Case Presentation: A 25 year old male with history of recurrent left seminoma, on Cycle one and Day 15 of bleomycin, etoposide, and platinum (BEP) combination chemotherapy admitted from infusion center reporting new onset of dry cough, shortness of breath, solid food odynophagia and dysphagia. Symptoms began suddenly after a meal of chicken with rice. He also endorsed mild discomfort in his chest while supine. Patient denied sick contacts. Last BEP treatment was one week prior. BEP treatment was held now. Physical exam showed stable vitals; Oropharyngeal, Neck, Heart – benign; Chest – Mediport right upper chest intact. No skin changes. Labs: White blood cell count showed leukopenia to 1.3K, absolute neutrophils count was 100.Imaging: Chest X-ray (CXR). (Image 1) – Mediport distal tip was coursing into neck abnormally within right internal jugular vein (IJV). CT Chest angiogram ruled out Pulmonary embolism. Interventional Radiology provider repositioned the Mediport catheter back into its expected position, cavo-atrial junction (Image 2). Patient reported immediate resolution of dysphagia, cough and shortness of breath and tolerated regular diet.
Discussion: This is a unique case of symptomatic Mediport tip migration into right Internal Jugular Vein (IJV). Risk factors are left-sided catheters, changes in thoracic cavity pressure (weight-lifting, straining, etc), high flow infusion rate, congestive heart failure. Clinical presentation can be asymptomatic, development of thrombophlebitis and/or neck, shoulder and ear pain. Pathophysiology of symptoms in this case explained as that the Vagus nerve accompanies the IJV medially in the carotid sheath and lies between the artery and vein. Inferior ganglion branch of Vagus nerve serves the muscles of pharynx. In this patient most likely, abutting of mediport catheter tip to Vagus nerve led to his symptoms. And upon catheter tip retraction from IJV and repositioning it to normal cavo-atrial junction resolved cough, dysphagia and odynophagia symptoms.
Conclusions: We learned that the differential for a new dry cough, shortness of breath, odynophagia, and dysphagia should be broad and to include referred symptoms from hardware related spontaneous catheter tip migration into the right IJV in a patient receiving chemotherapy to treat underlying malignancy.
