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Abstract Details

Treatment of Cisplatin Induced Neurotoxicity with High Dose Pyridoxine and Pyridostigmine
Neuro-oncology
P4 - Poster Session 4 (5:30 PM-6:30 PM)
13-010

To describe a rare presentation of cisplatin-induced neurotoxicity and its management.
Some chemotherapeutic medications have been reported to induce symptoms of neuromuscular junction (NMJ) dysfunction; specifically cisplatin, Interferon-α, Interleukin-2 and ipilimumab. This can present as a myasthenia-like syndrome with symptoms such as ptosis, diplopia, weakness and respiratory difficulty that gets worse with repetitive activity. 
Single Case Report and review of literature
47-year-old woman with high grade osteosarcoma of left femur developed sustained right sided ptosis and double vision after being treated with three rounds of Cisplatin and Doxorubicin. Symptoms were worse with exertion. Examination showed right eye ptosis without any oculomotor dysfunction, binocular diplopia with left lateral gaze and fatigability on sustained deltoid strength testing. Myasthenia antibodies were negative. Vit B12, folate, copper, and zinc levels were normal. MRI brain with and without contrast was unremarkable. Based on neuroprotective treatments described in similar cases, the patient was initiated on pyridostigmine 3 mg/kg po and Pyridoxine 150 mg/m2. By day five of treatment, her ptosis and strength had markedly improved. At her one month outpatient follow up, she continued to do well with resolution of her diplopia, no ptosis or fatigability on sustained upgaze for 60 seconds and 20 push downs of the deltoids. 

Our case elucidates an uncommon side effect of commonly used chemotherapy drugs and also presents a successful treatment option. While cisplatin-induced neuropathy can present with cranial nerve palsies, the concurrent presence of asymmetric ptosis and fatigable proximal muscle weakness point to a NMJ disorder in our patient.  Treatment with a combination of pyridoxine and pyridostigmine has been reported to be effective in patients on vincristine with similar clinical presentation. Patients on chemotherapy who develop an antibody negative myasthenia-type syndrome should undergo a trial of pyridostigmine and pyridoxine to see if their symptoms improve.

Authors/Disclosures
Nicole Thomason
PRESENTER 		No disclosure on file
No disclosure on file
Zafer Keser, MD (Mayo Clinic) Dr. Keser has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Elsevier Practice Update.
Yvo A. Rodriguez-Linares, MD (UTHealth McGovern Medical School Neurology Department) Dr. Rodriguez-Linares has nothing to disclose.
Haris Kamal, MD (University of Texas At Houston) Dr. Kamal has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Microvention .
Shivika Chandra, MD, FAAN (University of Texas Health Science Center at Houston) The institution of Dr. Chandra has received research support from American Board of Psychiatry and Neurology Faculty Innovation in 好色先生 Award. The institution of Dr. Chandra has received research support from Michael J Fox Foundation.