LAUSR

Introduction We present a 41 year old female, HIV positive, on antiretroviral therapy with a CD4 count of 387 and a suppressed viral load. She was diagnosed and treated for tuberculosis in 2008. She presented with hemoptysis and chest pain at 27 + 4 weeks in her fourth pregnancy. She had an early first trimester miscarriage in 2016, documented with a B-HCG of 364. She was hypoxic and in respiratory failure. A chest Xray revealed multiple, bilateral round lesions. A CT scan confirmed cannon ball lesions in the lung fields. An obstetric ultrasound done ten days prior to presentation showed a normal intrauterine pregnancy with a smooth normal placenta. Three days after presentation the patient passed away after a failed resuscitation attempt. Results On post mortem examination her cause of death was found to be a massive hemorrhage secondary to a ruptured metastatic choriocarcinoma lesion lying adjacent to her spleen. The patient had several hemorrhagic lesions in both lungs. The placenta and uterus showed no evidence of tumor. All other organ structures were normal. Discussion Choriocarcinoma is a malignancy of the syncytiotrophoblast or cytotrophoblast and can arise during or after any gestation. It is usually preceded by a molar pregnancy or miscarriage. Choriocarcinoma coexisting with a normal viable pregnancy is extremely rare, with an estimated occurrence of 1 per 160 000 pregnancies. There are case reports in the literature of choriocarcinoma presenting with metastasis that responded well to chemotherapy. Unfortunately a delay in diagnosis lead to this woman’s death. It is important that choriocarcinoma be recognised as a rare yet dangerous cause of breathlessness and chest pain in otherwise healthy pregnant women. It is also important to consider choriocarcinoma as a differential diagnosis of multiple round lesions on a chest Xray in the HIV community.