Follicular Lymphoma Patient Relapsing with Paraneoplastic Sensory Neuronopathy (Ganglioneuropathy)

Neurological symptoms can be seen in 5%-8% of lymphoma patients. The most frequent causes of neurological symptoms are herpes virus infection, neurotoxicity due to vincristine, Guillain–Barré syndrome, and the nerve involvement of the tumor [1]. Paraneoplastic polyneuropathy is a rare neurological complication of lymphoma [2]. Here we report a case of relapsed follicular lymphoma presenting with paraneoplastic sensory neuropathy (ganglioneuropathy). A 45-year-old woman was admitted to the hospital 2 years ago with the complaints of numbness in the hands and feet, unsteadiness, weight loss, fever, and swellings in the neck, axilla, and inguinal region. She was diagnosed with follicular lymphoma through the excisional biopsy of the cervical lymph node. She was diagnosed with stage 3B disease based on the presence of lymphadenopathies in the paratracheal, precarinal, axillary, and inguinal regions and no infiltration by bone marrow examination. The treatment started with rituximab (500 mg/day), cyclophosphamide (1125 mg/day), adriablastine (80 mg/day), vincristine (2 mg/day), and prednisolone (80 mg/day). Therapy was completed in 8 courses with 21-day intervals. After the therapy, all of the symptoms had regressed and the case was evaluated as in remission with a follow-up PET scan (Figure 1). Gradually increasing unsteadiness, numbness, and pain and burning sensation in the hands and feet developed 1 month following that PET study. She applied to the neurology service and it was found that she had normal muscle strength but mild ataxia, positive Romberg test, and prominent hypoesthesia in the distal regions of the extremities and bilateral impairment of the deep tendon reflexes and indifferent plantar responses. Informed consent was obtained. An electromyography revealed sensorial gangliopathy. On physical examination the positioning and the vibration sensations of the patient were found to be diminished. Intravenous pulse steroid therapy (1000 mg/day) was administered for 5 days. Two days after this therapy, a severe and generalized pain developed in all of the extremities and joints. In neurological examination, distinct quadriparesis, ataxia, dysmetria, dysdiadochokinesia, hypoesthesia of the 4 extremities, and bilateral abolished deep tendon reflex with indifferent plantar responses were determined. There was Letter to the Editor DOI: 10.4274/TJH-2013.0125