Unusual presentation of more common disease/injury

CASE REPORT

An unusual cause of a fall: an unusual presentation
of lung carcinoma
Xin-Ying Kowa,1 Catherine Hyams,1 Mark Farrugia,2 Sara Lightowlers1
1

Care of the Elderly, Newham
University Hospital,
London, UK
2
Radiology Department,
Newham University Hospital,
London, UK
Correspondence to
Dr Catherine Hyams,
catherinehyams@doctors.org.uk
Accepted 11 April 2014

SUMMARY
An 80-year-old gentleman presented with a fall and
subtle symptoms suggestive of a cerebellar lesion, on a
background of hemiparesis due to a previous cerebral
vascular accident. On admission it was thought that
changes on a chest radiograph were consistent with a
community-acquired pneumonia. A CT of the head
showed a space-occupying lesion in the right cerebellum
with surrounding oedema. A previous MRI of the brain
performed 8 months earlier for investigation of dementia
showed evidence of this lesion although it was
significantly smaller and without midline shift; however,
this had not been discussed on the MRI report. A
subsequent CT of the thorax confirmed a thick-walled
cavitating mass in the left upper lobe, with biopsy of this
lesion and bronchial washings showing metaplastic and
atypical cells suggestive of adenocarcinoma. This report
highlights both the importance of accurate imaging
reporting, even of incidental findings, and the insidious
nature of lung malignancy and its broad clinical
presentation.

BACKGROUND
▸ Highlights the insidious nature of lung malignancy, and its broad presentation in clinical
practice.
▸ Highlighted the importance of accurate radiology reporting and awareness of the importance of incidental findings on radiological
investigations.
▸ Differential diagnoses of falls in the elderly.
▸ Differentials of a cavitating mass in the lung.

CASE PRESENTATION

To cite: Kowa X-Y,
Hyams C, Farrugia M, et al.
BMJ Case Rep Published
online: [ please include Day
Month Year] doi:10.1136/
bcr-2013-203019

An 80-year-old gentleman presented following a
fall to the floor, which had occurred from a sitting
position while the patient was at prayer. Witnesses
to the fall report that the patient did not loose consciousness, and did not have convulsive activity
although they believed that the patient did lightly
hit his head on the floor. The patient had complained of headaches and a sensation of ‘fullness in
the head’ over the preceding week. He did not feel
nauseous, and his headache seemed to be a dull
ache that was constant and independent of position
or movement. The patient denied any visual disturbance, denied dizziness or vertigo, and had not
noted any limb weakness or problems in mobilising
himself in comparison to normal. However, his
family had noted that he was becoming increasingly
unsteady on his feet and that his gait had deteriorated, with a tendency to fall to the right. In addition, the family had also observed that over the

Kowa X-Y, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203019

preceding few weeks the patient had intermittently
been unable to fully open his left eye. The patient
had also experienced a cough with yellow sputum
production in the week before admission, but
denied fevers or sweats. Neither he nor his family
had noticed any weight loss. On systems review no
notable cardiovascular, urinary or abdominal symptoms were discovered.
The patient’s medical history included a rightsided cerebrovascular accident leaving a mild left
side residual weakness. There was also a history of
Alzheimer’s dementia, along with bilateral deafness.
The patient also suffered from hypertension, hypercholesterolaemia, benign prostatic hypertrophy and
glaucoma. There was no history of tuberculosis.
The patient currently lives with his family at home,
who had noticed a general deterioration in his level
of independence over the month prior to admission. They felt that he was beginning to require
some assistance with the activities of daily living,
and now required a stick to mobilise. The patient
had never consumed alcohol, had a 50-pack-year
history of smoking but had stopped smoking about
10 years previously. He had previously worked in
an industrial factory, although it was unclear as to
whether he may have been exposed to asbestos.
On examination of the patient, his respiratory rate
was 17 and his saturations were 96% on room air.
His pulse was 78 bpm, with a blood pressure of
138/68 mm Hg and he was afebrile. He was noted to
have coarse crackles in the left lung in the lower and
mid-zones. Cardiovascular examination revealed an
ejection systolic murmur. His abdominal examination
was unremarkable and there was no palpable cervical,
axillary or inguinal lymphadenopathy.
Examination of the cranial nerves revealed horizontal nystagmus to the right and his left eyelid was
reported as droopy. Other than his known hearing
impairment, there was no other cranial nerve
lesion. His upper limb examination revealed evidence of mild proximal weakness (4/5) consistent
with the patient’s previous cerebral vascular accident (CVA). There was no noted sensory deficit or
loss of joint position sense. There was some evidence of dysmetria in the upper as well as lower
limbs, worse on the right than the left. He was
noted to have an unsteady gait on mobilisation
which was difficult to classify, and was positive for
Romberg’s sign to the right side.

INVESTIGATIONS AND TREATMENT
Admission blood tests showed a normocytic
anaemia (haemoglobin 10.9 g/dL, mean corpuscular volume 85 fL), raised white cell count
1

Unusual presentation of more common disease/injury
(12.2×109/L) with predominant neutrophilia (9.2×109/L). His
C reactive protein was mildly elevated (38.2 mg/L). His renal
function was at baseline, with creatinine 165 mg/dL, urea 8.3 g/
dL and calculated epidermal growth factor receptor 37 mL/min/
1.73 m2. Liver function tests showed bilirubin 7 mg/dL, alkaline
phosphatase 101 mg/dL, alanine transaminase 9 units/L,
albumin 29 g/dL. A bone profile was normal with corrected
calcium of 2.26 mg/dL and phosphate 1.1 mg/dL.
A urine dipstick test had some evidence of mild proteinuria
( protein 1+) but did not reveal any evidence of infection. His
admission chest radiograph (figure 1) was interpreted as
showing consolidation in the left mid and lower zones, in
keeping with a diagnosis of community-acquired pneumonia.
The patient was empirically started on co-amoxiclav and clarithromycin, in keeping with local hospital and BTS guidelines.
The patient’s new onset nystagmus and gait instability was
investigated using a non-contrast CT of the head. This revealed
an ill-defined, low-density lesion within the right cerebellar
hemisphere measuring approximately 2.5 cm in diameter (figure
2A). There was evidence of midline shift of the cerebellum, and
surrounding oedema, but no evidence of hydrocephalus was
seen. Old lacunar infarcts were noted in the basal ganglia and
there was evidence of periventricular change. There was no evidence of intracranial haemorrhage, collection or cerebral infarct.
Following neurosurgical advice MRI of the brain was
obtained (figure 2B, C), and the patient was started on highdose dexamethasone to reduce oedema and decrease the risk of
occlusion of the fourth ventricle. T1-weighted postgadolinium
MRI of the head showed a 2.5×2 cm ring-enhancing lesion at a
similar level. There was extensive vasogenic oedema, midline
shift of the medulla oblongata and some compression on the
fourth ventricle. Old areas of ischaemia and generalised cerebral
atrophy were identified in keeping with previous imaging.
Retrieval of archived radiological images revealed MRI of the
brain that had been performed 8 months previously, for investigation of the patient’s dementia. An ill-defined 15 mm slightly
hyperintense lesion involving the right superior cerebellar peduncle could clearly be seen on MRI of the brain taken at this
time (figure 2D), however it was not commented on in the
formal radiology report and was not noted by the clinicians
reviewing MRI of the brain imaging. Hence the lesion was
noted to have significantly expanded in the interceding
8 months, during which time the patient had not undergone
further investigation or treatment.

Figure 2 (A) A non-contrast CT of the head obtained in August 2013,
showing a large ill-defined low-density lesion involving the right
cerebellar hemisphere with extensive vasogenic oedema and midline
shift of the medulla oblongata. (B) Axial T2-weighted (T2W) MRI of the
brain at the level of the posterior fossa showing a large ill-defined right
cerebellar mass with surrounding vasogenic oedema and midline shift,
obtained in August 2013. Compared to the previous MRI, the lesion is
occupying a larger volume and there is an increase in the surrounding
oedema. (C) Axial T1W postgadolinium MRI of the brain at the level of
the posterior fossa showing a ring-enhancing 2.5 cm lesion with
surrounding vasogenic oedema causing mild midline shift, also
obtained in August 2013. (D) Axial T2W image through the posterior
fossa showing an ill-defined 15 mm slightly hyperintense lesion
involving the right superior cerebellar peduncle, taken in January 2013.

Given the range of differential diagnoses, the patient underwent a CT of the thorax, abdomen and pelvis. CT of the thorax
revealed a cavitating lesion measuring 7×5 cm in the left upper
lobe (figure 3A–C) with the presence of mediastinal lymphadenopathy. There was also a moderate left-sided pleural effusion.
The patient underwent a bronchoscopy under the respiratory
physicians for grading of the presumed malignancy. Bronchial
washings revealed large atypical cells suggestive of adenocarcinoma with accompanying neutrophil polymorphs. Bronchial
biopsies showed focal squamous metaplasia but no granulomatous inflammation, dysplasia or malignancy.

DIFFERENTIAL DIAGNOSIS

Figure 1 Anteroposterior chest radiograph taken on admission in
August 2013, showing extensive left basal consolidation.
2

The potential differential diagnosis for the brain imaging in isolation includes a primary brain lesion such as an astrocytoma,
glioma, haemangioblastoma or lymphoma or a secondary brain
tumour with an unknown primary.1 A tuberculoma or brain
abscess are also possible differentials,2 3 although are less likely
given the appearance of the mass on radiological investigations.
In addition, toxoplasmosis can occasionally cause a single
lesion4 and is found in the context of the late phase of HIV
infection.
The differential diagnosis of a cavitating lesion in the lung
alongside a ring-enhancing lesion in the cerebellum includes
malignancy, tuberculosis and abscesses that have seeded to multiple sites.5 Furthermore, there is the possibility of dual pathology, with no histopathology sample available from the
cerebellar lesion. However, given the radiological imaging,
Kowa X-Y, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203019

Unusual presentation of more common disease/injury
OUTCOME AND FOLLOW-UP
Following discussion at a respiratory multi-disciplinary team
(MDT), the patient was diagnosed as having stage III lung
cancer with a radiological staging T3N3M1. It was felt that
this malignancy was most likely an adenocarcinoma, and given
the patient’s comorbidities that a palliative approach was most
suitable. The patient responded to the high-dose dexamethasone treatment from a neurological point of view, and did not
undergo palliative radiotherapy. He was discharged home once
medically fit to the on-going care of his family, with regular
oncology and palliative care follow-up.

DISCUSSION

Figure 3 (A) Axial, (B) coronal and (C) sagittal sections of CT of the
thorax (August 2013) showing a 7×5 cm thick-walled cavitating mass
in the left-upper lobe and a moderate-sized left pleural effusion.

histopathology specimens and patient’s significant smoking
history as well as possible asbestos exposure, it was felt that the
findings were most likely to represent a primary lung malignancy with metastasis to the cerebellum. Ziehl-Nielson staining
was negative, and there was no growth in blood or sputum cultures for Mycobacterium.
Kowa X-Y, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203019

One in three people over 65 years old falls each year,6 and falls
remain the leading cause of fatal and non-fatal injury in this
population of patients.7 Elderly patients frequently present to
hospital following a fall, and it is recognised that there are a
large number of conditions that can precipitate such events,
including pathology such as stroke, epileptic activity, vasovagal
syncope, musculoskeletal disease and the side effect of medication as a consequence of polypharmacy.8 9 Elderly patients are
particularly susceptible to deterioration or delirium following
infection,10 and this accounts for a large proportion of geriatric
patients seen by acute medical teams.11 Often the precise cause
for a patient’s fall may remain elusive, and thorough investigation is needed to try to determine the underlying pathology.
Investigation of patients who have fallen should include postural
blood pressure measurements, 12-lead ECG, blood tests including full blood count, renal profile, bone profile, blood sugar
measurement and septic screen.12 Further investigations may
include an echocardiogram, ambulatory blood pressure and
ECG recording, brain imaging, tilt table testing and may follow
on from the results of initial investigation results. It is important
to ensure that elderly patients have their medication rationalised
to try to reduce the risks associated with polypharmacy.13
This case highlights how a fall can be caused by an unusual
and unsuspected pathology. Furthermore, new neurological
disease can be difficult to diagnose on the background of previous or underlying known disease. Hence it is important that
every patient presenting with a fall should undergo a complete
neurological examination by the responsible clinicians.12 In this
instance, the patient’s previous CVA and dementia possibly
delayed diagnosis of his underlying condition, as the family had
attributed his deterioration to his existing conditions.
Lung malignancy is frequently insidious in nature, and this
case report highlights the incidental presentation of such
patients to clinicians. Hence lung malignancy is often diagnosed
late in its course,14 with such patients having a worse prognosis
than if they were diagnosed at a less advanced stage. As such,
clinicians should be aware of the importance of early diagnosis
and remain vigilant against this disease. BTS guidelines reinforce
the importance of repeated investigation to confirm that consolidation on chest radiographs is attributable solely to an infective
process,15 and does not represent underlying malignancy. In this
patient, the chest radiograph was initially interpreted as representing a community acquired pneumonia, and only subsequent
CT imaging confirmed the presence of a cavitating lung mass
with pleural effusion. Diagnosis of lung malignancy is also complicated by difficulties in obtaining a tissue diagnosis, with some
patients being too unwell to undergo invasive procedures.
Samples obtained during bronchoscopy are also not necessarily
diagnostic, with brushing and biopsy samples having a diagnostic rate of above 80%.16
3

Unusual presentation of more common disease/injury
Previous case reports and published literature illustrate that
lung cancer can present as a brain metastases, with only neurological symptoms and no evidence of pulmonary disease.17
Other case reports in the literature highlight that lung carcinoma
can present with unusual radiological features.18–20 Lung malignancy frequently metastasis to the brain, and although the
cortex is predominant as the site for metastatic disease it is
known that metastases can involve the cerebellum.21 22 This can
occur as a single metastatic lesion, or as one of a number of
sites of metastatic disease. In this case, the opportunity for an
earlier diagnosis was missed. MRI of the brain from early 2013
did not report on the presence of the cerebellum lesion, and
was undertaken for investigation of the patient’s dementia.
Clinicians reviewing the imaging in an outpatient setting did not
recognise the abnormal appearance of the cerebellum, and
therefore further investigation at an earlier time was not undertaken. It is difficult to determine whether the patient’s clinical
course and outcome was affected by the delay in diagnosis.
Given the presence of the patient’s concurrent medical
comorbidities and the metastases that had already occurred on
the earlier MRI, it is likely that this patient would have received
similar management. However, this is not always the case and as
such it remains crucial that radiological images are reviewed
thoroughly and not solely in the context of the current clinical
condition. These findings should be communicated to and acted
upon quickly by the responsible clinical teams. Furthermore,
clinicians should review radiology imaging and be familiar with
interpretation of gross abnormalities on complex imaging
within their specialty. As such, radiology teaching at undergraduate and postgraduate level remains invaluable with modern
medical practice utilising radiological techniques more
frequently.

Contributors X-YK carried out the literature review and wrote the original
submitted article. CH edited the original manuscript and obtained consent for
the publication of the manuscript. X-YK and CH obtained radiological images for
publication. MF aided in the collection of radiology images and provided specialist
advice on the radiological findings. SL was the Consultant responsible for the care of
the patient and edited the manuscript.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES
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Learning points
▸ Falls in the elderly should be thoroughly investigated
especially if presenting with sinister symptoms.
▸ Chest malignancies may be relatively asymptomatic until an
advanced stage, and clinicians should be vigilant for
extrapulmonary signs and symptoms.
▸ Incidental lesions consistent with malignancy should be
investigated quickly and thoroughly, as per the 2-week wait
guidelines.
▸ Malignancies may have a delayed presentation especially in
patients with cognitive impairment(s) and sensory deficit(s)
due to the difficulty in verbalising symptoms.

15
16
17
18
19
20
21
22

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Kowa X-Y, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203019