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32 Vertigo with hearing loss as the first symptom of leptomeningeal carcinomatosis originating from colorectal carcinoma

Published online by Cambridge University Press:  24 June 2014

Hana Bokun,
Anita Marcinko,
Hrvoje Budincevic and
Ivan Bielen
Hana Bokun
Affiliation:
University Department of Neurology, General Hospital Sveti Duh, Sveti Duh 64, 10000 Zagreb, Croatia, E-mail: hana0806@gmail.com
Anita Marcinko
Affiliation:
University Department of Neurology, General Hospital Sveti Duh, Sveti Duh 64, 10000 Zagreb, Croatia, E-mail: hana0806@gmail.com
Hrvoje Budincevic
Affiliation:
University Department of Neurology, General Hospital Sveti Duh, Sveti Duh 64, 10000 Zagreb, Croatia, E-mail: hana0806@gmail.com
Ivan Bielen
Affiliation:
University Department of Neurology, General Hospital Sveti Duh, Sveti Duh 64, 10000 Zagreb, Croatia, E-mail: hana0806@gmail.com
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Abstract

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Introduction/Objectives:

Leptomeninges are common dissemination site of advanced malignant disease. The most frequent primary sites are breast, lung, melanoma and stomach, whereas colon is rarely reported. On the other hand, as the very first dissemination site of malignant disease leptomeninges appear to be quite rare.

Results:

We report a case of a 70-year-old man who was admitted to the neurology emergency room with a 3-week history of mild frontal headache, vertigo and vomiting going back 3 days. The patient had no history of malignancies or any other serious diseases. The neurological examination showed an ataxic gate with the tendency to lean to the right, spontaneous nystagmus increased during the left gaze and hearing loss on the right ear. Findings of the multi-slice computed tomography (MSCT) of the brain were unremarkable. Magnetic resonance imaging (MRI) of the brain showed multiple periventricular white matter lesions. During the next few days the patient symptoms progressed to include right peripheral facial nerve palsy, complete hearing loss and mental alteration. Body temperature and inflammation parameters were normal all of this time. In order to ascertain the cause of the neurological deterioration gadolinium-enhanced MRI was performed, which revealed diffuse leptomeningeal enhancement of the cranial base a thickening of both of the vestibulocochlear nerves especially right one. Cerebrospinal fluid (CSF) analysis showed sterile hypercellular (1184/3 mm3) CSF with predominantly low-differentiated malignant cells with numerous mitoses, hypoglycorrhachia (1.7 mmol/l) and elevated protein level. The highly increased serum levels of the tumor marker carbohydrate antigen 19–9 led us to investigate weather any GI tract malignancy was present. Ultrasound and MSCT of the abdomen, esophagogastroduodenoscopy as well as ultrasound of the thyroid gland and chest X-ray did not find any signs of malignant disease. However, colonoscopy revealed an infiltrating process that prominates to the lumen of the ascending colon. The patient showed no symptoms of intestinal obstruction or any other GI tract symptoms. Histopatological analysis of biopsy samples verified adenocarcinoma. The patient refused intratecal chemotherapy and underwent whole-brain radiotherapy. Despite treatment, the patient's state deteriorated and as a result he died shortly after.

Conclusions:

Unilateral hearing loss progressing to bilateral deafness within short period of time is a rare clinical manifestation of the leptomeningeal carinomatosis. To our knowledge this is the first case of vertigo with hearing loss as the first symptom of leptomeningeal carcinomatosis which originated from colorectal carcinoma.