Is it cancer? Another case study

As I wrote in my previous post, sometimes other diseases may masquerade as cancer. Tay CW et al. reports another such case published in the International Journal of Surgery Case Reports.

They reported a case of a 33 year old female patient who presented with difficulty in swallowing, technically termed as dysphagia. There were no other symptoms. She was a non-smoker and there were no significant previous medical conditions. Chest X-ray and routine blood examination was normal. Physical examination did not reveal much.

Now the differential diagnosis of dysphagia is pretty long, involving the mouth, pharynx and the esophagus. Whether the symptom of dysphagia is progressive or not have to be considered. Progressive dysphagia suggests a malignant lesion. The type of  food which is difficult to swallow is also significant. Dysphagia which was initially to solids and gradually progresses to liquids indicates a malignant lesion. Dysphagia to liquids from the onset indicates a motility disorder of the esophagus. Dysphagia particularly aggravated on eating acidic food indicates an ulcerative lesion of the esophagus. In this case, the dysphagia was progressive for two weeks.

During the course of further investigation an upper gastrointestinal endoscopy was done. Upper gastrointestinal endoscopy is done to directly visualize the esophagus to look for any abnormal mass, ulceration or stricture that may cause dysphagia. A large submucosal esophageal mass was found, 25 cm from the incisor teeth. In the esophagus, any position is denoted by its length from the incisor teeth. The end of the esophagus is at about 40 cm from the incisor teeth. The mass was soft and covered by normal esophageal mucosa. Subsequently, a CT scan was done which showed a mid-esophageal mass, 4X2 cm in size. It was suggested to be an esophageal carcinoma and the patient was advised to undergo surgery.

Smoking and alcohol consumption are high risk factors for the development of esophageal carcinoma. They were absent in the patient. Dysphagia was the only complaint of the woman without any associated symptoms of cough, weight loss, fever, and hemetemesis (vomiting of blood). Squamous cell carcinoma is the commonest type esophageal carcinoma; adenocarcinoma is the second commonest. Other types are rare.

Sub carinal space. Modified screenshot from Google body browser.

At this stage the patient was referred to the authors for a second opinion. They arranged for an endoscopic ultrasound (EUS) and surprise! EUS detected a heterogeneous mass, 46 mm X 23 mm in size in the subcarinal window (subcarinal space is the space in front of the esophagus below the bifurcation of the trachea which is called the carina). It was suggested to be a lymph node which has enlarged and compressed the esophagus, causing the symptom of dysphagia. Fine needle aspiration was done endoscopically and cytological examination of the aspirate revealed an epithelioid granuloma, typically seen in tuberculosis. Molecular analysis of the aspirate was positive for Mycobacterium tuberculosis.

This finding changed the picture radically. Instead of surgery, the patient underwent medical treatment for tuberculosis with antitubercular drugs. EUS was the pivotal diagnostic study.

What is intriguing is that the lungs of the patient were completely clear. I would have thought of the presence of a primary lung lesion. In fact I double checked the article to see if I had missed it. The chest X-ray and CT scan of the lungs were clear. No esophageal lesions were present either. It appears to be a case of primary  mediastinal lymph node tuberculosis. At least it is better than esophageal cancer considering the poor prognosis of esophageal cancer.

Happy new year!

Tay, C., Deans, D., Khor, J., Seet, J., & So, B. (2010). Suspected oesophageal cancer in a 33 year old lady International Journal of Surgery Case Reports DOI: 10.1016/j.ijscr.2010.10.002

Is it cancer or is it not? A case study

A diagnosis of cancer carries a lot of significance for the patient who receives the diagnosis. But is it always cancer? Can it be another disease masquerading as cancer? It is rare, but it can happen as a case report by Smulders YE et al. published in the Journal of Medical Case Reports demonstrates.

They report a case of a 50 year old Caucasian male referred to their clinic. He had complaints of dysphonia (difficulty in speaking), dysphagia (difficulty in swallowing), and odynophagia (pain while swallowing). He also had a complaint of pain going to his right ear. All these had been going on for two months. The patient also suffered from recurrent aspiration of liquids and had lost 3 kg of body weight.

The larynx. From Wikipedia.

The authors visualized his larynx (voice box) with a laryngoscope. There was an ulcer on the right false vocal cord (present above the true vocal cords, also called ventricular fold or vestibular fold) which extended to the epiglottis (a cartilage of the larynx). The right true vocal cord was edematous and mobility of the vocal cord was decreased. Contrast enhanced CT scan of the neck showed an enhanced mass present in the right false cord which had extended in to the anterior commissure (front end of the vocal cords) and upwards in to the piriform sinus.

(A) Initial antero-posterior chest X-ray. Miliary nodules predominantly bilaterally distributed in the upper parts of the lung parenchyma. (B) Axial contrast-enhanced computed tomography image of the neck: enhanced mass (arrows) in the false vocal cord which extends into the anterior commissure and obliteration of the paraglottic fat (arrowhead). (C) Axial high resolution computed tomography image of the chest: diffusely distributed interstitial nodular alterations with formation of central cavities (arrows).
Smulders et al. Journal of Medical Case Reports 2009 3:9288 doi:10.1186/1752-1947-3-9288

Direct laryngoscopy under general anesthesia showed a tumor covering the entire right false vocal cord with extension to the laryngeal surface of the epiglottis without involvement of the glottis (true vocal cord). A routine chest X-ray showed mainly bilaterally distributed miliary nodules in the upper part of the lung parenchyma. Full blood count and electrolytes were within normal limits. No lymph nodes were involved in the neck. The clinical diagnosis was T3N0 supraglottic laryngeal carcinoma. 

Let us stop here and take a look at the rationale behind the diagnosis. The man was 50 years old. Laryngeal carcinoma commonly occurs in this age group. He was a smoker for 40 years. Smoking is a known risk factor for laryngeal carcinoma. All the symptoms fit laryngeal carcinoma. Imaging and endoscopic visualization showed a tumor like mass in the larynx. T3 means the tumor is limited to the larynx with vocal cord fixation and/or invasion of the following – postcricoid area (area behind the cricoid cartilage), pre-epiglottic tissues, paraglottic space and/or minor cartilage invasion. N0 means no lymph nodes were involved by the carcinoma.

Is there any reason to doubt the diagnosis? The only thing is that the chest X-ray does not fit in the picture. The finding of the chest X-ray is more consistent with tuberculosis. But I can say this only because I have the advantage of hindsight; I already know what the diagnosis is. Moreover there are other conditions that may be consistent with the X-ray finding.

The authors then did a histopathological examination of the tumor mass. This is the diagnostic test and it sprang forth a surprise. They did not find any malignancy in the mass. Instead they found tuberculosis. This was a case of tuberculosis of the larynx in the guise of a laryngeal malignancy. They also found tubercle bacilli in the sputum of the patient meaning it was quite possible for the patient to infect others. A CT scan of the chest of the patient showed cavity formation in the lungs, indicating pulmonary tuberculosis. Two nurses, two of the patient’s relatives and two of his friends tested positive in skin with purified protein derivative (PPD). The patient was treated with antituberculous drugs and the contacts were treated prophylactically with tuberculostatics.

This case demonstrates that you can never be too sure in medicine. The features of laryngeal cancer and laryngeal tuberculosis are overlapping and there needs to be an index of suspicion to differentiate the two. Tuberculosis can cause all the symptoms of laryngeal carcinoma, from weight loss to tumor like mass. Here there was a clue in the chest X-ray finding but without a degree of suspicion, TB is not the first thing that would come to your mind. In this case, the laryngeal tuberculosis was probably secondary to the pulmonary tuberculosis with the larynx becoming infected from the coughed up tubercle bacilli. I would have been interested to know if the patient had been suffering from chronic cough, which I strongly suspect as his contacts came out to be positive in the PPD test. Erythrocyte sedimentation rate would also have given a clue as it would have been elevated in TB.

Merry Christmas!

Reference :

Smulders, Y., De Bondt, B., Lacko, M., Hodge, J., & Kross, K. (2009). Laryngeal tuberculosis presenting as a supraglottic carcinoma: a case report and review of the literature Journal of Medical Case Reports, 3 (1) DOI: 10.1186/1752-1947-3-9288

Tuberculosis of the Parotid gland

Recently I came across a case report on tuberculosis of the parotid gland by Garg et al. published in Lung India. Although rare, parotid tuberculosis should be considered in the differential diagnosis of parotid swelling that is slowly progressive. The diagnosis of parotid tuberculosis requires a high degree of clinical suspicion to avoid unnecessary surgery.

Parotid tuberculosis: Features

Parotid gland is the largest salivary gland in the body, draining in the oral cavity via Stenson’s duct opposite the upper second molar tooth. The swelling in case of parotid tuberculosis is a slowly progressive one, toothache and trismus may also be present.

Discharging sinuses may also be present over the swelling in case of parotid tuberculosis. There may be associated enlargement of the lymph nodes of the neck. Facial nerve involvement should also be noted. Fever may also be present. History of tuberculosis should also be worked out.

Infection of the parotid gland by M. tuberculosis causing parotid tuberculosis may occur directly through the oral cavity or it may be a blood borne infection from distant foci or via the lymphatics from the oral cavity.

Investigations

Hemoglobin levels may be decreased. This may be due to the chronic infection or it may be due to malnutrition. There may be predominance of lymphocytes in the blood.

Imaging: High resolution ultrasonography of the parotid region is the initial investigation of choice. This is important as it provides an index of suspicion. In another case report by Kundu et al. preoperative diagnosis of parotid tuberculosis was not done as this investigation was not performed. The diagnosis as made on subsequent histopathological examination of the excised lesion. Ultrasonographically, parotid tuberculosis can be divided in to parenchymal type and periparotid type.

Chest X-ray should also be done to look for any pulmonary lesions.

Tests for Tuberculosis

• Mantoux test – it is not diagnostic.
• Sputum for presence for acid fast bacilli.
• ELISA for anti tubercular IgM and IgG.
• FNAC with Ziehl-Neelsen staining for acid fast bacilli.
• Histopathological examination.

Treatment

Multidrug therapy for 6 months with 4 drugs (Isoniazid, Rifampicin, Pyrazinamide, Ethambutol) in the intensive phase and 2 drugs (Isoniazid, Rifampicin) in the continuation is the treatment of choice.

The authors also state that 3 (Isoniazid, Rifampicin, Pyrazinamide) drugs in the intensive phase and 2 drugs in the continuation phase may also be adequate as this is a paucibacillary form.

Links

• Parotid Tuberculosis
• Tuberculosis of Parotid gland: A rare clinical entity.