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Case presentation
A man in his 30s presented to the emergency department with a 3-month history of progressively worsening cough, pleuritic chest pain, 7 kg weight loss and night sweats. CT of the thorax (figures 1 and 2) showed a large, rounded, well-circumscribed mass within the right hemithorax, with mass effect in the right atrium and superior vena cava. CT of the abdomen and pelvis revealed multiple liver lesions and intermediate pulmonary nodules. Tumour markers were elevated: beta human chorionic gonadotropin 26 µ/L, alpha fetoprotein 16 855 ng/mL and lactate dehydrogenase 695 µ/L. Ultrasound of the testes was negative. Percutaneous liver biopsy revealed primary mediastinal non-seminomatous germ cell cancer.
The patient’s CT of the thorax (axial view) depicting mediastinal mass measuring 10.7×11.8×13.6 cm.
The patient’s chest X-ray depicting extent of mediastinal tumour.
The previously well man was originally from South America but presently residing in Ireland with his wife. The couple have no children. Attempts at sperm banking before chemotherapy were unsuccessful, owing to his poor health. Chemotherapy with bleomycin, etoposide and cisplatin (BEP) was commenced.
He had constant hiccups and an intractable cough, from his mediastinal mass, which greatly impacted upon his quality of life.1
Treatment
He was referred to palliative care early in his disease course because of the symptom burden. For cough, methadone 2 mg two times per day was prescribed, later increased to 4 mg two times per day. Methadone has a D-isomer called D-methadone, which is antitussive.2 3 The apparent ‘source’ of his intractable cough was a central brain protective mechanism, as the brain perceived the tumour as a ‘foreign body’ in the mediastinum (figures 1 and 2).
The source of the hiccups was irritation of the …
Footnotes
Contributors TJM—writing and formatting. DW—title idea, referencing, reviewing, editing, composing palliative medicine treatment plan and involvement in patient management. CC—reviewing and editing the material. GK—reviewing and editing the material. DM—reviewing and editing the material. CL—reviewing and editing the material. CF—reviewing clinical/patient information. KJL—reviewing and editing the material. PD—reviewing and editing the material, formulating oncology treatment plan, treatment timeline and involvement in patient management.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.