Description

A 63 year old man was admitted with fever, increasing breathlessness, cough with green sputum, weight loss, and loss of appetite. He was a heavy smoker and drinker. Other past medical history included depression, and benign oesophageal stricture. He had persistently abnormal liver function tests (raised g-glutamyl transferase, and alkaline phosphatase) over the past 3-4 years that were attributed to a high alcohol intake. Barium enema and flexible sigmoidoscopy done 5 years ago for investigation of weight loss were normal and subsequently his weight had increased until this recent episode.

Examination revealed a pale emaciated man with a temperature of 38.50C, hepatomegaly with a firm non-tender liver edge palpable 2 cm below the costal margin and signs of right lower lobe consolidation of the lung. He had gingivitis and extensive caries. There were no heart murmurs. Laboratory findings included a Hb of 7.3 g/l, white cell count of 5.2×109/l, microscopic haematuria, urea nitrogen of 4.1 mmol/l, and creatinine of 82umol/l. Liver function tests revealed alkaline phosphatase level of 330 IU/l, and the g-glutamyl transferase was 10IU/l. Sputum culture showed no growth.

CXR revealed right lower lobe consolidation and bilateral pleural effusions. Bronchoscopy was done to exclude malignancy and was normal. Ultra-sound scan of the abdomen, upper gastro-intestinal endoscopy and barium enema were all normal.