Matthew Chan, DO, Akash Patel, DO, Jacqueline Bowers, MD
Albert Einstein Medical Center, Philadelphia, PA
Introduction: Esophageal masses can present in a variety of ways, such as a result of mediastinal mass effect leading to cough, hoarseness, and/or dysphagia, or they can be incidental findings on imaging as part of the evaluation of an unrelated condition. A definitive diagnosis generally requires tissue sampling. We present a case of a woman with a recent diagnosis of asthma unresponsive to standard therapies who was found to have an esophageal mass that unfortunately led to respiratory arrest.
Case Description/Methods: A 32-year-old African American female with history of G6PD deficiency, alpha thalassemia, GERD, morbid obesity, and recent diagnosis of asthma presented with dyspnea. A month prior, she was seen in the ER on two separate occasions for similar symptoms and treated for asthma exacerbations and subsequently discharged home. Chest x-rays performed then were unremarkable. Upon further history, the patient also had progressive dysphagia from solids to liquids and globus pharyngis. There was no history of tobacco or alcohol use, and no family history of malignancy. On admission, vitals were unremarkable. Exam revealed hoarseness, biphasic stridor greater upon inspiration, and expiratory wheezing throughout lung fields. Labs showed a chronic microcytic anemia, and chest x-ray was again unremarkable. She was treated for presumed asthma exacerbation and started on IV PPI and IV steroids for possible airway edema due to GERD. ENT was consulted to assess for any airway obstruction.
Flexible nasopharyngolaryngoscopy showed paralysis of the left true vocal cord, and a CT with IV contrast of the neck and chest was performed that showed a large mass involving the mid-thoracic esophagus compressing the trachea. Gastroenterology and Cardiothoracic Surgery were consulted, and the patient was transferred to an outside hospital for emergent tracheal stenting. Unfortunately, the patient had respiratory arrest prior to intervention. Family declined autopsy studies to determine the etiology of the mass.
Discussion: This case illustrates that careful history and physical examination clues be obtained in cases of asthma unresponsive to standard therapy. A low threshold for obtaining further dedicated imaging such as chest CT can help with prompt identification and management of life-threatening processes such as respiratory compromise. Some differentials for esophageal masses include squamous cell cancer, adenocarcinoma, and lymphoma among others, and this case highlights that everything that wheezes is not asthma.
Citation: Matthew Chan, DO, Akash Patel, DO, Jacqueline Bowers, MD. P0301 - AN ESOPHAGEAL MASS MASQUERADING AS ASTHMA EXACERBATION: AN UNFORTUNATE OUTCOME. Program No. P0301. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.