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A 59-year-old woman provided a 3-month history of decreased hearing in her right ear. One month later, she developed a complete right-sided ptosis and progressive dysarthria. On examination, there was right third cranial nerve palsy with mydriasis, right-sided sensorineural hearing loss and left lower motor neurone facial weakness. There were signs of a left brachial plexopathy (with weakness, wasting and partial hypoaesthesia in the left arm), unchanged since these features had developed following radiotherapy for a local recurrence of breast cancer 10 years previously.
The breast carcinoma had initially presented 17 years previously (Grade: T1 N0 M0) and was managed with surgery and adjuvant chemotherapy.
What is the differential diagnosis?
The pattern of neurological signs is against a single lesion and can be summarised as sequential, subacute, multiple cranial nerve palsies. The initial clinical suspicion was of basal meningitis, possibly due to malignancy, subacute infection or granulomatous disease.
She was admitted to a district general hospital where initial screening blood tests were normal, including bone profile. An MRI scan of the brain and whole spine, including postcontrast images, was normal. She underwent three lumbar punctures (table 1).
What would you do next?
Despite the history of breast cancer and the strong clinical suspicion of metastatic basal meningitis, the cerebrospinal fluid (CSF) cytology was negative on three separate occasions. However, the persistently raised CSF protein suggested possible central nervous system neoplasia or an inflammatory or infectious process.
CT scan of the chest abdomen and pelvis, performed to assess for local recurrence or metastases of the breast tumour, was normal. Blood cultures, treponemal serology, angiotensin-converting enzyme, serum electrophoresis, antineutrophil cytoplasmic antibodies, antidouble-stranded DNA antibodies and serology for HIV, cryptococcal antigen, Epstein–Barr virus and cytomegalovirus were sent and she underwent a further lumbar puncture; all tests were …
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