SHM Converge Scientific Abstract ePoster Gallery-The Diagnostic Challenge of Carcinomatous Meningitis With Repeatedly Negative Lumbar Punctures

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This case describes a 42-year-old woman with metastatic lung adenocarcinoma who developed four weeks of pressure-like headaches, nausea, vomiting, and poor oral intake. Initial lumbar punctures repeatedly showed a pattern concerning for chronic meningitis: lymphocytic/monocytic pleocytosis, low CSF glucose, elevated opening pressure, and negative cytology. Because early studies were unrevealing, she was treated empirically for infectious causes, including bacterial meningitis, tuberculosis, and later coccidioidal meningitis after a positive serum Coccidioides IgM returned. She improved transiently on steroids and empiric therapy.<br /><br />However, one month later she returned with recurrent headache, neck pain, nausea, and vomiting. A repeat lumbar puncture finally revealed malignant TTF-1-positive cells, confirming carcinomatous meningitis. MRI and PET imaging then demonstrated multifocal leptomeningeal and intraparenchymal brain metastases, plus additional systemic metastatic disease. Antifungal and TB therapies were stopped, and she received whole-brain radiation and systemic chemotherapy.<br /><br />Despite treatment, her cancer progressed over the following months, leading to cord compression concerns, pleural effusion, dysphagia, and overall clinical decline. She ultimately transitioned to hospice care.<br /><br />The key lesson from this case is that carcinomatous meningitis should remain high on the differential when CSF repeatedly shows mild lymphocytic pleocytosis, elevated protein, hypoglycorrhachia, and high opening pressure, especially in patients with a cancer history—even if early CSF cytology is negative. False-positive infectious serologies can delay diagnosis, and earlier recognition may allow more timely treatment, although prognosis remains poor, with median survival often only 2–4 months.

Asset Subtitle

Kevin S. Wei

Meta Tag

Author List Chanidapa Klinhom, Darin Poei, Evan J. Chen, Kevin S. Wei, Mollee Chu, Sarah Wang, Vivian H. LeTran

Category Clinical Vignettes

Concept Carcinomatous Meningitis

Concept Cerebrospinal Fluid

Concept CSF Lymphocytic Pleocytosis

Concept Lumbar Puncture Cytology

Concept Protein

Distinguished Non-Finalist

Presenter Organization USC/Los Angeles General Medical Center

Presenting Author Kevin S. Wei

Track Adult

Keywords

carcinomatous meningitis

metastatic lung adenocarcinoma

leptomeningeal metastases

cerebrospinal fluid cytology

lymphocytic pleocytosis

hypoglycorrhachia

elevated opening pressure

TTF-1 positive cells

false-positive coccidioides serology

whole-brain radiation

Carcinomatous Meningitis

Cerebrospinal Fluid

CSF Lymphocytic Pleocytosis

Lumbar Puncture Cytology

Protein