CANCER GOT MY WORLD SPINNING

Document Type

Conference Proceeding

Publication Date

7-17-2025

Publication Title

J Gen Intern Med

Keywords

carboplatin, cobalamin, copper, corticosteroid, cyanocobalamin, prostate specific antigen, thiamine, adult, carcinomatous peritonitis, case report, cerebellum, cerebellum degeneration, cerebrospinal fluid, clinical article, conference abstract, diagnosis, dizziness, drug therapy, Eaton Lambert syndrome, encephalitis, germ cell tumor, Hispanic, human, immunosuppressive treatment, lumbar puncture, male, mesothelioma, motor neuron disease, MRI scanner, myasthenia gravis, myelitis, nausea, nuclear magnetic resonance imaging, paraneoplastic neurological syndrome, paraneoplastic syndrome, peritoneum mesothelioma, physical examination, plasma exchange, therapy, vertical gaze palsy, vertigo

Abstract

CASE: 61 year old male with recently diagnosed peritoneal carcinomatosis presented with dizziness, vertigo and nausea. On admission CT and MRI head were non remarkable. On physical examination, the patient had conjugate vertical gaze palsy. This was followed by a battery of tests including vitamin B-12, thiamine, copper, and finally a lumbar puncture all of which were non remarkable. Prior to the hospitalisation patient had undergone a biopsy for peritoneal carcinomatosis which resulted negative for CK20, CDX2, S100, P40, TTF1, PSA, NKX 3.1, MOC 31, NKX3.1, Ber-Ep4, With more common pathologies ruled out, HemOnc team requested a more robust panel for staining which ultimately yielded positivity for Pancytokeratin AE1/AE3, CK7, calretinin, CK5/6, WT1, D2-40, hence confirming the diagnosis of peritoneal mesothelioma with epitheoid features. A carboplatin based paliative chemotherapy was discussed but patient's major concern remained the initial presenting symptoms. Then paraneoplastic panel was run on the cerebrospinal fluid. His anti-Ma2 antibodies were positive indicating a paraneoplastic syndrome as the cause of the vertical gaze palsy. So prior to his chemotherapy, a treatment with IVIG was initiated for paraneoplatic cerebellar symptoms. IMPACT/DISCUSSION: Paraneoplastic neurologic syndromes are immune mediated symptoms which could affect any part of the nervous system. Symptoms include encephalitis, myelitis, subacute cerebellar degeneration, myasthenia gravis or lambert eaton syndrome etc. Currently, the most widely used definite diagnostic criteria includes a classical syndrome and cancer developing within 5 years of a neurological disorder's diagnosis or non-classical syndrome resolving or significantly improving after cancer treatment or a non-classical syndrome with onconeural antibodies and cancer developing within 5 years of a neurological disorder's diagnosis or a neurological syndrome with well-characterized onconeural antibodies and no cancer. Anti-Ma2 antibody are notorius for involving the CNS. It is more common in men with germ cell tumors but varied association and diverse symptoms have been reported. In a small study on hispanic poulation, isolated cerebellar symptoms were seen but absence of MRI evidence of the same was unlikely. Moreover presence of such antibodies with mesothelioma has only been reported once in literature. In general, anti-Ma2 antibody-positive PNS is subacute, if untreated turns irreversible and can be expected to improve by approximately 30% after tumor removal and immunosuppressive therapy. IVIG, corticosteroid and even plasma exchange play a key role if initiated early. CONCLUSION: - Peritoneal mesothelioma is rare, association with Anti Ma antibodies even though rarer, likely occurs in paucity of diagnosed cases. Hence any patient with the diagnosis and neurological symptoms should be worked up for paraneoplastic syndrome. - Early initiation of treatment with IVIG can prevent the disease from being irreversible.

Volume

40

First Page

S168

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