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 Table of Contents 
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 5  |  Page : 2548-2551  

Persistent cough: An unexpected diagnosis


Department of Medicine, Tata Main Hospital, Jamshedpur, Jharkhand, India

Date of Submission08-Jan-2020
Date of Decision12-Mar-2020
Date of Acceptance07-Apr-2020
Date of Web Publication31-May-2020

Correspondence Address:
Dr. Bhagyalakshmi Satyanarayan
Department of Medicine, Tata Main Hospital, Jamshedpur - 831 001, Jharkhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_41_20

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  Abstract 


Esophageal cancer is the eighth most common cancer and the sixth most common cause of cancer death globally. Esophageal squamous cell carcinoma (ESCC) accounts for 70%–90% of esophageal cancers worldwide, 5% are adenocarcinoma, and 5% represent rare malignancies and metastases from other organs. We present a case where a 54-year-old lady, with multiple readmissions for persistent dry cough and respiratory symptoms, turns out to be an esophageal malignancy. CECT thorax revealed an enhancing wall thickening of the esophagus with paraoesophageal fat stranding, mediastinal lymphadenopathy, and subsegmental right lobe atelectasis, suggestive of a probable esophageal malignancy. An upper gastrointestinal endoscopy showed a circumferential esophageal growth which on biopsy and histopathological examination turned out to be a moderately differentiated squamous cell carcinoma of esophagus.

Keywords: Chronic cough, squamous cell carcinoma of esophagus


How to cite this article:
Panda SK, Satyanarayan B, Prasad SK, Koshy B. Persistent cough: An unexpected diagnosis. J Family Med Prim Care 2020;9:2548-51

How to cite this URL:
Panda SK, Satyanarayan B, Prasad SK, Koshy B. Persistent cough: An unexpected diagnosis. J Family Med Prim Care [serial online] 2020 [cited 2020 Sep 19];9:2548-51. Available from: http://www.jfmpc.com/text.asp?2020/9/5/2548/285128




  Introduction Top


Cancer has been the leading cause of death worldwide. The International Agency for Research on Cancer (IARC) issued the worldwide cancer burden for 2018 based on GLOBOCAN.[1] It was estimated that there would be 18.1 million new cases and 9.6 million cancer deaths worldwide.[1] Esophageal cancer (EC) is a common malignancy worldwide. According to the International Agency for Research on Cancer, EC is one of the eight most common malignancies and sixth most deadliest tumors in the world.[2] Studies have shown that lower socioeconomic status (SES) is associated with increased incidence or mortality due to EC.[3] EC is a disease of older age with a peak incidence in sixth to seventh decade.

Histologically, there are two predominant types of primary ECs: squamous cell carcinoma (SCC) and adenocarcinoma.[4] Esophageal squamous cell carcinoma (ESCC) accounts for 70%–90% of ECs worldwide, 5% are adenocarcinomas, and the remaining 5% represent rare malignancies and metastases from other organs.[5] Over the past few decades, the rates of ESCC have declined and that of esophageal adenocarcinoma (EAC) has increased in the Western world. The decrease in ESCC is probably due to the decrease in alcohol and tobacco abuse, while the increase in EAC is linked to the increase in obesity and GERD.[4] They commonly present with gastrointestinal (GI) symptoms, that is, dysphagia, odynophagia, and weight loss. Because there is effective medication available over-the-counter to relieve gastroesophageal reflux symptoms, most individuals will not seek medical advice.[6] EC has a very poor 5-year survival rate of 5.0%–26.2%.[7] EAC arises from the distal third of the esophagus, while ESCC arises from the proximal two-thirds of the esophagus.[6],[7]


  Case Report Top


A 54-year-old female patient presented with dry cough and generalized weakness for 20 days, throat discomfort, and breathlessness for 2–3 days, after being referred from a local hospital.

In the preceding 6 months, she was admitted thrice with complaints of persistent dry cough and discharged each time with a diagnosis of acute exacerbation of bronchial asthma. There was no history suggestive of GERD, esophagitis, or aspiration pneumonia. She gave no history of fever, chills, or night sweats. She is a homemaker with no h/o smoking or tobacco addiction. She also never complained of chest pain, heart burn, dysphagia, odynophagia, nausea, vomiting, or weight loss.

On general examination, her vitals were stable. Systemic examination also did not reveal any abnormality except for scattered bilateral expiratory rhonchi.

ENT examination revealed only the posterior pharyngeal wall congestion. Her hemoglobin was 8.9 g%, total leukocyte count (TLC) 14,200/mm3, N73 L13 E05 B01, platelet count 223,000/mm3, RBS 94 mg%, S. creatinine 0.87 mg%, S. bilirubin 0.83 mg%, ALT 10.8, AST 15.3, alkaline phosphatase 86.9 unit/L, S. protein 6.4 g%, and S. albumin 3.4 g%. Urine routine examination was normal.

Chest X-ray showed clear lung fields [Figure 1], and ECG showed sinus rhythm with no ST-T changes.
Figure 1: Initial chest X-ray: normal

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Throat swab culture sensitivity reported non-pathogenic, normal upper respiratory tract flora. Sputum for AFB was negative. She was treated with antibiotics, antihistaminics, bronchodilators, and steam inhalation, and discharged after 5 days with advice for follow-up.

She got readmitted the very same evening with paroxysmal cough and shortness of breath. She was conscious, oriented, and afebrile. Her pulse was 132/min and the blood pressure was 160/100 mmHg. She was dyspnoeic and having a respiratory rate of 28/min with SpO2 of 94% on room air. On systemic examination, she had tachycardia with bilateral crepitations and diffuse rhonchi.

Blood reports showed hemoglobin 10.2 g/dL, TLC 15,900/mm3, and N87% L10% M3%. The chest X-ray repeated next morning revealed right paratracheal soft tissue opacity with clear lung fields [Figure 2].
Figure 2: Readmission chest X-ray:Rt. paratracheal soft tissue opacity

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A CECT thorax [Figure 3] was planned because of her persistent cough, absence of any significant findings on general systemic or ENT examination, and the new finding of a right paratracheal opacity. CECT thorax revealed an enhancing wall thickening of the esophagus with paraoesophageal fat stranding, mediastinal lymphadenopathy, and subsegmental right lobe atelectasis suggestive of a probable esophageal malignancy.
Figure 3: CECT thorax: enhancing wall thickening of esophagus

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Upper GI endoscopy [Figure 4] showed a normal oropharynx, an irregular, friable, circumferential growth in the esophagus from 16 to 26 cm, and the GE junction at 35 cm distance from incisor teeth. Stomach and duodenum were normal. Histopathological examination revealed a moderately differentiated SCC of the esophagus [Figure 5]. CECT abdomen and bronchoscopy was normal.
Figure 4: UGIE showing irregular, friable, circumferential growth in the esophagus

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Figure 5: Moderately differentiated squamous cell carcinoma of the esophagus

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In view of inoperability, she was referred to medical oncology with T3N1M0, Grade 2 SCC at lower one-third of esophagus and received concomitant radiation and chemotherapy.

She completed her radiotherapy and chemotherapy and is on regular follow-up in oncology.


  Discussion Top


This case is unique as she presented with a chronic cough. First, the patient had respiratory symptoms rather than the most common gastroenterological symptoms. EC can present with respiratory symptoms of cough and lung infection due to the presence of an acquired tracheoesophageal fistula (TEF), which our patient did not have. EC can present with acute respiratory symptoms rather than chronic, without a history of respiratory disease or acquired TEF.[5]

Yacoubaet al. showed that of 22 reported cases of ECs with unusual presentations, 6 cases presented with osteolytic lesions, 3 cases presented with cutaneous nodules, 2 cases with dyspnea, 2 cases with upper abdominal pain, and 1 case each with gluteal mass,[8] adrenal mass, thyroid mass,[9] headache with SOL, solitary jejunal mass, painful breast lump, hip pain, cervical pain, and chronic cough.[5] Of these 22 cases, 19 were metastatic ECs and only 3 cases were nonmetastatic cancer like our case.[5] Of the total 22 cases reported, only 5 cases had typical symptoms and the remaining 17 cases had atypical presenting symptoms.[5]

Endoscopy with biopsy is the diagnostic test of choice for EC. Staging of EC should first be done with computed tomography (CT) and positron emission tomography (PET)/CT.[10] If the patient is a surgical candidate, endoscopic ultrasonography (EUS) should be used to determine the regional extent of disease.[10]

Declaration Consent of patient was taken and Ethics comittee approval has been obtained. (23/12/2019)


  Conclusion Top


This case of a 54-year-old female patient with EC presenting with none of the classical symptoms but with atypical and unusual presentation of chronic cough and breathlessness was an enriching learning experience. In primary care settings, for all patients presenting with chronic cough, keeping EC as differential diagnosis, clinician should advise CECT thorax and upper GI endoscopy. The prognosis of EC is poor because of its concealed and invasive nature. Identifying it early can effectively reduce the mortality associated with EC.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Feng RM, Zong YN, Cao SM, Xu RH. Current cancer situation in China: Good or bad news from the 2018 global cancer statistics? Cancer Commun 2019;39:22.  Back to cited text no. 1
    
2.
Liu L, Huang C, Liao W, Chen S, Cai S. Smoking behavior and smoking index as prognostic indicators for patients with esophageal squamous cell carcinoma who underwent surgery: A large cohort study in Guangzhou, China. Tob Induc Dis 2020;18:9.  Back to cited text no. 2
    
3.
Kou K, Baade PD, Guo X, Gatton M, Cramb S, Lu Z, et al. Area socioeconomic status is independently associated with esophageal cancer mortality in Shandong, China. Nature.com/Scientific Reports 2019;9:6388.  Back to cited text no. 3
    
4.
Jain S, Dhingra S. Pathology of esophageal cancer and Barrett's esophagus. Ann Cardiothorac Surg 2017;6:99-109.  Back to cited text no. 4
    
5.
Yacouba AT, Frantsb R, Bankc L, Sidhud JS, Nicholsone P. An unusual presentation of esophageal cancer: A case report and review of literature. J Med Cases 2016;7:60-5.  Back to cited text no. 5
    
6.
di Pietro M, Canto MI, Fitzgerald RC. Endoscopic management of early adenocarcinoma and squamous cell carcinoma of the esophagus: Screening, diagnosis, and therapy. Gastroenterology 2018;154:421-36.  Back to cited text no. 6
    
7.
Zhang Y. Epidemiology of esophageal cancer. World J Gastroenterol 2013;19:5598-606.  Back to cited text no. 7
    
8.
Smyth S, O'Donnell ME, Kumar S, Hussain A, Cranley B. Atypical presentation of an oesophageal carcinoma with metastases to the left buttock: A case report. Cases J 2009;2:6691.  Back to cited text no. 8
    
9.
Chen ED, Cheng P, Yan XQ, Ye YL, Chen CZ, Ji XH, et al. Metastasis of distal esophageal carcinoma to the thyroid with presentation simulating primary thyroid carcinoma: A case report and review of the literature. World J Surg Oncol 2014;12:106.  Back to cited text no. 9
    
10.
Aggarwal AN. How appropiate is the gold standard for diagnosis of airway obstruction. Lung India 2008;25:139-41.  Back to cited text no. 10
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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