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Washington University Experience | NEOPLASMS (METASTASES) | Meningeal | 12A0 Case 12 History
Case 12 History ---- The decedent is a 60 year old female with arthritis, asthma, hypertension, and metastatic vulvar cancer to the lungs status post chemoradiation and local resection who presented with a one week of progressive lower extremity weakness with decreased urine output and worsening constipation. Of note, the patient was on the PD-1 inhibitor, Nivolumab. The patient presented in April 2017 after one week of lower extremity weakness in which she reported her leg giving out when previously she was walking fine with a cane, used for her arthritis. Spine CT and MRI showed results consistent with transverse myelitis. On initial examination the patient showed lower extremity weakness. Patellar and Achilles reflexes were areflexic with hyperreflexia in the upper extremities. Decreased vibratory and proprioception was noted in the lower extremities. The patient did fall but denied any head trauma with no acute process found. The patient noted that she was urinating less and had not had a bowel movement in a few days when she previously had bowel movements at least every other day. Prior to admission at BJH she experienced acute kidney injury with creatinine of 2.3 that resolved with IV fluids and Foley catheterization. The patient's weakness progressed until the patient could no longer walk. The patient also reported new onset of back pain that localized between her shoulders. The patient denied any diarrhea, dysuria, cough, nasal congestion, fever, chills, night sweats, weight loss, or sick contacts. The patient's vulvar cancer was first noted in the fall of 2015 with metastasis to lymph nodes. A resection followed by chemotherapy with Cisplatin and 32 cycles of field radiation was completed by the summer of 2016 with no evidence of disease at that time. A PET scan in the fall of 2016 showed three positive nodules in the patient's right lower lobe of the lung that were biopsied consistent with the previous vulvar cancer. The patient then received 32 more cycles of radiation to the right lung completed at the end of February 2017 and was started on chemotherapy with cisplatin, nivolumab, and Abraxane. The patient's last dose of chemotherapy was in mid-March 2017. The patient's hospital course involved initial lower extremity weakness improvement from steroids followed by progressive ascending muscle weakness. An LP at an outside hospital in March 2017 showed 93 nucleated cells with neutrophilic predominance (81%), protein of 142, and glucose of 31. Cytology of the LP showed acute and chronic inflammatory cells with no evidence of malignancy. A LP on April 3rd showed 239 nucleated cells with 77% neutrophils, glucose less than 20 and protein of 735 with no positive serology for infection or culture growth. Additionally, since March 29th, the patient had continuously decreasing platelets dropping for 202K on March 29th to 62K a few days later. The patient reportedly had acute thrombocytopenia following her previous chemotherapy cycles. A chest CT suggested a left lower lobe pulmonary embolism (PE) and right lower lobe nodular opacity, suggesting that the cancer was likely stable. The patient was managed with IV heparin for the PE. The patient’s weakness continued to progress and by April 10th bilateral soleal vein and left peroneal vein deep vein thromboses were noted. On April 11th, the patient showed right upper and lower face weakness. An electromyography (EMG) at this time also showed diffuse sensorimotor peripheral polyneuropathy. On April 12th, the patient had an MRI that showed a posterior fossa leptomeningeal disease with increasing enhancement that was concerning for tuberculosis with mild communicating hydrocephalus. The patient was started on RIPE treatment for potential TB. The patient was intubated on April 13th for worsening respiratory status. The patient was started on Vancomycin/cefepime on April 14 for right lung infiltrate. Almost daily CT scans showed gradual enlargement of ventricles. Neurosurgery placed an extra ventricular drain on April 17th. Due to the poor prognosis, on April 18th 2017 the family decided to place the patient on comfort care with extubation. The patient expired that day.
