Case Report

Cognitive Decline in an Elderly Hospitalized Patient With Primary Leptomeningeal Melanomatosis

Authors: Ravi Bobba, MD, Edward Arsura, MD, FACP

Abstract

Delirium is one of the most common disorders in hospitalized patients. The authors present the case of an elderly male patient with postoperative cognitive decline that did not resolve with the conventional treatment. The diagnosis was only established on autopsy. A 75-year-old man was evaluated after a fall. Initial evaluation revealed voluntary guarding in the right epigastric region, and free air was detected under the right hemidiaphragm on abdominal radiography. An exploratory laparotomy revealed a perforation that had apparently sealed off. After surgery, he had initial improvement toward baseline; however, after several days, his postoperative course was complicated by a progressive deterioration in mental status, recurrent seizures, and aspiration pneumonia. Computed tomographic scan of the brain showed communicating hydrocephalus. Examination of the cerebrospinal fluid revealed an elevated opening pressure and elevated protein. His mental status continued to deteriorate, and he died. Autopsy revealed the pathologic diagnosis of primary leptomeningeal melanomatosis.


Key Points


* Prolonged delirium in elderly patients should be evaluated cautiously.


* Malignancy of the structures of the brain can be included in the differential diagnosis.


* Abnormal imaging and cerebrospinal fluid findings should be correlated clinically, and rare pathologies should be considered.

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