Reactions 1213 - 2 Aug 2008

SAntineoplastics/tacrolimus

Guillain-Barre syndrome?: 2 case reportsTwo patients developed Guillain-Barre syndrome after

exposure to high-dose antineoplastics andimmunosuppressants associated with peripheral blood stemcell (PBSC) transplantation.

Patient 1, a 47-year-old man was diagnosed with multiplemyeloma in January 2004 and received vincristine,doxorubicin and dexamethasone. After priming with high-dosecyclophosphamide [dosage not stated] and granulocytecolony-stimulating factor, PBSCs were harvested. Six monthsafter diagnosis, he underwent autologous PBSCtransplantation preceded by high-dose melphalan 200 mg/m2.He started maintenance therapy with thalidomide 3 monthslater. In April 2005, he experienced weakness and numbnessin his feet, which ascended to his thighs and upper limbs.Thalidomide was withdrawn, but his condition continued todeteriorate. Laboratory findings only revealed elevated protein(137 mg/dL) in his CSF. He was transferred to a specialinstitution; at this time he was unable to ambulate. He had adecreased sensitivity to touch and pain below the T12 level,with grade 0/5 muscle strength in distal muscles of the lowerextremities. His deep tendon reflexes were absent. Changesconsistent with severe sensorimotor demyelinatingpolyneuropathy were evident in electromyography and nerveconduction studies. Guillain-Barre syndrome was suspectedand he received immune globulin. His symptoms improvedsignificantly and he was able to ambulate unaided by the endof May.

Patient 2, a 39-year-old woman, had been previously treatedwith high-dose cytarabine, daunorubicin, etoposide,mitoxantrone and asparaginase [dosages and durations notstated], for recurrent acute myeloid leukaemia. Following aconditioning regimen of cyclophosphamide 60 mg/kg/day for2 days and full body irradiation, she underwent allogeneicPBSC transplantation. After transplantation, she beganreceiving tacrolimus and methotrexate [dosages not stated] forgraft-versus-host disease prophylaxis. Two months later, shedeveloped diplopia; MRI suggested possible leukaemicinvolvement. She was generally weak but ambulatory at thetime. She underwent irradiation and received cytarabine andasparaginase [dosages not stated] and donor lymphocytes, dueto persistent disease. She achieved remission; however, inMarch 2004, she developed progressive weakness andbecame bed ridden. Laboratory findings revealed elevatedprotein (97 mg/dL) in her CSF. Electromyography and nerveconduction studies were consistent with Guillain-Barresyndrome. She received immune globulin with gradualimprovement of her lower limb paralysis. However, she died9 months after transplant of refractory leukaemia.

Author comment: In transplantation, Guillain-Barresyndrome development may be related to tacrolimus. . . Ithas also been suggested high dose chemotherapy can directlydamage neural sheaths leading to exposure of neural antigensto immune-reactive cells. . . Immunosuppressive drugs mayalso play a role through alteration of T-cell activation inresponse to peripheral myelin.Zhang L, et al. Guillain-Barre syndrome after transplantation. Leukemia andLymphoma 49: 291-297, No. 2, 2008 - USA 801118350

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Reactions 2 Aug 2008 No. 12130114-9954/10/1213-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved