Widely Disseminated Neuroblastoma Presenting as Acute Flaccid Paralysis in a Two Year Old Child: A Clinical Dilemma

Introduction: Neuroblastoma is a tumor derived from primitive cells of sympathetic nervous system and is the most common solid tumor in childhood. Most of them (75%) arise from either adrenal and rest usually in midline from pre-sympathetic ganglia. Here we present an interesting and rare presentation of neuroblastoma masquerading as acute flaccid paralysis.

Case brief: A two year child presented with history of insidious onset fever and increasing weakness of bilateral lower limbs along with sphincter disturbance. On examination the child had loss of tone and power in both lower limbs with absent deep tendon reflexes. There was also sensory loss below the level of umbilicus. The upper limbs and neck muscles were normal. Significant cervical lymphadenopathy was also noted along with a palpable globular swelling in upper thoracic area posteriorly. The child was immunized as per age and stool examination for poliovirus was negative. A tubercular work-up was also negative. MRI of whole spine and abdomen showed left adrenal SOL. In addition, extensive pre and paravertebral masses with intraspinal extension and extradural soft tissue choloroma posteriorly were noted, causing cord compression and odema, consistent with a diagnosis of neuroblastoma.

Case discussion: The present case highlights extensive neuroblastoma extensions and multifocality involving majority of lower cervical and thoracic spinal column, leading to compressive myelopathy. The clinical presentation as acute flaccid paralysis with fever suggested a transverse myelitis like picture requiring work-up for underlying common viral and other infectious causes. However in these cases an emergency MRI/CT is must to rule out compressive cord lesions.