Abstract | November 17, 2023
Altered mental status in a patient with diabetic ketoacidosis, urinary tract infection, and metastatic endometrial malignancy
Learning Objectives
- This case is an unusual presentation of a common gynecological condition. The patient presented with a triad of conditions known to cause AMS in the form of DKA, UTI, and metastatic brain lesions of endometrial source. This patient had no known history of malignancy prior to this visit. Although her intermittent focal weakness and aphasia were presumably caused by cerebral edema from the brain metastases, her mental status changes were most likely due to the interplay of all three diagnoses.
Introduction:
Endometrial cancer is the most common gynecological malignancy in the United States, primarily affecting postmenopausal women. Risk factors include nulliparity, early menarche/late menopause, polycystic ovary syndrome, obesity, diabetes mellitus (DM), unopposed estrogen replacement therapy, and history of breast cancer/tamoxifen treatment. Endometrial cancer commonly metastasizes to the pelvic or para-aortic lymph nodes, and infrequently to the liver, lung, and bone. Brain metastases occur rarely in 1.16% of cases. Common presenting symptoms of brain metastases are headache, focal weakness, and aphasia. Urinary tract infection (UTI) in geriatric populations and diabetic ketoacidosis (DKA) are also associated with altered mental status (AMS).
Case Presentation:
72-year-old female with a history of DM, hypertension, hyperlipidemia, peripheral neuropathy, rheumatoid arthritis, and chronic kidney disease stage 3A presented with AMS and blood glucose greater than 500. Per the caregiver, the patient had six months of frequent falls and increasing forgetfulness. Labs revealed anion gap metabolic acidosis, with a negative drug screen. Urinalysis suggested a UTI. Computed tomography (CT) of the head and cervical spine revealed areas of cerebral edema within the left parietal lobe suspicious of metastatic lesions. Chest x-ray showed retrocardiac consolidation, suspicious for pneumonia. Magnetic resonance imaging of the brain and CT chest revealed multiple pulmonary nodules in the bilateral upper lobes concerning metastatic disease. CT abdomen/pelvis was suggestive of uterine malignancy. CT-guided biopsy of the right lung confirmed the diagnosis of non-small cell carcinoma. The lung nodule was suspected to be of endometrial origin with metastases to the lungs and brain. Additionally, the patient was noted to have intermittent right-sided motor deficits and aphasia throughout her admission.
Final Diagnosis:
Endometrial cancer with metastasis to lungs and brain.
Outcome:
The patient was admitted to the intensive care unit. Neurology, pulmonology, general surgery, and hematology-oncology were consulted. Appropriate treatment was initiated for DKA and UTI. The family requested that the patient be immediately transferred to Huntsville Hospital due to personal preferences for treatment location. The patient was transferred immediately after.
References and Resources
The case presentation was presented at the Medical Association of the State of Alabama’s Annual Meeting in Huntsville, AL, by the secondary author. However, the case presentation was never published. Eligibility for submitting the case presentation was confirmed by official personnel within the Southern Medical Association. Please contact me if you have any questions or concerns.
