MD seeks opinion on unusual CSF leak case

Paul Prior MD pprior at fast.net
Sat Jul 15 21:26:07 EST 1995


Below please find a case involving a family member of an associate of
mine.  Being an OB/Gyn resident, I have minimal knowledge of the
specifics of the diagnoses to be entertained, but would like any
suggestions anyone might have.

Email replies PLEASE!

advTHANKSance

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	Pt is a 64 y.o. G5P5 menopausal women with a PMHx significant for
breast Ca in 1982. She has no known hx of sinus pblms or head trauma.
She developed a nasal drip two weeks prior to admission.  The drip was
treated with Claritin with no relief.  The fluid irritated her nose
and lips.
	The pt then developed a severe h/a with a fever to 103 F.  She was
taken to the ER where an EKG, CXR, labs, blood cultures, neuro checks
and u/a were all WNL.  A Cat scan was normal. A spinal tap revealed
milky white fluid with granulocytes but negative cultures and
cytology.  She was Rxed with Rocephin, Vanco and Ampicillin for 4
days.
	A repeat CAT scan was performed which revealed multiple holes in the
cribiform plate but without lesions or bleed. A MRI was neg.  A bone
scan and bone survey were performed secondary to the pt's hx of breast
Ca and it only revealed thinning of the left parietal bone.  
	The pt was transferred to another institution where a
lumbar-peritoneal shunt was placed to relieve CSF pressure and heal
the continuing leak.  The shunt leaked abdominally and the pt was
treated with Nafcillin and the shunt was anchored better into the abd
wall.
	The pt was sent home for 10 days where she developed left leg weakness
and fell several times.  A repeat CAT scan was normal.  The pt fell
again when attempting to get up from a wheelchair.  She was admitted
to the hospital again where she had a tonic-clonic witnessed seizure
that lasted at least two minutes.

The pt reported that the seizure "hurt very much."  She was placed on
Tegretol.

	Doppler flow of carotids, an EEG, and a MRI were all normal.  The pt
continued to have left arm and leg weakness that necessitates her
walking with a cane.  The episodes of weakness are decreasing.
	The shunt then developed a block in the back and a lump appeared.  The
lump was tapped for 15 ml of CSF.  The lump presented again and was
retapped.  The plan is to remove the shunt soon.

	The CAT scan films were reviewed by a specialist at a large academic
center who felt that the pt had multiple myeloma even though her Ca++
was normal.  No other physician concurred with his diagnosis.  A
neurologist felt that the seizure may have been a residual effect from
her meningitis.



-----------------pprior at fast.net--------------------------------
Paul Prior MD    Disclaimer: No medical    I am Homer of Borg...
Ob/Gyn PGY-II     opinions are implied     resistance is fut...
TRHMC             by my postings/email.    hmmmm... donut!...




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