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Lung Cancer |

While You Were Sleeping

Sreelatha Naik*, MD; Abdulilah Arafeh, MD; Vagram Ovnanian, MD; Georges Ghacibeh, MD; Geena Varghese, MD
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University of Medicine and Dentistry of New Jersey - New Jersey Medical School, Newark, NJ


Chest. 2012;142(4_MeetingAbstracts):569A. doi:10.1378/chest.1389967
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Abstract

SESSION TYPE: Cancer Case Report Posters II

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Paraneoplastic Limbic Encephalitis (PLE) can be an underlying cause of seizures. Recognizing PLE symptoms can aid the diagnosis of an underlying malignancy, as in the case of our patient.

CASE PRESENTATION: A 63 year-old woman with a history of breast cancer, in remission after mastectomy and anastrozole treatment, presented with a generalized tonic-clonic seizure. Initial evaluation and admission did not reveal the etiology. She was discharged on antiepileptics. She was readmitted two months later with tonic-clonic seizures and a marked decline in her mental status. Electrolytes, urine toxicology, and electroencephalogram were unremarkable. Lumbar puncture showed twelve lymphocytes; cultures were negative. MRI of the brain showed increased signal intensity in the right hemisphere. The patient then progressed to status epilepticus, at which time she was intubated for airway protection. Her seizures were eventually controlled, but she remained comatose for weeks. A right-brain biopsy showed unremarkable parenchyma. Given prior history of breast cancer, CSF was sent for paraneoplastic markers, which returned positive for anti-GABA-B receptor antibodies in the CSF. Based on these findings, consistent with a PLE, the patient was started on rituximab, plasmapheresis and intravenous immunoglobulin, after which she started to regain purposeful movement. PET-CT then showed hypermetabolism in a subcarinal lymph node. Bronchoscopy with transbronchial biopsy of that lymph node revealed small cell lung carcinoma. After initiation of chemotherapy and radiation the patient became more awake and verbal, but continued to have marked memory loss.

DISCUSSION: PLE is a rare disorder characterized by personality changes, seizures and memory loss. It occurs in association with cancer even without brain metastasis, and most commonly with small-cell lung carcinoma. Neuropsychiatric symptoms often precede the diagnosis of cancer, making diagnosis of PLE difficult. A number of antibodies have now been recognized to be markers of PLE. Among them are anti-GABA-B-, anti-NMDA-, anti-AMPA-, and anti-potassium channel receptor antibodies, as well as anti-Hu, anti-Ma and anti-CRMP5 antibodies which target intracellular antigens [1]. The mechanism of formation of these antibodies and their implication in the prognosis of the malignancy are not well-known. However, if PLE is diagnosed, evaluation for a malignancy including PET scan should be completed as it may increase the probability of curative treatment.

CONCLUSIONS: PLE is a rare cause of seizures. In patients with neuropsychiatric symptoms without any other etiology, PLE should be considered, given that treatment of the underlying malignancy can result in a drastic improvement in the patient’s symptoms.

1) Blaes F, Tschernatsc M. Paraneoplastic neurologic disorders. ExpRevNeuroth 2010; 10:1559-1569.

DISCLOSURE: The following authors have nothing to disclose: Sreelatha Naik, Abdulilah Arafeh, Vagram Ovnanian, Georges Ghacibeh, Geena Varghese

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University of Medicine and Dentistry of New Jersey - New Jersey Medical School, Newark, NJ

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