Atypical Facial Pain: A Rare Sentinel Manifestation of Lung Cancer (P03.241)

Abstract

Objective: To document unilateral atypical facial pain as a possible sentinel manifestation of lung cancer, possibly due to referred vagal pain. Background Atypical facial pain is a persistent, daily, deep and poorly localized unilateral facial pain. A serious, little-recognized association is the occurrence of atypical facial pain as a sentinel manifestation, preceding detection of an ipsilateral lung neoplasm. Fewer than 50 cases of atypical facial pain have been reported as initial symptoms signaling the presence of a lung neoplasm. Design/Methods: Case report. Results: A 65-year-old woman presented with 3 months of severe left facial pain starting near her mouth and spreading to her left ear and orbit. The pain was continuous, without lancinating character, and had worsened since onset. She endorsed several months of nonproductive cough and 3-pound weight loss; she had a 40-pack-year smoking history. Her neurological exam was unremarkable. Physical exam revealed occasional crackles in the left lung base. Routine blood tests were normal; ESR was 30. Cognizant of the link between facial pain and lung cancer, we obtained a CT scan of the chest, which revealed left lower lobe consolidation with hilar adenopathy. Bronchoscopic biopsy showed stage IV adenocarcinoma. An MRI brain scan was normal. Serum paraneoplastic antibody testing was negative for both intracellular and surface antineuronal antibodies, performed by Dr. Josep Dalmau9s laboratory. CSF cytology was negative for malignant cells. Narcotics, pregabalin and NSAIDs produced marginal relief of facial pain. Six months after initial diagnosis, she died following progression of an aggressive cancer. Conclusions: Unilateral facial pain may be the sentinel manifestation of lung malignancy, which should be considered in patients with new onset persistent facial pain, history of smoking or other systemic manifestations. In the absence of paraneoplastic antibodies, the presumed mechanism is referred pain from involvement of the vagus nerve by cancer. Disclosure: Dr. Drachman has nothing to disclose. Dr. Zhang has nothing to disclose.