Rare presentation of occult malignancy (Internal Medicine)

Medical Case Details:

41 years old female, resident of Pune, no comorbids, healthy lifestyle, h/o sudden loss of husband 4 months before since then she was little upset and had depressed affect due to Grief..2 months before started having intermittent mild frontal headache with nausea and few episodes of non bollous vomiting intermittently withput h/o fever , weight loss, night sweets or any other symptoms. No h/o tuberculsois or contact with TB patient in past. No hallucinations or delusions were noted. Headache could not affect her active daily routine but since 15 days she prefers to take more rest and eat less with sudden emotional upset - crying .feels better after vomiting .There is no h/o ear discharge , rigors or chills, or any other symotoms s/o organic disease.consulted two physicians and psychiatrist after which she was started on antidepressants with NSAIDs.resulted in partial relief.now started speaking slowly because headache.there eas no neck stifdnrss , alreration in consciousness level.kernings sign negative.underwent CSF sampling whixh revealed glucose 30 proteins 390 and cells -80% lymohocytes with ADA 5 and culture sterile.Brucella Negative, cryptococcal antigen negative. HIV/HBV/HCV negative, AFB CULTRE AND TB PCR NEGATIVE.MRI s/o meningitis hence empirically started on Anti tubercular therapy alongwith steroids.her symptoms were persistent.Meningeal biopsy s/o was reactive inflammation.rest all labs were within nomal limits.viral etiology ruled out by PCR assay.CXR and USG were non contributory.she underwent PET CT which has shown 2-4 mm lesion in left upper lung with few reactive nodes around.underwent biopsy s/o adenocarcinoma. Her LAT was stopped and Discharged after chemotherapy.

Diagnosis: carcinomatous meningitis.
Points in favour were high protein with low glucose in csf with subclinical history of symptoms.patient might look depressed or psychotic but close observation and investigations were the clue.