Neuropatia periférica induzida por quimioterápicos: sintomas e o risco de queda em mulheres idosas com câncer / Peripheral neuropathy induced by chemotherapy: symptoms and the risk of falling in elderly women with cancer

Introdução: Os avanços nas áreas da saúde e tecnologia favoreceram o processo de transição demográfica e o aumento da expectativa de vida. Consequentemente, o aumento da população idosa ocasiona um aumento das doenças crônicas não-transmissíveis, que incluem o câncer, considerado a segunda principal causa de morte em todo mundo. Dentre as diversas opções de tratamento do câncer destaca-se a quimioterapia, que durante seu uso o paciente pode apresentar diferentes eventos adversos. Um destes eventos é a neurotoxicidade, conhecida como neuropatia periférica induzida por quimioterápicos (NPIQ), que é caracterizada como uma lesão inflamatória ou degenerativa dos nervos periféricos. Manifesta-se por sintomas sensoriais típicos, como perda de sensibilidade nos membros e perda de reflexos, fraqueza em mãos e pés e disestesias, perda de discriminação entre o toque e temperatura (frio e calor), cujas manifestações clínicas incluem dor, formigamento, choque e queimação, e podem implicar em consequências negativas para a vida cotidiana e tornando-se mais vulnerável a ocorrências de quedas. Objetivos: Avaliar a ocorrência da NPIQ e o risco de queda em mulheres idosas com diagnóstico de câncer. Métodos: Estudo quantitativo, descritivo e transversal, desenvolvido com 60 mulheres idosas que realizavam o tratamento quimioterápico para qualquer tipo de câncer. Os dados coletados foram sócio-demográficos e sobre o câncer, e foram aplicados os instrumentos: Escala de Risco de Queda (Fall Risk Score), Escala de Fragilidade de Edmonton (Edmonton Frail Scale) e Ferramenta de Avaliação de Neuropatia Periférica Induzida por Quimioterapia (FANPIQ). Os dados foram digitados no Microsoft Excel, e analisado no Statistical Package for the Social Sciences - SPSS v. 22.0. Foram realizadas análises descritivas com média e desvio padrão, analítica e testes de regressão multivariada. Resultados: A média de idade das participantes foi 69,57 (DP±7,63) anos, 58,3% apresentava hipertensão arterial e 30% diabetes mellitus, 96,7% utilizavam algum tipo de medicação e 75% apresentavam câncer de mama. Quanto ao risco de queda, 36,7% das participantes afirmaram já ter apresentado algum tipo de queda nos últimos 12 meses, com ou sem lesão; entretanto somente 6,7% apresentaram algum déficit sensorial. Na avaliação da fragilidade, 58,3% das idosas não precisavam de auxílio para realizar atividades básicas da vida diária, e 48,3% das participantes foram aprovadas na cognição. Quanto aos sintomas neuropáticos que avaliou a ocorrência de dormência, formigamento, sensibilidade e neuralgia durante o tratamento quimioterápico, todos com influência em algumas atividades cotidianas das mulheres. De acordo com as análises de regressão, a dormência e formigamento nas mãos, neuralgia, dormência nos pés e sensibilidade ao frio foram itens com associação estatística na escala de fragilidade. Conclusão: Este estudo avaliou a ocorrência da NPIQ e o risco de queda em mulheres idosas com diagnóstico de câncer. Apesar de pouco descrito na literatura, foi possível identificar a influência da NPIQ nas atividades cotidianas, com a associação entre os sintomas e o risco de queda, bem como as limitações funcionais no cotidiano da mulher

Introduction: Advances in the areas of health and technology favored the process of demographic transition and increased life expectancy. Consequently, the increase in the elderly population causes an increase in non-communicable chronic diseases, which include cancer, considered the second leading cause of death worldwide. Among the various cancer treatment options, chemotherapy stands out, as during its use the patient may experience different adverse events. One of these events is neurotoxicity, known as chemotherapy-induced peripheral neuropathy (CIPN), which is characterized as an inflammatory or degenerative lesion of the peripheral nerves. It is manifested by typical sensory symptoms, such as loss of sensitivity in the limbs and loss of reflexes, weakness in the hands and feet and dysesthesias, loss of discrimination between touch and temperature (cold and heat), whose clinical manifestations include pain, tingling, shock and burning, and may result in negative consequences for everyday life and make them more vulnerable to falls. Objective: To assess the occurrence of CIPN and the risk of falling in elderly women diagnosed with cancer. Method: Quantitative, descriptive and cross-sectional study, developed with 60 elderly women who underwent chemotherapy treatment for any type of cancer. The data collected were socio-demographic and about cancer, and the following instruments were applied: Fall Risk Score, Edmonton Frail Scale, and the Chemotherapy-Induced Peripheral Neuropathy Assessment Tool (FANPIQ). Data were entered into Microsoft Excel, and analyzed using the Statistical Package for the Social Sciences - SPSS v. 22.0. Descriptive analyzes were performed with mean and standard deviation, analytical and multivariate regression tests. Results: The participants' mean age was 69.57 (SD±7.63) years, 58.3% had arterial hypertension and 30% had diabetes mellitus, 96.7% used some type of medication and 75% had breast cancer. As for the risk of falling, 36.7% of the participants stated that they had already had some type of fall in the last 12 months, with or without injury; however, only 6.7% had some sensory deficit. In the assessment of frailty, 58.3% of the elderly women did not need help to carry out basic activities of daily living, and 48.3% of the participants passed the cognition test. As for the neuropathic symptoms, it evaluated the occurrence of numbness, tingling, sensitivity and neuralgia during chemotherapy treatment, all of which influenced some of the women's daily activities. According to the regression analyses, numbness and tingling in the hands, neuralgia, numbness in the feet and sensitivity to cold were items with statistical association in the frailty scale. Conclusion: This study evaluated the occurrence of CIPN and the risk of falling in elderly women diagnosed with cancer. Although little described in the literature, it was possible to identify the influence of CIPN on daily activities, with the association between symptoms and the risk of falling, as well as functional limitations in women's daily lives

Síndrome POEMS: desafios no diagnóstico de um caso atípico / POEMS syndrome: challenges in the diagnosis of an atypical case

Introdução: Síndrome POEMS trata de um raro evento paraneoplásico, sem relato atual na literatura sobre sua real prevalência. A maior parte dos casos ocorre em homens de meia idade; Relato do Caso: Relatamos o caso de um paciente masculino, 65 anos, admitido com queixa edema e parestesia em pernas que evoluiu para plegia, associada a hiporexia e fadiga. Investigação ambulatorial inicial evidenciou polirradiculoneuropatia inflamatória desmielinizante crônica (PIDC) de etiologia indefinida. Excluídos secundarismos para polirradiculoneuropatia inflamatória desmielinizante crônica, o paciente foi a seguir diagnosticado com hipotireoidismo primário, hipogonadismo severo, lesões hipercrômicas em pele, ascite, derrame pleural e trombocitose, além de gamopatia monoclonal IgA Lambda por imunofixação sérica. Sorologias para HIV, Sífilis e Hepatites todas negativas. Excluída a possibilidade de Mieloma Múltiplo e outras gamopatias, foi aventada a hipótese de Síndrome POEMS, sendo realizada dosagem de Fator de Crescimento Endotelial Vascular (VEGF) plasmática (425 pg/mL; VR = <96.2). O paciente passou então a preencher os critérios obrigatórios para diagnóstico, além de um maior (VEGF elevada) e vários outros menores. Trata-se de um caso atípico na medida em que, lesões ósseas, presentes em até 97% dos casos, não foram evidenciadas no paciente em questão, tornando desafiador o diagnóstico e sendo então necessário recorrer à dosagem de VEGF. O diagnóstico de síndromes raras, embora desafiante, traz ao clínico um olhar mais amplo do paciente na medida em que incrementa o raciocínio clínico. Difundir e explorar esse universo é cada vez mais necessário

Introduction: POEMS syndrome is a rare paraneoplastic event, with no current report in the literature about its real prevalence. Most cases occur in middle-aged men; Case Report: We report the case of a male patient, 65 years old, admitted with complaints of edema and paresthesia in the legs that progressed to plegia, associated with hyporexia and fatigue. Initial outpatient investigation revealed Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP) of undefined etiology. Excluding secondaries for chronic inflammatory demyelinating polyradiculoneuropathy, the patient was subsequently diagnosed with primary hypothyroidism, severe hypogonadism, hyperchromic skin lesions, ascites, pleural effusion and thrombocytosis, in addition to monoclonal IgA Lambda gammopathy by serum immunofixation. All serologies for HIV, Hepatitis and syphilis were negative. Excluding the possibility of Multiple Myeloma and other gammopathies, the hypothesis of POEMS Syndrome was raised, and plasma Vascular Endotelial Growth Factor (VEGF) measurement was performed (425 pg/mL; RV = <96.2). The patient then started to fulfill the mandatory criteria for diagnosis, in addition to a major (elevated VEGF) and several other minors. This is an atypical case in that bone lesions, present in up to 97% of the cases, were not evidenced in the patient in question, making the diagnosis challenging and therefore requiring the use of VEGF dosage. The diagnosis of rare syndromes, although challenging, brings the clinician a broader view of the patient as it increases clinical reasoning. Spreading and exploring this universe is increasingly necessary

Vasculitis with a neuromuscular presentation and associated cancer revealed by autopsy

Peripheral neuropathy is common, but rarely due to vasculitis. This report is the case of a 74-year-old woman with systemic vasculitis who presented with progressive arm and leg weakness associated with numbness. Autopsy revealed a colon cancer, which may have triggered the vasculitis. This case illustrates the association between vasculitis and malignancy. The best treatment of vasculitis in patients with cancer-associated vasculitis is usually treatment of the cancer, which often yields remission of the vasculitis. This case also illustrates the difficulty of suspecting vasculitis since the symptoms and signs are nonspecific and protean. It is important not to miss a diagnosis of vasculitis. It is often life-threatening. It is treatable. The critical step in the diagnosis of vasculitis is to think of it.

Neuropatía periférica como forma de presentación inicial en ataque agudo de porfiria. Reporte de caso clínico / Peripheral neuropathy as initial symptom in porphyria attacks: A case report

Las porfirias constituyen un grupo de ocho enfermedades de baja prevalencia, causadas por defectos enzimáticos en la vía metabólica de la síntesis del grupo hem. Una de sus formas es la porfiria intermitente aguda; afecta a 1,5/100.000 personas año y se presenta con dolor abdominal, taquicardia, parestesias, constipación y vómito. La neuropatía porfírica es en esencia motora, simétrica y suele ser proximal. Se presenta el caso de una paciente de sexo femenino con neuropatía periférica, dolor abdominal y elevación de las transaminasas, en quien se documentó porfiria intermitente aguda. Después de instaurado el manejo, los síntomas se resolvieron...(AU)

Porphyrias are a group of eight low prevalence disorders of heme metabolism, each characterized by a defect in an enzyme required for the synthesis of heme. Acute intermittent porphyria, affecting 1.5 per 100.000 people per year manifesting with abdominal pain, tachycardia, paresthesia, constipation and vomiting, is one type of porphyria. Porphyric neuropathy is fundamentally motor, symmetrical and often has a proximal predilection. A case is presented in a female patient in whom acute intermittent porphyria was documented. Her symptoms included peripheral neuropathy, abdominal pain and elevation of transaminases. Her symptoms resolved after receiving treatment...(AU)

Síndrome de Sjögren asociado a neuritis periférica, pupila tónica de Adie y fenómeno de Raynaud / Sjögren syndrome associated with peripheral neuropathy, Adie tonic pupil and Raynaud phenomenon

Objetivo: Describir el caso clínico de una paciente con Síndrome de Sjögren asociado a Neuritis periférica, pupila tónica de Adie y fenómeno de Raynaud. Diseño del estudio: Reporte de caso. Metodología: Reportamos el caso clínico de una paciente con Síndrome de Sjögren y sus asociaciones poco frecuente, que consulto a la clínica Instituto Oftalmológico Fernández Vega, Oviedo ­ España. Se realizó una revisión exhaustiva de la historia clínica, del paciente y sus paraclínicos. Resultados: Paciente femenino con antecedentes de Síndrome de Sjögren acude por presentar cervicalgia y neuralgias, además de sensación de ojo seco y disconfort ocular de predominio en OI. En el examen se evidenció agudeza visual mejor corregida (AVMC) 20/20, fenómeno de Raynaud, pupila tónica de Adie en OI (Test de pilocarpina positiva), Test de Schirmer 6 mm en ambos ojos (AO), estesiometría y Lancaster normal AO. Se manejó con corticoides e inmunomoduladores tópicos sin mejoría. La analítica sanguínea para estudios de causas infecciosas e inmunologicas resultópositiva para ANA. Se diagnosticó síndrome de Sjögren asociado a neuropatía periférica. Se inicia tratamiento a metotrexato sistémico con mejoría notoria de síntomas. Test de Schirmer control 16 mm OD y 20 mm OI. Conclusión: Las neuropatías periféricas son posibles manifestaciones del síndrome de Sjögren primario, y se podrían presentar con más frecuencia cuando se asocian a los anticuerpos y fenómeno de Raynaud. Por su parte las neuropatías periféricas podrían ser la primera manifestación en el síndrome de Sjögren en alrededor del 50% de los pacientes.

Objective: To report the clinical case of a female patient with Sjögren syndrome associated with peripheral neuropathy, Adie tonic pupil and Raynaud phenomenon. Study design: Case report. Methods: We performed a descriptive case report with detailed review of the medical record of a female patient with Sjögren syndrome and its associations. The patient was treated at Fernandez Vega Eye Institute, Oviedo-Spain. Her medical records was reviewed and analyzed. Ancillary tests were taken. Results: Female patient with a previous history of Sjögren's syndrome complained about neck pain, neuralgia, dry eye and ocular discomfort predominantly in OS. Best-corrected visual acuity (BCVA) was 20/20. Raynaud's phenomenon was positive. Slit lamp examination: Adie tonic pupil in OS. Schirmer Test 6 mm OU. We started corticosteroids and topical immunomodulators without improvement. Blood tests for infectious and immunological studies (ANA) were positive. After these results Sjögren syndrome associated with peripheral neuropathy was diagnosed and started methotrexate systemic treatment with improvement. Conclusion: Peripheral neuropathies are manifestations of primary Sjögren's syndrome. These manifestations can be present more often when are associated with antibodies (ANA) and Raynaud's phenomenon. On the other hand peripheral neuropathies may be the first manifestation in Sjögren's syndrome in about 50% of patients.

Evaluación del efecto del Compvit-B sobre la neuropatía periférica en pacientes con SCA2 en estadio ligero de la enfermedad / Evaluation of the effect of Compvit-B on peripheral neuropathy in patients with mild SCA2

INTRODUCCIÓN: la Ataxia Espinocerebelosa tipo 2 (SCA2) es una enfermedad neurodegenerativa severa que representa un serio problema de salud en Cuba, debido a las altas tasas de prevalencia e incidencia y a la ausencia de tratamientos curativos. OBJETIVOS: evaluar el efecto y la seguridad del tratamiento con altas dosis de vitaminas del complejo B (Compvit-B) sobre la neuropatía periférica en pacientes con SCA2. MÉTODOS: se realizó una investigación prospectiva de intervención clínica en 20 enfermos en estadio ligero los que se sometieron a un protocolo terapéutico mediante la administración intramuscular del COMPVIT B por 12 semanas. Durante las primeras 4 semanas los individuos recibieron dos bulbos semanales y a partir de la 5tasemana un solo bulbo. Inmediatamente antes y después del tratamiento los pacientes fueron evaluados mediantes exámenes clínicos y electrofisiológicos. RESULTADOS: una vez concluido el tratamiento, los pacientes mostraron un aumento significativo de las amplitudes de los potenciales de acción sensitivos de nervios mediano y sural, y en este último nervio se observó además reducción de la latencia y aumento de la velocidad de conducción. Los parámetros de la conducción nerviosa motora no se modificaron. Los potenciales evocados somatosensoriales de nervio mediano arrojaron una reducción significativa de la latencia del potencial de Erb. De manera interesante se observó una la disminución significativa de la frecuencia de aparición de las contracturas musculares dolorosas en el 53% de los casos después del tratamiento. Durante el estudio no se registraron eventos adversos. CONCLUSIONES: el presente estudio identifica una nueva opción terapéutica sintomática en la SCA2, brinda nuevas evidencias sobre las bases fisiopatológicas y el manejo clínico de las contracturas musculares dolorosas y justifican la realización de estudios más amplios en pacientes y portadores de la mutación, los que presentan tales manifestaciones muchos antes de debutar con la ataxia.

INTRODUCTION: Spinocerebellar ataxia type 2 (SCA2) is a severe neurodegenerative disease which constitutes a serious health problem in Cuba due to its high prevalence and incidence rates and the lack of curative treatments. OBJECTIVES: Evaluate the effect and safety of the treatment with high doses of B-complex vitamins (Compvit-B) on peripheral neuropathy in patients with SCA2. METHODS: A prospective clinical intervention study was conducted of 20 patients in the mild stage of the disease undergoing a therapeutic protocol consisting in intramuscular injection of Compvit-B for 12 weeks. Patients were administered two ampoules weekly in the first 4 weeks and one from the fifth week onwards. Immediately before and after the treatment patients underwent clinical and electrophysiological examination. RESULTS: Upon completion of the treatment patients showed a significant increase in the amplitude of the sensitive action potentials of the median and sural nerves. In the latter case there was also a decrease in latency and an increase in conduction velocity. Motor nerve conduction parameters were not modified. Somatosensory evoked potentials of the median nerve showed a significant reduction in the latency of Erb's potential. A significant decrease was also found in the frequency of painful muscle contractures in 53% of the cases after treatment. Adverse events were not recorded during the study. CONCLUSIONS: The study identifies a new therapeutic option for symptomatic SCA2, and provides new evidence of the pathophysiological bases and clinical management of painful muscle contractures. Broader studies should be conducted with patients and carriers of the mutation, who typically present such manifestations long before developing ataxia.

Síndrome neurológico paraneoplásico como manifestación de un carcinoma de colon / Paraneoplastic neurological syndrome as a colon cancer manifestation

Los síndromes paraneoplásicos neurológicos son poco comunes, más frecuentes en neoplasias ginecológica y pulmonar; muy rara en neoplasias intestinales. Más del 60% de los pacientes con Síndrome Paraneoplásico presentan el cuadro neurológico antes de ser diagnosticados como portadores de una malignidad. Por otro lado, solo 5% de los casos de cáncer de colon aparece en jóvenes. Una complicación poco usual es la perforación intestinal. El objetivo de este artículo es mostrar mediante un estudio descriptivo (caso clínico) las manifestaciones poco comunes del cáncer de colon en una paciente joven, quien debutó con un síndrome paraneoplásico. La patología maligna se expresó como una perforación. Se trata de paciente femenina de 32 años de edad, quien consulto por disminución progresiva de fuerza muscular predominio proximal (cintura escapular y pélvica) y episodios de dolor abdominal difuso de l mes de evolución, hospitalizada en otra Institución durante ese período, sin diagnóstico definitivo; por exacerbación de la sintomatología es remitida. Ingresa con deterioro neuropático motor que precisó ventilación mecánica en unidad de terapia intensiva, con signos de sepsis, irritación peritoneal. Fue sometida a exploración quirúrgica con impresión diagnóstica de peritonitís difusa asociada a tumor pélvico. En los hallazgos intraoperatorios se evidenciaron 3000 cc de pus en cavidad abdominal, perforación del ángulo hepático del colon. Se realizó hemicolectomía derecha, ileostomía terminal y fistula mucosa del transverso. Resultado anatomopatológico: Adenocarcinoma de colon (Dukes B2). La paciente evolucionó satisfactoriamente con restitución de fuerza muscular hasta IV/V. Recibió posteriormente quimioterapia coadyuvante. Diagnóstico de egreso: Adenocarcinoma de colon bien diferenciado.- Síndrome Paraneoplásico Neurológico: Polineuropatía motora desmielinizante crónica.

Neurologic Paraneoplastic Syndromes (NPS) are rare, most common in pulmonary and Gynecologic tumor and are very rare in intestinal neoplasms. Over 60% of patients with paraneoplastic syndrome begin with neurological manifestations before being diagnosed as having a malignancy. On the other hand, only 5% of cases of colon cancer appear in young people. An unusual complication is intestinal perforation. The aim of this paper is to show through a descriptive study (case report), rare manifestations of colon cancer in a young patient who presented with a NPS. The malignant disease was shown as a perforation. This female patient aged 32, who consulted with progressive decline of muscle strength predominantly proximal (shoulder and pelvic girdle), and episodes of diffuse abdominal pain of one month of evolution was hospitalized in another institution during that period with no definitive diagnosis. For exacerbation of symptoms she was referred to our hospital. She began neuropathic motor impairment needing mechanical ventilation, signs of sepsis and also signs of peritoneal irritation. She underwent surgery with clinical impression of diffuse peritonitis and pelvic tumour. Findings: 3000 cc of pus in the abdominal cavity and a perforation at the hepatic flexure of the colon. Right hemicolectomy and end ileostomy and mucous fistula of the transverse were performed. Anatomopathology: colon adenocarcinoma (Dukes B2). Patient recovered satisfactorily with restoration of muscle strength to IV/V. Subsequently, she received adjuvant chemotherapy. Discharge diagnosis: colon well differentiated adenocarcinoma - Paraneoplastic Neurological Syndrome: Chronic demyelinating motor polyneuropathy.

Neuropatia paraneoplásica associada ao mastocitoma canino / Paraneoplastic neuropathy associated with canine mast cell tumor

As síndromes paraneoplásicas compreendem um grupo diverso de alterações clínicas associadas a neoplasias e ocorrem em sítios distantes do tumor primário ou de suas metástases. As neuropatias paraneoplásicas são distúrbios raros em cães, mas representam morbidade significativa e servem como importantes indicadores diagnósticos e prognósticos. O presente trabalho relata a ocorrência de dois casos de neuropatia paraneoplásica em cães com mastocitoma, considerando a apresentação clínica, o diagnóstico e as formas de tratamento utilizadas.

Paraneoplastic syndromes comprise a diverse group of clinical anomalies associated with neoplasias and occur in a location distant from the primary tumor or of your metastasis. Paraneoplastic neuropathy are rare disturbs in dogs, but represent significant morbidity and are useful as diagnostic and prognostic indicators. This work report the occurrence of two cases of paraneoplastic neuropathy in dogs with mast cell tumor, considering the clinical signs, diagnosis and treatment used.

Anti-Hu Antibody Associated Sensory Neuronopathy Accompanied by Autonomic Dysfunction

Paraneoplastic sensory neuronopathy may present with autonomic dysfunction resulting either from autonomic neuropathy, or invasion/compression by tumor. We present a 61-year-old female presented with frequent syncope, anhidrosis, and sensory change. Investigations disclosed sensory-autonomic polyneuropathy with positive anti-Hu antibody. The chest computed tomography showed a left mediastinal mass with invasion to the brachiocephalic vein, and a small cell lung cancer was confirmed. She was treated with radiation therapy showing limited improvement. The possible causes of autonomic dysfunction in our patient were discussed.