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Washington University Experience | PERIPHERAL NEUROPATHY | 15 NEUROPATHY ASSOCIATED WITH NEOPLASIA | 2 Paraneoplastic Neuropathy | 6A0 Case 6 History
Case 6 History ---- The decedent is a 66 year-old woman with type 2 diabetes mellitus, hypertension, metastatic Merkel cell carcinoma receiving immunotherapy (pembroluzimab) who presented on 4/22 with a one month history of falls and weakness. She was hyponatremic in the emergency department. CT scan of the head was negative for an acute intracranial abnormality, and spinal MRI showed severe spinal canal stenosis from C4 to C7 and at L3/L4. Neurologic examination was consistent with a neuronopathy given profound sensory loss in all modalities, sensory ataxia, areflexia, and lack of clear length dependence (even trigeminal nerve affected). Nerve conduction studies confirmed the presence of a sensory ganglionopathy/neuronopathy, and serological testing revealed positive antibody titers for antineuronal nuclear antibody-1 (ANNA-1), consistent with a paraneoplastic autoimmune sensory ganglionopathy. Regarding treatment, she was started on high dose steroids on 5/2 a total of 5g IV solumedrol, with a brief pause because of concern for GI bleeding (eventually found to be ingested oral blood) and infection. She also received Plasma Exchange (x5) from 5/4-5/12. Her condition slightly improved, with return of light touch and vibration sense, although it was still impaired. Her neurological condition later declined, along with emergence of other organ system failure (acute kidney injury, acute respiratory failure), and the decision was made to move her to hospice. Palliative care was consulted on 5/15 and comfort measures were started. She passed away on 5/20.
