W S Waring, J A McKnight*. The Royal Infirmary of Edinburgh, Little France, and *Western General Hospital, Crewe Road, Edinburgh
Correspondence to: Dr W Stephen Waring, Scottish Poisons Information Bureau, The Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA E-mail: stephen.waring@ed.ac.uk
SMJ 2005 50(1): 30-31
Abstract:
We report a recent clinical case of an elderly patient who presented with weight loss and fatigue and who was diagnosed with hyperthyroidism. Some time later, he was discovered to have underlying oesophageal lymphoma. The latter diagnosis was believed to contribute, at least in part, to his symptoms at the time of initial presentation. The case illustrates the potential difficulties associated with establishing the diagnosis of oesophageal lymphoma. Furthermore, symptoms of weight loss and fatigue are commonly encountered in general medical patients. This case reminded us that even when a diagnosis of hyperthyroidism has been established, these symptoms may be attributable to other pathology.
Keywords: Hyperthyroidism, oesophageal lymphoma
Case report
An 84-year-old man was admitted to hospital for in-patient investigation of unexplained sweating, fatigue and breathlessness on exertion, and 10 kg weight loss over six weeks. He had suffered a myocardial infarction 11 years earlier, and had stopped smoking at that time. Since then, he had been taking propranolol 40 mg three times daily, and remained fit and active with a healthy exercise capacity. On examination, there was a symmetrical coarse resting tremor in both hands, and palmar erythema. Resting heart rate was 120/min, blood pressure 158/86 mmHg and weight was 67.5 kg. There was no goitre, lymphadenopathy, or signs of septicaemia. Full blood count, serum electrolytes, creatinine phosphokinase and liver biochemistry were normal. Thyroid function tests showed TSH < 0.05 mU/l, free T4 = 71 pmol/ l, total T3 = 1.7 nmol/l, and free T3 = 10.3 pmol/l, indicating a diagnosis of primary hyperthyroidism.1 Resting electrocardiogram showed sinus tachycardia, and echocardiography and nuclear ventriculography showed normal cardiac structure and ejection fraction. Plain chest radiography showed widened superior mediastinum, suggesting retrosternal goitre (Fig 1). Carbimazole 40 mg daily was commenced, and a single dose of 400MBq I131 was administered. Hospital stay was prolonged by a left basal pneumonia, which required antibiotic treatment. He reported mild discomfort on swallowing and, in view of this, an abdominal ultrasound and upper gastrointestinal endoscopy were arranged. The latter found Barrett’s oesophagus beyond 36 cm and a 2- week course of omeprazole was prescribed before discharge home.
On review in clinic, 10 weeks later, he reported excess sweating but improved exercise tolerance. Weight was 66.5 kg, he was clinically euthyroid, and TSH = 0.21 mU/l and free T4 = 15 pmol/l. Four weeks later his weight was 64.0 kg, and he was complaining of progressive dysphagia. Repeat endoscopy examination showed small varices in the upper oesophagus, but was otherwise normal. Barium swallow identified complete obstruction to contrast flow beyond the proximal oesophagus. Computed tomography, after intravenous contrast administration, showed a retrosternal diffuse mass with calcification, in keeping with goitre. A separate abnormality with different tissue density was found encasing 5-6 cm of the upper oesophagus, which narrowed the oesophageal lumen by more than 50% (Fig 2). Trans-bronchial biopsy showed infiltration of the posterior tracheal wall by blast and lymphoid cells, and immunohistochemistry indicated positive staining for CD20 antigen, but not CD30 or CD5 antigens. This pattern strongly suggested high-grade non-Hodgkins B-cell lymphoma. Computed tomography of thorax, abdomen and pelvis found no other sites of involvement, indicating a clinical diagnosis of primary oesophageal lymphoma.
The patient was referred for specialist management, and underwent one cycle of chemotherapy. Unfortunately he suffered progressive fatigue and died several weeks later, eight months after initial presentation. The gastrointestinal tract is the commonest extra-nodal site of non- Hodgkins lymphoma, but the oesophagus is involved in less than 1% of cases.2 Human immunodeficiency virus is an important predisposing factor, and isolated primary oesophageal non-Hodgkins lymphoma is exceptionally rare in the absence of infection. Typical symptoms are dysphagia, weight loss, hoarseness, and epigastric pain.2 Radiological findings are non-specific, and include stricture, intramural mass and polypoidal masses encroaching the lumen. Gastrointestinal lymphoma arises from submucosal lymphoid patches, and are easily overlooked by endoscopic examination due to intact overlying mucosa3. Endoscopic biopsies are often negative,3-5 and thoracic imaging by computed tomography is the favoured diagnostic modality.5
Discussion
This case reminds us that lymphoma can arise in extranodal sites, and its association with hyperthyroidism raises the possibility of a common immunological aetiology. An earlier report has described the occurrence of hyperthyroidism in a woman with B-cell lymphoma, in whom chemotherapy caused both tumour remission and restoration of normal thyroid function;6 the authors had attributed hyperthyroidism to thyroiditis due to lymphomatous infiltration. Other reports in the literature illustrate the association between hyperthyroidism and extra-nodal lymphoma, including those arising from gut associated lymphoid tissue (GALT), and underpin the possibility of a common pathogenetic link.7,8
Key Learning Points
1. Weight loss in elderly patients can be due to more than one aetiology, and the possibility of a second diagnosis should not be overlooked.
2. Patients treated for hyperthyroidism require follow-up.
3. Oesophageal lymphoma is often missed during endoscopic investigation of upper gastrointestinal symptoms, and its identification is commonly delayed.
4. Thoracic CT scanning is important in establishing the diagnosis of oesophageal lymphoma.
This unfortunate man presented with symptoms, examination findings, and biochemical tests consistent with severe primary hyperthyroidism.1 Weight loss is a common presenting symptom in elderly patients. We believed that Key Learning Points 1. Weight loss in elderly patients can be due to more than one aetiology, and the possibility of a second diagnosis should not be overlooked. 2. Patients treated for hyperthyroidism require follow-up. 3. Oesophageal lymphoma is often missed during endoscopic investigation of upper gastrointestinal symptoms, and its identification is commonly delayed. 4. Thoracic CT scanning is important in establishing the diagnosis of oesophageal lymphoma. hyperthyroidism was an adequate explanation for his reported weight loss at presentation. In retrospect this might have due, at least in part, to underlying lymphoma. This case highlights the importance of considering the possibility of more than one underlying aetiology in elderly patients who present with fatigue and weight loss, and an important learning point is that all patients treated for hyperthyroidism should be followed up.
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