The insights of this case study include the paucity of data surrounding diagnosis and treatment of lung cancer in non-smokers available for South Africa. The current data that are available is for the developed world only. Some evidence incidence might be related to exposure of biofuels, which has significance for our local population and requires more exact research.
A 58-year-old male, human immunodeficiency virus (HIV)-negative, nonsmoker presented acutely to the authors’ emergency unit with respiratory distress. He reported a 7-day history of progressive shortness of breath, fatigue and chest pain. On further systemic enquiry, he had a long-standing (> 3 months) history of dry cough, unintentional weight loss and loss of appetite. His background medical history was remarkable for dermatomyositis, hypertension, dyslipidaemia, Type 2 diabetes and morbid obesity, with a poor baseline status. He resided permanently in a care facility because of both social and medical reasons.
On presentation, he was acutely distressed with a blood pressure of 106/79 mmHg, heart rate of 118 beats per min, body temperature of 36.3 °C, respiratory rate of 35 breaths per min and oxygen saturation of 84% on room air. On physical examination, he had an elevated jugular venous pressure (JVP), bilateral basal lung crepitations, a displaced apex beat and soft, distant heart sounds.
Electrocardiogram (ECG) (
Electrocardiogram on presentation of cardiac tamponade.
Chest X-ray on presentation showing increased cardiothoracic ratio.
Initial laboratory serum values.
Diagnostic test | Serum value |
---|---|
White cell count | 13.8 |
Haemoglobin | 12.0 |
Mean corpuscular volume | 92.8 |
Red cell distribution width | 15.6 |
Platelet count | 200 |
Sodium | 135 |
Potassium | 3.6 |
Urea | 9.7 |
Creatinine | 70 |
eGFR | > 60 |
Calcium (corrected) | 2.23 |
Magnesium | 0.68 |
Phosphate | 0.77 |
C-Reactive protein | 141 |
Troponin T | 72 |
HbA1c | 7.8% |
Beta-human chorionic gonadotropin | < 1 |
Alpha foetoprotein | 2.2 |
Prostate-specific antigen | 0.23 |
Cancer antigen 125 | 486 |
Cancer antigen 19-9 | 1 |
eGFR, estimated glomerular filtration rate; HbA1c, glycated haemoglobin.
Despite pericardial fluid drainage, commencement of antituberculous treatment and initiation of corticosteroids, the patient remained distressed with poor oxygen saturation. His condition continued to deteriorate over the following week, with a repeat chest X-ray (
Repeat chest X-ray showing recurrent pericardial effusion.
Echocardiography image of re-accumulation of pericardial fluid posteriorly.
Pericardial effusion (PE) is a commonly occurring medical condition with clinical manifestations ranging from incidental small effusions to large, life-threatening cardiac tamponade.
Tuberculous pericarditis (TBP) remains a severe form of extrapulmonary TB. In the HIV-infected population, TB is the cause of PE in the overwhelming majority of patients and often associated with more aggressive disease as a result of disseminated TB infection.
In an oncology patient, there are several mechanisms by which a PE may present.
Lung cancer is the most common cancer involving the pericardium.
The co-existence of lung malignancies and TB infection has been well described. However, extrapulmonary manifestations of TB such as TBP and concurrent lung malignancies are more complex and less well-known. Considering the high prevalence of both conditions in South Africa, the dual diagnosis of TBP and MEP may be underdiagnosed because of poor outcomes with limited survival data.
This case demonstrates the rare presentation of an undiagnosed metastatic lung malignancy in a nonsmoking patient, with simultaneous extrapulmonary TB presenting in cardiac tamponade. In addition, his pre-existing inflammatory condition of dermatomyositis may have put him at risk for developing a PE. There is also a known association between dermatomyositis and the development of malignancies, specifically lung malignancies in male patients.
South Africa is facing a ‘colliding of epidemics’ of smoking, TB and HIV, increasing the likelihood of concurrent lung malignancies and TBP.
Sub-Saharan Africa faces a disproportionate burden of disease, with high rates of infectious diseases such as TB and HIV continuing and the disease burden attributable to cancer rising.
Tuberculosis and malignancy are the commonest causes of cardiac tamponade but may present in a similarly nonspecific manner, posing several diagnostic challenges.
Clinicians should maintain a high index of suspicion in patients with poor response to anti-TB treatment presenting with cardiac tamponade.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
K.N, S.D., Q.S.-H. and M.N contributed equally to this work.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
This research was submitted as part of a sub-study approved by the University of Cape Town Human Research Ethics Committee (HREC) (ref. no. 570/2021). Written informed consent was obtained from the patient.
Data sharing is not applicable to this article as no new data were created or analysed in this study.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.