Douglas Wells1, Jeffrey Kuerbitz1, Kristen Fisher1
1Child Neurology, Baylor College of Medicine and Texas Children's Hospital
Objective:
To describe the presentation and workup of a patient presenting with neuropathy found to have vitamin deficiency and anti-GD1a antibodies.
Background:
Peripheral neuropathy is a common finding in children with leukemia, particularly those treated with vincristine. Patients typically present with paresthesia, hyporeflexia, and weakness, often in a distal to proximal gradient. In patients receiving vincristine, symptoms typically improve within several months of stopping therapy.
Design/Methods:
Not applicable.
Results:
We present a case of a 13-year-old male from Qatar who has a history of T-cell acute lymphoblastic leukemia (T-ALL), diagnosed one year prior to presentation as well as 50lb weight loss over the past 6 months. He was admitted for cycle 3 of maintenance therapy with vincristine, prednisone, and intrathecal methotrexate. At time of admission, he reported diffuse weakness and was only able to ambulate a few steps. However, on day 7 of admission he developed complete inability to bear weight or turn in bed as well as diffuse neuropathic pain despite last vincristine dose being 6 weeks prior. Exam was notable for diffuse weakness, worse proximally and absent reflexes. Nerve conduction studies showed decreased velocity with signs of conduction block in multiple nerves suggestive of a diffuse demyelinating pathology. MRI showed no pathologic enhancement and CSF protein was normal. However, laboratory workup was notable for positive anti-GD1a antibodies as well as low levels of B1 and B6. He was started on treatment with IVIG and subsequently plasmapheresis as well as B1 and B6 supplementation.
Conclusions:
This case illustrates the need to consider a broad range of etiologies including vitamin deficiencies and immune mediated neuropathy when evaluating neuropathy in pediatric leukemia patients despite high prevalence of medication-induced neuropathy in this population.