Subacute-onset paraneoplastic autonomic neuropathy associated with prostate cancer
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LETTER TO THE EDITOR
Subacute‑onset paraneoplastic autonomic neuropathy associated with prostate cancer Lorenzo Muccioli1 · Marianna Nicodemo2,3 · Pietro Cortelli1,3 · Maria Guarino2,3 Received: 28 July 2020 / Accepted: 13 August 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Dear Editors, Isolated autonomic failure of acute or subacute onset suggests an immune cause, such as autoimmune autonomic ganglionopathy (AAG) and paraneoplastic autonomic neuropathy/ganglionopathy (PAN) [1]. While PAN may present with a limited enteric neuropathy, both disorders may present with diffuse autonomic failure and be clinically indistinguishable. Characteristic features include orthostatic hypotension, constipation and cholinergic failure such as sicca syndrome, urinary retention and impaired pupil responses. The antibodies most commonly associated with PAN might be directed to intracellular (anti-Hu, anti-CV2) or surface antigens (anti-ganglionic nicotinic acetylcholine receptor [anti-gAchR]) [1]. The former are onconeural antibodies strongly associated with underlying malignancy, most frequently small cell lung carcinoma (SCLC), and related to other paraneoplastic neurological syndromes [2, 3]. AntigAchR antibodies are identified at high levels (> 1.0 nmol/L) in more than half of patients with AAG and, in a minority of cases (about 15%), are associated with underlying malignancy (SCLC, thymoma or adenocarcinomas) [1, 4]. Here, we report the case of an elderly patient in whom subacute-onset pandysautonomia lead to the diagnosis of metastatic prostate cancer associated with low titer antigAchR antibodies. A 75-year-old-man with a past history of benign prostate hyperplasia presented at the emergency department with acute urinary retention. A urethral catheter was placed, * Maria Guarino [email protected] 1
Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
2
Neurology Unit, S. Orsola-Malpighi University Hospital, Via Giuseppe Massarenti 9, 40139 Bologna, IT, Italy
3
IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
resulting in drainage of ca. 1000 cc of urine, and the patient was dismissed with a urology appointment scheduled. After 2 days, he had several syncopal episodes while standing during the morning, and was therefore admitted for further investigation. He was found to have orthostatic hypotension, with a blood pressure drop 3 min after standing of 30/20 mmHg (from 130/80 to 100/60 mmHg, heart rate of 70 bpm, unchanged). Moreover, because of rapidly progressive abdominal bloating and constipation, he underwent an abdominal radiography and, subsequently, colonoscopy, which were consistent with acute colonic pseudo-obstruction (ACPO) [Fig. 1]. Abdominal ultrasound also showed bilateral ureteronephrosis. Neurological examination was unremarkable and, specifically, no sensory-motor symptoms or signs were present. Considering the isolated subacute-onset pandysautonomia of possible paraneoplastic origin, the patient underwent a co
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