Discussion
Neoplastic meningitis continues to be diagnostically challenging due to
its subtle, varied, and non-specific clinical features. This case
illustrates an initial presentation of vertigo, with sub-acute
progression to cerebral involvement and higher executive dysfunction.
Headache remains the most common symptom of neoplastic meningitis
(present in 66% of cases) but is non-specific. 50% present with
myelopathy, with symptoms such as lower limb weakness, paraesthesia or
bowel or bladder disturbance. 35% present with isolated or grouped
cranial nerve palsies, and 15% present with cerebral dysfunction
manifesting as higher cortical deficits such as confusion or
dysphasia.5-6 In retrospect, it is likely that the
initial dizziness in this case was related to an isolated
8th (vestibulocochlear) nerve palsy with branch
involvement leading to vestibular neuronitis.
Treatment of neoplastic meningitis is palliative and although cannot
reverse existing neurological deficits may prevent
deterioration.7 Aggressive treatment can increase
survival time from 4-6 weeks to 6 months,5-7highlighting the importance of early recognition and diagnosis.
Clinicians must therefore be aware of the many manifestations and
maintain a high index of suspicion.
With reference to diagnosis, a triad of factors including classical
symptoms and signs, appropriate findings on MRI imaging, and CSF
analysis should be used.5 MRI imaging is used to look
for features of meningeal enhancement, whilst CSF findings of increased
lymphocytes, high protein, very low CSF:serum glucose ratio, and high
lactate, illustrated perfectly in this case, are highly suggestive of a
diagnosis. 5-6 Positive cytology from CSF is gold
standard although this cannot always be obtained and may require
multiple, large volume LPs.5-6 This case exemplifies
the important role an LP can play in investigating new neurological
symptoms.
Lastly, this case provides us with the opportunity to reflect on reasons
behind diagnostic error. The prevalence of, and harm, that can arise
from diagnostic error is well documented in the literature8-9 and it is therefore important that, as clinicians,
we reflect on our practice in order to understand the factors
influencing our decision-making. This case offers a reminder of the
particular challenge recurrent attenders present, and the bias that can
arise from anchoring to an initial or previous diagnosis. This patient
received a diagnosis of BPPV from a consultant neurologist and, despite
changing clinical features on subsequent presentations, this diagnosis
was maintained following review by three experienced general physicians.
This highlights the importance of remaining open minded in such cases
and recognising diagnostic bias that may exist.
List of Abbreviations
BPPV = Benign Paroxysmal Positional Vertigo
CSF = Cerebral Spinal Fluid
CT = Computed Tomography
LP = Lumbar puncture
MRI = Magnetic Resonance Imaging
Author Contributions
Author 1: Dr Catriona Davidson MBBS MRCP, CT2 Addenbrookes Hospital,
catriona.davidson@nhs.net
– Joint lead author
Author 2: Dr Katerina Achilleos BSc (Hons) MBBS MRCP, Consultant
Rheumatologist West Suffolk Hospital, katerina.achilleos@wsh.nhs.uk –
Joint lead author
Author 3: Dr Francesca Crawley MBBCh, FRCP, Consultant Neurologist West
Suffolk Hospital, francesca.crawley@wsh.nhs.uk – Author
Author 4: Dr William Petchey BSc (Hons) BM PhD MRCP, Consultant
Nephrologist West Suffolk Hospital, william.petchey@wsh.nhs.uk – Senior
author