Bilateral hearing loss as presentation in meningeal carcinomatosis

Trigo López, Javier; Martínez Pías, Enrique; Pedraza Hueso, Maria Isabel

doi:10.1016/j.medcle.2019.06.034

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Hyper-enhancement in both cerebellar hemispheres with extension to both vestibulocochlear nerves." ] ] ] "textoCompleto" => "Dear EditorMeningeal carcinomatosis (MC) is characterized by the infiltration of the cerebrospinal fluid (CSF) and the meninges by malignant cells from a solid primary tumour. A prevalence of around 4%–15% is estimated in solid neoplasms.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> An increase in their presence has been described due to an improvement in diagnostic tests, a low penetrance of the blood-brain barrier of the new antineoplastic agents and an overall increase in the survival of cancer patients.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>The most commonly involved tumours in MC are breast cancer (12%–35%), lung cancer (12%–26%), and melanoma (5%–25%). Less common are gastrointestinal (4%–14%) or unknown primary tumours (1%–7%).<a class="elsevierStyleCrossRef" href="#bib0005">1</a>We report a case of MC that started with bilateral hearing loss in which lung adenocarcinoma was diagnosed as a primary tumour.A 65-year-old woman presented with a 2-month history of bilateral hearing loss associated with tinnitus, gait instability, nausea, vomiting and a 4 kg weight loss.Neurological examination revealed bilateral sensorineural hearing loss, positive Romberg test with a tendency to fall backwards and to the left, gait instability with an increase in the support base and impossibility for tandem gait. Only the slight increase of CA125 stood out in the laboratory tests (50 U/mL, range: 0–35). A brain magnetic resonance imaging (MRI) was performed, which showed a pial hyper-enhancement was evidenced on the surface of both cerebellar hemispheres with extension towards both vestibulocochlear nerves (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Given these findings, it was decided to carry out a lumbar puncture. CSF biochemistry showed lymphocytic pleocytosis (124 white blood cells/μl, 85% monocytes), hypoglycorrhachia (9 mg/dl) and an elevated protein count (125 mg/dl). The CSF microbiological study was negative, including bacteria culture, PCR for tuberculosis and herpes group. Malignant cells with a pattern compatible with adenocarcinoma were observed in CSF cytology.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The patient was diagnosed with meningeal carcinomatosis, completing the study with a chest-abdominal-pelvic computed tomography (CT), in which a nodule was observed in the right lower pulmonary lobe, and a CT-guided biopsy of said nodule which showed malignant cells with a pattern compatible with epidermal growth factor receptor (EGFR)-positive lung adenocarcinoma.The oncology department initiated treatment with erlotinib, bevacizumab and dexamethasone on an outpatient basis. Six weeks later, the patient returned to the emergency department due to seizures and deterioration of the general condition, dying within a few hours after her admission.The clinical manifestations associated with MC are produced by either an obstruction of CSF flow, which generates intracranial hypertension, or by tumour infiltration of the cerebral hemispheres, the cranial nerves, or the spinal cord. Cranial nerve involvement occurs in 35% of cases, with the oculomotor nerves being the most commonly affected (15%). Others, such as the optic nerve, the facial nerve, and the trigeminal nerve, are less commonly involved. Vestibulocochlear nerve involvement is rare, with hearing loss occurring as a presenting symptom in only 4% of the cases.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Even rarer is the occurrence of bilateral hearing loss as an initial symptom.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>Contrast-enhanced MRI is the imaging test of choice for suspected MC, with the typical finding being leptomeningeal hyperenhancement. Contrast-enhanced MRI has a sensitivity of 70%, so a normal study does not exclude the diagnosis. An established diagnosis is carried out by pathological analysis of the CSF and the finding of malignant cells in it. CSF cytology has a low sensitivity, positive results can increase from 71 to 90% between the first and third test with repeated punctures.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>The median survival of patients with MC is 4–6 weeks in untreated patients, mainly depending on the type of primary tumour. Regarding cases with lung adenocarcinoma as the primary tumour, those with the best prognosis are EGFR-positives, in which treatment with erlotinib has been shown to increase median survival.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>In conclusion, MC must be considered in the etiological diagnosis of bilateral hearing loss of acute or subacute onset." "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Dear Editor" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Trigo López J, Martínez Pías E, Pedraza Hueso MI. Hipoacusia bilateral como forma de presentación en la carcinomatosis meníngea. Med Clin (Barc). 2020;155:276–277." ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1470 "Ancho" => 1505 "Tamanyo" => 159481 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "T1-weighted sequence MRI + intravenous contrast, axial section. Hyper-enhancement in both cerebellar hemispheres with extension to both vestibulocochlear nerves." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Leptomeningeal metastases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S. Kesari" 1 => "T.T. Batchelor" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0733-8619(02)00032-4" "Revista" => array:6 [ "tituloSerie" => "Neurol Clin." "fecha" => "2003" "volumen" => "21" "paginaInicial" => "25" "paginaFinal" => "66" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12690644" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Carcinomatous meningitis: leptomeningeal metastases in solid tumors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E. Le Rhun" 1 => "S. Taillibert" 2 => "M.C. Chamberlain" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/2152-7806.111304" "Revista" => array:7 [ "tituloSerie" => "Surg Neurol Int." 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"fecha" => "2012" "volumen" => "18" "paginaInicial" => "328" "paginaFinal" => "342" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22810130" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bilateral sudden sensorineural hearing loss caused by leptomeningeal carcinomatosis: case report and review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Öztürk" 1 => "K. Ila" 2 => "C. Düzgöl" 3 => "G. Akansel" 4 => "A. Almaç" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5606/kbbihtisas.2014.37029" "Revista" => array:6 [ "tituloSerie" => "Kulak Burun Bogaz Ihtis Derg." "fecha" => "2014" "volumen" => "24" "paginaInicial" => "287" "paginaFinal" => "291" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25513873" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => ""Pulsatile" high-dose weekly erlotinib for CNS metastases from EGFR mutant non-small cell lung cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Grommes" 1 => "G.R. Oxnard" 2 => "M.G. Kris" 3 => "V.A. Miller" 4 => "W. Pao" 5 => "A.I. Holodny" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/neuonc/nor121" "Revista" => array:6 [ "tituloSerie" => "Neuro Oncol." 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Vol. 155. Issue 6.

Pages 276-277 (September 2020)

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