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Washington University Experience | NEOPLASMS (METASTASES) | Meningeal | 6A0 Case 6 History
Case 6 History ---- The patient was a 60 year old male with a history of tobacco use and neck carcinoma with metastases to the leptomeninges. He initially presented with left cervical lymph node enlargement in July 2001 was diagnosed with metastatic squamous cell carcinoma with a likely lung primary by FNA biopsy. He returned for further evaluation of right tonsil fullness in August 2001. Multiple biopsies of the oropharynx, including a right tonsillectomy, did not show evidence of malignancy. Cytology of LP fluid was positive for malignant cells. An MRI of the brain showed multifocal leptomeningeal masses, including the posterior right frontal lobe, the surface of the right cerebellum and the right occipital lobe. A right frontal Ommaya reservoir was placed for administration of intrathecal methotrexate. MRI of the neck in December 2001 revealed an ill-defined left oropharyngeal mass. The patient was treated with 11 cycles of high dose Methotrexate, with his last cycle finishing in March 2002. At that time, the patient had bilateral lower extremity weakness and gait difficulty. The patient never received radiation treatment. His second MRI on March 2002 showed interval increase in leptomeningeal carcinomatosis located in the superior aspect of the cerebellum and in the suprasellar region near the hypothalamus compared to February 2002. He was readmitted March 2002 with a two day history of headache, lethargy, nausea, and urinary incontinence. He was febrile with a stiff neck and CSF fluid showed a glucose of 154 mg/dL (serum = 310), protein 52 mg/dL, 26 red blood cells, and 25 nucleated cells. Routine cultures, including CSF cultures, were negative. He was treated with Vancomycin and ceftazidime and improved over four days, becoming more alert and tolerating oral intake and physical therapy. He was readmitted in April for increased lethargy for four days. On admission, his serum glucose was 450 mg/dL. On 4/2002 the nurse and his family noted that he was unresponsive. An endotracheal tube was placed. He had a brief period spontaneous breathing with oxygen saturation of 90% and a normal pulse. Quickly he became apneic with a narrow complex and pulseless electrical activity. He was cardioverted twice without success. Pericardiocentesis did not release any fluid. Resuscitation continued for about 20 minutes and he was pronounced dead in 4/2002. His past medical history included diabetes, hypertension, and back surgery.
