Received: 24 November 2016 Revised: 16 May 2017 Accepted: 17 May 2017 DOI: 10.1002/pbc.26677 Pediatric Blood & Cancer The American Society of Pediatric Hematology/Oncology RESEARCH ARTICLE Vincristine-induced neuropathy in pediatric patients with acute lymphoblastic leukemia in Oman: Frequent autonomic and more severe cranial nerve involvement Hanan F. Nazir 1,2 Amna AlFutaisi 1 Mathew Zacharia 1 Mohamed Elshinawy 1,2 Surekha T. Mevada 1 Abdulhakim Alrawas 1 Doaa Khater 1,2 Deepali Jaju 3 Yasser Wali 1,2 1 Child Health Department, Sultan Qaboos University Hospital, Muscat, Oman 2 Pediatric Department, Faculty of Medicine, Alexandria University, Egypt 3 Department of Clinical Physiology, Sultan Qaboos University Hospital, Muscat, Oman Correspondence Yasser Wali, Child Health Department, Sultan Qaboos University Hospital, POB 35 Alkhodh, ZIP 123, COMHS, SQU, Muscat, Oman. Email: yasser_wali@hotmail.com Abstract Background: Vincristine (VCR) induced peripheral neuropathy is a common complication in chil- dren with acute lymphoblastic leukemia (ALL). Procedures: A retrospective data analysis over an interval of 10 years (2006–2016) of all children with ALL seen at Sultan Qaboos University Hospital was carried out. Electronic medical records of eligible patients were reviewed. Patients with clinical evidence of neuropathy and abnormal nerve conduction studies (NCSs) were included in the study. Results: Nineteen (nine females and 10 males) out of 103 pediatric patients developed VCR- related neuropathy, and their age ranged between 2.5 and 14 years. Symptoms started after 2– 11 doses of VCR. All 19 patients had documented peripheral neuropathy on NCSs. The autonomic nervous system and cranial nerves affection was relatively common in our patients; two presented with bradycardia, two patients with unexplained tachycardia, and five had abdominal pain and con- stipation, complicated by typhlitis in two patients. One patient developed unilateral hearing loss. Two patients developed severe life-threatening cranial nerve involvement with bilateral ptosis and recurrent laryngeal nerve involvement presented as vocal cord paralysis, hoarseness of voice, frequent chocking, and aspiration episodes. Conclusions: Peripheral neuropathy was the commonest form of VCR-related neuropathy. Auto- nomic neuropathy was relatively common in our patients. Cranial neuropathy is a serious side effect of VCR that can be severe, involving multiple cranial nerves and needs prompt recognition and management. Concomitant administration of pyridoxine and pyridostigmine does not seem to protect against further neurological damage in some patients. KEYWORDS autonomic, cranial, leukemia, neuropathy, vincristine 1 INTRODUCTION Vincristine (VCR) is an antineoplastic agent of the family vinca alkaloids, which is a cornerstone in treatment protocols of acute lymphoblastic leukemia (ALL) and other solid tumors. Neuropathy is a Abbreviations: ALL, acute lymphoblastic leukemia; BP, blood pressure; CTCAE, the Common Toxicity Criteria for Adverse Events; HR, heart rate; HUT, head-up tilt; NCS, nerve conduction study; TFM, task force monitor; VCR, vincristine; VR, vascular resistance; RR, R waves interval in electrocardiogram well-known dose-limiting side effect of VCR, and it can be presented as peripheral, autonomic, or cranial neuropathy. Cranial neuropathies are less frequently described; however, it can be associated with more serious morbidity. Severe VCR toxicity is quite uncommon; in a detailed review, only 3.6% of the patients in Pediatric Oncology Group protocol 9201 developed significant toxicity, with only 2.9% of patients required treatment modification. 1,2 Peripheral neuropathy commonly manifests as loss of deep tendon reflexes, neuropathic pain, paresthesia, wrist and foot drop, while autonomic neuropathy mainly present as constipation and/or urine Pediatr Blood Cancer. 2017;e26677. c  2017 Wiley Periodicals, Inc. 1 of 5 wileyonlinelibrary.com/journal/pbc https://doi.org/10.1002/pbc.26677