lymphadenitis usually respond well to treatment thus lack of clinical improvement should prompt clinician to suspect possibility of malignancy as it is still remained the most common cause of SVCO.