CRA68 THE DUAL ASSAULT: THE MALIGNANCY THAT SPOKE IN FLOODS AND CLOTS
Jason Tan Seng Hong1, Seow Chu Ee1, Julia Hanim Jaafar1,
1Department of Medicine, Hospital Banting, Selangor, Malaysia
Introduction
Malignant pericardial effusion (MPE) and venous thromboembolism (VTE) are ominous complications of advanced lung cancer, often indicating an advanced stage of the disease. Atypical presentations of MPE can delay the diagnosis.
Case Report
A 63-year-old non-smoking woman presented with fever, vomiting, and diarrhea, initially managed as gastroenteritis. An echocardiography unexpectedly revealed a 5 cm pericardial effusion at the apex with features suggestive of cardiac tamponade, requiring urgent pericardiocentesis that drained 1700mL of hemorrhagic pericardial fluid. Four days later, she developed shortness of breath, with CT angiography confirming pulmonary embolism (PE). Further workup identified a 10.1 cm heterogenous solid left lung mass with mediastinal lymphadenopathy, with histopathology confirmed poorly differentiated squamous cell carcinoma (SCC). Despite pericardiocentesis and anticoagulation, she succumbed to sepsis within four months.
Discussion
Concurrent MPE and VTE as the initial manifestation of squamous cell carcinoma (SCC) are exceptionally rare, particularly in non-smokers, and pose significant diagnostic and therapeutic challenges. Most malignant effusions are asymptomatic at initial presentation with only a small proportion present with massive pericardial effusion as their first presentation of a metastatic carcinoma. The presentation of VTE together with the massive pericardial effusion can further complicate the diagnosis, as this dual presentation is rare in the setting of a lung malignancy. Malignant pericardial effusion is an uncommon manisfestation of non-small cell lung carcicoma (NSCLC) as in our case, and is linked to be a pre-terminal event with exceedingly poor prognosis.
Conclusion
This case highlights the diagnostic pitfalls of MPE and VTE as the first signs of occult lung malignancy, especially with non-specific symptoms It underscores the need for heightened suspicion of cancer in unexplained effusions or thromboembolism.