www.thelancet.com Vol 390 September 2, 2017 1003 Case Report The empress of subterfuge: cancer of the fallopian tube presenting with malapropism Lucy Gilbert, Timothée Revil, Charles Meunier, Kris Jardon, Xing Zeng, Claudia Martins, Jocelyne Arseneau, Lili Fu, Krystle North, Alicia Schiavi, Eric Ehrensperger, Giovanni Artho, Todd Lee, David Morris, Jiannis Ragoussis A 58-year-old realtor presented to her community hospital with an acute left-sided facial droop in December, 2015. She reported that in the past 2 months her children had noticed (and teased her for) malapropisms (video 1), but she had no other symptoms and had continued to manage complicated sales. She did not smoke and consumed alcohol occasionally. Her body-mass index was 23 kg/m². On examination she had a left lower facial weakness and made occasional paraphasic errors during speech. Her platelet count was 117 × 10⁹ per L (normal range 140–450 × 10⁹ cells L), and blood glucose, cholesterol, and triglycerides were slightly raised. A CT scan of the brain showed changes suggestive of an acute ischaemic event in the right insular region, with loss of cortical and subcortical diferentiation. MRI showed multifocal acute infarcts, probably thrombo- embolic in origin. An electrocardiogram (ECG), CT angiogram of the neck and circle of Willis, blood cultures, and transthoracic echogram were normal, as were investigations for a haemolytic cause, disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, antiphospholipid antibody syndrome, lupus, and B12 defciency. The facial droop resolved within 1 day and she was discharged a week later, having been started on regular clopidogrel, atorvastatin, and metformin. 2 weeks later she returned to the same hospital with acute onset confusion and disorientation. Her platelets had dropped to 66 × 10⁹ per L. Repeat CT showed no further changes but her symptoms continued to worsen, and 48 h later she was transferred to our institution for further assessment. On admission she was alert but had difculty follow- ing instructions, expressive speech difculties, and sensory neglect on the left side. Her platelets were 58 × 10⁹ per L, white cell count 15·20 × 10⁹ per L (normal 4·50–11·0 × 10⁹ per L), lactate dehydrogenase was 507 IU/L (110–210 IU/L), and C-reactive protein was 30·50 mg/L (<5·0 mg/L). MRI of the brain showed new acute bihemispheric infarcts (fgure) and a transoesophageal echocardiogram identifed two mobile echo-densities on the atrial surface of the mitral valve leafets (video 2). CT scan showed a slightly enlarged right ovary (6 cm × 4·3 cm × 3·6 cm) and mild fat-stranding of the omentum. On PET/CT there was FDG uptake (standard uptake value [SUV] 7·3) in the right ovary and a small focal FDG uptake (SUV 4·88) in the left ovary; there were no other abnormalities. Her CA125 level was 1667 IU/mL (<35 IU/mL) and carcinoembryonic antigen was 29·4 µg/L (<4·9 µg/L). A CT-directed biopsy sample showed high- grade serous carcinoma, probably of ovarian or tubal origin. We concluded that she had non-bacterial thrombotic endocarditis caused by high-grade serous carcinoma. Despite anticoagulation treatment she continued to have cerebral and systemic embolic events, with add- itional strokes and infarctions afecting both kidneys and the spleen (fgure) so despite her low platelet count (28–36 × 10⁹ per L) we started dose-dense chemotherapy (carboplatin area under the curve [AUC] 2 and paclitaxel 80 mg/m² once a week) because the patient was too unwell to receive a full dose every 3 weeks, which is the standard of care. After one cycle platelets had risen to 218 × 10⁹ per L, the CA125 had reduced to 555 IU/mL; she had no further embolic events and we were able to Lancet 2017; 390: 1003–04 Division of Gynaecologic Oncology, Department of Obstetrics and Gynaecology (Prof L Gilbert MD, K Jardon MD, X Zeng MD, C Martins PhD, K North BA, A Schiavi MSc), Department of Pathology (J Arseneau MD, L Fu MDCM), Division of Neurology (E Ehrensperger MD), Department of Radiology (G Artho MD), and Department of Medicine (T Lee MD, D Morris MD), McGill University Health Centre, Montreal, QC, Canada; and Department of Human Genetics, McGill University and Genome Quebec Innovation Centre, Montreal, QC, Canada (T Revil PhD, C Meunier PhD, Prof J Ragoussis PhD) Correspondence to: Prof Lucy Gilbert, Division of Gynaecologic Oncology, McGill University Health Centre, Cedars Cancer Centre, Montreal, QC H4A 3J1, Canada lucy.gilbert@mcgill.ca See Online for videos A B C 500 μm Tubal plicae Serous carcinoma Figure: Non-bacterial thrombotic endocarditis caused by high-grade serous carcinoma (A) MRI of the head at second presentation, showing multiple acute infarcts of the frontal, parietal, and left occipital lobes. (B) CT scan showing bilateral renal infarcts. (C) Histopathology showing high-grade serous carcinoma of the fallopian tube.