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A case of cough and dysphagia
  1. C M Smyth,
  2. C C Evans
  1. Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XB, UK
  1. Correspondence to:
 Dr Smyth;
 colin.smyth{at}tesco.net

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A 70 year old women was referred to the accident and emergency department by her general practitioner with a three month history weight loss of two stone (13 kg) and progressive dysphagia for solids. This had worsened to the extent that over the week before presentation, she had difficulty swallowing soft food and fluids. She also reported recent onset of cough productive of purulent sputum, and cough on attempted swallowing. She had a past history of resection of aDukes's stage B colon carcinoma eight years earlier. She was a smoker of 15 cigarettes a day, and drank little alcohol. She took no regular medication.

On examination she appeared thin and dehydrated. Cardiovascular and abdominal examination was unremarkable. Chest auscultation revealed crackles at both lung bases.

Blood tests revealed a urea of 13.7 mmol/l (normal 2.5–7.0) and a neutrophilia of 9.1 × 109/l (normal 2.0–7.5). Chest radiography showed patchy shadowing throughout both lung fields.

The patient was rehydrated intravenously and started on broad spectrum antibiotics. A nasogastric tube was passed. Upper gastrointestinal endoscopy revealed an obstructing mass at the mid-oesophagus. A bronchoscopic examination and computed tomography of the thorax were performed.

QUESTIONS

  1. What abnormalities are seen on the computed tomogram (fig 1) and on views of the right main bronchus at bronchoscopy (fig 2)?

  2. What is the most likely cause of these appearances?

  3. What other conditions may cause similar appearances?

  4. What treatment options are available?

Figure 2

Right main bronchus at bronchoscopy.

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