16 August 2018

Published by Oxford University Press on behalf of the Association of Physicians 

QJM: An International Journal of Medicine, 2017, 187

doi: 10.1093/qjmed/hcw201

Photographs and text from: C.V. Tong and W.L. Chai, From the Medical Department, Hospital Melaka, Melaka, Malaysia 

Our patient is a 31-year-old lady who delivered her third child 3 months prior to the current admission. The delivery was uneventful but she continued to have per vaginal spotting occasionally. She presented with cough and breathlessness for 2 months associated with significant weight and appetite loss. On examination she was pale and tachycardic. She had fine tremor but no goiter or Grave’s opthalmopathy. Breath sounds were reduced bilaterally.

Endocrine team was consulted as her thyroid function test showed freeT4 of 50 pmol/l with suppressed thyroid stimulating hormone (TSH) of <0.01 mIU/L. There were multiple canon ball lesions bilaterally in her chest x-ray (Figure 1). Beta human chorionic gonadotrophin (HCG) was markedly elevated (>200 000 mIU/ml). Trans-abdominal ultrasound revealed uterine mass with snowstorm appearance. 250 cc vesicle-like tissue was removed during evacuation. Histopathology examination of endometrial tissue was consistent with choriocarcinoma. Hyperthyroidism was treated with Lugol’s iodine, Carbimazole and propanolol.

Chemotherapy Methotrexate, Actinomycin and Etoposide) was initiated post surgery. Her thyroid function test improved dramatically with reduction of Beta HCG. Pulmonary metastases, seen in up to 54% of extrathoracic malignancies, are reached through hematogenous, lymphatics, pleural space, airway or direct invasion.1,2 One of the commonest cause of canon ball metastases is indeed choriocarcinoma. Hyperthyroidism in gestational throphoblastic disease occurs due to molecular mimicry between HCG and TSH and resolves with treatment of the underlying condition.3 

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