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Change in mental status
History of Present IllnessThe patient is a 64 year old African-American woman admitted with altered mental status. Approximately 4 months prior to admission, she had developed a mass on the back of her neck that was painless.
Three months later she was admitted to an outside hospital with abdominal pain, nausea, and vomiting. Computed tomography (CT) imaging revealed a large mass in the right kidney with periaortic lymph node enlargement, bilateral lower lobe lung nodules, and filling defects in the lower lobe pulmonary arteries consistent with pulmonary emboli. Lytic bony defects were also noted in the left ilium and lumbar vertebral bodies. An MRI of the head demonstrated scattered microinfarcts and severe periventricular white matter ischemic changes. Her stay was complicated by catheter-induced MRSA bacteremia for which she was treated with vancomycin. She was stabilized and discharged home off antibiotics.
Approximately 3-4 days after discharge from the outside hospital, her mental status declined. She became unable to ambulate, had greater lethargy, and developed confusion.
At that point, the patient's husband brought her to The Johns Hopkins Hospital Emergency Department because of a change in mental status, decreased appetite, lethargy, and lack of ambulation.
Prior to this illness, she had mild diabetes, hypertension, and hyperlipidemia controlled with medications. She had no notable infectious exposures and had not traveled outside the region in the past year. Her husband denied any autoimmune history as well as joint, eye, skin symptoms.
Past Medical History
Diabetes mellitus
Hypertension
Hyperlipidemia
Pulmonary embolism
IVC filter placement
MRSA bacteremia
The patient had a sister and a brother with cancer (unknown types). One brother and the patient's father died of myocardial infarction. The patient's mother died of complications of diabetes mellitus.
Social HistoryThe patient was a retired cashier who lived with her husband. She reportedly used tobacco approximately 20 years ago. No alcohol or illicit drug abuse.
MedicationsLovenox 70mg SQ; Hyzaar 100/25; Metoprolol 100 mg BID; Duragesic 75 mcg/hr; Sular 20 mg daily; Prandin 1 mg TID.
AllergiesPercocet (nausea)
Review of SystemsConfusion, decreased appetite, lethargy, lack of ambulation.
Physical Exam on Admission
- Weight: 80 kg Height: 161 cm T: 100.4 BP: 155/90 P: 100
- General: African-American female, drowsy but arousable.
- HEENT: Sclera anicteric. Extraocular movements intact. Oral thrush. 3/3 mass at base of skull with a superficial ulcer and yellow exudate.
- CV: Regular rate and rhythm with no murmurs appreciated.
- Lungs: Diminished breath sounds at right base. No wheezes, rales, or rhonchi.
- Abdomen: Normal bowel sounds, non-tender, non-distended. Liver edge palpable and firm. No splenomegaly.
- Extremities: No cyanosis or clubbing. Trace edema to mid calf bilaterally. Pulses 2+.
- Rectal: Normal rectal tone, no stool.
- Neuro: Poor effort. 5/5 strength in all extremities. Sensation and cranial nerves intact. Somnolent, with difficulty following conversation or commands. Intermittant confusion. Reflexes and strength appear symmetric.
- Na 126; K 4.0; Cl 88; BUN 12; Cr 1.0; Glucose 164; Calcium 11.0; Ionized Calcium 1.41
- WBC 29,460; Hemoglobin 9.0; Hct 27.8; MCV 86.1; Platelets 205
- CEA-TOSOH 98.8; PTH 13; Vancomycin level 5.4; Toxicology screen, codeine/ morphine; PT 11.2; INR 1.1; PTT 31.0
CT Scan (approximately 18 days prior to admission at outside institution) (not shown): Large mass arising in right kidney with enlarged lymph nodes in right renal hilum and periaortic area compressing vascular pedicle and probably invading vena cava. Small nodule in mid pole of left kidney and multiple nodules in lower lungs bilaterally. Prominent bilateral hilar nodes. Lucent bony defects in left ileum, and lumbar vertebral bodies. Filling defects in lower lobe pulmonary arteries consistent with pulmonary emboli.
Chest X-ray: Left midlung infiltrate, probably pneumonia. Probable right middle lung lobe infiltrate. Cardiomegaly. Minimal tortuosity and atherosclerosis of moderately dilated thoracic aorta. Hypoinflation with elevation of right hemidiaphragm.
CT Chest (See Figures 1A-1D below): Bilateral pulmonary nodules/masses. Mediastinal and hilar adenopathy. Small left and moderate right pleural effusion. Left upper lobe infiltrate.
CT Abdomen/Pelvis (See Figures 2A-2F below): Numerous liver defects measuring 2-4 cm. Large Mass replacing upper mid pole of right kidney with right hilar and retroperitoneal lymphadenopathy. Nodularity of left adrenal gland and diffuse thickening of right adrenal gland. Pelvic side wall lymphadenopathy with nodular infiltrates in muscles near right hip (4.0 cm). Lytic bony lesions in left iliac bone and lumbar spine.
Clinical CourseThe patient was given aggressive hydration and empiric IV antibiotics without improvement in her mental or physical status. She became obtunded and began showing signs of significant pain. Her white blood cell count continued to rise into the high 40,000s. Goals of care discussions were had with the family, who decided with comfort care only and possible transition to hospice. Palliative care only was initiated but she expired comfortably on JHH hospital day 7.
Images of Radiologic Studies
FIG 1A. Contrast enhanced chest CT, lung windows. Multiple bilateral lung
nodules (arrows). Small left and moderate right pleural effusions (arrowheads).
FIG 1B. Contrast enhanced chest CT, lung windows. Infiltrate left upper lobe
(arrows). Moderate right pleural effusion (arrowhead).
FIG 1C. Contrast enhanced chest CT, mediastinal windows. Moderate adenopathy
(arrows). Bilateral pleural effusions.
FIG 1D. Contrast enhanced chest CT, mediastinal windows. Moderate hilar
adenopathy (arrows). Bilateral pleural effusions (arrowheads).
FIG 2A. Contrast enhanced abdominal CT, soft tissue windows. Low density lesion
right hepatic lobe (arrow). Bilateral pleural effusions.
FIG 2B. Contrast enhanced abdominal CT, soft tissue windows. Enlarged right
adrenal gland, nodularity left adrenal gland (arrows)
FIG 2C. Contrast enhanced abdominal CT, soft tissue windows. Infiltrative mass
right kidney (arrow), adenopathy right renal hilum (arrowhead).
FIG 2D. Contrast enhanced abdominal CT, soft tissue windows. Enhancing mass in
muscles near right hip (arrow).
FIG 2E. Contrast enhanced abdominal CT, bone windows. Lytic lesion left iliac
bone (arrow).
FIG 2F. Contrast enhanced abdominal CT, bone windows. Lytic lesion lumbar spine
(arrow).
What is the most likely cause of the neck, abdominal, and lung lesions?
If the lesions are malignant, what is the most likely site of origin?
What types of malignancies often present with metastatic disease of clinically
unclear origin?
FIG 1A |
FIG 1B |
FIG 1C |
FIG 1D |
FIG 2A |
FIG 2B |
FIG 2C |
FIG 2D |
FIG 2E  |
FIG 2F  |
| See Answer to CPC |
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