To detail an unusual pattern of mixed peripheral nervous system (PNS) and central nervous system (CNS) deficits as presenting symptoms of T-cell acute lymphoblastic leukemia (ALL).

Immune-mediated neuropathies, with varied phenotypes, are often considered in patients with subacute PNS deficits. Typical syndromes are symmetric, without accompanying asymmetric CNS deficits. Paraneoplastic disorders, a subset of these syndromes, have shown distinct patterns of PNS and CNS involvement. Asymmetric, mixed features of PNS and CNS dysfunction associated with T-cell ALL have not been previously described.

N/A (Case report)

We present the case of a 29-year-old Hispanic male construction worker, admitted to the hospital after developing bilateral lower extremity weakness and pain, followed by a high-pitched voice, decreased hearing, and subsequent asymmetric upper extremity weakness, over six weeks. Symptoms were accompanied by chills, night sweats and unintentional weight loss.

Initial neurologic examination revealed bilateral asymmetric weakness in all limbs, with upper and lower motor neuron features, along with left upper extremity hyperreflexia, left lower extremity aflexia, and a left extensor plantar response. Sensory examination demonstrated asymmetric, moderately decreased sensation to all modalities in distal extremities. Other findings included a high-pitched voice and severe bilateral hearing loss.

Brain and spine MRIs were unremarkable. Initial CSF analysis demonstrated a normal protein (32) and normal WBC count. Given suspicion for immune-mediated polyneuropathy, the patient was empirically treated with intravenous immunoglobulin, without improvement. Repeat CSF demonstrated an elevated protein (203) and pleocytosis, with unrevealing investigations for infectious etiologies. Bone marrow biopsy showed T-cell ALL, and CSF flow cytometry revealed a T-cell-predominant pleocytosis. Serum anti-ganglioside antibodies (GD1a, GD1b, and GQ1b) were elevated. Electromyography demonstrated a multifocal, predominantly axonal, polyneuropathy. Motor symptoms improved with steroids.

We present the case of an unusual, multifocal neuropathy with CNS features as a paraneoplastic syndrome in the context of an underlying hematologic malignancy.