Small-cell Lung Cancer Presenting as Fatal Pulmonary Hemorrhage

Lim, Jun Hyeok; Ryu, Jeong-Seon; Cho, Sang Yong; Kim, Hyun-Jung; Jeon, Sang Hoon; Kim, Jung Soo; Nam, Hae-Seong; Cho, Jae Hwa; Kwak, Seung Min; Lee, Hong Lyeol

When he returned after 10 days, he was admitted with blood-tinged sputum and aggravated dyspnea (Borg scale 6). His ECOG performance status was two. He was afebrile. An arterial blood gas study revealed pH 7.44, PaCO 2 37.5 mmHg, PaO 2 77.6 mmHg, HCO 3 25 mmol/L, and SpO 2 95% on room air. Complete blood count results were as follows: leukocytes 6,270/mm 3 (neutrophil 61.2%, lymphocyte 27.5%, monocyte 3.9%, eosinophil 3.9%, and basophil 0.7%), hemoglobin 10.6 g/dL, hematocrit 29.6%, and platelets 11,000/mm 3 . The serum lactate dehydrogenase level was 1,324 IU/L; C-reactive protein, 6.40 mg/dL. Hepatic and renal function testing were within normal range. Prothrombin time, activated partial thromboplastin time, and D-dimer were within normal range as well. A 1.6 cm sized mass in the lower lobe of the right lung and multiple lymphadenopathies in mediastinal and right supraclavicular areas were noted on chest CT scan ( Fig. 1) . A peripheral blood smear revealed leukoerythroblastosis with nucleated erythrocyte, left shifted neutrophils. Anti-platelet antibody and anti-neutrophil cytoplasmic antibody were negative. Anti-nuclear antibody was within Pulmonary hemorrhage at SCLC presentation normal range (1:20). Because of the risk of bleeding due to severe thrombocytopenia, a bronchoscopic examination was not feasible and was postponed. A bone marrow examination was not performed because the patient was unable to maintain prone position due to dyspnea. Platelet concentrates and packed red blood cells were started, given daily, and dexamethasone, 40 mg was intravenously administered for four days. However, his platelet count remained stationary (Fig. 2) . On the fifth day after admission, cytological examination of his sputum yielded a diagnosis of SCLC. Metastatic lesions were not observed on brain MRI and bone scintigraphy.