Apical Malignant Pleural Mesothelioma Presenting as Horner's Syndrome: A Case Report

Our plain-English summary of Apical Malignant Pleural Mesothelioma Presenting as Horner's Syndrome: A Case Report, by S. Mankal, C. Jacobs (Curēus, 2025).

The study

• Authors: S. Mankal, C. Jacobs
• Journal: Curēus
• Published: 2025;17(10):e94484
• Type of article: Case report
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Horner's syndrome is a well-recognized presentation of apical lung tumors, though rarely associated with malignant pleural mesothelioma (MPM), with only a few cases documented. We report the case of an 82-year-old man with persistent right-sided chest pain who developed unilateral right-sided ptosis, miosis and a sunken appearance to the eye, in the context of known asbestos exposure. Initial chest radiograph was reported as normal; however, subsequent computed tomography revealed an irregular right apical pleural mass measuring 7.0×4.3×7.5 cm. Biopsy with immunohistochemistry confirmed sarcomatoid MPM. This case report illustrates apical MPM mimicking Pancoast syndrome through compression of the upper thoracic sympathetic chain, resulting in preganglionic Horner's syndrome characterized by unilateral ptosis, miosis and anhidrosis ipsilateral to the lesion. In patients with known asbestos exposure, persistent respiratory symptoms should prompt a thorough investigation for MPM. The presence of preganglionic Horner's syndrome alone, or in combination with brachial plexopathy (arm pain, paresthesia or weakness, shoulder pain, or chest pain) - termed Pancoast syndrome, should heighten clinical suspicion of apical MPM. Cross-sectional imaging should be considered in all cases with a high index of suspicion, even if initial radiographs appear normal. Early recognition may facilitate timely diagnosis. This report contributes valuable insight to the limited literature documenting the association between apical MPM and pre-ganglionic Horner's syndrome.

Copyright © 2025, Mankal et al.

In plain English

This case report described one 82-year-old man who had occupational asbestos exposure from working as a railway fitter and a 20-pack-year smoking history. The article did not state the type of asbestos. He first had two months of right-sided chest pain that did not improve with antibiotics. A chest X-ray taken during that period was reported as normal, although the published image is labelled as showing subtle shading in the right upper zone. Two months later he developed a tremor in his right arm and signs of Horner's syndrome in the right eye: a drooping eyelid, a small pupil and a sunken appearance. A CT scan showed an irregular mass at the top of the right pleura measuring 7.0 by 4.3 by 7.5 cm. A biopsy confirmed sarcomatoid malignant pleural mesothelioma. He was judged unfit for chemotherapy, received palliative care, and died of metastases nine months after his symptoms began. The authors concluded that Horner's syndrome in this patient with prior asbestos exposure was a key sign that prompted investigation. They also concluded that CT should be considered when suspicion remains high, even if an X-ray looks normal.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Case report (one patient)
• Who was studied: One 82-year-old man first seen in primary care. The authors are based at Great Western Hospital NHS Foundation Trust, Swindon, UK; dates of care are not stated.
• Exposure: Occupational asbestos exposure as a railway fitter (fiber type not stated), plus a 20-pack-year smoking history
• Main results:
  • In this patient, a chest radiograph taken during the first two months of chest pain was reported as normal. The figure caption describes subtle opacification in the right upper zone.
  • Two months later the patient developed a right arm tremor, and examination showed Horner's syndrome on the right side.
  • CT of the thorax showed a lobulated right apical pleural mass measuring 7.0 x 4.3 x 7.5 cm, with displacement of the superior vena cava and pretracheal lymphadenopathy.
  • Biopsy and immunohistochemistry were consistent with sarcomatoid mesothelioma, confirming malignant pleural mesothelioma.
  • The patient was deemed unfit for chemotherapy, managed palliatively, and died nine months from symptom onset secondary to metastases.
• The authors' conclusion: The authors concluded that preganglionic Horner's syndrome in this patient with prior asbestos exposure was a key clinical indicator that prompted investigation. They also concluded that radiologist review and cross-sectional imaging are needed when suspicion remains high despite normal radiographs.
• Limitations the authors state:
  • The authors note that anhidrosis (absence of sweating), part of the classic triad, was not documented in this case.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Horner Syndrome, Asbestos Exposure, Chest X-Ray, Biopsy, Immunohistochemistry, Sarcomatoid.

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