Photoclinic

A 30-year-old white man noticed right supraclavicular enlargement and signs of thrombophlebitis in the ipsilateral upper extremity. He also reported epigastric and lumbar pain, nausea, vomiting and progressive dyspnea. Since his 12 years of age, he has been a tobacco dependent and is categorized as a daily heavy smoker. On physical examination, the patient had tachypnea and a painless hard nodule (3 cm × 3 cm) in the right supraclavicular area. In the right pulmonary base there was mild dullness on percussion, and diffuse fine rales were heard. Chest radiographs showed images of a density in the right lung with mediastinal lymph node enlargement, and reticular interstitial opacities similar to Kerley B lines (Figure 1a and 1b). Lung function tests showed a mixed ventilation disorder with normal carbon monoxide diffusion and hypoxemia at rest without hypercapnia. He presented features of heart failure with rapid evolution to circulatory shock and death, in spite of intensive care support. Complete necropsy study was authorized and revealed the etiology of the lungs involvement, epicardium, pericardium, mediastinum, and lymphatic structures (Figure 1c to 1h).