Superior vena cava obstruction presenting as acute allergy

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Abstract

Conflict of interest: none declared. We report a case of apparent acute allergy, the underlying cause of which was found to be superior vena cava obstruction (SVCO). A 57‐year‐old woman presented to an allergy clinic with a 4‐month history of persistent facial swelling, which she reported had started after a ‘flu‐like’ illness and nasal congestion. No improvement had occurred despite six courses of oral antibiotics. Blood tests had shown eosinophilia, leading her general practitioner to start the patient on fexofenadine and prednisolone for presumed ‘allergy’. Owing to her persistent facial swelling, the patient attributed her ‘reactions’ to a number of food types. Despite her avoidance of dairy products, fish and eggs, there was no improvement in her symptoms. She was a life‐long smoker, and her medical history included chronic obstructive pulmonary disease and osteoporosis. Her regular medications included codydramol, lansoprazole and alendronate. The patient was referred to a dermatologist, but 1 month before this appointment was due, she presented to the accident and emergency department with acute breathlessness and swelling of her face and arms. She was given intravenous hydrocortisone and chlorphenamine. The trigger for this episode was unclear, but blood tests (full blood count, renal and liver function) and chest radiograph were reported as normal. She had a plethoric complexion with facial swelling and marked bilateral infraorbital oedema (Fig. 1a). There were prominent veins on her chest wall and flanks, with a raised jugular venous pressure (Fig. 2b–d). Her right arm was more swollen than the left, with finger clubbing and nicotine staining of all fingernails (Fig. 2a). The differential diagnosis included dermatomyositis and SVCO.

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