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A patient presenting with hoarseness
  1. Kim-Hatt Lim,
  2. Chong-Kin Liam,
  3. Catherine Mee-Ming Wong
  1. Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
  1. Dr Kim-Hatt Lim (email: limkh{at}medicine.med.edu.um.my)

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Answers on p 518.

A non-smoking 34 year old man was seen for hoarseness of voice and non-productive cough of three months' duration. Apart from mild weight loss he was otherwise well. He had no significant past medical illness.

Findings of physical examination were unremarkable except for the hoarseness. Laryngoscopy revealed paralysis of the left vocal cord with no intrinsic lesion of the larynx. Neurological and lung examinations showed no abnormal finding.

  Laboratory investigations revealed a haemoglobin of 135 g/l, total white cell count of 7.5 × 109/l with 64% neutrophils, 24% lymphocytes, 9% monocytes, and 3% eosinophils. The erythrocyte sedimentation rate was 15 mm/hour. His serum protein concentration was 78 g/l, albumin 33 g/l, alkaline phosphatase 203 IU/l, aspartate aminotransferase 33 IU/l, alanine aminotransferase 52 IU/l, and calcium 2.38 mmol/l. Twenty four hour urine calcium was raised at 9.3 mmol/24 hours (normal range 2.2–7.5). His renal function was normal. Chest radiography (fig 1) and computed tomography of the thorax (fig 2) were performed. The Mantoux test (10 tuberculin units) produced a negative response on two occasions.

Figure 1

Chest radiograph, posterioanterior view.

Figure 2

Computed tomogram of thorax.

Questions

(1)
What does the computed tomogram of the thorax show?
(2)
What is the most probable diagnosis?
(3)
Describe the three mechanisms causing hoarseness in this condition?

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