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Washington University Experience | NEOPLASMS (GLIAL) | Gliomatosis cerebri | 1A0 Case 1 History
Case 1 History ---- The patient was a 33 year old attorney transferred to BJH on 8/29 for evaluation and treatment of a possible intracranial mass. He was well until 4 weeks prior to admission when he complained of a severe bifrontal headache, which did not respond to antibiotic therapy. Two weeks prior to admission he developed episodes of mild confusion, dysphasia and shortened attention span. Four days prior to admission he noticed a tingling of the right arm and he was admitted to BJH after he became somnolent. Physical examination showed a lethargic man who was oriented only to time and place, who would not follow commands consistently, and whose speech was generally unintelligible. The cranial nerves were intact except for a mild right central facial weakness. He had a mild spastic right hemiparesis with increased tone and hyperreflexia. A positive Kernig's sign was obtained by some examiners, but otherwise the general examination was unremarkable and he remained afebrile throughout the hospitalization. A CT scan showed a diffuse lucency of the entire left cerebral hemisphere with a left to right shift. An arteriogram confirmed a diffuse left hemispheric mass effect and also revealed a possible diffuse blush of the left hemispheric white matter. Lumbar puncture showed an increased opening pressure of 330 mm with 10 red cells, 1 mononuclear cell, protein 20, and glucose 98. The remainder of the diagnostic studies were normal, including a radionuclide brain scan, CSF cytology, CSF cultures, herpes titer, and ANA. The patient was started on treatment with Ara-A (for possible Herpes simplex type I encephalitis), seemed to be gradually improving, and was able to answer some questions appropriately. Unfortunately, over a 2 hour period on 9/4, the patient developed increased headache, decreased level of consciousness and a dilated left pupil. Shortly thereafter a cardiorespiratory arrest occurred, and, despite cardiopulmonary support, Mannitol, and an emergency ventriculostomy, he expired that evening. This case illustrates the high level functioning of the human brain even with extensive involvement by diffuse glioma which must have grown for years before becoming symptomatic.
