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A 54-year-old female smoker presented with a three-month history of anorexia, fatigue, weight loss, dizziness, and a burning sensation in her hands and feet. She had marked postural hypotension. Her pupils were irregular, asymmetric (Panels A and B), and unresponsive to light and accommodation. Nerve-conduction studies confirmed a mononeuritis multiplex. Computed tomography of the thorax showed an irregular centimeter-sized nodule within the right middle lobe (Panel C, arrow). A screen for antineuronal antibodies identified anti-Hu. This antibody is usually found in patients with neuroendocrine lung carcinomas in the context of a paraneoplastic neurologic syndrome. It has been implicated in the development of tonic pupils, autonomic dysfunction, and painful sensory neuropathies. The pulmonary lesion was excised, and a localized large-cell neuroendocrine tumor was confirmed. The clinical presentation and the presence of anti-Hu enabled us to predict the primary pathological abnormality in this case. The patient received three cycles of adjuvant chemotherapy (carboplatin and etoposide), and she has subsequently shown a steady improvement, with weight gain and a slow resolution of her sensory and autonomic symptoms.
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