Case 69 yr old female Known non small cell cancer of lung Post 4th cycle of chemotherapy Cisplatin Vinotubuline Ongoing radiotherapy Admitted to Oncology ward Complaints: Worsening pins and needles both legs Vibrations through arms and legs Shooting pains both legs Dropping things held in hands Worsening gait/ stiff legs/ unsteadiness Decreased awareness of bladder fullness

Symptoms started after 3rd cycle of chemotherapy Worsened abruptly after 4th cycle Constipation and incontinence of feces Decreased urinary stream On amitriptyline

O/E: Motor system: Feet in dropped posture while sitting Pseudoathetosis upper limbs worst on right grade 4+/5 in all four limbs and preserved reflexes and down going plantars Ataxic on finger nose Sensory: Decreased pin prick, light touch glove and stocking distribution up to groins bilaterally in lower limbs and upto mid arm bilaterally in upper limbs Decreased proprioception toes/ ankles/ fingers/ wrists bilaterally Decreased vibration sensation toe/ankle bilaterally Rombergs positive Gait Ataxic with broad base

Mobility: Transfer with light assistance and 4WW Gait: Difficulty holding 4 WW Ataxic Gait Light assist to close standby

Labs: Folate and Vit B12 normal TFT Normal Antibodies: ANA negative Antineuronal Ab negative Anti Purkunje Cell Ab Negative Anti Hu/ Yu negative CSF: Proteins 0.48 Gluc 3.3 RBCs 150 PMN 2 Cytology:?

Severe sensory neuropathy consistent with Cisplatin induced neuropathy

Oncology Review Odd presentation of Cisplatin induced neuropathy Progressively worsened for more than 2 weeks post chemotherapy Low cumulative dose of 249 mg/m2 Other possibilities: Paraneoplastic peripheral neuropathy Autoimmune neuropathy

Neurology Review Dorsal root ganglionitis consistent with paraneoplastic neuropathy Should improve with treatment of cancer Other Differentials: Paraproteinemia Sjogren’s Syndrome Recommendations: Check EPG/ Syphilis VDRL 1:16 false positive EPG reported as normal IVIG 0.4 g/kg for five days

TREATMENT Indwelling catheter Decreased amitriptyline dose Fluids IVIG

PROGRESS Developed AF rate controlled with metoprolol Muscle spasms improved with diazepam Continue to worsen functionally Transferred to rehabilitation C 2 controlled falls Diazepam tapered Gabapentin commenced Mobility improved with physiotherapy to independent on frame Bowel and bladder continent

DISCHARGE PLAN Respite pending home modifications Driving license suspended Taxi vouchers DVA personal alarm Small aids Home modification

NEUROMUSCULAR COMPLICATIONS OF CANCER