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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 11  |  Issue : 2  |  Page : 202-204

Syndrome of inappropriate antidiuretic hormone presenting with recurrent hiccups in a case of small cell neuroendocrine carcinoma of the lung with concomitant pulmonary tuberculosis


1 Department of Internal Medicine, Max Super Specialty Hospital, Ghaziabad, Uttar Pradesh, India
2 Department of Preventive and Health Care, Max Super Specialty Hospital, Ghaziabad, Uttar Pradesh, India

Date of Submission16-Apr-2022
Date of Decision17-May-2022
Date of Acceptance26-May-2022
Date of Web Publication14-Jun-2022
Date of Print Publicaton14-Jun-2022

Correspondence Address:
Saurabh Puri
House No 1111, Kujada Ka Bag, Shahganj, Sultanpur City, Sultanpur - 228 001, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_60_22

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  Abstract 


Tuberculosis (TB) and lung cancer are the leading causes of mortality and morbidity in the world. The burden of TB is significantly high in developing countries causing serious public health concern, and the incidence of lung cancer is also increasing all around the world with high mortality. Pulmonary TB coexisting with lung cancer can mask the underlying disorder producing diagnostic dilemma resulting in a delay in diagnosis leading to decreased survival of the patients. Here, we report a rare case of a 66-year-old male diagnosed with microbiologically confirmed TB along with coexisting small cell neuroendocrine carcinoma of the lung presenting with syndrome of inappropriate antidiuretic hormone.

Keywords: Hiccups, lung carcinoma, pulmonary tuberculosis, small cell neuroendocrine tumor, syndrome of inappropriate antidiuretic hormone


How to cite this article:
Puri S, Panwar V, Agrawal R, Saurabh S, Gera P. Syndrome of inappropriate antidiuretic hormone presenting with recurrent hiccups in a case of small cell neuroendocrine carcinoma of the lung with concomitant pulmonary tuberculosis. Int J Mycobacteriol 2022;11:202-4

How to cite this URL:
Puri S, Panwar V, Agrawal R, Saurabh S, Gera P. Syndrome of inappropriate antidiuretic hormone presenting with recurrent hiccups in a case of small cell neuroendocrine carcinoma of the lung with concomitant pulmonary tuberculosis. Int J Mycobacteriol [serial online] 2022 [cited 2022 Jul 6];11:202-4. Available from: https://www.ijmyco.org/text.asp?2022/11/2/202/347521




  Introduction Top


One of the leading causes of cancer-related mortality worldwide is lung carcinoma, whereas tuberculosis (TB) is a major cause of morbidity and mortality in developing countries, despite availability of effective antibiotic therapy. Simultaneous or concomitant coexistence of both the diseases is poorly understood and underreported but causes a serious impact on the outcome of patients along with public health. Due to similar clinical and radiological presentation of both TB and lung cancer, it is often overlooked and there is a delay in diagnosis causing poor outcomes of the patients. We present a case of an elderly male who was suffering from pulmonary TB and was diagnosed with coexistent small cell neuroendocrine lung carcinoma on further investigation in view of persistent hyponatremia not responding to IV normal saline.


  Case Report Top


A 66-year-old male presented with complaints of nausea, persistent vomiting, weight loss, and loss of appetite from the last 30 days, followed by continuous hiccups for 14 days. He is a known case of diabetes mellitus on regular treatment. He was diagnosed with pulmonary TB, and antitubercular therapy (ATT) was initiated 21 days back. On examination, he was conscious and oriented to time, place, and person. At admission, his vitals were pulse rate 118/min, blood pressure 110/80 mmHg, respiratory rate 24/min, oxygen saturation (SpO2) 97% on room air, temperature 99°F, and random blood sugar 96 mg/dl. General examination revealed dry tongue and systemic examination revealed decreased breath sound in the left supra- and infraclavicular region. Blood count revealed normal hemoglobin (Hb), leukocyte count, and platelet count (Hb: 12.0 g/dl, total leukocyte count: 6.54 × 109/L, and platelet: 243 × 109/L). Liver function test revealed transaminitis (serum glutamic-oxaloacetic transaminase: 194.8 U/L, serum glutamic-pyruvic transaminase: 263.0 U/L, alkaline phosphatase: 88 U/L, and gamma-glutamyl transpeptidase: 51 U/L). Renal profile showed normal urea and creatinine with hyponatremia (sodium: 114 mmol/L and potassium: 4.4 mmol/L). Chest X-ray posteroanterior view showed homogenous opacity in the left upper and mid zone [Figure 1]. He was managed with intravenous normal saline, proton-pump inhibitor, and antiemetic. His serum sodium was repeated the next day, which was further decreased to 112 mmol/L. Normal saline was stopped and intravenous 3% saline was initiated; however, his serum sodium further dropped to 109 mmol/L. A workup for hyponatremia was done which revealed normal serum uric acid (4.8 mg/dl), low serum osmolality (224 mOsm/kg), high urine osmolality (540 mOsm/kg), and spot urine sodium (120 mmol/L) suggestive of syndrome of inappropriate antidiuretic hormone (SIADH). His fluid intake was restricted to 1 L/day. Serial monitoring of serum sodium was done, which revealed a rising trend after fluid restriction was initiated. Contrast-enhanced computed tomography (CT) of the chest showed a heterogeneously enhancing irregularly marginated mass lesion with nonenhancing necrotic areas within and few tiny calcifications in the left upper lobe [Figure 2]. A thick-walled cavitary lesion in the right upper lobe was also noted [Figure 3]. USG guided lung biopsy showed poorly differentiated carcinoma favoring small cell carcinoma with granulomatous inflammation in surrounding tissues with immunohistochemistry Tumor cells expressing Synaptophysin and CD56, Ki-67 proliferation index - 60% in immunohistochemistry. PET/CT scan was done to rule out any metastasis, which revealed a large FDG Avid heterogenous enhancing lobulated mass lesion involving anterior segment left lung upper lobe, extending to left suprahilar region encasing the left pulmonary artery and abutting arch of aorta suggestive of malignant etiology [Figure 4]. Final diagnosis was made as SIADH induced by small cell neuroendocrine carcinoma lung with concomitant pulmonary TB, and he was referred to an oncologist for further management of lung carcinoma with a continuation of ATT.
Figure 1: Chest X-ray PA view showed homogenous opacity in the left upper and mid zone. PA: Posteroanterior

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Figure 2: CECT of the chest showed a heterogeneously enhancing irregularly marginated mass lesion with nonenhancing necrotic areas within and few tiny calcifications in the left upper lobe. CECT: Contrast-enhanced computed tomography

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Figure 3: A thick-walled cavitary lesion in the right upper lobe was also noted

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Figure 4: PET/CT scan showing large FDG Avid heterogeneous enhancing lobulated mass lesion involving anterior segment left lung upper lobe, extending to left suprahilar region encasing the left pulmonary arteryand abutting arch of aorta

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  Discussion Top


Since coexistence of lung carcinoma and pulmonary TB was first reported by Bayle in 1810,[1] both lung carcinoma and TB are the important causes of morbidity and mortality, especially in poor and developing countries.[1],[2] However, an association between both the diseases is seldomly discussed, but it creates a great impact over public health.[3] 0.7% of cases of lung cancer have been found to have pulmonary TB, whereas Chandra et al. found that 17% of cases of lung carcinoma were suffering from pulmonary TB.[4],[5] Both the diseases can occur in the following patterns: (1) carcinoma over TB ground, reactivating old focus of TB; (2) carcinoma from previous TB scars (scar carcinoma); (3) carcinoma from epithelium metaplasia of TB cavities; (4) independent and develop simultaneously; (5) metastatic carcinoma in old TB lesion; and (6) secondary TB in a cancer patient.[6] In our case, both the diseases possibly occurred independently and developed simultaneously. Wu et al. proposed a theory of reverse causality explaining the reactivation of latent TB due to a weakened host immune system caused by occult lung cancer and diagnosed during the TB treatment.[7]

Clinically, both pulmonary TB and lung cancer can present clinically with fever, loss of appetite, weight loss, fatigue, chest pain, and hemoptysis along with similar radiological features, leading to delay in diagnosis and management causing poor outcomes.[8] Lung cancer is often overlooked and delayed due to masking by tubercular lesions in active TB cases.[9] Similar to our case, Ting et al. suggested radiographic features increasing suspicion of lung carcinoma in patients with preexisting pulmonary TB, foremost was the progression of pulmonary infiltrates while on anti-TB drugs.[10] Histologically, the most common type was non-small cell lung cancer, especially adenocarcinoma;[2] however, in the case described above, he was found to have small cell neuroendocrine lung carcinoma.

Since SIADH in lung cancer was described in 1957 by Schwartz et al.,[11] 10% of patients of lung cancer present with paraneoplastic syndrome, with SIADH occurring in 7%–16% of patients of SCLC, linked with the worst outcome.[12],[13]


  Conclusion Top


Physicians should be aware of protean manifestations of both TB and cancer and simultaneous coexistence should be considered in a high index of suspicion due to misleading clinical and radiological presentations. In patients who are nonresponsive to ATT and radiological worsening, physicians should look for other potential diagnostic clues and go for establishing additional diagnoses.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bayle CH. Recherches Sur la Phitisue Pulmonaire. Paris, France: Galon; 1810.  Back to cited text no. 1
    
2.
Silva DR, Valentini DF Jr., Müller AM, de Almeida CP, Dalcin Pde T. Pulmonary tuberculosis and lung cancer: Simultaneous and sequential occurrence. J Bras Pneumol 2013;39:484-9.  Back to cited text no. 2
    
3.
Liang HY, Li XL, Yu XS, Guan P, Yin ZH, He QC, et al. Facts and fiction of the relationship between preexisting tuberculosis and lung cancer risk: A systematic review. Int J Cancer 2009;125:2936-44.  Back to cited text no. 3
    
4.
Tamura A, Hebisawa A, Tanaka G, Tatsuta H, Tsuboi T, Nagai H, et al. Active pulmonary tuberculosis in patients with lung cancer. Kekkaku 1999;74:797-802.  Back to cited text no. 4
    
5.
Chandra S, Mohan A, Guleria R, Singh V, Yadav P. Delays during the diagnostic evaluation and treatment of lung cancer. Asian Pac J Cancer Prev 2009;10:453-6.  Back to cited text no. 5
    
6.
Harikrishna J, Sukaveni V, Prabhath Kumar D, Mohan A. Cancer and Tuberculosis. J Indian Acad Clin Med 2012;13:142–4.  Back to cited text no. 6
    
7.
Wu CY, Hu HY, Pu CY, Huang N, Shen HC, Li CP, et al. Pulmonary tuberculosis increases the risk of lung cancer: A population-based cohort study. Cancer 2011;117:618-24.  Back to cited text no. 7
    
8.
Kaur A, Kajal N, Goyal A. Lung cancer coexisting with pulmonary tuberculosis: A rare case report. Indian J Respir Care 2021;10:126.  Back to cited text no. 8
  [Full text]  
9.
Singh SK, Ahmad Z, Bhargava R, Pandey DK, Gupta V, Garg PK. Coincidence of tuberculosis and malignancy: A diagnostic dilemma. South Med J 2009;102:113.  Back to cited text no. 9
    
10.
Ting YM, Church WR, Ravikrishnan KP. Lung carcinoma superimposed on pulmonary tuberculosis. Radiology 1976;119:307-12.  Back to cited text no. 10
    
11.
Schwartz WB, Bennett W, Curelop S, Bartter FC. A syndrome of renal sodium loss and hyponatremia probably resulting from inappropriate secretion of antidiuretic hormone. Am J Med 1957;23:529-42.  Back to cited text no. 11
    
12.
Vanhees SL, Paridaens R, Vansteenkiste JF. Syndrome of inappropriate antidiuretic hormone associated with chemotherapy-induced tumour lysis in small-cell lung cancer: Case report and literature review. Ann Oncol 2000;11:1061-5.  Back to cited text no. 12
    
13.
Gross AJ, Steinberg SM, Reilly JG, Bliss DP Jr., Brennan J, Le PT, et al. Atrial natriuretic factor and arginine vasopressin production in tumor cell lines from patients with lung cancer and their relationship to serum sodium. Cancer Res 1993;53:67-74.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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