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A 60-year-old woman was admitted with dysarthria, unsteady gait and limb weakness. She had been diagnosed 5 years previously with symptomatic IgG k multiple myeloma and had been treated with ABCM [adriamycin, BCNU (carmustine), cyclophosphamide, melphalan], melphalan autograft, alphainterferon maintenance and a combination of cyclophosphamide with dexamethasone for relapsed disease. At this presentation she was transfusion-dependent despite erythropoietin/granulocyte colony-stimulating factor support and her general health was deteriorating. On examination she had dysarthria and an ataxic gait. Investigations showed a stable IgG paraprotein of 22 g/l. Preand post-contrast head computed tomography was normal. A magnetic resonance imaging scan of her head demonstrated marked meningeal enhancement, particularly in the posterior fossa, consistent with leptomeningitis (left image, post gadolinium contrast). A lumbar puncture was performed and showed a low glucose (0AE5 mmol/l), a high protein (2AE3 g/l) and a high white cell count. The cerebrospinal fluid cytology showed a large number of plasma cells, all with a neoplastic phenotype CD19–56+/) (right image). Treatment options were discussed and she was treated palliatively with dexamethasone and died peacefully 12 d after this presentation.