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Warning
A range of neurological events have been described, including polyneuropathy, facial nerve palsy, demyelination, myasthenia gravis, Guillain Barré syndrome, posterior reversible leukoencephalopathy, transverse myelitis, enteric neuropathy, encephalitis and aseptic meningitis.
Important to rule out progression of the underlying cancer, seizure activity, infection and metabolic derangement as causes of neurological impairment.
Early involvement of neurologist recommended.
Condition Assessment Management
Peripheral neuropathy
Diabetic screen, B12/Folate, HIV, TSH, vasculitis screen, alcohol and drug history
Consider MRI/MRA brain and spine, nerve conduction studies, lumbar puncture, PFT
Steroids G2: Oral prednisolone 0.5-1mg/kg G3: IV methylprednisolone 2mg/kg
Guillain-Barre syndrome
Progressive symmetrical muscle weakness with reduced tendon reflexes involving extremities, facial, respiratory, oculomotor muscles; dysregulation of autonomic nerves
Nerve conduction studies Lumbar puncture PFT Antibody testing for GBS variant (GQ1b in Miller Fisher variant)
Use of steroids not recommended in idiopathic GBS, but trial of 1-2mg methylprednisolone reasonable Plasmapheresis/IVIG Consider location of care where ventilatory support available
Myasthenia Gravis
Fluctuating muscle weakness (proximal limb, trunk, ocular) with fatigability, respiratory muscles may also be involved
AChR and anti-MuSK antibodies EMG
Steroids (Route of administration and dose pending severity) Pyridostigmine 30mg TDS Plasmapheresis/IVIG Additional immunosuppresants (azathioprine, ciclosporin, mycophenalate mofetil) Avoid certain medications (ciprofloxacin, B blockers) that may precipitate cholinergic crisis
Aseptic meningitis
Headache, neck stiffness, photophobia, fever, vomiting
Exclusion of infection paramount CT/MRI head Lumbar puncture
Exclude bacterial or viral infection prior to commencing steroids Consider concurrent antibacterial/antiviral Oral prednisolone 0.5-1mg/kg or IV methylprednisolone 1-2mg/kg
Encephalitis
Altered behaviour, confusion, headache, motor or sensory deficit
Exclusion of infection and metabolic causes paramount CT/MRI head Lumbar puncture Viral serology
Exclude bacterial or viral infection prior to commencing steroids Concurrent IV antiviral (aciclovir) until result of PCR Oral prednisolone 0.5-1mg/kg or IV methylprednisolone 1-2mg/kg
Transverse myelitis
Acute or subacute of motor/sensory/ autonomic symptoms; may have sensory level; often bilateral
MRI brain/spine Lumbar puncture Serum B12, TSH, HIV, ANA, anti-Ro, anti-La, anti-aquaporin 4 IgG
Methylprednisolone 2mg/kg If no improvement, plasmapheresis may be required
Acute Oncology Guidelines
