From the Guidelines
Intravenous steroid treatment is indicated for this patient, as the clinical presentation strongly suggests an acute demyelinating disorder or an immune-related adverse event (irAE) with neurological involvement. The recommended regimen is methylprednisolone 1-2 mg/kg/day IV, as suggested by the most recent guidelines 1. Before initiating treatment, baseline labs including complete blood count, comprehensive metabolic panel, and blood glucose should be obtained. The patient should be monitored for potential side effects including hyperglycemia, hypertension, mood changes, and insomnia. The clinical findings of bilateral upper and lower limb weakness, right-sided hyperreflexia, sensory deficits, positive Romberg's sign, paresthesia, and subtle nystagmus indicate central nervous system involvement with asymmetric distribution, suggesting inflammatory demyelination or an irAE. IV steroids work by reducing inflammation and edema in the central nervous system, suppressing the immune response that causes demyelination, and restoring the blood-brain barrier integrity, which can lead to faster recovery of neurological function and potentially prevent long-term disability. It is essential to rule out other causes of neurologic symptoms, such as CNS progression of cancer, seizure activity, infection, and metabolic derangement, and to consult with a neurologist for further guidance 1. In addition to IV steroids, other treatment options, such as IVIG or plasma exchange, may be considered for more severe cases or if there is no improvement with steroid treatment 1. The patient's symptoms and treatment response should be closely monitored, and adjustments to the treatment plan should be made as needed to ensure the best possible outcome. The management of irAEs, including neurological toxicities, should be guided by the most recent clinical practice guidelines, such as those from the American Society of Clinical Oncology (ASCO) 1.
From the Research
Indications for IV Steroid Treatment
The patient's symptoms, including subtle nystagmus, weakness of both upper limbs (grade 4), lower limbs (grade 4+), exaggerated deep tendon reflexes (DTRs) on the right side, decreased sensation on the right side, positive Romberg's sign, and paresthesia on the right side of the body, may indicate a demyelinating disease or an autoimmune disorder.
- The use of IV steroids, such as methylprednisolone, has been reported in the treatment of acute disseminated encephalomyelitis (ADEM) 2.
- In autoimmune autonomic ganglionopathy, combined immunomodulatory therapy, including prednisone and plasmapheresis, has been shown to provide substantial clinical improvement 3.
- IV steroids have potent anti-inflammatory and immune-modulating properties, which can be beneficial in the treatment of various disease states 4.
Considerations for Treatment
When considering IV steroid treatment, it is essential to weigh the potential benefits against the risks of side effects, such as toxicity to articular cartilage and systemic side effects like increases in blood glucose levels and reduced immune function 5.
- The use of plasmapheresis, in combination with immunosuppressive therapy, has been shown to be effective in certain autoimmune disorders, such as anti-glomerular basement membrane (anti-GBM) disease 6.
- The decision to use IV steroids should be made on a case-by-case basis, taking into account the individual patient's condition, medical history, and potential risks and benefits.
Potential Benefits and Risks
The potential benefits of IV steroid treatment include:
- Reduction of inflammation and modulation of the immune system
- Improvement of symptoms, such as weakness and sensory deficits
- The potential risks of IV steroid treatment include:
- Side effects, such as increases in blood glucose levels and reduced immune function
- Toxicity to articular cartilage and other tissues
- The need for careful monitoring and management of potential side effects 4, 5.