Matthew Low

James Noake Verified account @DrJN_SportsMed · Jan 21

Consent ✅

A very sad case with some important lessons that I recalled whilst writing my book

40s - trying to increase exercise to lose weight

Worsening bilateral shin pain, with altered sensation and progressive weakness

Pain worse on extension, relieved by flexion – for example, preferred cycling to running / elliptical trainer

Admitted ‘off legs’ to my medical unit – lower limb neurological exam very abnormal with patchy deficits

Initially treated as Guillain-Barré syndrome with intravenous immunoglobulins but no improvement

When I removed their top to do the lumbar puncture, small scar seen on their back (“they removed a lump four years ago, it was a melanoma I think”)

CSF looked gelatinous and bloody - protein levels sky high at 12g/l (Froin’s Syndrome) and Red Blood Cell count elevated

Sent for histopathology – macrophages seen containing ingested melanin granules (see pathology slide)

MRI lumbar spine image (sagittal) with contrast – cauda equina nerve roots infiltrated by tumour and central canal dilated due to obstructed CSF flow

Diagnosis – Malignant Meningitis (leptomeningeal carcinomatosis) secondary to disseminated malignant melanoma

Rapid deterioration due to brain metastases (CT image) and died several weeks after admission

Pearls –

Whenever possible, try and expose a patient fully and remove appropriate clothing to observe eg for scars and explore their past medical history; the patient may consider some of their medical history irrelevant

Patchy bilateral neurological deficits should always ‘ring the alarm bells’ – as should comments like ‘my legs don’t feel like my own’

Research link –

Noake, J - Melanomatous Leptomeningeal Carcinomatosis masquerading as Guillain-Barré Syndrome

pubmed.ncbi.nlm.nih.gov/21597563/

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