International Journal of Clinical & Medical Images

Clinical Image

A 63-year-old man with a recentlydiagnosed squamous cell cancer of the left lung was brought to the hospital byhis wife due to a 2-week history of progressive altered mentalstatus and a few months of hoarseness. Laboratory studiesshowed a calciumlevel of 14.4 mg per deciliter (reference range, 8.5 to 10.5). After treatment with intravenous fluids, calcitonin, and zoledronate, his serum calcium normalized after about three days and mental status improved back to baseline. Positron emission tomography with 2-deoxy-2-[18F] fluoro-D-glucose integrated with computed tomography (18F-FDG PET/CT) showed a large FDG-avid massin the left upper lobe involving the left hilum and left prevascular region (Panel A), and also an asymmetrically increased FDG uptake within the right vocal fold (Panel B, arrow; Panel C) (Figure 1) likely secondary to left vocal fold paralysis from left recurrent laryngeal nerve compression. Bedside flexible laryngoscopy was consistent with left vocal fold paralysis fixed in medial position. He was discharged with outpatient plans for chemotherapy initiation, and injection laryngoplasty for a stronger cough, voice restoration, and airway protection. However, his hypercalcemia progressively became refractory to calcitonin, bisphosphonates and denosumab delaying chemotherapy as well as his laryngoplasty. He started radiation therapy in the interim, but ultimately succumbed to the disease threemonthslater.

Declaration of Interests: The authors declare that they have no competing interests.