A 32-year-old male with a past medical history of genital herpes and a 1 week history of headaches, presented with nausea, vomiting and diarrhoea, and had a generalised tonic-clonic seizure. His temperature was 38.1degC and CSF laboratory values were: 14 white blood cells (WBC) (100% monocytes), 16 red blood cells, protein 498 mg/dl and glucose 86 mg/dl; serum WBC 12.7 with 75% neutrophils (polymorphomiclear leucocytes). T1 weighted MRI with gadolinium revealed patchy enhancement of the meninges (figure 1A). Serum herpes simplex virus IgG was positive. Viral, herpes simplex virus and bacterial CSF cultures were negative. Acyclovir was started empirically. Two weeks later he suddenly became unresponsive. MRI revealed worsening meningea/temporal lobe enhancement and hydrocephalus (figure IB). Serum WBC was 22.7. An exhaustive work-up for common and exotic infectious diseases, inflammatory disease and neoplastic disease, including CSF studies, was negative. He improved with CSF diversion via ventriculostomy to a GCS-14 until day 17 when he developed acute paraparesis (2/5) (figure 1C). He was taken to the operating theatre for lumbar leptomeningeal and nerve root biopsy. Immunohistochemical staining of the nerve roots revealed tumour cells staining positively for vimentin, the melanoma specific markers HMB45 and Mart-1, and S-100 protein, confirming the diagnosis of meningeal melanomatosis (figure 2). No cutaneous/ocular nevi or melanoma were found on further physical examination conducted by the dermatology and ophthalmology departments. The patient developed ascending paralysis of the upper extremities and then of the cranial nerves (figure ID). The family withdrew medical support and declined a request for autopsy.
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