Case Report Diagram
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Figure-1
Case Report
A 48 year-old nonsmoking man with a long-standing diagnosis of asthma presented with a 2-week history of worsening shortness of breath, productive cough, and pleuritic chest pain. Chest X ray confirmed right-middle lobe consolidation suggestive of pneumonia. His symptoms resolved with a 6-day course of antibiotics, but a follow-up chest X ray demonstrated worsening of the consolidation. Bronchoscopy revealed a right middle-lobe tumor, and the biopsy was posi- tive for small-cell lung carcinoma.
The patient was born in Hong Kong and immigrated to England around 1990 at 35 years of age. According to his medical his- tory, at 4 years of age he was diagnosed with asthma, which was treated with Chinese tradi- tional medicine (CTM) pills known to con- tain arsenic until he was 14 years of age, when he was diagnosed with Bowen's disease. In 1988, a skin biopsy of a lesion on his right elbow was positive for squamous cell carci- noma in situ. He had never smoked cigarettes, and he drank alcohol only once a month. He had no other known exposures to arsenic through drinking water, diet, or occupation.
When seen by the medical oncologist, he complained of a cough that produced clear sputum and dull pain over the right costal margin, but he denied constitutional symp- toms. A physical exam revealed an afebrile Asian male with no palpable lymphade- nopathy. Chest examination was consistent with right middle lobe consolidation. The liver edge was palpable 3 cm below the costal margin but was neither nodular nor tender. Multiple 3-8 cm scaly, purple-brown, well- demarcated tear-drop-shaped patches were distributed over the skin of his trunk and extremities; these patches were consistent with his history of Bowen's disease. His neurologic examination was normal.
Computed tomography of the patient's chest and abdomen confirmed a right hilar mass completely obstructing the right mid- dle-lobe bronchus with distal pneumonitis and large mediastinal nodes. Multiple hypo- dense liver lesions suggestive of metastatic dis- ease were also found.
A diagnosis of extensive stage small-cell lung cancer was made. The patient entered a phase III clinical trial comparing cisplatin and etoposide to cisplatin and irinotecan and was randomized to the latter arm. Because more than 37 years had passed since the cessation of his known arsenic exposure, direct testing to confirm a diagnosis of arsenic exposure would probably have served little purpose. He achieved a complete remission but died of complications of progressive disease 8 months later.
