Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old

Winston W. Tan, MD; Matthew Tan

Disclosures

October 16, 2020

Non-small cell lung cancer accounts for approximately 85% of all lung cancers. Histologically, it is divided into adenocarcinoma, squamous cell carcinoma, and large cell carcinoma. Patients with non-small cell lung cancer require a complete staging work-up to evaluate the extent of disease because stage plays a major role in determining the choice of treatment.[1]

The patient in this case has the typical presentation of chronic cough. Typically, a cough that is initially thought to be an infection is noted. A chronic cough without improvement of symptoms despite treatment for infection should prompt further evaluation for potential lung mass. CT of the chest is often used as a diagnostic tool to clarify the suspicion of a lung mass.[2]

Because of the importance of stage in the therapeutic decision-making process, all patients must undergo proper staging of disease. A complete staging work-up should be performed to evaluate the extent of disease. In the United States, the standard staging work-up includes the following:

  • CT of the chest and upper abdomen

  • Complete blood count with differential

  • Serum chemistry studies, including creatinine, electrolytes, and calcium

  • Alkaline phosphate

  • Aspartate aminotransferase

  • Pulmonary function testing

  • Mediastinoscopy (if surgical resection is considered)

The information obtained from these tests guides additional testing (eg, imaging studies). Invasive staging procedures (eg, mediastinoscopy, mediastinotomy) may be required to assess mediastinal lymph nodes in patients who may undergo surgical resection. PET may be useful in detecting affected nodes, which may influence decisions about operability.

Paraneoplastic syndromes are more likely to occur in small cell lung cancer than in non-small cell lung cancer. Patients are at risk for the following:

  • Cushing syndrome

  • Lambert-Eaton myasthenic syndrome (Onset of proximal lower-extremity weakness is gradual; proximal upper-extremity weakness is usually less noticeable; the syndrome may be worse in the morning and improve during the day; although extraocular muscle involvement is uncommon, ptosis is often found)

  • Hypercalcemia (usually occurs with squamous cell carcinoma)

  • Syndrome of inappropriate antidiuretic hormone secretion

  • Enlargement of the extremities and painful, swollen joints (hypertrophic osteoarthropathy)

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