Germ cell tumors occur in a younger population and can present with aggressive metastatic disease. We are presenting an elderly gentleman with respiratory failure due to an extragonadal mixed germ cell tumor.
Patient was a 76 year old white male with past medical history of hypertension and microscopic hematuria who was in his usual state of health until three days prior to admission when he developed acute back pain and gross hematuria. He was admitted to a local hospital and was treated for an enterococcal urinary tract infection. Patient’s chest radiograph on admission was significant for bilateral nodular infiltrates that were not present on a chest radiograph performed two weeks prior to admission. Patient denied chest pain, shortness of breath, fever, chills, night sweats, weight loss, or hemoptysis.The patient’s past medical history included benign prostatic hypertrophy, essential tremor, bladder diverticulae. His outpatient medications included aspirin, clopidogrel, atenolol, finasteride, primidone, and terazosin. Patient was a former heavy smoker and alcohol user, but he denied any illicit drug use. He had not traveled recently, had no pets, and denied ill contacts. He served in the military during the Korean War, and was a retired maintenance worker. Patient had a chest CT which showed multiple nodules (Figure 1), as well as bilateral pleural effusions without airspace disease or mediastinal lymphadenopathy. On hospital day 3, patient developed a cough with brown sputum and became hypoxic; broad spectrum antibiotics were started. Flexible bronchoscopy revealed no endobronchial abnormalities. Transbronchial biopsies and bronchoalveolar lavage specimens were non diagnostic. Patient was referred to our institution for an open lung biopsy. Upon transfer, hospital day 7, patient was in moderate respiratory distress, requiring a 100% non-rebreather mask to achieve a oxygen saturation above 90%. He was afebrile and hemodynamically stable. Physical exam was significant for no palpable lymphadenopathy, decreased breath sounds at both bases, no murmurs, and no hepatosplenomegaly. His genitourinary exam was remarkable for an enlarged left testicle, which was smooth and without discrete mass. The white blood cell count 8X103cells/mm3 with normal differential, hemoglobin 14.4 g/dL, lactate dehydrogenase 233U/L, ESR 27mm/60sec. Urinalysis revealed no proteinuria or casts. HIV serology was negative, as were blood and urine cultures. Urinary legionella and histoplasma antigens were negative, as was a serum cryptococcal antigen. Antinuclear cytoplasmic antibodies were negative. The presence of asymmetric testes prompted a serum beta HcG that was 2318 mIU/ml, however, a testicular ultrasound showed no testicular mass. The open lung biopsy revealed a mixed germ cell tumor which stained positive for beta HcG (Figure 2). Thyroid transcription factor 1, alpha-fetoprotein, and CD 30 markers were negative. Despite treatment with cisplatin, patient remained on mechanical ventilation and his radiographs revealed persistent infiltrates. Nine days after his last dose of chemotherapy patient had a PEA arrest and expired.
Mixed germ cell tumors account for one third of all germ cell tumors and the average age at diagnosis is 30 years of age. Tissue diagnosis is imperative, due to favorable outcomes with chemotherapy. Extragonadal germ cell tumors usually present with a primary focus either in the mediastinum or retroperitnoeum without evidence of malignancy in the testes or ovaries. In our patient no primary focus was identified.
This case illustrates a rapidly progressive course of an extragonadal mixed germ cell tumor associated with hypoxemic respiratory failure. To our knowledge no cases of a mixed germ cell tumor with progressive respiratory failure have been reported. Our case illustrates how germ cell tumors must be part of the differential diagnosis in a patient with diffuse, rapidly progressive pulmonary lesions.
Sam Parsia, None.