Chronic lymphocytic leukemia is a hematologic malignancy characterized by overproduction of monoclonal B cells. Most people diagnosed with CLL do not immediately undergo treatment due to treatment guidelines. There are few cases of paraneoplastic syndrome associated CLL. This case is unique in that it is a paraneoplastic KLHL 11 antibody associated CLL. The patient is a 68-year-old female who originally presented to the hospital with abdominal pain and upon further imaging was found have retroperitoneal lymphadenopathy. After further studies including flow cytometry, she was diagnosed with CLL. She failed trials of Pembrolizumab, ibrutinib, and Obinutuzumab due to side effects. The patient then started experiencing excessive fatigue, bilateral temporal headache, nausea, vomiting, vertigo, tremor of bilateral upper extremities, and head bobbing. Her brain imaging was negative for acute abnormalities. Lumbar puncture was positive for CLL cells and the paraneoplastic panel came back positive with KLHL 11 antibodies. The patient’s symptoms continued to persist and her tremor and dysmetria continued to worsen. Due to the positive paraneoplastic panel, the patient was started on intravenous immunoglobulin but did not experience improvement. She was then trialed on intravenous methylprednisolone and still experienced no relief. She then underwent plasma exchange. Finally, she was given rituximab infusions with slight improvement. Her imaging remained negative for signs of leptomeningeal enhancement. Given the patient’s symptoms, negative brain imaging, and positive paraneoplastic panel, it was determined that the patient developed an irreversible paraneoplastic syndrome related to her CLL versus possible leptomeningeal disease. There are a few cases of paraneoplastic syndrome associated CLL involving paraneoplastic phemphigus, hypercalcemia, and nephrotic syndrome. This case is unique in that her symptoms presented with an ataxic syndrome with positive KLHL11 antibodies. It is important to be aware that some cases of CLL can present with unique paraneoplastic syndromes.
The inculcation of techniques of persuasion by Greeks and Romans, i. e. rhetoric, in those days a highly necessary form of vocational training for top people, led eventually to the British classical education. But it is probable that few topics are more disliked by classical students of today than rhetoric; and examinees blench at the mere sight of questions in which the word ‘rhetoric’ appears. As E. R. Dodds remarks, ‘To the average modern Englishman “rhetoric” means a distastefully emotional or showy way of talking;… to the contemporaries of Socrates it meant the practical art of influencing men's will through the spoken word.’ Such an art is presumably still of some importance, and it is still worth considering what Plato/Socrates had to say about it. The enquiry is made the more piquant by the fact that Plato himself has been called e.g. ‘an orator himself in mocking other orators’ (Cic. De Or. 1.47), a ‘propagandist’,2 and most recently ‘[a man who] writes not as a scholar or scientist but from first to last as an advocate, an heir to the tradition of didactic poetry, a nursling of Attic drama and a product, no less than the politicians and litigants whom he criticized so articulately, of a culture which admired the art of the persuader’.
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