Immune-related neurological toxicity

Acute Oncology Guidelines
NHS Lothian

A range of neurological events have been described, including polyneuropathy, facial nerve palsy, demyelination, myasthenia gravis, Guillain Barré syndrome, posterior reversible leukoencephalopathy, transverse myelitis, enteric neuropathy, encephalitis and aseptic meningitis. 

Important to rule out progression of the underlying cancer, seizure activity, infection and metabolic derangement as causes of neurological impairment.  

Early involvement of neurologist recommended.

Condition Assessment Management
Peripheral neuropathy
  • Diabetic screen, B12/Folate, HIV, TSH, vasculitis screen, alcohol and drug history 
  • Consider MRI/MRA brain and spine, nerve conduction studies, lumbar puncture, PFT 
  • Steroids  
  • G2: Oral prednisolone 0.5-1mg/kg  
  • G3: IV methylprednisolone 2mg/kg 

Guillain-Barre syndrome 

Progressive symmetrical muscle weakness with reduced tendon reflexes involving extremities, facial, respiratory, oculomotor muscles; dysregulation of autonomic nerves 
  • Nerve conduction studies 
  • Lumbar puncture 
  • PFT  
  • Antibody testing for GBS variant (GQ1b in Miller Fisher variant)
  • Use of steroids not recommended in idiopathic GBS, but trial of 1-2mg methylprednisolone reasonable 
  • Plasmapheresis/IVIG 
  • Consider location of care where ventilatory support available  

Myasthenia Gravis 

Fluctuating muscle weakness (proximal limb, trunk, ocular) with fatigability, respiratory muscles may also be involved 

 
  • AChR and anti-MuSK antibodies  
  • EMG  
  • Steroids (Route of administration and dose pending severity) 
  • Pyridostigmine 30mg TDS 
  • Plasmapheresis/IVIG 
  • Additional immunosuppresants (azathioprine, ciclosporin, mycophenalate mofetil) 
  • Avoid certain medications (ciprofloxacin, B blockers) that may precipitate cholinergic crisis 

Aseptic meningitis  

Headache, neck stiffness, photophobia, fever, vomiting 

 
  • Exclusion of infection paramount 
  • CT/MRI head 
  • Lumbar puncture 
  • Exclude bacterial or viral infection prior to commencing steroids 
  • Consider concurrent antibacterial/antiviral 
  • Oral prednisolone 0.5-1mg/kg or IV methylprednisolone 1-2mg/kg

Encephalitis  

Altered behaviour, confusion, headache, motor or sensory deficit 

 
  • Exclusion of infection and metabolic causes paramount  
  • CT/MRI head 
  • Lumbar puncture  
  • Viral serology
  • Exclude bacterial or viral infection prior to commencing steroids 
  • Concurrent IV antiviral (aciclovir) until result of PCR  
  • Oral prednisolone 0.5-1mg/kg or IV methylprednisolone 1-2mg/kg

Transverse myelitis 

Acute or subacute of motor/sensory/ autonomic symptoms; may have sensory level; often bilateral
  • MRI brain/spine 
  • Lumbar puncture  
  • Serum B12, TSH, HIV, ANA, anti-Ro, anti-La, anti-aquaporin 4 IgG
  • Methylprednisolone 2mg/kg  
  • If no improvement, plasmapheresis may be required

Editorial Information

Last reviewed: 22/11/2021

Next review date: 22/11/2024

Author(s): Edinburgh Cancer Centre.

Version: 1.0

Approved By: Authorised by CTAC. Refer to Q-Pulse for approval details.

Reviewer name(s): Stewart J.