870 - Rehabilitating Anti-Myelin Associated Glycoprotein Neuropathy in a Patient with Diffuse Large B-Cell Lymphoma

Case Diagnosis: A 67-year-old male with history of DLBCL presented with severe lower extremity and upper extremity weakness, bilateral foot drop, paresthesias, and urinary retention several months following R-CHOP chemotherapy, which consisted of rituximab, cyclophosphamide, vincristine, doxorubicin, and prednisone. Evaluation revealed anti-myelin associated glycoprotein (MAG) neuropathy.

Case Description: The diagnosis of anti-MAG neuropathy was confirmed with both serum antibody testing and nerve conduction studies. Further imaging and cerebrospinal fluid studies ruled out lymphoma progression and other spinal pathology. He received intravenous solumedrol for five days, three sessions of plasmapheresis, two additional doses of rituximab, and gabapentin for symptomatic management with mild improvement of symptoms. He subsequently underwent physical rehabilitation and was able to improve his strength and progress from requiring moderate assistance with ambulation to minimal assistance with use of a rolling walker. He was ultimately discharged home with outpatient therapy. His condition necessitated complex management including both pharmacologic management and rehabilitation.

Discussions: This case highlights a rarer anti-MAG neuropathy in a patient with DLBCL, a neuropathy in which antibodies target glycoproteins on Schwann cells resulting in peripheral nerve damage due to demyelination. Diagnosis requires a high clinical suspicion given that chemotherapeutic agents also commonly contribute to neuropathy, detecting anti-MAG antibodies in the serum, and ruling out other causes of peripheral neuropathy. Management involves treatment of the monoclonal gammopathy with chemotherapy or immunotherapy, symptomatic treatment with steroids and plasmapheresis, and rehabilitation.

Conclusions: Anti-MAG neuropathies can be both challenging to diagnose and manage, and patients often present with symptoms affecting their quality of life. They require an integrated strategy, with pharmacologic treatments for the underlying immunologic issue and rehabilitation focusing on restoring their functional impairments and quality of life. This approach is crucial for achieving the best outcomes in patients with this challenging condition.