Case Studies

Correct answer: The most likely diagnosis in this case is malignant meningitis. This involves the seeding of the tumour on the meninges where it grows and in the process of which it picks off nerves typically the lower lumbar and cranial nerves. It is often painful and so the constellation of progressive lower cranial nerve palsies with pain in a lady with previous breast carcinoma would make this the most likely diagnosis. Furthermore the CSF examination is very much in keeping with this with the high number of cells, raised protein and low glucose.

Correct answer: Whilst tuberculous meningitis is a possibility the way to prove the diagnosis would be to do cytology on the specimen of CSF to see whether the cells within it look like breast carcinoma cells. In order to exclude TB one would have to do specific stains and PCR to look for the infective organism.

Correct answer: The prognosis for malignant meningitis is often extremely poor - although there are rare cases of people responding to chemotherapy, and, in the case of breast carcinoma, drugs which target the oestrogen receptor may be helpful such as tamoxifen. Generally speaking though the disease progresses rapidly with most patients dying within a few months of onset.

Correct answer: The CT scan was unhelpful because it is very poor at looking at the meninges as well as the posterior fossa. Quite often the diagnosis of malignant meningitis can be difficult as the meninges are involved in a disseminated fashion with relatively little in the way of thickening and even on MRI scan with contrast one can often not see any abnormalities on the scan.