We report the case of a 51-year-old male diagnosed with metastatic lung adenocarcinoma, with hepatic involvement, right supraclavicular and bilateral pulmonary nodules.
The patient had been previously treated with four lines of chemotherapy including cisplatin-pemetrexed-becomeizumab, cisplatin-gemcitabine, docetaxel, and Irinotecan monotherapy.
The patient was admitted to our hospital with fever due to a presacral abscess, being surgically drained by the General Surgery Department and receiving antibiotic coverage according to the antibiogram.
During admission, the patient required third step analgesic medication with subcutaneous morphine 5 milligrams every 4 hours.
The pain was mainly located in the right hypochondrium in relation to the tumoral hepatic affectation and, less intensely, in the perianal area by surgical debridement.
Both pains were acceptablely well controlled, rated as 4/10 on the verbal numerical scale (VNS).
After a week with this medication the patient reported highly structured visual disturbances (see family members not present in the room) that the patient recognized as non-real.
She did not present myoclonus or somnolence and maintained a good rhythm with laxative treatment.
The minimental test was normal.
A new severe pain (EVN 10/10) in the right shoulder that, due to its characteristics, suggested tendinous or muscular alteration was diagnosed.
The patient denied having suffered any recent trauma in this location.
Ultrasonography of the area was performed without any alteration that would justify the pain and the previous CT images were reviewed without observing bone lesion in this location.
Blood tests were performed, highlighting: total bilirubin 1.52 mg/dL (normal <1.2 mg/dL), TOG 156 IU/L (normal <46 mEq/L), normal creatinine 1.546 mEq/L (normal range 0.846 mEq/L).
Brain magnetic resonance was also performed, which was normal, ruling out tumor involvement.
Intravenous magnesium was administered for the first 24 hours and orally thereafter with excellent tolerance.
Twenty-four hours later, the patient had seizures and 48 hours later the shoulder pain disappeared.
Analytical control was performed 48 hours later, observing total bilirubin 1.47 mg/dL, AST/ ALT 252/223 IU/L, creatinine 0.8 mg/dL, magnesium 2.1 mEq/L, calcium 8.1 μg.
The patient maintained good control of other pains with the opioid regimen, with no subsequent presentation of seizures and maintaining correct levels of magnesium and calcium in blood in the control analyses performed.
