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Washington University Experience | NEOPLASMS (METASTASES) | Meningeal | 1A0 Case 1 History
Case 1 History ---- The patient was a 71 year old female admitted to BJH in 5/82 for continuing care from an OSH where she had been evaluated because of cough, fever and weight loss, resulting in a diagnosis of right upper lobe lung adenocarcinoma. Metastatic skeletal involvement was suspected on bone scan. In the days prior to her admission, there had been progressive change in her sensorium and mental state with confusion, lethargy and slurred speech. She developed generalized paratonia with neck stiffness, bilateral hyperreflexia and a left Babinski response. Extra-ocular movements were conjugate and full. Her fundi were benign. A CT of the head done with and without contrast at that time was unremarkable. ---- Her admission labs were remarkable for an alkaline phosphatase of 231, a blood white cell count of 68,000, and a UA with 15 white blood cells. Chest x-ray showed an aspiration pneumonitis, successfully treated with antibiotics. Several LPs showed normal protein and glucose without cells. Multiple samples for cytology were sent. Her white count climbed to 105,000. She was started on Chlorambucil. She developed fleeting neurological findings consisting of left Babinski sign, a right facial nerve palsy and as a right hemiparesis. She continued to deteriorate in terms of her mental status, developing a profound pseudobulbar affect. She became non-verbal but developed no new peripheral neurological findings. During the hospitalization, she had 4 head CTs with and without contrast on separate occasions, all failing to demonstrate focal mass lesions. EEG was moderately abnormal due to a poorly developed occipital alpha rhythm and slowing consistent with diffuse organic or metabolic process. A diagnosis of adenocarcinoma was made on pleural fluid. Extensive evaluations for DIC were negative. Multiple CSF cytologies were negative. She developed a state of fetal positioning with hand and leg flexion paratonia with pseudobulbar affect. She refused to swallow, wouldn’t take liquids, and was placed on intravenous fluids. She remained in that state for several days prior to her discharge at the end of 6/82. At that time the diagnoses that were being entertained included marantic endocarditis, non-responsive to Heparin, rapidly progressive paraneoplastic leuko-encephalopathy and central pontine myelinolysis, though she had no CT evidence of this and had intact eye movements throughout. Her Chlorambucil was stopped and she was sent to a nursing home for continued supportive care and passed away shortly thereafter.
