D24-05 Robotic Bronchoscopy in the ICU for Diagnosis of Leptomeningeal Carcinomatosis

Abstract Leptomeningeal carcinomatosis with associated coma is an uncommon complication of pulmonary adenocarcinoma. In this case, we discuss a rare presentation of newly diagnosed pulmonary adenocarcinoma with leptomeningeal carcinomatosis diagnosed by robotic bronchoscopy at bedside in the ICU. Our patient is a 63 year old male with a longstanding smoking history who presented for acute onset of headaches, falls, and encephalopathy after seeing his outpatient neurologist. Early in his hospitalization, he had a witnessed seizure and worsening encephalopathy prompting intubation for airway protection. The patient underwent multiple lumbar punctures, MRI brain and spine, and received IVIG and high dose methylprednisolone for possible autoimmune encephalitis. Needing further neurologic care, he was transferred to our hospital. On initial work up, he was found to have a spiculated cavitary solid nodule in his right upper lung lobe. His CSF paraneoplastic panel was positive only for potassium channel antibodies. CSF evaluations were otherwise unremarkable. He continued to have poor neurologic engagement despite minimal sedation. Neurology, infectious disease, and interventional pulmonology were consulted for his obtundation. Paraneoplastic, malignant, infectious, and autoimmune etiologies were considered. Given the new pulmonary mass and potassium channel antibody presence in his CSF, robotic bronchoscopy was arranged in the ICU for RUL nodule biopsy. Cytologic analysis revealed non-small cell lung cancer. With a new diagnosis of metastatic lung cancer, oncology was consulted. A repeat lumbar puncture was then performed and positive cytologically for non-small cell carcinoma as well. Curative or palliative chemotherapy or immunotherapy would be unlikely to provide benefit given his poor prognosis. After extensive discussion with his family, the patient transitioned to comfort care and was palliatively extubated. He expired peacefully in the subsequent days. This case is noteworthy for the complicated and acute presentation of his illness, and the use of robotic bronchospy in the ICU setting. He was generally well approximately two weeks prior to his eventual diagnosis and death. While non-small cell lung cancer has an overall poor prognosis, leptomeningeal disease carries a life expectancy of only 4-6 weeks. With this, there are significant end-of-life implications with leptomeningeal carcinomatosis. Patients develop physical disabilities, cognitive disabilities, mental status changes, ataxia, seizures, among other neurologic complications. Diagnosis is important to establish a lack of reversible cause for his non-specific symptoms. Robotic bronchoscopy, while a standard mode of pulmonary nodule sampling, is rarely used in the ICU setting, since it is most often done in an ambulatory setting. This abstract is funded by: None