Dados do Trabalho

Título

Relapse of acute lymphocytic leukemia mimicking guillainbarre syndrome: case report

Apresentação do caso único

A 7-year-old girl, with a history Acute Lymphocytic Leukemia type B (B-ALL) treated two years ago, developed in February 2024 pain in the lower limbs and paresis that progressed in about 2 weeks to inability to assume orthostasis. Ocular misalignment and ptosis in the right eye was also noticed. She was admitted in an external service with suspicion of Guillain-Barré syndrome (GBS). The first CSF analysis disclosed protein-cytological dissociation, and intravenous immunoglobulin was indicated. Once no improvement was noticed, the patient was transferred to our service to further investigation.
The neurological examination revealed paresis of the upper and lower limbs, hyporeflexia, incomplete non-parcel involvement of the right third nerve and bilateral involvement of the sixth cranial nerve. CSF analysis demonstrated high cell count at the expense of blasts. Magnetic resonance image(MRI) demonstrated a heterogeneous signal in the fundus of the dural sac, which may correspond to neoplastic dissemination. Brain MRI showed signs of intracranial hypertension. Electroneuromyography study described a disseminated radicular involvement. Considering the complementary exams and the clinical presentation, we concluded that the patient experienced a recurrence of LLA-B, causing compression of both cranial nerves and nerve roots.

Discussão

Leukemias are the most frequent tumors in the pediatric age group, with 4% of cases involving the central nervous system(CNS). Among these, the vast majority are asymptomatic or present with nonspecific symptoms (nausea and vomiting).
Therefore, we must maintain a high level of diagnostic suspicion. Previous retrospective studies demonstrated involvement of cranial nerves, specially the facial nerve. To our knowledge, paresis of upper and lower limbs associated with involvement of extrinsic ocular movement was not reported yet. Despite the initial presentation suggesting a diagnosis of GBS in our patient, the previous diagnosis of leukemia, prompted us to broaden the investigation, confirming the recurrence of the disease.

Comentários finais

Considering the high incidence of leukemias, CNS involvement can be significant, even though asymptomatic in most cases. We present this case to highlight an atypical presentation, and to emphasize the importance of proceeding further investigations due to patients' previous diagnosis.

Referências

METTE LEVINSEN et al. Clinical features and early treatment response of central nervous system involvement in childhood acute lymphoblastic leukemia. Pediatric Blood & Cancer, v. 61, n. 8, p. 1416–1421, 12 fev. 2014.
‌THASTRUP, M. et al. Central nervous system involvement in childhood acute lymphoblastic leukemia: challenges and solutions. Leukemia, 20 out. 2022.
PUI, C.-H.; THIEL, E. Central Nervous System Disease in Hematologic Malignancies: Historical Perspective and Practical Applications. Seminars in Oncology, v. 36, p. S2–S16, ago. 2009.
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Palavras Chave

Leukemia; Sindrome de Guillain-Barre; Electromyography