A 61-year-old man with a 47 pack-year smoking history presented after a month of positional headache, blurry vision, early satiety, and weight loss. His neurologic examination demonstrated bilateral papilledema but was otherwise unremarkable. Lumbar puncture was significant for 40 cm H2O opening pressure, 27 mg/dL of glucose, 48 mg/dL of protein, 5 red blood cells, 8 leukocytes, and atypical keratin-positive cells. Skin examination revealed multiple nodules that had appeared a week before symptom onset (Figure, A and B). An MRI examination showed enhancement of (Figure, C) the facial and vestibulocochlear nerve complex (Figure, D), trigeminal nerve (Figure, E), patchy spinal leptomeninges, and (Figure, F) cauda equina nerve roots. Skin lesion biopsy and CSF cytology both revealed signet-ring carcinoma. Subsequent endoscopy revealed primary gastric cell adenocarcinoma. Leptomeningeal carcinomatosis is rare and occurs in only 0.14%–0.24% of all gastric carcinomas.1,2 Further, cutaneous and concurrent leptomeningeal spread of gastric cancer is extremely rare. This case highlights the relevance of a general examination and consideration of comorbidities in approaching an unclear neurologic presentation, particularly when considering possible leptomeningeal disease.
Pink and violaceous papules and nodules on the (A) back, (B) shoulder, and chest. Axial T1 postcontrast MRI brain sequences showing: (C) Linear enhancement of the left facial and vestibulocochlear nerve complex; (D) Enhancement of the right trigeminal nerve in Meckel cave; (E) Leptomeningeal enhancement at the level of T11; (F) Cauda equina nerve root enhancement, cumulatively concerning for diffuse, patchy leptomeningeal disease.
Author Contributions
A. Silverman, D. Loube, M. Lovall, C. Cheronis, E. Madill, and C. Karch: drafting/revision of the article for content, including medical writing for content. A. Silverman, D. Loube, M. Lovall, E. Madill, and C. Karch: major role in the acquisition of data. A. Silverman and C. Karch: study concept or design and analysis or interpretation of data.
Study Funding
The authors report no targeted funding.
Disclosure
The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Submitted and externally peer reviewed. The handling editor was Resident and Fellow Section Editor Whitley Aamodt, MD, MPH.
Teaching slides links.lww.com/WNL/C861
- Received November 14, 2022.
- Accepted in final form April 10, 2023.
- © 2023 American Academy of Neurology
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