A 60-year-old American Hispanic female presented to the emergency room for gradual onset dizziness, associated with lightheadedness, double vision and nausea. She described her symptoms as vertigo-like. She has a known past medical history of breast cancer and was treated with surgery and chemotherapy. The patient had been in remission for over six years. Patient denied any recent travel outside United States. Physical examinations of the patient were within normal limits, apart from the dizziness. Patient did not complain of any weight changes, vision changes, or any focal neurological deficits.

Computed tomography (CT) scan of head (Figure 1) showed a large, 4.3 cm cystic mass projecting in the mid-posterior aspect of the cerebellum causing anterior displacement of the fourth ventricle. It was repeated again and the results were similar. Her last CT scan of head was done a year before which was completely normal. Magnetic resonance imaging (MRI) scan of the brain with and without contrast (Figure 2) showed multiple ring enhancing intra-axial masses, the largest centered at the vermis measuring nearly 4 cm and compressing the fourth ventricle mildly. In the differential was either a metastatic neoplasm from primary breast cancer or a parasitic infection (Table 1). Since the patient did not have any likely risk factors for parasitic infections, such as any recent traveling or interactions with cats or cat feces, the likelihood of a parasitic infection was low. The patient was subsequently treated with radiotherapy with complete resolution of symptoms.

This case illustrates the importance of suspecting a metastatic neoplasm in the brain in a patient who presents with neurological abnormalities and has a past history of a malignancy. Although the patient had been in remission from breast cancer for more than six years, and had a normal head CT scan a year ago, this case shows how quickly a metastatic lesion can resurface and present itself. Breast cancer patients who achieve a pathological complete response after neoadjuvant chemotherapy usually have a favorable prognosis [1] [2][3]. From this case, we can learn that the breast cancer may have been eradicated from the original source, but we should always be suspicious of the malignancy re-emerging in other parts of the body. As physicians, we also must be aware of many of the symptoms of metastasis in women who have been eradicated of breast cancer, those symptoms include, but are not limited to, severe headaches, generalized fatigue, dizziness, vertigo, blurry vision, hypotension, difficulties with balance and coordination, and even polyuria and polydipsia [4] [5] .

For our patient, who presented with dizziness, we should always keep in mind that this simple symptom warrants concern. As physicians, we must always counsel our patients that they may not have the breast cancer physically at the moment but there is always a slight possibility for it to resurface in other parts of the body.

AbdallaYousif, MD

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