A 56-year-old man comes to the clinic due to recent-onset headache and dyspnea. The patient says he has had a puffy face for 2 weeks along with a persistent dry cough. He does not have any neck or shoulder pain. He has no other medical problems. Physical examination shows symmetrical facial swelling and conjunctival edema. The pupils are equal, round, and reactive to light. Dilated veins are noted over his neck and upper trunk. Heart and lung sounds are normal. Peripheral strength and sensation are intact. Which of the following is the most likely cause of this patient's condition?

Question

A 56-year-old man comes to the clinic due to recent-onset headache and dyspnea.  The patient says he has had a puffy face for 2 weeks along with a persistent dry cough.  He does not have any neck or shoulder pain.  He has no other medical problems.  Physical examination shows symmetrical facial swelling and conjunctival edema.  The pupils are equal, round, and reactive to light.  Dilated veins are noted over his neck and upper trunk.  Heart and lung sounds are normal.  Peripheral strength and sensation are intact.  Which of the following is the most likely cause of this patient's condition?

Quizplus · Accepted Answer

11ec160b_3b50_91d0_9249_c554dd0d9835_MD0001_00 This patient's symptoms are consistent with superior vena cava (SVC) syndrome, a condition that develops when SVC obstruction impairs venous return from the head, neck, upper trunk, and upper extremities. The SVC is formed by the union of the right and left brachiocephalic veins behind the right first costal cartilage and descends inferiorly for 6-8 cm before draining directly into the right atrium. During its course, the SVC is surrounded by multiple mediastinal structures (eg, trachea, right bronchus, aorta, right pulmonary artery) and is close to the perihilar and paratracheal lymph nodes. Due to its thin walls, the SVC can be easily compressed by mediastinal masses (most commonly malignancy) that either extend into the mediastinum from the central lung (eg, bronchogenic carcinoma) or nearby lymph nodes (eg, lymphoma) or arise from other mediastinal structures. Patients with SVC syndrome often experience the following symptoms due to increased venous pressure in the upper body: Face and neck swelling and conjunctival edema Distended veins due to increased collateral venous drainage Headache, dizziness, and/or confusion due to cerebral edema and elevated intracranial pressure Cough and/or dyspnea due to laryngeal edema and/or direct compression of adjacent structures (eg, trachea) by the mediastinal mass (Choices A and B) Airway obstruction and autoimmune disease can cause dyspnea, but facial swelling and dilated collateral veins would not be expected. (Choice C) Inappropriate secretion of ACTH by some small cell lung cancers can cause Cushing syndrome, which is often associated with a swollen or moon face due to increased fatty tissue deposits. However, Cushing syndrome is not associated with conjunctival edema or distended neck veins. (Choice E) Pericardial effusions can cause dyspnea and distended neck veins; however, facial swelling and headaches would not be expected. In addition, distant heart sounds or pulsus paradoxus (decrease in systolic blood pressure >10 mm Hg during inspiration) is often present. (Choice F) Patients with pleural effusions often have dyspnea but do not typically have facial swelling or dilated veins. In addition, decreased breath sounds and dullness to percussion are often present. (Choice G) Superior pulmonary sulcus tumors (Pancoast tumors) arise at the lung apex and can also cause SVC syndrome. However, shoulder pain is typically present due to tumor invasion into the brachial plexus or nearby chest wall. Horner syndrome (ptosis, miosis, and anhidrosis) also is common due to cervical sympathetic ganglia involvement. Neurologic deficits (eg, hand weakness) also can occur. This patient's lack of shoulder pain, Horner syndrome (his pupils are normal), and neurologic deficits (peripheral strength is normal) makes a superior sulcus tumor unlikely. Educational objective: Extrinsic compression of the superior vena cava by a mediastinal mass (eg, malignancy) can cause superior vena cava syndrome, with impaired venous return from the upper body. Signs and symptoms include facial swelling, distended collateral veins, headache, and dyspnea. __________ References: Superior vena cava syndrome: a medical emergency? (http://www.ncbi.nlm.nih.gov/pubmed/22477372) Review of evolving etiologies, implications and treatment strategies for the superior vena cava syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/27026923)

A 56-Year-Old Man Comes to the Clinic Due to Recent-Onset