Neuritis of the ophthalmic branch of the trigeminal nerve as isolated manifestation of leptomeningeal carcinomatosis

Abstract

bar palsy, however, is always more striking than the long tract signs. Not only has the syndrome been described in identical twins, but we have also found it in a pair of siblings, suggesting a genetic etiology in some cases.The very unusual seizure pattern described by Ambrosetto and Tassinari may be helpful in suggesting the diagnosis.The protean clinical manifestations of leptomeningeal carcinomatosis have been strongly emphasized in the medical literature El, 2). Nevertheless, uncommon clinical presentations of this entity can become diagnostically vexing problems. This report describes such a case.A 72-year-old woman underwent a left mastectomy in June 1988 for invasive ductal carcinoma and invasive lobular carcinoma. Her axillary nodes were positive for tumor. She declined chemotherapy but received a full course of radiation therapy. A year later, in May 1989, she saw a neurologist complaining of a severe right-sided headache. A computed tomography scan of the head was normal. In June 1989 she was seen in our clinic with a (,-month history of right-sided headache. The pain was intermittent and of lancinating quality associated with tenderness upon touching the right side of the head. She was unable to wear her hats. On physical examination there was hyperalgesia and dysesthesia limited to the distribution of the ophthalmic branch (V,) of the right trigeminal nerve. The rest of the neurological examination was normal. A lumbar puncture was performed and the spinal ffuid showed glucose 2.9 mm, protein 0.288 gmlL; and cytological examination was positive for malignant cells. The patient was given carbamazepine, 200 mg three times daily, with striking clinical improvement. Cranial radiotherapy and intrathecal methotrexate were started.This unique clinical presentation of a leptomeningeal carcinomatosis is worth reporting for two reasons. First, the involvement of only one branch of the trigeminal nerve is a true clinical oddity. As Wasserstrom and colleagues [2} have reported, when the Vth nerve is involved the usual manifestations are hemifacial numbness and paresthesias or hemifacial pain-in other words, involvement of the three roots of the trigeminal nerve. Second, the satisfying clinical response to carbamazepine is not surprising, as we are all aware of the efficacy of this agent in the neuralgic syndromes. We would like to stress the association of lobular breast carcinoma with leptomeningeal carcinomatosis that has been reported by Smith and associates f31 and Harris and associates [4}. In summary, any neurological manifestation in a patient with cancer should elicit the suspicion of meningeal carcinomatosis and prompt a cytological study of the cerebrospinal fluid, especially in cases of invasive lobular carcinoma of the breast. Hill Health CenterYale University New Haven, CT References 1. Bleyer WE, Byrrne TN. Leptomeningeal cancer in leukemia and solid tumors. Curr Probl Cancer 1988;12(4):181-238 2. Wasserstrom WR, Glass JP, Posner JB. Diagnosis and treatment of leptomeningeal metastasis from solid t...