Case report
A 50-year-old woman, with a past medical history of resected cutaneous melanomas, was transferred in from an outside hospital with unrelenting headaches. The patient’s mental status was normal and she was neurologically intact at presentation with motor, sensory, cranial nerve and cerebellar examination within normal limits. She had a 10-pack-year history of smoking as well as a past medical history of pulmonary Mycobacterium avium intracellulare complex (MAC) infection treated with multiple antibiotics. CT scan of her head revealed hydrocephalus and MRI revealed diffuse enhancement of her leptomeninges throughout her brain and spine, prominent over the basilar region (Fig. 1a–d). There was a relatively discrete focus of this extra-axial process involving the left temporal area. Cerebrospinal fluid samples obtained from multiple lumbar punctures and a ventriculostomy were nondiagnostic of the nature of the leptomeningeal process (consistent with previous reports) [5] and showed glucose 50 mg/dL, protein 158 mg/dL, 127 RBCs/mm3, 18 nucleated cells/mm3 (36% lymphocytes, 58% monocytes, and 6% macrophages) with negative gram stain, acid fast bacilli stain and cryptococcal antigen. CSF cultures for bacterial and fungi were negative. Cytologic studies did not reveal a neoplastic process. A work up with Positron Emission Tomography (PET) and CT scans of the chest, abdomen, and pelvis did not reveal a systemic malignancy. Ultimately the patient underwent a left peritoneal craniotomy and a frameless stereotaxic biopsy of her meningeal process. A ventriculo-peritoneal shunt was placed following which the patient underwent outpatient cranial irradiation and concomitant temozolamide chemotherapy for 42 days. Radiation dose was 3 Gy for the first three treatments then 1.8 Gy for an additional 23 treatments for a total whole brain dose of 50.4 Gy in 26 fractions. Treatments were completed with a 9 Gy “boost” in five fractions using an intensity-modulated radiation therapy (IMRT) technique. She then received three cycles of etoposide chemotherapy for progressive disease. The patient continued to deteriorate clinically and was transferred to hospice care where she expired 4 days later.
Fig. 1 Postcontrast T1 W MRI of brain (a, b), cervical (c) and lumbar (d) spine show diffuse enhancement of her leptomeninges throughout her brain and spine. Arrow in the axial brain image (a), points to the biopsy site