Vincristine-induced autonomic neuropathy.

Neurological adverse effects are known to complicate vincristine treatment. In occasional reports of bowel and bladder disturbance it has not been possible to incriminate autonomic neuropathy. We report here three patients with symptoms and signs which could be ascribed to vincristine-induced autonomic neuropathy. Case Reports Case 1.-A 75-year-old man presented with recurrent Hodgkin's disease. Chemotherapy with modified MOPP (intravenous mustine 6 mg/M2 and vincristine (Oncovin) 1 4 mg/M2 on days 1 and 8; oral procarbazine 100 mg/ m2 and prednisolone 40 mg/day for 14 days; 28 days between each course) was started. About 10 days after his first course he developed symptomatic postural hypotension, his blood pressure being 110/80 mm Hg lying and 70/40 mm Hg standing. The Valsalva response was characteristic of auto-nomic neuropathy. He also had marked peripheral neuropathy. Slow spontaneous improvement occurred and chemotherapy was resumed using vinblastine instead of vincristine. Case 2.-A 77-year-old man presented with diffuse lymphocytic lymphoma. Cyclical chemotherapy was begun with COPAd (intravenous cyclophos-phamide 400 mg/M2 and vincristine 1-4 mg/M2 on days 1 and 8; oral predni-solone 40 mg/day for 14 days; intravenous adriamycin 40 mg/M2 on day 1; 28 days between each course). One week after his first course he developed severe postural hypotension (blood pressure 160/80 mm Hg lying and 90/50 mm Hg standing). The Valsalva response was abnormal. Over the next few days he also developed peripheral neuropathy. His symptoms improved over the next two weeks and chemotherapy was continued using vinblastine instead of vincristine. Case 3.-A 56-year-old man presented with generalized Hodgkin's disease and received three rourses of modified MOPP. He was admitted with generalized weakness, constipation, and retention of urine. Clinical and radiological examination showed paralytic ileus. His blood pressure was 110/70 mm Hg lying and 80/20 mm Hg standing. Myoclonic jerks were observed and he had an extensive peripheral neuropathy. Spontaneous improvement occurred over three to four weeks. Chemotherapy was restarted , substituting vinblastine for vincristine, but he diecL.of septicaemia. Comment Neurotoxicity is a well recognized adverse effect of vincristine treatment. The predominant change is an axonal neuropathy,l which usually takes the form of peripheral neuropathy, though central nervous system abnormalities have been described. Constipation commonly occurs and bladder disturbance has been reported,2 and it has been suggested that these features (which usually postdate peripheral neuropathy) are a result of autonomic nerve damage.3 In primary autonomic degeneration4 sphincter disturbance usually precedes other neurological symptoms-for example, postural hypo-tension, …