Cáncer Esófagico Caso Clínico

5.- NEOPLASIAS ESOFAGICAS:

CASO CLINICO No. 4

A 57-year-old man was admitted to the medical service with a 4- to 5-month history of progressive dysphagia, initially to solids and then liquids, resulting in a 30-pound weight loss. He also noted a mid-epigastric burning sensation. He denied nausea, vomiting, bleeding, fever, chills, night sweats, or cough. He was given amoxicillin withoutimprovement.
Past medical history/medications: The patient's past medical history was remarkable for coronary artery disease, and he was status post coronary artery bypass graft in 1998. He had a history of hypertension, hypercholesterolemia, depression, glaucoma, and tuberculosis (treated with 6 months of antibiotic therapy) in the 1980s. His medications included aspirin, 325 mg/day; lisinopril;simvastatin; atenolol; terazosin; flunisolide; and rabeprazole, 20 mg/day.
Family and social history: Family history was negative for gastrointestinal malignancies. He had a long history of heavy smoking (1.5-2.0 packs per day for 42 years) and heavy alcohol use until 10 years ago. There was no history of intravenous-drug abuse and no prior blood transfusions. He reported a negative HIV test takenyears ago.
Physical exam: Results of physical examination revealed a thin, ill-appearing man. His temperature was 100.1°F. Head, eyes, ears, nose, and throat (HEENT) exam was normal. Neck exam revealed shotty, supraclavicular lymphadenopathy. His chest was clear, with a soft systolic murmur. The abdomen was soft, nontender, and nondistended; there was no organomegaly or mass.
Laboratorystudies: Results of laboratory investigations revealed the following: white blood cell count, 35.5 x 103 cells/mcL (with 46% neutrophils, 8% lymphocytes, 3% monocytes, 8% eosinophils, and 34% bands); hemoglobin, 8.2 g/dL; mean corpuscular volume, 79.8 fL; red (cell) distribution width (RDW), 15%; platelets, 525 x 103 cells; iron, 12 mcg/dL; transferrin, < 70 mg/dL; ferritin, 565 ng/mL; reticulocytecount, 1.6%; and albumin, 2.4 g/dL.
Initial studies: Chest x-ray showed interstitial infiltrates of the right upper lobe and left upper lobe. The patient had continued low-grade fevers and persistent leukocytosis (white blood cell count, 20-30 x 103 cells/mcL). Three sputum samples were negative for acid-fast bacilli.

Valores normales.

Hematocrit Male: 45 - 62% Female: 37 - 48%Hemoglobin Male: 13 - 18 gm/dL Female: 12 - 16 gm/dL
Iron 60 - 160 µg/dL (normally higher in males)
Iron-binding Capacity 250 - 460 µg/dL

Mean Corpuscular Hemoglobin (MCH) 27 - 32 pg/cell
Mean Corpuscular Hemoglobin Concentration (MCHC) 32 - 36% hemoglobin/cell
Mean Corpuscular Volume (MCV) 76 - 100 cu µm

Proteins:    Total 6.0 - 8.4 gm/dL   
Albumin 3.5 - 5.0 gm/dL   
Globulin 2.3 -3.5 gm/dL Prothrombin (PTT) 25 - 41 sec
Normal values for total WBC and differential in adult males and females are:
Total WBC: 4,500 - 10,000
Bands or stabs: 3 - 5 %
Neutrophils (or segs): 50 - 70% relative value (2500-7000 absolute value)
Eosinophils: 1 - 3% relative value (100-300 absolute value)
Basophils: 0.4% - 1% relative value (40-100 absolute value)
Lymphocytes: 25 - 35%relative value (1700-3500 absolute value)
Moncytes: 4 - 6% relative value (200-600 absolute value)

Paciente masculino de 62 años, jubilado, acude a consulta por cuadro clínico iniciado hace 5 meses caracterizado por disfagia y astenia. La disfagia de carácter progresivo a sólidos y posteriormente también a líquidos, desde hace 3 semanas se acompaña de dolor retroesternal de carácter opresivo,intensidad moderada, que se intensifica al ingerir sólidos o alimentos irritantes. Antecedentes heredofamiliares de diabetes mellitus tipo II y cardiopatía isquémica. Diagnóstico de hipertensión arterial hace 6 años, tratado con enalapril. Etilismo positivo: 10 cervezas semanales y whisky ocasional, desde los 18 hasta los 55 años. Tabaquismo positivo: 5 cigarrillos diarios desde los 25 años, y una...