Case Presentation: A 45-year-old woman with a Glasgow Coma Scale score of 7 was admitted to our hospital because of impaired consciousness. On the day of admission, she appeared well and was performing her routine work until approximately 6 pm. At 9 pm, her husband found her lying unresponsive on the bed, and she was brought to our hospital. She had relatively stable vital signs and miotic pupils and the absence of neck stiffness and palpable superficial lymph nodes. A huge tumor measuring 20 x 20 cm in diameter with pigmentary changes was observed on her left breast. According to her husband, the patient had previously appeared to be in good health. However, she developed a gradually enlarging mass on her left breast 3 years prior to admission. Despite presenting with a dry cough in the past several months, she adamantly refused to go to a hospital for evaluation. Following a head CT scan, the MRI revealed a viscous lesion with metastatic features in the right frontal lobe. Symmetrical high-intensity lesions in the thalamus and the right cerebellum, suggestive of the bilateral paramedian thalamic infarction syndrome, were observed on diffusion-weighted images. Enhanced chest CT imaging revealed a large left breast tumor with probable lung, bilateral hilar, and mediastinal lymph node metastases as well as cardiac invasion through the pulmonary vein.
The patient was diagnosed with breast carcinoma with multiple metastases and cardiac invasion. Impaired consciousness was believed to result from the bilateral paramedian thalamic infarction syndrome, and she regained consciousness after 3 days of conservative therapy for cerebral infarction. Aspiration cytology of the left breast mass subsequently revealed a mucinous carcinoma. Although the patient and her family refused chemotherapy because of anxiety and concerns with adverse drug effects and given the advanced stage of the disease, she agreed to therapy with tamoxifen, a selective estrogen receptor modulator. Follow up MRI of the brain on the 55th hospital day revealed the absence of the previously visualized symmetrical high-intensity thalamic lesions on diffusion-weighted images. This suggested that impaired consciousness was caused by the Trousseau syndrome, which resulted from the state of hypercoagulability produced by the mucinous breast carcinoma. After undergoing a lengthy rehabilitation, she was discharged on the 70thhospital day with a diagnosis of end-stage breast cancer, and her clinical condition gradually deteriorated at home.
Discussion: The Trousseau syndrome consists of various thromboembolic disorders of the arterial and venous systems, which occur in the presence of a malignancy usually involving the mucin-secreting carcinomas of the pancreas, breast, ovary, lung, and colon. Thromboembolism in tissues or organs, including the lung, brain, heart, kidneys, and spleen, is one of the leading causes of death among patients with this tumor type. The primary approach in the treatment of the Trousseau syndrome involves tumor resection and anticoagulation therapy. However, when patients present with persistent and progressive tumors, similar to our patient’s case, anticoagulation therapy may not be effective.
Conclusions: Although patients with advanced cancer often have impaired consciousness because of various factors, Trousseau syndrome presenting as cerebral infarction following hypercoagulability should be considered as a potential complication of any malignancy, particularly mucinous carcinoma.
To cite this abstract:Fujikawa T, Matsuura H. Impaired Consciousness with Indolent Breast Mass. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 671. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/impaired-consciousness-with-indolent-breast-mass/. Accessed May 22, 2019.