A 72-year-old Hispanic female was brought into the emergency department (ED) by her family member for 3 days of worsening confusion, urinary incontinence, and difficulty ambulating after an unwitnessed fall. The patient had initially become altered at home 3 weeks prior to arrival in the ED; however, she was still able to carry out her activities of daily living (ADLs). Over the course of 3 days, the patient had a sudden decline of neurological status, inability to perform ADLs, urinary incontinence, and echolalia, which prompted the family to bring the patient to the ED. The patient was previously diagnosed with breast cancer approximately 4 years prior to presentation, during a screening mammogram. After confirmation of breast cancer, the patient underwent a bilateral mastectomy and axillary lymph node dissection. She was found to have metastatic spread to her lymph nodes. An axillary sentinel lymph node biopsy revealed three out of four axillary lymph nodes positive for metastatic disease with a pathological stage of T2N2M0. Pathology revealed estrogen-positive, progesterone-positive, HER-2 negative invasive lobular carcinoma (Fig. 1) of the left breast and ductal carcinoma in situ of the right breast. She was treated with a regimen of 12 cycles of chemotherapy with paclitaxel, external beam-radiation to her left axilla, and daily anastrozole 1 mg orally for 3 years.
In the ED, a computed tomography (CT) of the head revealed mild hydrocephalus with transependymal CSF resorption without intracranial hemorrhage, mass, infarction, or skull fracture. Magnetic resonance imaging (MRI) of the brain revealed enlargement of the lateral and third ventricles and preserved size of cerebral aqueduct and fourth ventricle, T2 hyperintensity consistent with transependymal spread of CSF, confirming obstructive hydrocephalus.
An electroencephalogram (EEG) was negative for seizure-like activity. Initial lumbar puncture (LP) revealed CSF with an elevated white blood cell (WBC) count with lymphocytic pleocytosis, normal opening pressure, elevated glucose, and very elevated protein as shown in Table 2. She became febrile to 101  F and encephalopathic, and was started on empiric antibiotics, antivirals, and antifungals. CT imaging was negative for metastatic disease, but revealed bilateral pleural effusions, moderate right basilar consolidations, and intraluminal filling defects in the right pulmonary arteries suggestive of right pulmonary embolism. During her hospital course, she had a rapid deterioration in her neurological status. Eventually she was upgraded to the intensive care unit (ICU) for poor mentation and acute hypercapnic respiratory failure requiring intubation and mechanical ventilation. After ICU upgrade, a CT scan with intravenous contrast revealed a pulmonary embolism (PE). She was ultimately started on a heparin drip to prevent worsening of the PE.
On initial presentation, given her immunocompromised state, there was concern for tuberculosis. A quantiferon gold test was positive for tuberculosis; however, acid fast bacilli smears were negative on three separate occasions. CSF studies did not reveal any infectious etiology. Given her breast cancer history, LC remained high on our differential list. However, considerations were made for acute encephalitis secondary to an infectious etiology due to CSF findings of elevated glucose, protein, and WBCs. The patient was started on acyclovir due to suspicion of viral encephalitis. The patient was also on vancomycin and ceftriaxone for a suspected hospital acquired pneumonia. CSF studies were found to be negative for herpes simplex virus (HSV), varicella zoster virus (VZV), and coccidioidomycosis (antibodies were < 1:2).
Repeat CT of head showed interval improvement of the mild hydrocephalus, and MRI (Fig. 2) of the cervical and thoracic spine did not demonstrate any metastatic lesions. A CA 27-29 level was checked, which was found to be negative.
Throughout the patient's hospital course, there was noted improvement in mentation, which was noticeable especially after 26 mL of CSF was obtained after a lumbar drain was placed. This was seen as the patient had spontaneous opening of her eyes and started to follow minimal commands while in the ICU. Even though she was intubated, she was able to communicate with the medical staff and with her family members by answering to yes or no questions with her eyes. During her ICU stay, there were multiple spontaneous breathing trials attempted with the hopes of possible extubation; however, the patient unfortunately failed on these attempts.
CSF studies from lumbar drain revealed small groups of large vacuolated epithelial cells having circular nuclei with distinct nucleoli consistent with metastatic mammary adenocarcinoma (Fig. 3). The oncology department was heavily involved in the patient's hospital course as the decision was made to stop the anastrozole therapy given the progression of disease.
The diagnosis of LC was made. After extensive discussions with the family members, the patient's family decided to pursue comfort care given the extent of disease complicated by a PE. The patient was weaned off sedation then transitioned to dexmedetomidine, and then was successfully extubated. Per the family request, the patient was discharged home with family and was followed by hospice care.
All therapies were discontinued, and she was successfully extubated with discharge to home hospice. There was no follow-up regarding length of survival after discharge from the hospital.