Critical Care Medicine-Neurologic Disorders>>>>>Neuro Oncology
Question 2#

A 52-year-old woman with past medical history of infiltrating lobular carcinoma of the breast status post left mastectomy and neoadjuvant chemotherapy is brought to the ER by her family, reporting a 3-day history of headaches, nausea, vomiting, diplopia, and a witnessed fall prior to presentation. Neurological examination is notable for medial deviation of the right eye and inability to completely close the eyes. Lumbar puncture is performed and while waiting for the results, a brain MRI is obtained, which is notable for diffuse leptomeningeal contrast enhancement of the cortical surface and the basal cisterns along the ventral surface of the brainstem.

What is the CSF profile most consistent with this patient’s presentation? 

A. Elevated protein, low glucose, lymphocytic pleocytosis
B. Elevated protein, low glucose, neutrophilic pleocytosis
C. Normal protein, normal glucose, lymphocytic pleocytosis
D. Mildly elevated protein, normal glucose, normal WBC count

Correct Answer is A

Comment:

Correct Answer: A

The patient in the aforementioned scenario is presenting with leptomeningeal carcinomatosis (LM). CSF findings are characterized by elevated protein count, low glucose count, and lymphocytic pleocytosis. LM is defined by the spread of tumor to the arachnoid and pia mater (leptomeninges) as opposed to the dura mater and is diagnosed in 5% of patients with metastatic cancer. The most common solid tumors associated with LM are breast CA, lung CA, melanoma, and cancers of the GI tract. Patients often present with multifocal neurological signs and symptoms, including headaches, nausea/vomiting, and neck pain or stiffness, etc., which may indicate increased intracranial pressure and/or meningeal irritation. Other symptoms may include diplopia, facial weakness, sensorineural hearing loss, and dysphagia or dysarthria, which indicate invasion of cranial nerves. Gait instability, falls, and dizziness can result from brainstem invasion.

LM is suspected in patients presenting with multilevel neurological findings and diagnosis is confirmed by brain MRI and CSF analysis. Brain MRI is notable for diffuse leptomeningeal contrast enhancement. Prominent CSF findings include elevated protein count, low glucose count, and lymphocytic pleocytosis (option A is correct). Elevated protein, low glucose, and neutrophilic pleocytosis are consistent with findings in patients with bacterial meningitis (option B is incorrect). Normal to elevated protein count, with normal glucose count, and lymphocytic pleocytosis is consistent with viral meningitis (option C is wrong). Mildly elevated protein, normal glucose, and normal WBC count is consistent with CSF finding in patients with multiple sclerosis (option D is wrong).

References:

1. Grossman SA, Krabak MJ. Leptomeningeal carcinomatosis. Cancer Treat Rev. 2009;25(2):103-119.
2. Kaplan GJ, DeSouza TG, Farkash A, et al. Leptomeningeal metastases: comparison of clinical features and laboratory data of solid tumors, lymphomas, and leukemias. J Neurooncol. 1990;9:225.
3. Seehusen DA, Reeves MM, Fomin DA. Cerebrospinal fluid analysis. Am Fam Physician. 2003;68(6):1103-1109.
4. Freedman MS, Thompson EJ, Deisenhammer F, et al. Recommended standard of cerebrospinal fluid analysis in the diagnosis of multiple scelorsis. A concensus statement. Arch Neurol. 2005;62(6):865-870.