A 33‐year‐old male with synchronous acute myeloid leukemia M7 (AML) and anterior mediastinal germ cell tumor treated with cytarabine, idarubicin, cisplatin, ifosfamide, and etoposide presented with several weeks of nausea, vomiting and headache (HA). He developed altered mental status (AMS) after hydromorphone administration and experienced a fall. He was transferred for further evaluation. On arrival, he was alert only to his name. He denied HA, but noted nausea. He was placed on fall precautions. His AMS precluded a lumbar puncture (LP), and empiric acyclovir, ampicillin, cefepime and vancomycin were started. Of note, there was no evidence of AML after induction chemotherapy. The patient experienced a second fall and was now oriented to his name and location. He complained of HA and head computed tomography (CT) showed mild cerebral edema with mild enlargement of the lateral and 3rdventricles. He experienced 20 seconds of tonic clonic seizure activity during his CT. Neurology was consulted and he was placed on levetiracetam. LP showed a cerebrospinal fluid (CSF) protein count 62 mg/dL, glucose < 20 mg/dL, 0 red blood cells, and 76 nucleated cells/mcL (17% neutrophils, 2% lymphocytes, 26% monocytes, and 55% unclassified cells). Blood cultures were negative. CSF fungal culture, Cryptococcus neoformans antigen, and aerobic culture were negative. CSF PCR for cytomegalovirus, herpes simplex, Toxoplasma gondii, Epstein‐Barr, and varicella‐zoster were negative. LP opening pressure was > 55 cm. CSF flow cytometry showed numerous megakaryoblasts consistent with involvement by acute leukemia. Bone marrow biopsy demonstrated no evidence of acute leukemia. Brain magnetic resonance imaging showed marked leptomeningeal enhancement. He was diagnosed with leptomeningeal carcinomatosis and received multiple rounds of intrathecal methotrexate, cytarabine, and hydrocortisone. CSF cytology was negative for malignancy after his final round of intrathecal therapy. Repeat head CT showed persistent diffuse leptomeningeal enhancement. The patient developed progressive AMS and expired on hospital day 40.
Leptomeningeal carcinomatosis is a rare complication of AML. Its incidence has declined with induction and post‐remission cytarabine, occurring in < 5% of patients. A high index of suspicion is required as prompt therapy is essential to maintaining neurologic function and improving patient outcome. Our patient noted HA one month prior. Head CT was normal and an LP was not performed. This HA may have been the first symptom of leptomeningeal carcinomatosis, as head CT can be negative despite CNS involvement. Early consideration may have allowed prompt evaluation and therapy, potentially improving his outcome.
This case reminds hospitalists that leptomeningeal carcinomatosis is a rare and potentially fatal complication of AML. When considered early, prompt evaluation and treatment may improve patient outcome.
To cite this abstract:Cheng T, Plasencia A, Richard L, Rubio M. Leptomeningeal Carcinomatosis. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 381. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/leptomeningeal-carcinomatosis/. Accessed April 1, 2020.