FEVER AND PAINFUL BREAST SWELLING IN A 36 -YEAR-OLD MAN - UNUSUAL PRESENTATION OF AN EXTRAGONADAL CHORIOCARCINOMA

History and clinical findings: One week after returning from a two-wee k holiday in Sri Lanka a 35-year-old man started to have recurrent bou ts of fever, up to 39.2 degrees C, as well as pain over the left upper abdomen, the back of the right thorax and bilateral pain on pressure with swelling of both breasts. He went to the Tropical Institute in Mu nich to have malaria excluded. There signs of cholestasis were noted a nd sonography revealed multiple round foci in the liver. As he had los t 10 kg in 3 weeks he was admitted to a medical unit for further tests . Physical examination now showed bilateral gynaecomastia and marked p ressure resistance in the upper abdomen. Proprioceptor reflexes were g reatly increased but: equal bilaterally Investigations: inflammatory p arameters were raised (C-reactive protein 22.6 mg/dl, ferritin level 2 674 mu g/l, erythrocyte sedimentation rate 50/82 mm), there also were a leucocytosis (20,600 WBC/mm(3)) and a raised lactate dehydrogenase l evel of 613 U/l. In addition, thyroid stimulating hormone was reduced to < 0.03 mu U/ml, white free thyroxine was raised to 2.7 ng/dl. The p regnancy test was positive. On quantitative analysis the human beta-ch orionic gonadotropin (hCG) level was markedly raised to 193,200 mlU/ml . Abdominal and thoracic computed tomography revealed multiple round m etastasis-like masses in the liver and in the lung, and a thickened ca rdia. Serology for malaria, amoebiasis and echinococciasis was negativ e, sonography of the testes and thyroid was unremarkable. Endoscopy re vealed a polypoid tumour at the gastrooesophageal junction which histo logically was an undifferentiated hCG-positive choriocarcinoma. Treatm ent and course: The neoplasm at first responded with partial remission (hCG minimally 39 mlU/ml) to chemotherapy (PEI schema: cisplatin, eto poside, ifosfamide) but then progressed, also under treatment of recur rences with paclitaxel, ifosfamide and cisplatin, The patient has sinc e received high-dosage chemotherapy with autologous stem-cell transpla ntation.