Hematologic abnormalities associated with lung carcinoma.

At the Atlanta Veterans Affairs Medical Center, we saw a 60-year-old white male with an 80-pack-year history of smoking, mild COPD, and stage IV adenocarcinoma of the lung (diagnosed 4 months prior to this presentation). He presented to the emergency room after 2 weeks of worsening dyspnea and cough productive of yellow sputum. His wife also reported that his face and neck had become swollen over the past several weeks. He did not report fevers, chills, or any other complaints. Approximately 3 months before this presentation, he had undergone tracheal stenting for airway compromise caused by the impinging tumor. This was followed by chest radiotherapy (30 Gy in 12 fractions) over 14 days. At that time his white blood cell (WBC) count had decreased from 12.2 K cells/mL at the start of radiotherapy to 5.7 K cells/mL at the end. The hemoglobin and platelet counts were normal at the beginning of radiotherapy and had remained relatively unchanged afterwards. A computed tomogram 14 days after the conclusion of radiotherapy showed a slight reduction in tumor burden, but further imaging studies over the next 2 months showed rapid progression. One month before this presentation he was started on palliative chemotherapy with gemcitabine and carboplatin. The plan was to continue palliative chemotherapy and consider future radiotherapy in another 3 months’ time if he responded favorably to the former. On physical examination, he was afebrile (maximum temperature 37.4°C), normotensive (122/72 mm Hg), mildly dyspneic, and had a respiratory rate of 22 breaths/ min. He also had mild swelling and erythema of the face and neck, and blanching telangiectasias on the upper chest and back. Chest radiograph revealed a new right-upperlobe infiltrate and a possible associated cavitary lesion (Fig. 1). Computed tomogram confirmed the new cavitary lesion, which had a thick-walled border, thought to represent fibrosis and air-space consolidation secondary to radiation, rather than tumor progression. A persistent middle mediastinal and right-hilar mass and substantial narrowing of the superior vena cava were also visualized (Fig. 2). The tracheal stent was in place, and there was very mild tracheal narrowing distal to the stent (Fig. 3). Three weeks prior to the current presentation, his WBC count had been 4,000 K cells/mL, platelet count 258 K cells/ mL, hemoglobin 8.8 g/dL, and mean corpuscular volume 88.7 fL. At current presentation his WBC count was 39,500 K cells/mL (73% segmented neutrophils, 6% lymphocytes, 12% monocytes), platelets 942 K cells/mL, hemoglobin 7.5 g/dL, and mean corpuscular volume 87.8 fL. The chemistry panel was within normal limits, and culture results (both sputum and blood) remained negative. A venogram demonstrated a non-occlusive thrombus in the superior vena cava, and substantial tumor impingement on the vein. He underwent thrombectomy followed by angioplasty of the superior vena cava. He started another round of chest radiotherapy (30 Gy over 12 fractions) and his palliative chemotherapy was discontinued. Subsequent to admission, he also received an 8-day course of vancomycin, piperacillin-tazobactam, and levofloxacin for empirical treatment of healthcare-associated pneumonia (since his last hospital discharge had occurred less than 90 days prior to the current presentation). However, the first 6 days of this treatment failed to bring any substantial symptom improvement or an appreciable change Majid Shafiq MD and Saiprakash Venkateshiah MD are affiliated with the Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia. Saiprakash Venkateshiah MD is also affiliated with the Veterans Affairs Medical Center, Decatur, Georgia.