Pancoast's syndrome associated with invasive aspergillosis.

Abstract

The combination of lower brachial plexus root pain in the shoulder and arm and of ipsilateral Homer's syndrome was described by Pancoast in 1932 and is usually caused by a malignant tumour at the apex of the lung. We describe a case in which the syndrome occurred in an immunosuppressed patient and was due to invasive fungal infection.Case report A 34 year old woman was receiving induction chemotherapy with high dose cytosine arabinoside for relapsed acute myeloid leukaemia. During the neutropenic period she developed a fever, which responded to intravenous ceftazidime and amikacin. Blood cultures were sterile and antibiotic treatment was discontinued after nine days. One week later she developed an intermittent fever and some pain in the left shoulder. Over the next two days she complained of increasingly severe pain over the left scapula, which radiated along the medial aspect of the left upper arm. She had no cough or haemoptysis and a chest radiograph showed a small opacity at the left apex. Previous chest radiographs had been normal. Three days later she was noted to have a left Homer's syndrome with absence of sweating of the left hand. The neurological signs did not change over the next week but a chest radiograph showed an increase in the left apical opacity (fig 1). Myelography and computer assisted tomography of the root of the neck failed to show extrinsic root compression. The mass at the lung apex was demonstrated but no infiltration of the brachial plexus could be seen. A cytospin preparation of cerebrospinal fluid showed no evidence of central nervous system leukaemia. A percutaneous Trucut lung biopsy was performed via a suprascapular approach. Numerous fungal hyphae were seen on histological sections (fig2) and identified as Aspergillus species morphologically, though there was no growth on culture. Repeated tests for serum precipitins against Aspergillus gave negative results. Treatment with intravenous amphotericin was started and after one week of treatment she was afebrile. The root pain resolved over the next 10 days but there was no improvement in the Homer's syndrome. Treatment continued for six weeks with almost complete resolution of the left apical opacity. A bone marrow aspirate showed that the leukaemia was in remission. Three months later she had a second relapse of her leukaemia, which was treated successfully without reactivation of the aspergillus infection. One year later she remains well with a persistent left Homer's syndrome.

Pancoast's syndrome due to Pseudomonas aeruginosa infection of the lung apex.

“…7 Despite the absence of blepharoptosis and muscle atrophy, there was little doubt that the clinical findings in our patient were similar to those described by Pancoast' and consistent with a lesion of the left brachial plexus roots and the sympathetic chain. Computed tomography suggested that the lesion affecting these nerves was due to abnormal tissue extending from the lung apex.…”

Pancoast syndrome: A rare presentation of non-Hodgkin′s lymphoma

“…[8] Benign causes of Pancoast syndrome include pulmonary tuberculosis, hydatid cyst, histoplasmosis, aspergillosis, destructive sclerosing fibrosis following staphylococcal infection at lung apex. [9101112] Pancoast syndrome is due to involvement of the lower trunk of brachial plexus and inferior cervical ganglion by locally progressive pulmonary apical tumors, which often cause erosion of upper ribs and chest wall destruction before neural involvement.…”

Neoplastic Plexopathies

“…Metastases to intraneural plexus elements rarely occur. [39][40][41] Leukemic infiltrates may produce vascular occlusion and plexus infarction. 35 Neurolymphomatosis is the term used to describe nerve infiltration by neoplastic cells in non-Hodgkin's lymphoma and acute leukemia.…”