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Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 861-863
Small cell carcinoma of lung presented with only abnormal behaviour due to siadh - a case report


Dept of Chest Medicine Medical College, 88, College Street, Kolkata - 700073, India

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Date of Submission17-Aug-2006
Date of Acceptance10-Oct-2006
 

Keywords: Bronchogenic Carcinoma , SIADH , abnormal behaviour

How to cite this article:
Roy P P, Das S K, Sadhu A. Small cell carcinoma of lung presented with only abnormal behaviour due to siadh - a case report. Indian J Radiol Imaging 2006;16:861-3

How to cite this URL:
Roy P P, Das S K, Sadhu A. Small cell carcinoma of lung presented with only abnormal behaviour due to siadh - a case report. Indian J Radiol Imaging [serial online] 2006 [cited 2014 Jul 23];16:861-3. Available from: http://www.ijri.org/text.asp?2006/16/4/861/32369

   Introduction Top


Bronchogenic Carcinoma is the commonest cause of male death from primary malignant diseases [1]. Clinical manifestations vary from change in character of cough , haemoptysis ,chest pain, breathlessness etc with or without features of metastasis in different tissues .Very rarely , lung cancer of small cell type may manifest with only features of SIADH(Syndrome of inappropriate secretion of ADH) without any evidence of SOL in lung in X-ray chest [2]. Here is a patient who presented with abnormal behaviour due of SIADH (a component of para-neoplastic syndrome ) as the only symptom, who was ultimately diagnosed as having lung cancer (small cell carcinoma ) .


   Case Report Top


AA, a 52 years old male patient , admitted at Medical College , Kolkata on 6.6.2003 with marked breathlessness , fever and purulent expectoration for ten days . He was a known case of COPD and was on oral bronchodialator There was no history of haemoptysis or chest pain . Past history revealed nothing significant . He was a smoker who consumed one and a half pack of bidi per day for more than 20 years . On examination the following points were noted:- Anaemia - mild , Respiratory rate - 28 per min, Cyanosis absent . Accessory muscles of respiration- working. AP diameter of thorax increased . Bilateral hyper-resonant note on percussion. Breath sound - Vescicular with prolonged expiration . Bilateral rhonchi present , crepitation present . CVS , CNS and GI system examition -No abnormality was detected.


   Investigations Top


Haemoglobin - 13 gm % TLC - 12000/cu.mm. DLC-P72L20E8 , ESR - 20mm/hr , PPBS - 120mg% Urea - 22mg% , Creatinine -.7mg% . X-ray chest on 6.6.2003 showed evidence of emphysema . [Figure - 1] PFT could not be done .ECG - within normal limit . Ultrasonography of abdomen - NAD . Blood gas analysis - PaO2 -70mm , PaCO2 - 44 mm , PH -7.38

Following treatment with bronchodialator, oxygen and antibiotics , the fever subsided , cough and respiratory distress diminished .But on 23.6.2003, the patient developed new symptoms characterized by drowsiness, tremor, disorientation, irrelevant talks, without any evidence of breathlessness. No evidence of psychosis was found by the psychiatrist . Neurologists suggested CT scan of brain and measurement of electrolyte levels in blood . CT scan of brain was normal . Plasma sodium level was 120meq/litre .Potassium was 3.7meq/litre .Even with subsequent administration of several bottles of sodium chloride , sodium level in the blood was temporarily corrected but subsequently remained low .

Urinary hyper-osmolarity and serum hypo-osmolarity were detected. Ultrasonography of abdomen showed evidence of liver metastasis . CT guided FNAC of liver [Figure - 4]

showed metastatic small cell carcinoma . Chest X-ray on 28.6.2003 [Figure - 2] and 6.8.2003 [Figure - 3] showed appearance of SOL in the left lung with progressive increase in size . CT guided FNAC of lung revealed small cell carcinoma .Thus a rare case of small cell carcinoma of lung which presented with only features of SIADH without any evidence of SOL in the lung initially , was diagnosed .


   Discussion Top


SIADH , an important component of paraneoplastic syndrome , is rarely the only manifestation of lung cancer . In the present case, the patient presented with abnormal behaviour characterized by restlessness , tremor , agitation , disorientation , etc due to hyponatremia from SIADH . The initial X-ray chest (PA view) was normal . Subseqfluent X-ray chest (PA view) films showed the appearance of SOL in the left lower lung field . . CT scan of abdomen also showed evidence of metastasis. Nakazato A et al[3] reported a similar case of lung cancer which presented only with unpleasant sweet taste (dysgeusia) in the mouth due to SIADH .The abnormal taste sensation was the only symptom in that patient . The sodium level was as low as 113mmol/l . After 5 days of water restriction, serum sodium concentrations normalized (124 mmol/l) and dysgeusia disappeared. However, after one week spent out of the hospital, dysgeusia symptoms returned, and the serum sodium dropped to 109 mmol/l. Urinary osmolality increased to 489 mOsm/kg, while serum osmolality dropped to 226 mOsm/kg, leading to a diagnosis of SIADH. Subsequently, CT scan of thorax revealed right apical bronchogenic carcinoma with periaortic and peribronchial lymphadenopathy . Mayer S et al[4] reported a case of SIADH in an asymptomatic patient who was diagnosed later as small cell carcinoma of lung from CT guided FNAC of SOL of lung. Thus SIADH may present itself in multifaceted ways, such as abnormal behaviour, abnormal taste in mouth or in an asymptomatic manner before the appearance of SOL in Chest X-ray.

The present case initially created diagnostic dilemma and was referred to the psychiatrist and neurologist for abnormal behaviour . The case report emphasizes the importance of early recognition of SIADH which may be the only manifestation in the initial part of lung cancer.

 
   References Top

1.Haslett C, Chilvers E, Hunter J, Boon A, Davidson's Principles and Practice of Medicine ,Tumors of Bronchus and Lung , Eighteenth Edition Churchill Livingstone Press(1999) 356-363  Back to cited text no. 1    
2.Seaton A, Seaton D ,Gordonleitch A,Crofton and Douglas Respiratory Diseases , Cancer of the Lung . fourth edition Oxford University press(1989) 912-973  Back to cited text no. 2    
3.Nakazato Y, K Imai, T Abe, N Tamura and K Shimazu Unpleasant sweet taste: a symptom of SIADH caused by lung cancer , Journal of Neurology, Neurosurgery, and Psychiatry2006;77:405-406;  Back to cited text no. 3    
4.Mayer S , Cypess A, Kocher O , Berman S , Huberman S, Hartzband P, Halmos B Uncommon Presentations of some common malignancy , Journal of Clinical Oncology; 2005;23:6, 1312-1314.  Back to cited text no. 4    

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Correspondence Address:
P P Roy
Assoc. Professor and Head, Dept of Chest Medicine Medical College, 88, College Street, Kolkata - 700073
India
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DOI: 10.4103/0971-3026.32369

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

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    Introduction
    Case Report
    Investigations
    Discussion
    References
    Article Figures

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