Abstract | November 8, 2021
Lung Cancer Presenting Solely as Ascending Paralysis and Bilateral Bells Palsy from Leptomeningeal Carcinomatosis
Learning Objectives
- Identify that Leptomeningeal metastases (neoplastic meningitis) are a rare but frequently devastating complication of advanced cancer. Leptomeningeal metastasis (LM) results from dissemination of cancer cells to both the leptomeninges (pia and arachnoid) and cerebrospinal fluid (CSF) compartment. Breast cancer, lung cancer, and melanoma are the most common solid tumors that cause LM;
- Demonstrate the ability for tumor cells to gain access into the CSF in several ways; Hematogenous spread via the arachnoid vessels or direct extension from the brain parenchyma are probably the most common means;
- Identify that multifocal involvement is a hallmark of leptomeningeal disease, with headache or other focal neurological deficits being the most common symptoms.
Introduction: Leptomeningeal Carcinomatosis is diagnosed in approximately 5% of patients with metastatic cancer however incidence of post-mortem diagnosis is considerably higher. Despite its rare occurrence, it has been described in patients with lung cancer particularly in advanced stages. Neuroimaging show findings consistent with cranial and peripheral nerve involvement which may explain a presentation of ascending paralysis and Bell’s palsy. While most documented neurological presentations of lung cancer are typically paraneoplastic syndromes, leptomeningeal carcinomatosis may result as a direct CNS invasion by malignant cells. Here, we present a patient with ascending bilateral lower extremity weakness and bilateral bell’s palsy who was diagnosed with leptomeningeal carcinomatosis secondary to Lung adenocarcinoma.
Case presentation: 63 year old male presented with 3 months of worsening bilateral lower extremity weakness. His weakness started from his feet and spread towards both hips. His mobility worsened progressively and he required a cane, walker and eventually a wheelchair. Medical history notable for recent diagnosis of left-sided bell’s palsy, also of 3 months duration.
Examination revealed left-sided facial weakness, new onset right-sided facial weakness, ptosis and drooling. 3/5 motor strength and absent reflexes in bilateral lower extremity. Sensation intact, no atrophy or fasciculations noted.
CT head, MRI/MRA head and neck were unremarkable.
Lumbar puncture showed WBC – 444, glucose – 29, total protein of 1521.
Patient was started on steroids and IVIG for suspected AIDP/inflammatory neuropathy.
He was then discharged to rehab, 2 days thereafter he was re-admitted due to non-improving extremity weakness and dysphagia, now requiring NG tube feeds.
Further investigation with MRI thoracic spine showed post-contrast leptomeningeal enhancement.
Repeat LP with CSF analysis showed malignant cells consistent with adenocarcinoma. Chest CT showed left upper and lower lobe opacities suspicious for malignancy with destructive left 9th rib lesion.
Diagnosis: Leptomeningeal Carcinomatosis likely from primary lung malignancy
Management: Oncology, Infectious disease, Neurology, patient and his family, all agreed with hospice care, as the patient’s performance status was very poor and he has probably limited chance of neurologic recovery.
