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Table of Contents    
LETTER TO EDITOR
Year : 2021  |  Volume : 69  |  Issue : 5  |  Page : 1473-1474

Status Epilepticus as the Presenting Complication of Adenocarcinoma Lung in a Young Male


1 Consultant Neurologist, Yashoda Superspeciality Hospital, Malakpet, Hyderabad, Telangana, India
2 Consultant Pulmonologist, Yashoda Superspeciality Hospital, Malakpet, Hyderabad, Telangana, India
3 Consultant Physician, Yashoda Superspeciality Hospital, Malakpet, Hyderabad, Telangana, India
4 Consultant Radiologist, Yashoda Superspeciality Hospital, Malakpet, Hyderabad, Telangana, India

Date of Submission12-Apr-2020
Date of Decision13-May-2020
Date of Acceptance10-Jul-2020
Date of Web Publication30-Oct-2021

Correspondence Address:
Ravi Kanth Jakkani
Department of Radiology, Yashoda Superspeciality Hospital, Malakpet, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.329579

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How to cite this article:
Ramineni KK, Chakrahari UB, Gutha SR, Jakkani RK. Status Epilepticus as the Presenting Complication of Adenocarcinoma Lung in a Young Male. Neurol India 2021;69:1473-4

How to cite this URL:
Ramineni KK, Chakrahari UB, Gutha SR, Jakkani RK. Status Epilepticus as the Presenting Complication of Adenocarcinoma Lung in a Young Male. Neurol India [serial online] 2021 [cited 2021 Nov 30];69:1473-4. Available from: https://www.neurologyindia.com/text.asp?2021/69/5/1473/329579




Sir,

Status epilepticus is a potentially treatable neurological emergency. Common etiologies in adults include stroke, changes in medication, metabolic derangements, central nervous system infections, missing antiepileptic medication, autoimmune encephalitis etc.[1],[2] In already diagnosed patients of malignancy cerebral metastasis and carcinomatous meningoencephalitis may present with seizures as one of the cardinal manifestations. Here we report a young male who presented with status epilepticus and etiological workup revealed carcinomatous meningoencephalitis with adenocarcinoma lung as the primary, detected de novo.

A 34-year-old male presented to the emergency department with a history of recurrent episodes of generalized tonic-clonic seizures without regaining normal sensorium in between. He had a history of fever and headache for two days. No history of vomitings, double vision or weight loss. He was nonsmoker, nonalcoholic, not a known hypertensive or diabetic. On examination, he was stuporous and febrile with a temperature of 102 °F. Chest auscultation revealed bilateral basal inspiratory crepitations. Cardiovascular and other general examination was unremarkable. He had neck stiffness without focal neurological deficits. In the emergency department he received 4 mg intravenous lorazepam followed by 2500 mg loading dose of intravenous levetiracetam. He was intubated and shifted to neurointensive care unit with the working diagnosis of viral meningoencephalitis. Investigations revealed Hemoglobin-15 gr/dl, total wbc count of 12000/cumm, platelets 3.5 lakhs/cumm. Metabolic workup and other routine laboratory investigations were normal.

Chest radiograph revealed left lower zone and retrocardiac opacity with blunting of costophrenic angle favouring left pleural effusion with underlying lower lobe consolidation [Figure 1]a. Computed tomography (CT) chest showed features of left lower lobe consolidation with minimal pleural effusion [Figure 1]b. Contrast magnetic resonance imaging (MRI) of brain showed thick focal left fronto temporo parietal lepto-meningeal enhancement [Figure 2]a. Cerebro spinal fluid analysis revealed normal protein, sugar and Adenosine Deaminase values with 8 cells/cumm. No atypical cells or fungal elements were seen. Herpes simplex virus 1 and 2 polymerase Chain Reaction negative. Autoimmune encephalitis panel was negative. Intravenous levetiracetam 750 mg twice a day and parenteral antibiotics were continued. By 48 hrs patient improved significantly and was extubated and did not have any further seizures. However, on day 7 he reported severe headache with vomitings. Repeat CSF analysis was done which revealed atypical cells [Figure 2]b suggestive of malignancy. He was further evaluated with whole-body Positron Emission Tomography- CT which revealed metabolically active lesions in left lower lobe of lung [Figure 3]a with high standardized uptake value of 9.3. As it was located subpleurally CT guided biopsy was done which confirmed adenocarcinoma of lung [Figure 3]b. Final diagnosis of status epilepticus due to carcinomatous meningoencephalitis with lung primary adenocarcinoma was made. Oral levetiracetam was continued; he was started on chemotherapy but lost to follow up.
Figure 1: (a) Chest radiograph and (b) CT chest shows left lower zone and retrocardiac opacity with blunting of costophrenic angle and the corresponding area of consolidation on CT scan

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Figure 2: (a) Contrast-enhanced MRI showing thick leptomeningeal enhancement along the left temporoparietal region and (b) Giemsa stained centrifuged CSF specimen showed atypical cells with three-dimensional pleomorphism typical of adenocarcinoma

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Figure 3: (a) PET CT image showing heterogeneous left lower lobe consolidation with high SUV uptake and (b), CT-guided lung biopsy histopathology specimen showing brown pigmented nuclei positive for Thyroid Transcription Factor-1 suggestive of primary adenocarcinoma

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Status epilepticus is defined as a continuous, generalized, convulsive seizure lasting >5 min, or two or more seizures between which the patient does not return to baseline consciousness.[3]

Malignancy associated seizures can be due to cerebral metastasis, carcinomatous meningoencephalitis, metabolic derangements and treatment-related side effects. Carcinomatous meningitis is a special form of metastatic cancer in which dissemination of tumour cells occur throughout meninges and ventricles. In lung carcinoma, it is more common with small cell subtype. Very few cases of adenocarcinoma presenting with carcinomatous meningitis are reported.[4] Our case is unique in acute presentation with status epilepticus mimicking infective etiology. Carcinomatous meningitis typically presents with subacute course of headache, altered sensorium, cranial neuropathies, radiculopathies, seizures and multifocal involvement. Contrast-enhanced magnetic resonance imaging of brain reveals diffuse or scattered meningeal enhancement with or without hydrocephalus.[5] Our patient had peculiar disproportionate focal left side enhancement.

Diagnosis is established by identifying tumour cells in the Cerebrospinal fluid (CSF) by flow cytometry and centrifugation. Repeated CSF examinations may be required as in our patient. Treatment options include whole-brain radiation, intraventricular methotrexate, intrathecal cytarabine, gemcitabine etc. However, prognosis is poor especially in adenocarcinomas.[6]

Thorough and systematic evaluation may clinch the definite diagnosis in otherwise cryptogenic status epilepticus and meningoencephalitis cases. Although rare, carcinomatous meningoencephalitis can be the presenting manifestation of underlying solid tumours.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
DeLorenzo RJ, Towne AR, Pellock JM, Ko D. Status epilepticus in children, adults, and the elderly. Epilepsia 1992;33:S15-25.  Back to cited text no. 1
    
2.
Kirmani B, Barr D, Robinson D, Pranske Z, Fonkem E, Benge J, et al. Management of autoimmune status epilepticus. Front Neurol 2018;9:259.  Back to cited text no. 2
    
3.
Lowenstein DH, Alldredge BK. Status epilepticus. N Engl J Med 1998;338:970-6.  Back to cited text no. 3
    
4.
Paramez AR, Dixit R, Gupta N, Gupta R, Arya M. Non-small cell lung carcinoma presenting as carcinomatous meningitis. Lung India 2010;27:158-60.  Back to cited text no. 4
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5.
Singh SK, Leeds NE, Ginsberg LE. MR imaging of leptomeningeal metastases: Comparison of three sequences. Am J Neuroradiol 2002;23:817-21.  Back to cited text no. 5
    
6.
Chowdhary S, Chamberlain M. Leptomeningeal metastasis: Current concepts and management guidelines. J Natl Compr Canc Netw 2005;3:693-703.  Back to cited text no. 6
    


    Figures

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