Choriocarcinoma Syndrome: A Rare and Serious Complication of Testicular Germ Cell Tumors

Choriocarcinoma syndrome is a rare complication of metastatic germ cell tumors. The hallmark of the condition is metastatic tumor hemorrhage. We describe the case of a 28-year-old man with metastatic testicular choriocarcinoma who presented with dyspnea on exertion and lightheadedness. Symptoms started two days after completing cycle one of fractionated bleomycin, etoposide, and cisplatin (BEP) chemotherapy. Laboratory investigations showed severe anemia, with a hemoglobin of 5.4 mg/dL (normal: 13-17 mg/dL). His baseline hemoglobin was 15.1 mg/dL before chemotherapy initiation. Coagulation and hemolysis workup showed no significant evidence of disseminated intravascular coagulopathy or autoimmune hemolysis. Imaging showed a significant increase in the size of previous metastatic liver lesions with surrounding hypodensity representing hemorrhage. He was admitted to the intensive care unit and started on massive transfusion protocol. On the same day, he developed a maroon-colored stool. Urgent upper endoscopy showed blood in the entire stomach and the second part of the duodenum spurting out through the ampulla, which suggested bleeding from metastatic liver lesions into the biliary tree. No defined culprit vessel was identified on visceral angiography. Endoscopic and surgical interventions were unlikely to be successful in controlling the bleeding due to the diffuse nature. He underwent one dose of radiation therapy to the abdomen, which was successful in controlling the bleeding. He survived, and his chemotherapy was switched to etoposide, ifosfamide, and cisplatin (VIP) with no further episodes of bleeding.