A Case of Bellʼs Palsy Heralding Leptomeningeal Carcinomatosis from Metastatic Gastric Adenocarcinoma

Abstract

Purpose: Leptomeningeal carcinomatosis is a rare complication of solid tumors. We present an unusual case of a patient who presented with Bell's palsy and ocular symptoms as a result of meningeal carcinomatosis from metastatic gastric adenocarcinoma. A 27-year-old Hispanic woman presented to her primary care physician with headaches, left facial paresis, and was diagnosed with Bell's palsy. She was started on oral steroids and subsequently presented to our hospital 1 week later with intensifying headaches and blurry vision. She had no other significant comorbidities. Upon further review, she had an upper endoscopy 1 year ago in her home country for dyspepsia revealing a 1cm gastric ulcer on lesser curve, biopsy showing atypical cells and no follow-up. She had a strong family history of gastric cancer. Her physical exam findings were remarkable for left facial droop, decreased visual acuity, decreased left sided facial sensation and a palpable, 3-cm pelvic mass. Laboratory information revealed mild anemia and cholestatic liver function tests. An MRI of the brain revealed optic nerve enhancement and a few areas of dural enhancement. She underwent a lumbar puncture, CT of the chest and SPECT gallium scan revealing mediastinal, abdominal lymphadenopathy and a large pelvic mass. She was suspected to have sarcoidosis with neurologic involvement and bilateral uveitis. One week after discharge, she became icteric and had increasing abdominal pain; laboratory data showed AST 178, ALT 287, alkaline phosphatase 265, total bilirubin 1.5, and lipase of 3778. Magnetic retrograde cholangiopancreatography revealed obliteration of the pancreatic duct in the head and neck of the pancreas, extrinsic obstruction of the common bile duct from periportal lymph nodes, dilated intrahepatic bile ducts, multiple liver lesions, diffuse abdominal mediastinal lymphadenopathy and a large pelvic mass. Endoscopic retrograde cholangiopancreatography revealed a large friable mass extending from the gastro-esophageal junction to mid-body, along the lesser curvature of the stomach. The antrum and duodenum were free of tumor. A biliary plastic stent was placed and gastric biopsies revealed infiltrating high-grade adenocarcinoma, negative for Helicobacter pylori. The patient subsequently underwent pelvic mass biopsy and staging scans, which showed involvement of lungs, liver, pancreas, bone and meninges consistent with metastatic gastric adenocarcinoma. This case highlights leptomeningeal carcinomatosis presenting as Bell's palsy from a rapidly progressing gastric adenocarcinoma. Systemic symptoms in such cases should raise concern among clinicians for either direct organ involvement or paraneoplastic syndromes.