Acute motor and sensory axonal neuropathy in Burkitt-like lymphoma

A Case of Acute Motor and Sensory Axonal Neuropathy Secondary to SGN-LIV1A Therapy

Antibody-drug conjugate therapy is rarely associated with neurologic immune-related phenomena. In this case report, we present a patient on treatment with SGN-LIV1A antibody-drug conjugate for breast cancer who developed progressive asymmetric quadriparesis, more severe in the bilateral upper extremities. Acute motor and sensory axonal neuropathy (AMSAN), a sub-variant of Guillain-Barré syndrome, was diagnosed via electro-diagnostic studies. Serological studies were significant for vitamin B1, B2 and B6 deficiencies, and cerebrospinal fluid studies were significant for albuminocytologic dissociation. The patient was treated with intravenous immunoglobulin (IVIg), B complex supplementation, and aggressive physical therapy. There was recovery of muscle strength in all extremities over the course of three months. Our case explores the biologic response to treatment of experimental immunotherapy-induced AMSAN with intravenous immunoglobulin.

Clinical and pathological findings in neurolymphomatosis: Preliminary association with gene expression profiles in sural nerves

Although inflammation appears to play a role in neurolymphomatosis (NL), the mechanisms leading to degeneration in the peripheral nervous system are poorly understood. The purpose of this exploratory study was to identify molecular pathways underlying NL pathogenesis, combining clinical and neuropathological investigation with gene expression (GE) studies. We characterized the clinical and pathological features of eight patients with NL. We further analysed GE changes in sural nerve biopsies obtained from a subgroup of NL patients (n=3) and thirteen patients with inflammatory neuropathies as neuropathic controls. Based on the neuropathic symptoms and signs, NL patients were classified into three forms of neuropathy: chronic symmetrical sensorimotor polyneuropathy (SMPN, n=3), multiple mononeuropathy (MN, n=4) and acute motor-sensory axonal neuropathy (AMSAN, n=1). Predominantly diffuse malignant cells infiltration of epineurium was present in chronic SMPN, whereas endoneurial perivascular cells invasion was observed in MN. In contrast, diffuse endoneurium malignant cells localization occurred in AMSAN. We identified alterations in the expression of 1266 genes, with 115 up-regulated and 1151 down-regulated genes, which were mainly associated with ribosomal proteins (RP) and olfactory receptors (OR) signaling pathways, respectively. Among the top up-regulated genes were actin alpha 1 skeletal muscle (ACTA1) and desmin (DES). Similarly, in NL nerves ACTA1, DES and several RPs were highly expressed, associated with endothelial cells and pericytes abnormalities. Peripheral nerve involvement may be due to conversion towards a more aggressive phenotype, potentially explaining the poor prognosis. The candidate genes reported in this study may be a source of clinical biomarkers for NL.

Severe Guillain-Barré syndrome after surgery for multiple fractures: a rare case report with a 5-year follow-up and a brief review of the literature

Background

Guillain-Barré syndrome (GBS) is the most common and serious acute paralytic neuropathy and is usually caused by infection. It is thought to be the result of an aberrant response of the immune system. To our knowledge, GBS, especially severe GBS, after orthopaedic surgery has rarely been reported.

Case presentation

We herein report the case of a 58-year-old man who developed quadriplegia and respiratory failure on the 6th day after surgery for multiple fractures. The patient had no symptoms of respiratory or gastrointestinal tract infection within 4 weeks before the onset. The white blood cell count was normal, and there was no redness, swelling, heat or pain in the surgical incision. Brain, cervical and thoracic magnetic resonance imaging were normal, albuminocytological dissociation was found on cerebrospinal fluid examination, and electrophysiological examination showed that sensory and motor nerve evoked potentials could not be elicited. A diagnosis of post-traumatic GBS was made, and the patient was treated with intravenous immunoglobulin and plasma exchange, as well as supportive care and rehabilitation exercise. The length of stay was 18 months, and the in-hospital-related costs amounted to $127,171. At the last follow-up, the patient had recovered only grade 3 power in the upper limbs and grade 2 power in the lower limbs.

Conclusions

Severe GBS is a rare complication after orthopaedic surgery. When progressive weakness occurs in trauma patients, the possibility of GBS should be considered, and cerebrospinal fluid and electrophysiological examinations should be performed in a timely manner. For patients with severe GBS after trauma, the treatment costs may be high, and the prognosis may be poor.

Gastric lymphoma complicated by phlegmonous gastritis and Guillain-Barré syndrome: A case report

INTRODUCTION

Complications such as severe infection may occur during the chemotherapy of malignant lymphoma. Phlegmonous gastritis (PG) is a rare acute bacterial infection associated with high mortality, requiring early diagnosis, and prompt management. In addition, Guillain-Barré syndrome (GBS) occasionally requires early treatment and intensive care management due to the occurrence of severe neuropathy and respiratory failure.

PATIENT CONCERNS

A 70-year-old male was diagnosed with primary gastric diffuse large B-cell lymphoma (DLBCL) after the detection of several polypoid tumors with ulcers. The patient underwent chemotherapy for DLBCL and exhibited adverse effects (i.e., fever, vomiting, epigastric pain, and neutropenia). Computed tomography indicated widespread thickening in the gastric wall. Furthermore, approximately 2 weeks later, the patient presented with gradual symmetric lower extremity weakness and respiratory failure due to paralysis of the respiratory muscle.

DIAGNOSES

DLBCL was diagnosed through a gastric tumor biopsy. On the basis of the computed tomography findings, a culture of gastric juice, nerve conduction studies, and clinical symptoms, this case of gastric lymphoma was complicated with PG and GBS.

INTERVENTIONS

The patient was treated with antimicrobial therapy and administration of granulocyte colony-stimulating factor for PG, and with intravenous immunoglobulin and intensive care management for GBS.

OUTCOMES

Despite the aggressive progress of the condition, the patient improved without relapse of DLBCL.

CONCLUSION

PG was regarded as a precedent infection of GBS. In this article, we present the first reported case of gastric lymphoma complicated with PG and GBS.

Variant Guillain-Barré syndrome in a patient with Hodgkin lymphoma: AMSAN

Lymphomas are solid tumors characterized by the malignant proliferation of lymphoid cells. Neurologic signs encountered in patients with Hodgkin's lymphoma can be due to the direct spread of tumor to the nervous system, secondary to chemotherapy or radiation, secondary to tumor mass compression, infectious causes and paraneoplastic syndromes. Paraneoplastic neurologic syndromes are rarely encountered in patients with Hodgkin's lymphoma and non-Hodgkin's lymphoma. Except for paraneoplastic cerebellar degeneration in Hodgkin's lymphoma and dermato/polymyositis in both Hodgkin's lymphoma and non-Hodgkin's lymphoma, other paraneoplastic syndromes are uncommon and have only been reported as isolated case reports or short series. Here, we present a patient with Hodgkin's lymphoma with symptoms of bilateral lower extremity weakness and loss of sensation before the start of therapy, who was eventually diagnosed as having motor and sensory axonal neuropathy.

Neuromuscular complications in cancer

Cancer is becoming a treatable and even often curable disease. The neuromuscular system can be affected by direct tumor invasion or metastasis, neuroendocrine, metabolic, dysimmune/inflammatory, infections and toxic as well as paraneoplastic conditions. Due to the nature of cancer treatment, which frequently is based on a DNA damaging mechanism, treatment related toxic side effects are frequent and the correct identification of the causative mechanism is necessary to initiate the proper treatment. The peripheral nervous system is conventionally divided into nerve roots, the proximal nerves and plexus, the peripheral nerves (mono- and polyneuropathies), the site of neuromuscular transmission and muscle. This review is based on the anatomic distribution of the peripheral nervous system, divided into cranial nerves (CN), motor neuron (MND), nerve roots, plexus, peripheral nerve, the neuromuscular junction and muscle. The various etiologies of neuromuscular complications - neoplastic, surgical and mechanic, toxic, metabolic, endocrine, and paraneoplastic/immune - are discussed separately for each part of the peripheral nervous system.

Variant Guillain-Barré Syndrome in a Patient with Non-Hodgkin's Lymphoma

We report a 72-year-old female patient with diffuse large B cell non-Hodgkin's lymphoma (NHL) with previous treatment with standard chemotherapy presenting as an acute, ascending, sensorimotor polyneuropathy. Nerve conduction studies and lumbar puncture supported a rare, but ominous, axonal variant of Guillain-Barré Syndrome (GBS) known as acute motor and sensory axonal neuropathy (AMSAN), which is distinguished from the more common, acute demyelinating forms of GBS. Previous reports have largely focused on toxicities secondary to chemo- or radiotherapy as a major contributor to the development of acute neuropathies in malignancy. Clinicians should also be mindful of direct neoplastic invasion or, less commonly, paraneoplastic phenomenon, as alternative mechanisms, the latter possibly reflecting immune dysregulation in particularly aggressive lymphomas. At the time of writing, this is the first report in the literature of an axonal variant of GBS in a patient with diffuse large B cell NHL. A discussion regarding common and uncommon neuropathies in haematological malignancies is made, with a brief review of the anecdotal evidence supporting a paraneoplastic association with GBS or its variant forms in the setting of lymphoma.

Lymphoma-associated dysimmune polyneuropathies

Lymphoma consists of a variety of malignancies of lymphocyte origin. A spectrum of clinical peripheral neuropathy syndromes with different disease mechanisms occurs in about 5% of lymphoma patients. There exists a complex inter-relationship between lymphoproliferative malignancies and autoimmunity. An imbalance in the regulation of the immune system presumably underlies various immune-mediated neuropathies in patients with lymphoma. This article reviews lymphoma and more-or-less well-defined dysimmune neuropathy subgroups that are caused by humoral and/or cell-mediated immune disease mechanisms directed against known or undetermined peripheral nerve antigens.

Guillain-Barre Syndrome in a Patient with Primary Extranodal Intestinal Non-Hodgkin's Lymphoma: Paraneoplastic, Drug Induced or Coincidental?

Neurological involvement is observed in 5%-25% of patients with lymphoma being either the first presentation of the disease or emerging during its course. However, Guillain-Barré syndrome is rarely reported. In this article, we present a case with intestinal lymphoma developing Guillain-Barré syndrome during the course of the disease. A 66-year-old male patient with primary extranodal intestinal lymphoma developed quadriparesis, sensory deficits and autonomic dysfunction while receiving chemotherapy. The findings of clinical, electrophysiological and laboratory examinations were consistent with Guillain-Barré syndrome. Guillain-Barré syndrome can potentially be fatal and mimic chemotherapy-induced neurotoxicity, especially in patients with lymphoma, and therefore, must be considered in the differential diagnosis.

Chemotherapy-induced peripheral neurotoxicity: a critical analysis

With a 3-fold increase in the number of cancer survivors noted since the 1970s, there are now over 28 million cancer survivors worldwide. Accordingly, there is a heightened awareness of long-term toxicities and the impact on quality of life following treatment in cancer survivors. This review will address the increasing importance and challenge of chemotherapy-induced neurotoxicity, with a focus on neuropathy associated with the treatment of breast cancer, colorectal cancer, testicular cancer, and hematological cancers. An overview of the diagnosis, symptomatology, and pathophysiology of chemotherapy-induced peripheral neuropathy will be provided, with a critical analysis of assessment strategies, neuroprotective approaches, and potential treatments. The review will concentrate on neuropathy associated with taxanes, platinum compounds, vinca alkaloids, thalidomide, and bortezomib, providing clinical information specific to these chemotherapies.

Recurrent acute inflammatory demyelinating polyradiculoneuropathy following R-CHOP treatment for non-Hodgkin lymphoma

Acute flaccid paralysis following chemotherapy has a wide differential diagnosis, including drug toxicity, acute inflammatory demyelinating polyradiculoneuropathy (AIDP), and malignant nerve infiltration. We present a case of recurrent acute quadriparesis due to AIDP following chemotherapy for non-Hodgkin lymphoma, which resolved each time following administration of intravenous immunoglobulin. Although many chemotherapeutic agents can cause neurologic side effects, such as peripheral neuropathy, drug toxicity as a cause is a diagnosis of exclusion.

CD5-positive diffuse large B cell lymphoma infiltrating the central nervous system presenting Guillain-Barré-like syndrome after chemotherapy

An 83-year-old woman was admitted to our hospital with abdominal pain. Examination revealed mediastinal lymphoadenopathy, hepatosplenomegaly, and infiltration of abnormal cells into the bone marrow with hemophagocytosis, and CD5-positive diffuse large B cell lymphoma was diagnosed. Chemotherapy was administered and progressive weakness of the limbs, resembling a Guillain-Barré-like syndrome, subsequently appeared. Cerebrospinal fluid examination indicated lymphoma cell infiltration. Although immune globulin and steroid therapies were not effective, intrathecal injection of methotrexate, predonisolone, and cytarabine improved these symptoms. Subsequent to chemotherapy, cell surface antigen changes were observed in the cerebrospinal fluid relative to those in bone marrow.

Acute onset flaccid quadriparesis in pediatric non-Hodgkin lymphoma: vincristine induced or Guillain-Barré syndrome?

Immunological involvement of peripheral nervous system in non-Hodgkin lymphoma (NHL) is very rare and it may be difficult to differentiate it from vincristine-induced neuropathy. We report clinical and electrophysiological findings of an 8-year-old male with NHL who developed acute onset fulminant motor sensory autonomic neuropathy during induction chemotherapy which included vincristine. Characteristic clinical picture and nerve conduction studies favored Guillain-Barré syndrome. The patient improved rapidly with intravenous immunoglobulin and supportive care. It is possible that an immune mechanism damaged the peripheral nervous system in the patient without ruling out the adverse effects of vinca alkaloids.

Idiopathic polyradiculoneuropathy in a Bengal cat: electrophysiological findings and 1 year follow-up

This report describes a rapidly progressive loss of motor function in a 16-month-old male neutered Bengal cat, beginning in the pelvic limbs and progressing to involve all limbs and rendering the cat non-ambulatory. The neurological examination revealed flaccid tetraparesis with decreased spinal reflexes but preserved conscious proprioception and skin sensation. Extensive electrophysiological tests were conducted including electromyography, motor and sensory peripheral nerves potential recordings and 'late' potentials, defining the electrodiagnostic characteristics of this disease. Based on the electrophysiological findings, a generalised proximal and predominantly axonal neuropathy affecting the ventral (motor) nerve roots was suspected. As no aetiology was identified, this disease was classified as idiopathic polyradiculoneuropathy. Over a year, the cat presented three separate episodes of tetraparesis, each with a spontaneous complete recovery, consistent with the reportedly good prognosis for this disease.