A 44-year-old woman with a history of triple-negative breast cancer metastatic to the brain presented with changes in mental status, lower back pain, and a left facial Bell's palsy.The patient had previously been ambulatory and fully cognizant of her surroundings until one week prior to presentation when she began to exhibit progressively worsening confusion. As her mental status began to change, the patient developed new onset pain over her lumbar spine, supra-pubic area, bilateral flanks, hips, and knees. The pain was refractory to an epidural injection into her lumbar spine performed at the patient's local hospital. Other complaints included a recent onset urinary retention, weakness of the left lower extremity, a left facial Bell's palsy, and difficulty walking. On admission, the patient was taking gabapentin, citalopram, aspirin, enoxaparin, nystatin, lopressor, docusate, lorazepam, and methylprednisone. The patient was treating her pain with hydromorphone hydrochloride as needed. No other medications had recently been prescribed.Past medical history included breast cancer status post bilateral mastectomies, four cycles of chemotherapy with paclitaxel, and neo-adjuvant radiation. One month prior to presentation, the patient was found to have metastases to her brain, and underwent a left fronto-temporal craniotomy that was then followed by a course of whole brain irradiation.Upon examination, the patient was confused and had difficulty speaking and swallowing. Her temperature was 97.4˚F, her pulse was 95 beats per minute, her respiratory rate was 20 breaths per minute, and her blood pressure was 143/88 mm Hg. The patient's pulse oximetry on room air was 95%. Her pupils were anicteric and equally round and reactive to light, but a left visual field defect was noted. The patient exhibited facial nerve palsy involving the entire left side of the face. All other cranial nerves appeared intact. The patient showed diffuse myoclonic jerks in her upper extremities. Motor testing revealed 3/5 strength in the left leg and 4/5 strength in the right leg. Sensation was preserved throughout the extremities. The patient's cardiac exam was normal, and her lungs were clear to auscultation bilaterally. Her abdomen was soft and non-distended, and her legs were non-edematous. The patient's white blood cell count was 6300 cells/mm 3 with a differential of 76.3% neutrophils and 11.9% lymphocytes. Hemoglobin was 13.5 g/dL, hematocrit was 40.4%, and platelets were 229,000/ml. Electrolyte values and coagulation tests were both within normal limits. The patient's ESR was elevated at 60. Her liver function tests showed a total protein of 6.9 gm/ dl, albumin of 4.2 gm/dl, total bilirubin 1.4 mg/dl, direct bilirubin 0.6 mg/dl, AST of 33 U/L, ALT 32 U/L, and alkaline phosphatase of 82 U/L. Blood and urine cultures were negative for bacterial growth.A CT scan of the patient's spine revealed mild multilevel degenerative changes with no evidence of lytic or blastic lesions. An MRI of the spine showed no evidence of bony metastases, spinal c...
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