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Thyrotoxicosis of a rare aetiology

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Q1: What is the diagnosis?

The most likely explanation for the association of haemoptysis and menstrual irregularities with multiple pulmonary nodules in a young woman with recent childbirth is choriocarcinoma.

Q2: What diagnostic procedure supports it?

Serum β human chorionic gonadotrophin (hCG) level is the most specific and sensitive marker for trophoblastic tumours.1The value in our patient was 125 000 IU/l. Normal is less than 10 IU/l in the non-pregnant woman. Free β subunit is present in normal pregnancy and averages less than 4% of total hCG up to the time of hCG peak (peak level of total hCG, 100 000 IU/l after 60–80 days).2

Q3: What is the cause of thyrotoxicosis?

Occasionally, thyrotoxicosis is present in patients with a very high concentration of hCG because of cross reaction between α subunits of hCG and thyroid stimulating hormone.3

Discussion

Primary tumours of the breast, skeleton, and urogenital system account for approximately 80% of pulmonary metastases.4Our patient with thyrotoxicosis and initial menorrhagia had a choriocarcinoma. The association of amenorrhoea with choriocarcinoma in this case is of interest and could have resulted from the thyrotoxicosis or from intrauterine adhesions following the curettage. Choriocarcinoma is most often preceded by a hydatidiform mole. Abortion or ectopic pregnancy are the next most common antecedents, followed by live births. The incidence following normal term delivery is 1 in 50 000, presentation usually being within the first year. Vaginal bleeding is the most common presentation. In approximately one third of the cases, symptoms arise not from the primary but from metastases. The long term survival in patients treated with chemotherapy ranges from 93% in high risk groups to 100% in low and medium risk groups.5

Learning points

  • Choriocarcinoma should be considered in a young woman with recent childbirth, menorrhagia, thyrotoxicosis, and pulmonary secondaries.

  • Long term survival following chemotherapy ranges from 93% in high risk groups to 100% in low and medium risk groups.

  • Most metastatic pulmonary nodules have their primaries in the breast, skeleton, or urogenital system.

Final diagnosis

Choriocarcinoma complicated by pulmonary secondaries and thyrotoxicosis.

References

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