Table of Contents
Washington University Experience | PERIPHERAL NEUROPATHY | 15 NEUROPATHY ASSOCIATED WITH NEOPLASIA | 2 Paraneoplastic Neuropathy | 3A0 Case 3 History
Case 3 History ---- The patient was a 64 year old woman who experienced transient loss of vision in the right eye in 11/1985 which lasted from 1 to 3 hours and gradual loss of vision in the right eye which persisted coupled with intermittent numbness of the thumb and fifth finger of the right hand. Left carotid stenosis, treated with endarterectomy, resulted in no change. She was discharged on anticoagulants and tetracycline. She had an extensive workup without a diagnosis. She developed orthostatic hypotension. In 7/86 there was further decline in mental status, increasing weakness and radicular back pain resulting in a diagnosis of Shy-Drager syndrome with neuropathy. Over a 7-10 day period she developed monoplegia of the right arm in the presence of degenerative arthritis at C5-6. The patient continued to deteriorate with worsening weakness, dementia, and weight loss of approximately 70 lbs since the onset. In 10/86 she had 2 spells of loss of consciousness when she was seated which was felt to be either syncopal episodes or seizure activity. An EEG showed theta and delta wave activity in a pattern much worse than in 1/86. Her past medical history was significant for a 125 pack/year smoking history and COPD. Visual acuity decreased with an inferior visual field cut in the right eye. Pupils were 5 mm and fixed to light with some weakness on upgaze. She had positive corneal reflexes, normal touch and pin prick sensation on the face; she had a right central 7th nerve palsy and had decreased hearing bilaterally. She had marked muscle weakness and loss of pin-prick and proprioceptive function (upper > lower limb) and was diffusely hyporeflexive. Clinical impression was a neurodegenerative process with dementia, optic atrophy, disturbance of eye movements, and sensorimotor and probable autonomic neuropathy. Differential diagnosis included CNS syphilis (FTAA-AB negative), multiple system atrophy (too much dementia), leptomeningeal carcinoma, and/or paraneoplastic syndrome. NCV on 11/19 demonstrated denervation of the right tibialis anterior, both deltoids, and intrinsic hand muscles. Bilateral ulnar neuropathy was noted with a lesion at the elbow on the left. On 11/24 the patient suffered a respiratory arrest presumably from aspiration which required intubation. An endoscopic lung biopsy showed undifferentiated small cell (“oat-cell”) carcinoma. At this time it was felt that the patient's neurological status was due to a paraneoplastic syndrome. The decision was made that this patient would not benefit from chemotherapy. Shortly thereafter the patient suffered an unwitnessed cardiorespiratory arrest and died.
