変形視と欝血乳頭を呈した50歳男性

A 50-year-old Man with Metamorphopsia and Optic Nerve Swelling

症例呈示

　症例　HY50歳右利き男子（90-827639）。

　主訴　食欲低下，体重減少。

We report a 50-year-old male having metamor-phopsia associated with retinal edema. He was well until one month prior to the present admission when he developed occipital headache and backache. Three weeks later, he noted a sudden onset of twist-ing of visual images.

On admission, he was in no acute distress with well preserved general conditions. Only neur-ological abnormalities were bilateral papilledema, retinal edema and horizontal nystagmus with a rotatory component. Routine blood chemistries were unremarkable. The CSF contained 28 cells/ cmm with 60% consisting of large atypical cells. Cranial CT scans revealed no mass, however, the magnified orbital CT showed bilateral swelling of the optic nerve. He was treated with ventriculo-peritoneal shunt and Ommaya tube placement through which methotrexate, cytarabine and pred-nisolone were administered. He was also treated with systemic cisplatin, mitomycin-C and 5-fluor-ouracil. With these therapy, his headache, metamorphopsia and papilledema improved. He was discharged for out-patient follow-up, however, he had to admitted again because of progressivedifficulty of gait and loss of appetite.

On admission, he complained of severe backache, and his gait disturbance appeared to be in part due to his backache. A slight weakness was noted in all four limbs with loss of deep reflexes. Mentally he was alert and cranial nerves appeared intact with-out papilledema. But nuchal rigidity was noted. Cranial CT scan revealed attenuation of all the cortical sulci and marked diffuse low density changes in the cerebral white matter, and his chest film re vealed a ring-shape shadow in his left lung field. He deteriorated progressively with terminal gastrointestinal hemorrhage. He expired three weeks after his second admission.

The patient was discussed in a neurological CPC, and the chief discussant made a clinical diagnosis of meningeal carcinomatosis with a probable primary lesion in the stomach. His metamorphopsia wasthought to be caused by retinal edema, and the diffuse white matter change by anti-cancer drugs. Post-mortem examination revealed a Bormann type IV carcinoma in the stomach. Histological examination revealed signet-ring cell adenocar-cinoma. The central nervous system showed diffuse meningeal carcinomatous cell infiltration in the subarachnoid space and along the optic nerve sheath. The diffuse low density change in the CT scan was thought to be caused by circulatory distur-bance secondary to meningeal dissemination of the carcinoma cells. This patient was unique in that his three cardinal findings, i. e., metamorphopsia, the optic nerve swelling, and the diffuse low density change in the cerebral white matter, were all caused by infiltration of the carcinoma cells along the subarachnoid space and the optic nerve sheath.