Brain magnetic resonance spectroscopy in Sydenham's chorea and ADHD

This report presents clinical, laboratory, and neuroimaging findings in a 7-year-old male with Sydenham's chorea associated with attention-deficit hyperactivity disorder. Western immunoblotting revealed serum anti-human basal ganglia tissue antibodies. Magnetic resonance imaging results were normal. Proton magnetic resonance spectroscopic imaging disclosed increased choline/creatine ratio in basal ganglia, frontal, and parieto-occipital areas, and decreased N-acetyl aspartate/creatine ratio in both basal ganglia and frontal areas. Moreover magnetic resonance spectroscopy revealed a peak between 3.6-4.2 ppm of unclear significance. The findings of this study are compared with the previous magnetic resonance spectroscopic studies reported on Sydenham's chorea and attention-deficit hyperactivity disorder. Magnetic spectroscopic imaging suggests an autoimmune basal ganglia damage in the pathogenesis of Sydenham's chorea and fronto-striatal impairment in attention-deficit hyperactivity disorder. In the present case, the previous history of an attention-deficit hyperactivity disorder suggests that this neurobehavioral disorder could be a risk factor for Sydenham's chorea in children with rheumatic fever.

Sydenham's chorea is associated with decreased verbal fluency

BACKGROUND

Sydenham's chorea (SC) is a disorder associated with rheumatic fever and related to Streptococcus-induced immune reaction cross-reactive with basal ganglia antigens. Obsessive-compulsive disorder and other behavioral abnormalities have been described in SC. There are scarce data of cognitive function in this condition.

OBJECTIVE

To assess verbal fluency in patients with SC.

PATIENTS AND METHODS

We have compared the semantic (SVF) and phonemic verbal fluency (PVF) of 20 subjects with SC and 40 controls matched by age, gender and years of school.

RESULTS

The scores of the control group on the SVF and PVF tests were 26.3 +/- 5.7 and 18.0 +/- 6.4 whereas the SC patients scored 25.1 +/- 6.9 and 12.5 +/- 8.2. PVF was significantly decreased in the SC group (p < 0.01).

CONCLUSION

SC is associated with reduction of PVF. This finding may reflect disruption of the dorsolateral prefrontal-striatal circuit caused by the auto-immune process characteristic of SC.

A family with McLeod syndrome and calpainopathy with clinically overlapping diseases

The authors describe a family with six patients with muscular dystrophy with a variable course. One is a compound heterozygote for CAPN3 mutations (calpainopathy) and the others have a single CAPN3 mutation. Linkage analysis and sequencing revealed a XK gene mutation (McLeod syndrome). This illustrates the variable phenotype of XK mutations and suggests the possibility that CAPN3 heterozygotes may have their condition caused by nonallelic mutations in other unrelated genes.

Effect of levetiracetam on truncal tic in neuroacanthocytosis

We report on an uncommon manifestation of neuroacanthocytosis in a 31-year-old woman and the successful use of levetiracetam in the treatment of her neurological symptoms. Truncal tic is one of the major presenting features of this patient. We find that Levetiracetam, a new antiepileptic drug, was effective in eliminating this patient's truncal jerks and motor tic manifestations, such as eyelid blinking and head nodding. Levetiracetam can therefore be considered as a choice for the symptomatic therapy in neuroacanthocytosis.

Paraneoplastic chorea with leukoencephalopathy presenting with obsessive-compulsive and behavioral disorder

Chorea is a rare manifestation of paraneoplastic disease and is associated with CV2/CRMP-5 antibodies. Obsessive-compulsive disorder and large-scale white matter abnormalities on MRI have not been previously reported in association with these antibodies. We report on a case of CV2 paraneoplastic syndrome with obsessive-compulsive behavior preceding the motor manifestations of chorea with associated leukoencephalopathy on MRI. The literature on paraneoplastic chorea is reviewed.

[A case of adult-onset Sydenham chorea accompanied with psychiatric symptoms]

We report a 56-year-old man with adult-onset Sydenham chorea. Since January 2003, he had often troubled other persons, and in October 2003, following an episode of fever in August of the same year, he noticed left shoulder joint pain and involuntary movements of his limbs, especially on the left side. These involuntary movements gradually worsened and he became unable to converse due to psychiatric symptoms. On admission, neurological examination revealed dementia, emotional incontinence, abnormal behavior and chorea in four limbs. Brain MRI disclosed swelling of bilateral caudate heads that was more marked on the right side. Hypermetabolism in bilateral caudate nuclei, especially on the right, was found on FDG-PET study, which was compatible with his left side-dominant chorea and might reflect inflammation as a nature. A gallium scintigram demonstrated excess accumulations in the plural joints of his extremities, which gradually decreased in parallel with joint pain relief. The present case was diagnosed as Sydenham chorea, because of the presence of arthritis, chorea, fever, increased erythrocyte sedimentation rate and elevated CRP. We believe that this is a first report of adult-onset Sydenham chorea accompanied with psychiatric symptoms.

A clinical method for the detection and quantification of quick respiratory hyperkinesia

PURPOSE

Quick respiratory hyperkinesia can be difficult to detect with the naked eye. A clinical method is described for the detection and quantification of quick respiratory hyperkinesia.

METHOD

Flow at the airway opening is sensed during spontaneous apnea (rest), voluntary breath holding (postural fixation), and voluntary volume displacement (intentional movement). The method is designed to reveal quick respiratory hyperkinesia independent of the function of the larynx and/or upper airway. Theory underlying the method is discussed, and a protocol is offered for clinical use.

CONCLUSIONS

This method may be useful to neurologists, pulmonologists, and speech-language pathologists. Because it depends on nonspeech observations, its application to speech and/or voice production must be inferred.

Bilateral Stimulation of the Globus Pallidus Internus to Treat Choreathetosis in Huntingtonʼs Disease: Technical Case Report

OBJECTIVE AND IMPORTANCE

Huntington's disease (HD) produces debilitating motor abnormalities that are poorly responsive to medical therapy. Deep brain stimulation (DBS) may offer a treatment option for afflicted patients, but its role in the management of HD remains unclear. In the present case, DBS leads were implanted bilaterally into the posteroventral globus pallidus internus (GPi) to control disabling and medically intractable choreathetosis in a severely affected HD patient. The surgical procedure, intraoperative electrophysiological findings, and 12-month postoperative course, with patient video, are presented.

CLINICAL PRESENTATION

This 41-year-old man with genetically confirmed HD developed motor symptoms at age 28. He had completed multiple medical trials without alleviation of his progressive and debilitating choreathetosis. Extensive clinical assessment, including neuropsychological testing, was performed to determine surgical candidacy.

INTERVENTION

DBS leads were bilaterally implanted, under stereotactic guidance, into the posteroventral GPi. Disease progression and symptom control were assessed at regular postoperative intervals. Bilateral pallidal stimulation produced a dramatic reduction in choreathetoid movements and improvement in overall motor functioning. The patient also exhibited normalization of body weight, mood, and energy level, as well as improved performance of activities of daily living. These effects were sustained at 1 year after surgery.

CONCLUSION

The clinical benefits of DBS observed in this HD patient were comparable to those reported in other hyperkinetic disorders and demonstrate that pallidal stimulation can provide long-term alleviation of HD-associated choreathetosis.

[Dyskinesias of the tongue and other face structures]

PURPOSE

A dyskinesia is a permanent disorder consisting of compulsory movements of the tongue, lips and facial muscles. Dyskinesias of other parts of the body are also known. They improve the diagnosis and treatment in dentistry and oral surgery.

AIM

The aim of the study is to present cases of dyskinesia manifesting as involuntary movements and their treatment.

RESULTS

Dyskinesias of various body parts accompanying Huntington's disease, Parkinson's disease, Down syndrome, Joubert's syndrome, arteriosclerosis, cerebral palsy, and tetanus are discussed.

Two cases of hemiballism-hemichorea with T1-weighted MR image hyperintensities

Two cases of hemiballism-hemichorea have been reported in woman patients with hyperglycemia; this was a feature of striatal hyperintensity on the T1-weighted MRI. In the first case, strict management of diabetes and treatment with pimozide effectively suppressed the movement disorder. The Z-score Imaging System revealed hyperperfusion in the bilateral dentate nuclei, left striatum, and bilateral motor cortices. In the second case, painful hemiballism-hemichorea limb, followed by the upper limb. The severity of HB-HC corresponded to the expansion of the striatal lesion. The mechanism of HB-HC by using statistical cerebral blood flow evaluation has also been discussed.

[A case of MELAS presenting juvenile-onset hyperglycemic chorea-ballism]

We report herein the case of a 28-year-old man presenting with hyperglycemic chorea-ballism (HCB) in addition to mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS). He was admitted to a local hospital due to weight loss, general fatigue and thirst. The patient had diabetes mellitus, with a blood glucose level of 738 mg/dl and HbA1c of 19.8%. Although insulin therapy improved hyperglycemia, he noticed involuntary movements in the right upper and lower limbs, which subsequently extended to the left side. The patient was thus transferred to our hospital. He displayed short stature (154 cm) and emaciation, and a maternal family history of diabetes mellitus was elicited. He had no history of stroke-like episode, headache, vomiting and seizure. Neurological examination revealed low intelligence (IQ 57), mild sensorineural deafness, and chorea-ballism in the extremities and head without ptosis or eye movement disturbance. Brain computed tomography (CT) demonstrated areas of high density, while T1-weighted magnetic resonance imaging (MRI) revealed extreme hyperintensity and T2-weighted MRI showed hyperintensity in bilateral caudate nuclei, putamina and globi pallidus. HCB was diagnosed. In, CSF, lactate level was increased to 43.9 mg/dl (n, 4-16), pyruvate level was 1.65 mg/dl (n, 0.3-0.9) and total protein concentration was 59 mg/dl. Histological examination of a biopsy sample from the biceps brachii muscle demonstrated ragged-red fibers. An A3243G point mutation in the tRNA(Leu(UUR)) gene was detected, indicating the presence of MELAS. Involuntary movements improved on treatment with haloperidol up to 4.5 mg/day. HCB usually appears in elderly individuals, and cases less than 40-years-old are very rare. The mitochondrial dysfunction in MELAS may accelerate development of HCB.

Perfusion abnormality of the caudate nucleus in patients with paroxysmal kinesigenic choreoathetosis

PURPOSE

Previous cerebral blood flow and glucose metabolism studies suggest that the basal ganglia or thalamus is involved in the pathogenesis of paroxysmal kinesigenic choreoathetosis (PKC). However, the underlying cerebral abnormalities in idiopathic PKC have not been elucidated. To localise cerebral perfusion abnormalities in PKC, we performed interictal brain perfusion 99mTc-ethylcysteinate dimer (ECD) single-photon emission computed tomography (SPECT) in PKC patients and in normal controls.

METHODS

Sixteen patients with idiopathic PKC and 18 age- and sex-matched normal controls were included. The patients were de novo diagnosed as having PKC, or had not taken medication for at least 3 months; none of them had structural abnormalities on MRI. Patients had a history of PKC attacks of a duration not exceeding 5 min and starting either on one side or on both sides of the body. These attacks were always induced by a sudden initiation of voluntary movement. PKC attacks were recorded in a hospital after being induced by neurology staff in 13 of the 16 patients. Interictal brain perfusion 99mTc-ECD SPECT was performed in all 16 patients and 18 normal controls. Differences between the cerebral perfusion in the PKC group and the normal control group were tested by statistical parametric mapping. Student's t test was used for inter-group comparisons.

RESULTS

Compared with normal controls, patients with idiopathic PKC showed interictal hypoperfusion in the posterior regions of the bilateral caudate nuclei (false discovery rate-corrected P<0.001 with a small volume correction).

CONCLUSION

This study showed that cerebral perfusion abnormality of bilateral caudate nuclei is present in idiopathic PKC.

Calcium-sensitive potassium channelopathy in human epilepsy and paroxysmal movement disorder

The large conductance calcium-sensitive potassium (BK) channel is widely expressed in many organs and tissues, but its in vivo physiological functions have not been fully defined. Here we report a genetic locus associated with a human syndrome of coexistent generalized epilepsy and paroxysmal dyskinesia on chromosome 10q22 and show that a mutation of the alpha subunit of the BK channel causes this syndrome. The mutant BK channel had a markedly greater macroscopic current. Single-channel recordings showed an increase in open-channel probability due to a three- to fivefold increase in Ca(2+) sensitivity. We propose that enhancement of BK channels in vivo leads to increased excitability by inducing rapid repolarization of action potentials, resulting in generalized epilepsy and paroxysmal dyskinesia by allowing neurons to fire at a faster rate. These results identify a gene that is mutated in generalized epilepsy and paroxysmal dyskinesia and have implications for the pathogenesis of human epilepsy, the neurophysiology of paroxysmal movement disorders and the role of BK channels in neurological disease.

Successful long-term deep brain stimulation for hemichorea—hemiballism in a patient with diabetes

✓ The authors report a case of hemichorea—hemiballism (HC-HB) that was successfully treated using deep brain stimulation (DBS). A 65-year-old right-handed man exhibited a sudden onset of right HC-HB without a diabetic coma. At admission T1-weighted magnetic resonance (MR) images revealed a high-intensity signal in the left striatum, contralateral to the patient's involuntary movements.

The HC-HB continued for 5 months after onset of the condition despite medical treatment and a decreased intensity of the signal on T1-weighted MR images.

The patient underwent placement of a quadripolar DBS electrode in the left thalamus, including the left ventral oralis (VO) anterior and posterior nuclei (the VO complex). Postoperatively, the right-sided HC-HB disappeared rapidly during electrical stimulation and there were no neurological deficits.

The authors demonstrate that DBS can be an effective treatment for medically refractory HC-HB. This is the first case of HC-HB that has been successfully treated with DBS.

Rupture of quadriceps tendon in a patient with postanoxic choreoathetosis

PURPOSE

To describe a case of quadriceps tendon rupture in a patient with postanoxic choreoathetotic movements.

CASE REPORT

A 20-year-old man was admitted to a rehabilitation hospital after anoxic brain injury. As a result of the injury, he developed continuous flowing choreoathetotic movements. He contracted fever and swollen and painful right knee, and only when periarticular edema decreased did a suprapatellar gap appear and quadriceps tendon rupture was diagnosed.

CONCLUSIONS

Considering the possibility of tendon rupture when evaluating a patient with non-volitional movements and 'arthritic' presentation in a rehabilitation setting, may prevent delay of quadriceps surgical repair.

Topiramate therapy for paroxysmal kinesigenic choreoathetosis

We observed the clinical efficacy of topiramate for paroxysmal kinesigenic choreoathetosis (PKC). Topiramate was administered as a monotherapy with titrated dosages to 8 patients with PKC. Target daily dose of topiramate was 100 to 200 mg; the follow-up period ranged from 8 months to 2 years. All of the patients became attack-free, and side effects were mild. The results show that topiramate is effective as a monotherapy for treating patients with PKC. The response to topiramate indicates that the disease may be caused by an ion channel defect.

Obsessive-compulsive symptoms among patients with Sydenham chorea

BACKGROUND

Among patients with tic disorders, a distinctive clinical profile of obsessive-compulsive symptomatology has been described. The present investigation was designed to document the phenomenology of obsessive-compulsive symptoms (OCS) among patients with Sydenham chorea (SC), the neurologic variant of rheumatic fever. We hypothesized that OCS occurring in association with SC would be similar to those among patients with tic disorders.

METHODS

The authors studied the presence of OCS in 73 patients with SC by using the Yale-Brown Obsessive-Compulsive Scale at the Pediatric Clinics of the University of Sao Paulo Medical Center in Sao Paulo, Brazil (n = 45) and at the National Institute of Mental Health in Bethesda, Maryland (n = 28).

RESULTS

The most frequent symptoms observed among subjects with comorbid SC and OCS were aggressive, contamination, and somatic obsessions and checking, cleaning, and repeating compulsions. A principal component factor analysis yielded a five-factor solution (accounting for 64.5% of the total variance), with contamination and symmetry obsessions and cleaning compulsions loading highly.

CONCLUSIONS

The symptoms observed among the SC patients were different from those reported by patients with tic disorders but were similar to those previously noted among samples of pediatric patients with primary obsessive-compulsive disorder.

Clinical manifestation and carbamazepine treatment of patients with paroxysmal kinesigenic choreoathetosis

Paroxysmal kinesigenic choreoathetosis (PKC) is characterized by episodes of brief dystonia or choreoathetosis which is induced by sudden movement. We report the clinical manifestations and efficacy of treatment with carbamazepine in familial PKC. Seven patients from two families were diagnosed with PKC. The most common precipitating factors in our patients were sudden movement, anxiety and stress. The mean age of the first attack was around early puberty, and the symptoms became remarkable during early adulthood. Interictal single-photon emission computed tomography of the brain revealed abnormal perfusion of regional cerebral flow in either the basal ganglia or thalami in most of the patients. Four of seven patients were prescribed low dose of carbamazepine (1.5-2.0 mg/kg/day); the follow-up period ranged from 14 to 30 months. The patients who received carbamazepine treatment became attack-free without decline in school performance. The results suggest that the prognosis of PKC is a relatively benign entity due to spontaneous resolution since adulthood, and a low dose of carbamazepine is sufficient to manage PKC. Abnormal cerebral perfusion flow over the basal ganglia or thalami in these patients leads us to believe that PKC is a form of extrapyramidal disorder.

Annotation: PANDAS: a model for human autoimmune disease

BACKGROUND

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus infections (PANDAS) is a recently recognized syndrome in which pre-adolescent children have abrupt onsets of tics and/or obsessive-compulsive symptoms, a recurring and remitting course of illness temporally related to streptococcal infections, and associated neurologic findings including adventitious movements, hyperactivity and emotional lability.

METHODS

Inspired by observations of similar symptoms in children with Sydenham's chorea, a search was undertaken for clinical and laboratory evidence in support of the new syndrome.

RESULTS

Consistent and predictable clinical findings have been described in a large case series. Magnetic resonance imaging has supported the postulated pathobiology of the syndrome with evidence of inflammatory changes in basal ganglia. Antibasal ganglia antibodies have been found in some acute cases, mimicking streptococcal antigen epitopes.

CONCLUSIONS

While PANDAS remains a controversial diagnostic concept, it has stimulated new research endeavors into the possible links between bacterial pathogens, autoimmune reactions, and neuropsychiatric symptoms.

Amantadine for levodopa-induced choreic dyskinesia in compound heterozygotes for GCH1 mutations

Amantadine suppressed severe levodopa-induced choreic dyskinesia, which developed at initiation of levodopa therapy, in two siblings manifesting dystonia with motor delay phenotype of GTP cyclohydrolase I deficiency caused by compound heterozygous GCH1 mutations. Our finding suggests a beneficial effect of amantadine on this type of dyskinesia frequently observed in relatively severe dopamine-deficient metabolic disorders.

Neuroacanthocytosis: new developments in a neglected group of dementing disorders

Neurological abnormalities associated with spiculated, "acanthocytic" red cells in blood have been summarized as neuroacanthocytosis. This is a heterogeneous group of conditions that can now be clearly subdivided on the basis of genetic discoveries. The core neuroacanthocytosis syndromes are autosomal recessive chorea-acanthocytosis (ChAc) and the X-linked McLeod syndrome (MLS). Huntington's disease-like 2 (HLD2) and pantothenate kinase associated neurodegeneration (PKAN) can now also be included. All of these share dyskinesias, cognitive deterioration and progressive neurodegeneration mainly of the basal ganglia, but they are sufficiently distinct to permit a specific working diagnosis on the basis of clinical, laboratory and imaging findings. In addition, the VPS13A (formerly called CHAC), XK, JPH3 and PANK2 genes, respectively, may be examined for mutations. Unfortunately, little is yet known about the normal and abnormal physiology of the protein products of these genes, but they appear to be involved in membrane function and intracellular protein sorting. Since no cures are yet available, development and study of disease models in experimental animals (mouse, C. elegans) is a priority for current research. From a clinical point of view, the common occurrence of cardiomyopathy in MLS, the transfusion hazards due to the McLeod Kell phenotype and the possibility of improving the violent trunk spasms and orofacial dyskinesias typical for ChAc (with subsequent lip or tongue mutilations and feeding dystonia) by deep brain surgery or stimulation should be considered in patient management.