A 42-year-old Caucasian woman comes to the emergency department because of right-sided neck pain, persistent cough, and dyspnea for the past three days. Her past medical problems include hypertension and obesity. She takes enalapril and hydrochlorothiazide. She has smoked one pack of cigarettes daily for the past 25 years. She does not drink alcohol. She works as an executive secretary. Her temperature is 37.8C (100 F), blood pressure is 130/80 mm Hg, pulse is 92/min and respirations are 18/min. Examination shows decreased breath sounds in the upper part of the right lung. There is moderate swelling and erythema of the neck, moderate right jugular vein dilatation, and increased venous marks in the right arm. Her serum creatinine level is 0.8 mg/dL. A chest x-ray reveals a right-sided opacity. Which of the following is the most appropriate immediate step in the management of this patient?

Question

A 42-year-old Caucasian woman comes to the emergency department because of right-sided neck pain, persistent cough, and dyspnea for the past three days.  Her past medical problems include hypertension and obesity.  She takes enalapril and hydrochlorothiazide.  She has smoked one pack of cigarettes daily for the past 25 years.  She does not drink alcohol.  She works as an executive secretary.  Her temperature is 37.8C (100 F), blood pressure is 130/80 mm Hg, pulse is 92/min and respirations are 18/min.  Examination shows decreased breath sounds in the upper part of the right lung.  There is moderate swelling and erythema of the neck, moderate right jugular vein dilatation, and increased venous marks in the right arm.  Her serum creatinine level is 0.8 mg/dL.  A chest x-ray reveals a right-sided opacity.  Which of the following is the most appropriate immediate step in the management of this patient?

Quizplus · Accepted Answer

Explanation: The patient's history, physical findings, and radiologic findings suggest superior vena cava syndrome (SVCS) secondary to a lung malignancy. At least 80% of the cases of SVCS are due to bronchogenic carcinoma. The classic presentation of SVCS begins with dyspnea, persistent cough, facial fullness and neck pain, and progresses into hoarseness, dysphagia, chest pain and syncope. Pertinent physical findings are edema and erythema of the neck (which may sometimes compromise the face), and dilated veins of the arms and neck. Advanced disease is manifested by cyanosis, collateral veins in the thorax, ocular proptosis and lingual edema. The best diagnostic test for SVCS is a contrast CT scan of the chest and neck, which will reveal an obstruction of the superior vena cava due to the pulmonary mass, the metastatic nodes, or an intravenous thrombus. CT scan is very useful because it can reveal the extent of obstruction and provide a histopathologic diagnosis (via percutaneous biopsy), which will determine the particular therapeutic regimen required to manage the underlying malignancy. (Choice E) Magnetic resonance imaging (MRI) is a more expensive procedure, and does not offer any visual advantage over computed tomography. It is only used when a patient is allergic to the contrast dye used in CT scan, or when venous access cannot be obtained for contrast-enhanced studies. (Choice C) Immediate endotracheal intubation may be performed if there exists a risk of sudden airway occlusion, such as in patients with mediastinitis and deep neck infection; however, this patient does not have a history of esophageal disease, upper respiratory tract infection, fever, or chills, to make us suspect mediastinitis. (Choice A) The erythema of the patient is due to venous occlusion and possible thrombosis, not to facial or neck cellulitis. Antibiotic therapy may be subsequently needed if the patient is found to have an infection; however, it is not necessary at this point. (Choice D) Biochemical and hematological tests may be obtained after CT scan evaluation. Educational objective: Superior vena cava syndrome must be suspected in any patient who has a high risk of malignancy (e.g., family history or smokers) and presents with dyspnea, orthopnea, neck pain and swelling, and has cervical and upper extremities venous dilatation. The best diagnostic test to perform is computerized tomography of the neck and chest.

A 42-Year-Old Caucasian Woman Comes to the Emergency Department Because