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

Abstract

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.

Lymphoma-associated dysimmune polyneuropathies

“…CSF analysis was performed on 31 patients; findings were compatible with GBS, and by definition showed no evidence of lymphomatous spread or infectious disease. Electrodiagnostic studies were performed on 25 patients and were consistent with acquired, mostly acquired IDP; predominant axonal injury was recorded in 3 of these patients [93,96,100]. Pathological study of peripheral nerves confirmed acquired IDP (with/without secondary axonal injury) at autopsy in 4 patients [70,72,75,76,88] and on biopsy in 5 patients [75,76,81,84,93].…”

“…(2) In most patients, lymphoma was diagnosed before the development of GBS. Also this temporal correlation varied, so that the onset of GBS developed: (a) with lymphoma relapse [70,77,78,88,89,101]; (b) during lymphoma maintenance therapy [74]; (c) at varying intervals (2 weeks and 3 months) after completion of chemotherapy for lymphoma deemed in remission [72,73,75,76,82]; (d) while undergoing (interval 6 days to 3 weeks) chemotherapy for lymphoma (cycles #1 to #6) [91,93,95,97,98]; (e) after induction chemotherapy for lymphoma (interval 11 to 16 days) [87,96], or (f) during the course (as long as 10 years) of indolent disease not under active treatment e.g., CLL [73,86,101].…”

Chemotherapy-induced Peripheral Neuropathy in Pediatric Cancer Patients

“…Anderson, et al (2002) noted that one potential risk factor for CIPN in pediatric cancer patients is ventral nerve root vulnerability to intrathecal chemotherapy [70–71, 79]. Other studies indicate that a diagnosis of Guillain-Barre syndrome [80–81], Charcot-Marie-Tooth disease [82], prior treatment with platinum based therapies [70–73], or vitamin B and other nutritional deficiencies also place pediatric cancer survivors at greater risk for CIPNs [3, 6, 11, 13–15, 77–78]. Vincristine neurotoxicity may be aggravated by the following: a higher dosage regimen (>30–50 mg); hypersensitivity to the drug, pre-existing liver dysfunction; hereditary neuropathy; and concomitant use of other drugs, such as allopurinol, erythromycin, isoniazid, mitomycin C, phenytoin, and itraconazole [83].…”

CD5-Positive Diffuse Large B Cell Lymphoma Infiltrating the Central Nervous System Presenting Guillain-Barr^|^eacute;-Like Syndrome after Chemotherapy

“…In any case, GBS due to the infiltration of lymphoma cells in the CSF was not seen. 9,[14][15][16][18][19][20][21][22] In our DLBCL case, which was difficult to distinguish from IVL, GBS-like symptoms were also seen after chemotherapy. However, the accumulated dosage of vincristine was not more than 4 mg, 23 antecedent symptoms, such as diarrhea due to Campylobacter jejuni, were not seen, and CSF examination indicated lymphoma cell invasion.…”