Aseptic meningitis complicating metrizamide myelography.

A 62-year-old man was admitted for right arm radicular pain and diplopia. Eight months earlier he had documented metastatic adenocarc inoma, primary site unknown, with pleural and skeletal involvement. On physical examinat ion, he was alert, well oriented, and afebrile. Pertin ent findings included a supple neck, a left sixth cran ial nerve palsy with questionable left retinal mass, and mild weakness of the right upper extremity . Laboratory data were normal except for a mi ld elevation of the alkaline phosphatase . Computed tomography (CT) demonstrated an enhancing lesion eroding the right frontal bone with destruction of the orbital roof. Electromyography and nerve conduction studies confirmed a C7 Tl radiculopathy. The spinal fluid before instillation of metrizamide (10 ml, 200 mg I/ ml) was normal with a glucose con centration of 77 mg / dl. After th e procedure, the patient complained of a headache. Within 24 hr he developed a temperature of 40°C, nuchal rigidity , and d iso rientation. A lumbar puncture showed grossly cloudy fluid with a wh ite blood cell coun t of 14,000 / mm , 100% polymorphonuclear leukocytes, a protein concentration of 220 mg / dl , and a g lucose concentration of 58 mg / dl with a peripheral blood g lucose concentration before intravenous fluid s of 185 mg / dl. Counterimmunoelectrophoresi s, limulus lysate, and Gram stain of the spinal fluid were negative . A second CT scan was unchanged . Chloramphenicol, gentamic in , and nafc illin were begun empirically . The patient was alert and oriented 48 hr later with a temperature of 38.5°C. Another lumbar puncture revealed a white blood cell count of 650 / mm 3 , 93% polymorphonuclear leukocytes , a protein concentration of 232 mg / d l, and a glucose concentration of 70 mg / dl. A peripheral white blood cell count was 21,OOO / mm with 22% eosinoph ils. Cultures of the spinal fluid, blood, urine, and a sample from the same batch of metrizamide were negative and antibiotics were discontinued at 96 hr. The patient soon defervesced but eventually died several weeks later due to his underlying disease.