INTRODUCTION: Choriocarcinoma is a rare tumor in men, comprising less than 5% of germ cell tumors and frequently associated with an elevated serum beta-human chorionic gonadotropin (B-HCG). Markedly elevated B-HCG (> 50,000 miu/ml) is a marker of poor prognosis. Choriocarcinoma has high propensity for hemorrhage, and complications from the bleeding likely contribute to higher mortality.
CASE PRESENTATION: 21 year old Spanish-speaking male presented to the hospital with one week history of nausea and vomiting. He also had a mild epigastric pain and loose stools averaging 3/day for the past 3-4 days. His friends reported that patient had worked on a farm and was exposed to herbicides and pesticides. Additional history noted for patient becoming ill after eating a hamburger. No prior history of medical problems. Pertinent review of systems: Cough with yellowish white sputum of 10 days duration with occasional specks of blood. No history of weight loss, hemetemesis, fever, chills, night sweats, masses, or lymph node enlargement. Physical examination: T 97.7, BP 111/64, HR 117, RR 18, oxygen saturation 94% on room air. Well built and nourished Hispanic male in no acute distress. Lung exam revealed bilateral crackles at the bases. Abdominal exam showed mild epigastric and RUQ tenderness on deep palpation. Rest of the examination was unremarkable. Pertinent lab data: WBC 13000, hematocrit 38.8%. Chest radiograph showed bilateral diffuse air space/interstitial pattern predominantly in the lower zones with possible small effusion. Patient was admitted and initially treated for acute astroenteritis and community acquired / atypical pneumonia. Next day patient started coughing up small amount of blood and he was noted to ave increasing respiratory distress. Patient was transferred to the intensive care unit and subsequently intubated for the worsening respiratory failure. Following day patient had significant amount of blood from his endotracheal tube with his hematocrit dropping to 22%. Several differential diagnoses were considered including mycobacterial infection, HIV, opportunistic fungal infections, legionnaires, Good Pasteur's/autoimmune and connective tissue disorders. Following day patient continued to have massive hemoptysis. Despite aggressive resuscitative efforts,patient developed profound hypotension leading to cardiac arrest and death.
DISCUSSIONS: Autopsy revealed massively enlarged and hemorrhagic lungs with multiple metastases of choriocarcinoma. A single met-astasis was present in the left kidney. Testes were grossly normal, but the microscopic examination of the left testis showed a small focus of malignant intratubular germ cells without differentiating features. No invasive carcinoma was identified but there was a small scar with calcifications. Premortem serum was examined for B-HCG, which was found to be present in high concentration (331,819 miu/ml). Death in this case was the result of pulmonary hemorrhage and respiratory failure secondary to metastatic choriocarcinoma of testicular origin. Germ cell tumors can arise in normal testes, and this is particularly true of choriocarcinoma, which can metastasize widely, and yet leave minimal tumor or scar in the testis of origin.
CONCLUSION: Metastatic choriocarcinoma is a rare cause of massive hemoptysis. Radiographic features of pulmonary hemorrhage may obscure metastatic nodules of choriocarcinoma. Even with a normal testicular exam, germ cell tumors should be considered in young males with massive hemoptysis.
(1) Peckham MJ, Oliver RTD, et al. Prognostic factors in advanced non-seminomatous germ-cell testicular tumors: results of a multicenter study. Lancet. 1985;1:8-11
(2) Benditt JO, Farber HW, et al. Pulmonary hemorrhage with diffuse alveolar infiltrates in men with high volume choriocarcinoma. Ann Intern Meal. 1988 Oct 15; 109(8):674-5
(3) Duggard G, von der Masse H, et al. Carcinoma-in-situ in patients with assumed extragonadal germ-cell tumors. Lancet 1987; Sept 5:528-530
DISCLOSURE: K Dinesh Chandra, None.
K. M. Dinesh Chandra MD * Marshall Tanner MD Douglas Farman MD Jerome Tift MD University of Alabama at Birmingham, Birmingham, AL
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