Anti-Hu-associated brainstem encephalitis

OBJECTIVE

A series of patients with anti-Hu-associated brainstem encephalitis is reviewed to better define the clinical presentation and to improve its recognition.

METHODS

Data were collected from 14 patients diagnosed by members of the Paraneoplastic Neurological Syndromes Euronetwork, and eight patients from the literature who presented with isolated brainstem encephalitis and had anti-Hu antibodies.

RESULTS

The median age of the 22 patients was 64 years (range 42-83), and 50% were men. All patients developed a subacute neurological syndrome, in days or weeks. Brain MRI was always normal. Mild cerebrospinal fluid pleocytosis was reported in only two patients. The following syndromes were identified on admission: A medullary syndrome was seen in 11 (50%) patients. Seven of them presented with dysphagia, dysarthria and central hypoventilation. The other four in addition of bulbar symptoms, without central hypoventilation, presented pontine manifestations. Six (27%) patients developed a pontine syndrome with paresis of the VI or VII cranial nerves, nystagmus, usually vertical, and gait ataxia. There was a rapid downward progression to the medulla in all patients. Five (23%) patients presented a ponto-mesencephalic syndrome with uni- or bilateral palsy of the III and VI cranial nerves and gait ataxia, but rapidly progressed to complete gaze paresis and medullary dysfunction.

CONCLUSIONS

The study confirms the predominant medullary involvement but also shows that half of the patients present with clinical features that indicate an upper, mainly pontine, dysfunction before downward progression.

Collagen graft interposition in vesicovaginal fistula treatment

Vesicovaginal fistula (VVF) is a quite rare complication of gynecological surgery. The first attempt to repair the fistulous tract offers the best opportunity for cure. We report the successful repair of VVF in 2 patients using a combined anterior vaginal approach and porcine dermal collagen grafting as interposition tissue. Favorable results confirm technical simplicity, safety and efficacy of this procedure.

Neuronal surface antigen antibodies in limbic encephalitis: clinical-immunologic associations

OBJECTIVE

To report the frequency and type of antibodies against neuronal surface antigens (NSA-ab) in limbic encephalitis (LE).

METHODS

Analysis of clinical features, neuropathologic findings, and detection of NSA-ab using immunochemistry on rat tissue and neuronal cultures in a series of 45 patients with paraneoplastic (23) or idiopathic (22) LE.

RESULTS

NSA-ab were identified in 29 patients (64%; 12 paraneoplastic, 17 idiopathic). Thirteen patients had voltage-gated potassium channels (VGKC)-ab, 11 novel NSA (nNSA)-ab, and 5 NMDA receptor (NMDAR)-ab. nNSA-ab did not identify a common antigen and were more frequent in paraneoplastic than idiopathic LE (39% vs 9%; p = 0.03). When compared with VGKC-ab or NMDAR-ab, the nNSA associated more frequently with intraneuronal antibodies (11% vs 73%; p = 0.001). Of 12 patients (9 nNSA-ab, 2 VGKC-ab, 1 NMDAR-ab) with paraneoplastic LE and NSA-ab, concomitant intraneuronal antibodies occurred in 9 (75%). None of these 12 patients improved with immunotherapy. The autopsy of three of them showed neuronal loss, microgliosis, and cytotoxic T cell infiltrates in the hippocampus and amygdala. These findings were compatible with a T-cell mediated neuronal damage. In contrast, 13 of 17 (76%) patients with idiopathic LE and NSA-ab (8 VGKC-ab, 4 NMDAR-ab, 1 nNSA-ab) and 1 of 5 (20%) without antibodies had clinical improvement (p = 0.04).

CONCLUSIONS

In paraneoplastic limbic encephalitis (LE), novel antibodies against neuronal surface antigens (nNSA-ab) occur frequently, coexist with antibodies against intracellular antigens, and these cases are refractory to immunotherapy. In idiopathic LE, the likelihood of improvement is significantly higher in patients with NSA-ab than in those without antibodies.

Neuromyelitis optica and multiple sclerosis in sisters

INTRODUCTION

The association of neuromyelitis optica (NMO) and multiple sclerosis (MS) has been reported, but details of the cases were not described. We report two Venezuelan Caucasian sisters with human leukocyte antigen (HLA) typing.

RESULTS

Patient 1 fulfilled McDonald, et al. criteria with HLA A*24; B*07,*15; DRB1*01,*16 (DR2 positive). Patient 2 fulfilled the NMO revised criteria of Wingerchuck, et al. with HLA A*02,*24; B*07,*40; DRB1*04,*08, similar to Canadian aboriginal NMO cases and the Yukpa population from Venezuela.

CONCLUSION

These cases confirmed the coexistence of NMO and MS in sisters, and further studies are needed to understand the genetic linkage between these diseases.

[Clinical outcome 6 years after autologous hematopoietic stem cell transplantation in multiple sclerosis]

INTRODUCTION

Autologous hematopoietic stem cell transplantation (AHSCT) remains as an experimental treatment for severe forms of multiple sclerosis (MS). We describe the clinical outcome of 14 patients included in a protocol of AHSCT after a median follow-up period of 6 years.

METHODS

14 patients (5 relapsing-remitting and 9 secondary progressive) with a median number of relapses in the year before of 3 (1-7), Expanded Disability Status Scale (EDSS) of 6 (4.5-6.5) and decile of the multiple Sclerosis Severity Store (MSSS) 9 (7-10) were included. The procedure included carmustine, cyclophosphamide, antithymocyte globulin and T-cell depletion by CD34+ selection.

RESULTS

The 4.5-year progression-free survival was 71%. The 6 year actuarial probability of progression-free survival was 62.5% and the disease activity-free survival of 7.1%. The median EDSS was 6 (4-8.5) and the MSSS 8 (5-10). Only 2 patients presented enhanced T1 lesions. No long-term complications related to the procedure were observed.

CONCLUSION

AHSCT cannot be deemed a curative treatment but may cause prolonged stabilisation or change the aggressive course of the disease.

Midbrain lesions and paroxysmal dysarthria in multiple sclerosis

We describe three patients with relapsing–remitting multiple sclerosis who presented with paroxysmal dysarthria. In one patient, the symptoms were the only manifestation of an acute relapse. In the other two patients, the attacks appeared during the recovery of a brainstem relapse. All three patients had an acute lower midbrain lesion. The location was central in two patients and left paramedian in the other, and probably involving cerebellothalamocortical pathways. Treatment with carbamazepine was effective.

Analysis of antibodies to neuronal surface antigens in adult opsoclonus-myoclonus

Antibodies against neuronal surface antigens (NSA-ab) have been described in pediatric opsoclonus-myoclonus syndrome (OMS). We analyzed the presence of NSA-ab by flow cytometry and immunocytochemistry of live cerebellar granular neurons (CGN) in the serum of 25 adult patients with idiopathic (14) and paraneoplastic (11) OMS. Paraneoplastic, but not idiopathic, OMS sera showed a CGN surface binding by flow cytometry higher than that of controls (mean MFI (median fluorescence intensity): 29+/-6.9 vs. 20+/-5.8; p=0.001) but only one serum had a binding greater than three standard deviations of controls. OMS sera did not label live CGN by immunocytochemistry. Unlike pediatric OMS, NSA-ab were not detected in adult cases suggesting that the immunity to NSA in OMS is heterogeneous.

SOX1 antibodies are markers of paraneoplastic Lambert-Eaton myasthenic syndrome

BACKGROUND/OBJECTIVE

We reported that 43% of patients with Lambert-Eaton myasthenic syndrome (LEMS) and small cell lung cancer (SCLC) had an antibody called anti-glial nuclear antibody (AGNA), defined by the immunoreaction with the nuclei of the Bergmann glia of the cerebellum. This study was undertaken to identify the antigen recognized by AGNA and to confirm the association with paraneoplastic LEMS in a larger series.

METHODS

We probed a fetal brain cDNA library with AGNA-positive sera. The presence of antibodies against the isolated antigen was detected by immunoblot of phage plaques from two positive clones. We studied 105 patients with LEMS (55 with SCLC), 50 with paraneoplastic neurologic syndromes, SCLC, and Hu antibodies, and 50 with only SCLC.

RESULTS

Probing of the fetal brain expression library with AGNA sera resulted in the isolation of SOX1, a highly immunogenic tumor antigen in SCLC. IgG eluted from SOX1 clones produced the same cerebellar immunoreactivity as of AGNA sera. SOX1 antibodies were present in 64% of patients with LEMS and SCLC but in none of the 50 with idiopathic LEMS (p < 0.0001). Compared with paraneoplastic LEMS, the frequency of SOX1 antibodies was significantly lower in patients with Hu antibodies (32%, p = 0.002) and in those with only SCLC (22%).

CONCLUSIONS

SOX1 is the antigen recognized by anti-glial nuclear antibody-positive sera. The detection of SOX1 antibodies in patients with Lambert-Eaton myasthenic syndrome (LEMS) predicts the presence of small cell lung cancer and may be used to follow more closely those LEMS patients with no evidence of cancer at the initial workup.

[Chronic relapsing inflammatory optic neuropathy (CRION) without detection of IgG-NMO antibodies]

Chronic relapsing inflammatory optic neuropathy is a disease that should be distinguished from demyelinating optic neuropathy (ON). Long-term immunosuppressive therapy is usually necessary and either an inflammatory granulomatous origin or a relationship with neuromyelitis optica (NMO) is hypothesized. We report a 43-year-old man who suffered from several ON episodes affecting one eye or the other. These ON attacks completely disappeared with steroid therapy but relapsed after its withdrawal. IgG-NMO antibodies were negative.

Influence of timing on CSF tests value for Creutzfeldt-Jakob disease diagnosis

Background

The analysis of markers in the cerebrospinal fluid (CSF) is useful in the diagnosis of sporadic Creutzfeldt-Jakob disease (sCJD). However, the time at which the study of these markers is most sensitive remains controversal.

Objective

To assess the influence of time of sampling on the value of CSF tests in the diagnosis of sCJD.

Method

In the framework of a multinational European study, we studied the results of 14-3-3, S100b, neurone specific enolase (NSE) and tau protein in 833 CSF samples from sCJD patients at different stages of disease and in 66 sequentially repeated lumbar punctures (LP).

Results

14-3-3 and tau protein tended to increase in sensitivity from onset (88%, 81%) to the advanced stage (91%, 90%). This was significant only in the methionine-valine (MV) heterozygous group of patients at codon 129. The absolute levels of S100b (p < 0.05), NSE and tau protein increased in the last stage of disease. High levels of tau protein, NSE and S100b were associated with shorter survival times (p < 0.01). Sixty-six sCJD patients underwent repeated LP. These sCJD patients were younger, had longer disease durations and were more frequently MV at codon 129 (p < 0.001) than the whole group. 14-3-3 sensitivity increased from 64% to 82% in the second LP (p = 0.025) and 88% sCJD patients had at least one positive result.

Conclusions

Sensitivity and absolute levels of CJD markers increased with disease progression and were modulated by the codon 129 genotype. Early negative results should be inter-preted with caution, especially in young patients or those who are MV at codon 129.

Autologous stem cell transplantation for progressive multiple sclerosis: update of the European Group for Blood and Marrow Transplantation autoimmune diseases working party database

Over the last decade, hematopoietic stem cells transplantation (HSCT) has been increasingly used in the treatment of severe progressive autoimmune diseases. We report a retrospective survey of 183 multiple sclerosis (MS) patients, recorded in the database of the European Blood and Marrow Transplantation Group (EBMT). Transplant data were available from 178 patients who received an autologous graft. Overall, transplant related mortality (TRM) was 5.3% and was restricted to the period 1995-2000, with no further TRM reported since then. Busulphan-based regimens were significantly associated with TRM. Clinical status at the time of transplant and transplant techniques showed some correlations with toxicity. No toxic deaths were reported among the 53 patients treated with the BEAM (carmustine, etoposide, cytosine-arabinoside, melphalan)/antithymocyte globulin (ATG) regimen without graft manipulation, irrespective of their clinical condition at the time of the transplant. Improvement or stabilization of neurological conditions occurred in 63% of patients at a median follow-up of 41.7 months, and was not associated with the intensity of the conditioning regimen. In this large series, HSCT was shown as a promising procedure to slow down progression in a subset of patients affected by severe, progressive MS; the safety and feasibility of the procedure can be significantly improved by appropriate patient selection and choice of transplant regimen.

Prevalence of restless legs syndrome and REM sleep behavior disorder in multiple sclerosis

A total of 135 consecutive, unrelated, multiple sclerosis (MS) patients were interviewed for symptoms suggestive of restless legs syndrome (RLS) and REM sleep behavior disorder (RBD), using semi-structured questionnaires. Some 118 unrelated healthy controls of similar sex and age distribution were included for comparison. Patients and controls with equivocal symptoms were re-evaluated by a sleep disorders specialist and video-polisomnography in those who fulfilled the criteria for RBD. We did not find significant differences in frequency (13.3 versus 9.3%), proportion of females (66.7 versus 58.5%), and mean age (42.1±12.6 versus 43±7.8 years) among MS patients and controls with RLS. RBD was found in three patients (1.4%), one associated with antidepressant intake, but in none of the controls. Our study shows that RLS in MS is not more frequent than in the general population, and that RBD, although uncommon, may occur in the setting of this neurological disease. Multiple Sclerosis 2007; 13: 805-808. http://msj.sagepub.com

Benign adenomyoepithelioma of the breast: imaging findings mimicking malignancy and histopathological features

Adenomyoepithelioma of the breast is a rare neoplasm. We present a case of a benign adenomyoepithelioma of the breast in an asymptomatic 60-year-old woman. This report illustrates the mammogram, ultrasound, and magnetic resonance appearances of this unusual lesion, with histopathological correlation.

CSF analysis in patients with sporadic CJD and other transmissible spongiform encephalopathies

Patients with suspected Creutzfeldt-Jakob disease (CJD) often have routine cerebrospinal fluid (CSF) analysis performed to exclude treatable inflammatory conditions; however, little information is available about the range of results obtained for CSF tests in patients with sporadic CJD and other transmissible spongiform encephalopathies (TSE). Data from 450 patients with sporadic CJD and 47 patients with other TSEs were collected as part of an EC-supported multinational study. Raised white cell counts of >5 cells/microl were found in three of 298 patients with sporadic CJD, with two cell counts of 7 cells/microl and one of 20 cells/microl. Total protein concentrations of >0.9 g/l were found in five of 438 patients with sporadic CJD, although none had a concentration of >1 g/l. CSF oligoclonal IgG was detected in eight of 182 sporadic CJD patients. Of the patients with other TSEs, six had elevated cell counts ranging from 6 to 14 cells/microl but none had total protein concentrations of >0.9 g/l and one patient had detectable oligoclonal IgG. None of the patients with sporadic CJD or other TSEs had abnormalities in all three tests.

Protein kinase Cgamma autoimmunity in paraneoplastic cerebellar degeneration and non-small-cell lung cancer

BACKGROUND

The clinical and immunological profiles of patients with paraneoplastic cerebellar degeneration (PCD) and non-small-cell lung cancer (NSCLC) are not well known.

OBJECTIVE

To review the clinical and immunological features of patients with PCD, NSCLC and without well-characterised onconeural antibodies.

METHODS

The clinical features of nine patients with the diagnosis of classical PCD and NSCLC, included in our archives, were retrospectively reviewed. The presence of antibodies to cerebellar components was determined by immunohistochemistry and immunoblot of rat cerebellum. A cDNA library of human cerebellum was screened with the positive sera to identify the antigen.

RESULTS

Nine patients with PCD and NSCLC were identified. Six patients were men, and the median age at diagnosis of PCD was 63 (range 47-73) years. PCD was completely reversed in two patients, and partially in one, after treatment of the tumour. The serum of one of the patients with PCD showed a unique reactivity with Purkinje cells. The screening of a cerebellar-expression library resulted in the isolation of protein kinase Cgamma (PKCgamma). PKCgamma immunoreactivity was not observed in the serum of 170 patients with non-paraneoplastic neurological syndromes, 27 patients with PCD, no onconeural antibodies and small-cell lung cancer, and 52 patients with NSCLC without paraneoplastic neurological syndromes. The NSCLC from 11 patients without PCD did not express PKCgamma at either the RNA or protein level. However, many cells of the NSCLC of the patient with PKCgamma antibodies expressed PKCgamma.

CONCLUSION

PCD occurs in patients with NSCLC without typical onconeural antibodies and is associated with immune reactions against key proteins of the Purkinje cells.

[MM1 variant of sporadic Creutzfeldt-Jakob disease with long duration akinetic mutism state]

INTRODUCTION

When patients present with a characteristic clinical picture of Creutzfeldt-Jakob disease (CJD) associated with positive 14-3-3 assay, periodic sharp wave complexes, high-signal of the striatum on magnetic resonance imaging, and homozygosis methionine (M) in codon 129, the median survival is 4 to 6 months.

CLINICAL CASE

We report a 58-year-old woman with these typical features who survived 21 months, 19 of them in an akinetic mutism state. The autopsy confirmed the diagnosis of the most common CJD phenotype (MM1), usually associated with a shorter survival, and demyleinitation of the white matter (panencephalopathic form).

CONCLUSIONS

The MM1 variant of CJD, with a rapidly progressive course leading into an akinetic mutism shortly after disease onset can be followed by a long akinetic mutism state. This profile is suggestive of panencephalopathic form and should be taken into account when counselling about survival.