Review of 23 patients affected by the stiff man syndrome: clinical subdivision into stiff trunk (man) syndrome, stiff limb syndrome, and progressive encephalomyelitis with rigidity

Progressive encephalomyelitis with rigidity: a case report

BACKGROUND/OBJECTIVE

The most prominent clinical features of progressive encephalomyelitis with rigidity (PER) are painful spasms and rigidity accompanied by clinical signs of brainstem and spinal cord involvement. In initial reports, PER had fatal outcome. Later, clinical improvement related to corticosteroid therapy has been described in some cases. The objective of this study was to signify a reputed clinical significance of corticosteroid therapy in PER.

METHODS

Case report.

RESULTS

A 50-year-old man developed progressive syndrome of tonic extensor spasms. Magnetic resonance imaging (MRI) showed areas of signal changes in cervical spinal cord and lower brainstem, whereas cerebrospinal fluid analysis indicated subacute encephalomyelitis. His condition dramatically improved on oral corticosteroid therapy. Clinical improvement was accompanied by normalization of MRI findings.

CONCLUSION

For this patient with PER, corticosteroid therapy was a dramatically effective and life-saving treatment, although initiated rather late in the course of the disease.

Stiff person syndrome: presentation of a case with repetitive complex discharges in electromiograms

INTRODUCTION

Stiff person syndrome is characterized by rigidity of axial and proximal limb muscles, associated with muscle spasms, triggered by unexpected acoustic or somesthetic stimuli. It usually has an autoimmune basis, in which the blood contains antiglutamate decarboxylase antibodies, and is associated with different types of autoimmune diseases. The electromyogram provides evidences of continuous muscular activity.

CASE REPORT

A 41-year-old woman with a history of diabetes mellitus type I, Hashimoto thyroiditis, vitiligo, and pernicious anemia developed symptoms compatible with stiff person syndrome. In the electromyogram, in addition to continuous muscular activity, there was evidence of complex repetitive activity in the form of doublets and triplets.

CONCLUSIONS

Given the absence of clinical or electrophysiological neuropathic affectation, the presence of doublets and triplets in our patient could be due to a subclinical functional alteration of alpha motoneurons. They could produce the complex repetitive discharges when released from the inhibition mediated by GABAergic neurons.

Immunologically mediated dementias

Although most dementias are due to neurodegenerative or vascular disease, it is important to diagnose immunologically mediated dementias quickly because they can be both rapidly progressive and readily treatable. They usually affect function of limbic and cortical structures, but subcortical involvement can also occur. Because of the variety of symptoms and the rapid course, these dementias present a particular challenge to the clinician and may require evaluation and intervention in the inpatient setting. Diagnostic workup typically reveals evidence of an autoimmune process and, in some cases, cancer. In contrast to the neurodegenerative processes, many of the immunologically mediated dementias respond to immunomodulatory therapy.

Scleritis in a Person with Stiff-Person Syndrome

PURPOSE

To describe a case of anterior scleritis in a patient with stiff-person syndrome.

METHODS

Case report.

RESULTS

A 55-year-old woman with stable stiff-person syndrome and off immunomodulatory therapy developed unilateral anterior scleritis, which resolved over three weeks with systemic nonsteroidal anti-inflammatory therapy.

CONCLUSIONS

The authors are unaware of reports regarding the association of scleritis with stiff-person syndrome.

GAD65 vaccination: 5 years of follow-up in a randomised dose-escalating study in adult-onset autoimmune diabetes

AIMS/HYPOTHESIS

The aim of this study was to ascertain whether treatment of GAD65 autoantibody (GADA)-positive diabetic patients with alum-formulated recombinant GAD65 (GAD-alum) is safe and does not compromise beta cell function.

METHODS

This Phase 2, placebo-controlled, dose-escalation clinical trial, which was randomized through a central office, was performed in 47 GADA-positive type 2 diabetic patients, who received subcutaneous injections of GAD-alum (4 [n = 9], 20 [n = 8], 100 [n = 9] or 500 [n = 8] microg) or placebo (n = 13) at weeks 1 and 4 of the trial. Participants and caregivers were blinded to group assignments. The primary outcome was safety as assessed by neurological tests, medications and beta cell function evaluated over 5 years, representing the end of the trial.

RESULTS

No severe study-related adverse events occurred during the 5 year follow-up. None of the dose groups was associated with an increased risk of starting insulin treatment compared with the placebo group. The use of oral hypoglycaemic agents did not differ between the dose groups. After 5 years, fasting C-peptide levels declined in the placebo group (-0.24; 95% CI -0.41 to -0.07 log(10) nmol/l; p = 0.01) and the 500 microg dose group (-0.37; 95% CI -0.57 to -0.17 log(10) nmol/l; p = 0.003), but not in the 4 microg (-0.10; 95% CI -0.28 to 0.07 log(10) nmol/l; p = 0.20), 20 microg (0.04; 95% CI -0.12 to 0.19 log(10) nmol/l; p = 0.58) and 100 microg (0.00; 95% CI -0.20 to -0.20 log(10) nmol/l; p = 0.98) dose groups.

CONCLUSIONS/INTERPRETATION

The primary outcome of safety was achieved, since no severe study-related adverse events occurred.

TRIAL REGISTRATION

Because the study was initiated before 1 July 2005, the protocol was not registered in a registry.

Stiff limb syndrome: end of spectrum or a separate entity?

BACKGROUND

Stiff-person syndrome is a rare disorder characterized by rigidity of axial or limb muscles with episodes of co-contraction of agonist and antagonist muscles during the spasms. In some patients axial or limb involvement may predominate and may have unusual manifestations.

DESIGN

Case report.

SETTING

Tertiary care teaching hospital.

PATIENT

A 42-year-old farmer presented with seasonal occurrence of hiccup and vomiting during summer months for the last 3 years. He had painful lower limb spasms lasting for 2-3 minutes every 10-15 minutes for the past 20 days. His neurological examination was normal, erythrocyte sedimentation rate (ESR) was 50 mm at 1st hour, and cerebrospinal fluid protein 78 mg/dL without pleocytosis. Radiograph of chest, abdominal ultrasound, and craniospinal magnetic resonance imaging were normal. The patient improved on diazepam.

CONCLUSION

Our patient is a forme fruste of stiff person syndrome with hiccups and vomiting due to diaphragmatic spasm.

Anxious depression and the stiff-person plus syndrome

OBJECTIVE

To present the case of a patient with anxiety and depressive symptoms who developed the clinical picture of stiff-person plus syndrome (SPS-plus).

BACKGROUND

Before the onset of typical SPS symptoms, psychiatric symptoms (like depression and anxiety) may be prominent and as such misleading, resulting in the diagnosis of a psychiatric condition.

METHOD

We describe the case of a woman who initially presented with anxious depression and remained resistant to treatment with different classes of antidepressants and additional therapy with lithium and atypical antipsychotics.

RESULTS

Evidence of neurologic dysfunction and significantly increased levels of serum autoantibodies for glutamic acid decarboxylase supported the diagnosis of SPS. The patient appeared to benefit from short-term immunosuppressive therapy with methylprednisolone.

CONCLUSIONS

The authors believe that anxious depression and SPS-plus seen in this patient are the result of the same underlying autoimmune process, together forming a unique syndrome. Anxious and depressive symptoms in SPS can be explained by alterations in GABAergic neurotransmission.

Epilepsy and cerebellar ataxia associated with anti-glutamic acid decarboxylase antibodies

Anti-glutamic acid decarboxylase (GAD) antibodies are described in stiff-person syndrome and also in other neurological syndromes, including cerebellar ataxia and epilepsy. This paper reports the case of a patient who had chronic focal epilepsy, upbeat nystagmus and cerebellar ataxia, associated with a polyautoimmune response including anti-GAD antibodies. Both gait and nystagmus improved markedly after immunosuppressive treatment with corticosteroids and azathioprine. After the introduction of benzodiazepines, previously refractory seizures were completely controlled. Anti-GAD antibodies should be actively sought out in pharmacoresistant epilepsy, particularly if other neurological abnormalities are present. Combined treatment with immunosuppressants and γhydroxybutyric acidergic agents may be highly effective.

A case of adult-onset Satoyoshi syndrome with gastric ulceration and eosinophilic enteritis

BACKGROUND

The patient was misdiagnosed as having Sjögren's syndrome (on the basis of a lower-limb rash and dry eyes and mouth) in 1999, and then as having systemic lupus erythematosus (on the basis of hair loss and a high antinuclear antibody titer) in 2005. Total alopecia, muscular spasms and diarrhea developed over the following 2 years, and the patient experienced gastric ulceration in 2006. A rheumatologic opinion was sought in 2007.

INVESTIGATIONS

Physical examination, CBC, glucose tolerance test, iron studies, HLA typing, immunological investigations and complete gastrointestinal investigations, including gastroscopy, colonoscopy and small bowel biopsy.

DIAGNOSIS

Satoyoshi syndrome with autoimmune features (high levels of antinuclear antibody and antibodies to thyroid tissue) and malabsorption due to eosinophilic enteritis. This patient is only the fifth adult in the world reported to have Satoyoshi syndrome, and the first-reported adult case from South Africa.

MANAGEMENT

The patient had only a transitory response to glucocorticoid treatment. Complete amelioration of symptoms resulted on two occasions when treated with intravenous immunoglobulin; however, the remissions only lasted for 6-8 weeks. More-intensive immunosuppression with azathioprine is currently being attempted.

Advances in the pathogenesis and treatment of patients with stiff person syndrome

Advances in the clinical diagnosis, prognosis, pathogenesis, and therapies for stiff person syndrome (SPS), based on observations in more than 50 consecutive patients, are presented. The syndrome varies from mild to severe, but if untreated it can be progressive and disabling. SPS remains a largely underdiagnosed condition. Anti-glutamic acid decarboxylase (GAD) antibodies provide an excellent diagnostic marker, but their role in disease pathogenesis is uncertain. Research focused on identifying new autoantigens has provided evidence that gamma-aminobutyric acid (GABA)(A) receptor-associated protein (GABARAP), a 14-kD protein localized at the postsynaptic regions of GABAergic synapses, is a new antigenic target. In up to 65% of SPS patients, there are circulating anti-GABARAP antibodies that inhibit the GABA(A) receptor expression on GABAergic neurons. This review examines the diagnostic criteria for SPS, SPS variants, common errors in diagnosis, and a step-by-step therapeutic approach, including new advances in therapy.

[Steroid treatment in four cases of anti-GAD cerebellar ataxia]

INTRODUCTION

Few neurological diseases are linked with anti-glutamic acid decarboxylase antibodies (GAD-ab); stiff man syndrome is an example. Cerebellar ataxia is a new feature of this expanding spectrum. No therapeutic trial is yet available in these diseases. We here report on four patients suffering from cerebellar ataxia linked with GAD-ab and review the data in the literature on this recently described syndrome.

METHOD

We conducted an open trial with monthly pulsed steroids. Steroid pulses were given six months followed with placebo for another six months. Main clinical and biological parameters were monitored monthly (International Cooperative Cerebellar Ataxia Rating Scale [ICARS] and GAD-ab).

RESULT

The clinical response was found limited and inconstant. Transient decline in GAD-ab level was noted in two patients. Moreover, GAD-ab level was found highly variable and did not correlate with clinical parameters.

DISCUSSION

Cerebellar ataxia with GAD-ab is an increasingly described syndrome. Outcome can be severe, leading to definitive cerebellar atrophy. Diagnosis is supported by high level of serum GAD-ab with intrathecal secretion. Experimental data have suggested a direct excitotoxic effect of GAD-ab on Purkinje cells. Response to various treatments is often disappointing. Improvement has been obtained with veinoglobulins in individual patients. A weak clinical and biological response was associated with monthly steroid pulses.

Stiff-person syndrome with acute recurrent peripheral vertigo: possible evidence of gamma aminobutyric acid as a neurotransmitter in the vestibular periphery

OBJECTIVE

We report a case of a 58-year-old man suffering from stiff-person syndrome and recurrent peripheral vertigo.

METHOD

A case report and a review of the recent literature on stiff-person syndrome are presented.

RESULTS

The patient presented with recurrent episodes of vertigo with a pure peripheral pattern and with concomitant episodes of burning muscle pain, muscle twitching, weight gain and fatigue, worsening with tension or stress that also occurred in periods without vertigo. Cochlear examinations only showed presbyacusis-like hearing loss. The diagnosis of stiff-person syndrome was made with electromyographic examination and from findings in the blood and cerebrospinal fluid of high titres of anti-glutamic acid decarboxylase (GAD67) autoantibodies. In a two-year follow-up period, therapy for stiff-person syndrome abolished episodes of both stiffness and vertigo.

CONCLUSION

As far as we know, no other clinical case of acute vestibular damage with a possible correlation with anti-glutamic acid decarboxylase antibodies has been described. Peripheral vertigo possibly related to a lack of gamma aminobutyric acid underlines a possible role of gamma aminobutyric acid as a neurotransmitter in the peripheral vestibular system.

Stiff-person syndrome

Classic stiff-person syndrome (SPS) is a clinically diagnosed disease characterized by axial and often appendicular rigidity with lumbar hyperlordosis and painful spasms. Supportive data include increased glutamic acid decarboxylase autoantibody titers more than 20 nmol/L, a needle electromyography with continuous motor unit activity in at least one axial muscle, and normal MRI and cerebrospinal fluid studies. Variants of SPS include those with focal limb dysfunction (stiff-limb syndrome), encephalomyelitis ("SPS plus"), and those associated with paraneoplastic autoantibodies. Although the precise mechanism is unknown, an autoimmune etiology for SPS is proposed, based on its association with autoantibodies and other autoimmune diseases and its response to immunomodulatory therapy. The cornerstone of treatment consists of symptomatic care with benzodiazepines and/or baclofen. Other neuromodulators include antiepileptic medications and muscle relaxants. Continued disability despite first-line therapy should prompt consideration of agents aimed at immunomodulation and immunosuppression. Intravenous immunoglobulin is one of the few agents to be evaluated in a double-blind, randomized controlled trial. Other options include steroids, plasma exchange, and chemotherapy agents.

Rigidity and spasms from autoimmune encephalomyelopathies: stiff-person syndrome

Stiff-person syndrome (SPS) is a disorder characterized by progressive muscle rigidity with superimposed painful muscle spasms and gait impairment due to continuous motor activity. Evidence has accumulated in favor of SPS representing an autoimmune, predominantly encephalomyelopathic disorder resulting from B-cell-mediated clonal production of autoantibodies against presynaptic inhibitory epitopes on the enzyme glutamic acid decarboxylase (GAD) and the synaptic membrane protein amphiphysin. Recognition of the clinical spectrum of SPS is important, particularly the upper-limb, cervical, and cranial nerve involvement that occurs in paraneoplastic variants. The correlation between antibody levels and severity of disease offers evidence for a pathogenic role for the anti-GAD and anti-amphiphysin autoantibodies. The scarcity of neuropathological correlates stand in sharp contrast with the severity of the disability in affected individuals and suggests that functional impairment of inhibitory circuits without structural damage is sufficient to develop the full clinical spectrum of SPS. The rarity of this condition limits the feasibility of controlled clinical trials in the treatment of SPS, but the available evidence suggest that drugs that increase cortical and spinal inhibition such as benzodiazepines and drugs that provide immune modulation such as intravenous immunoglobulin, plasmapheresis, and prednisone are effective treatments.

Epilepsy and cerebellar ataxia associated with anti-glutamic acid decarboxylase antibodies

Anti-glutamic acid decarboxylase (GAD) antibodies are described in stiff-person syndrome and also in other neurological syndromes, including cerebellar ataxia and epilepsy. This paper reports the case of a patient who had chronic focal epilepsy, upbeat nystagmus and cerebellar ataxia, associated with a polyautoimmune response including anti-GAD antibodies. Both gait and nystagmus improved markedly after immunosuppressive treatment with corticosteroids and azathioprine. After the introduction of benzodiazepines, previously refractory seizures were completely controlled. Anti-GAD antibodies should be actively sought out in pharmacoresistant epilepsy, particularly if other neurological abnormalities are present. Combined treatment with immunosuppressants and gammahydroxybutyric acidergic agents may be highly effective.

Guidelines on the use of therapeutic apheresis in clinical practice—Evidence-based approach from the apheresis applications committee of the American society for apheresis

The American Society for Apheresis (ASFA) Apheresis Applications Committee is charged with a review and categorization of indications for therapeutic apheresis. This elaborate process had been undertaken every 7 years resulting in three prior publications in 1986, 1993, and 2000 of "The ASFA Special Issues." This article is the integral part of the Fourth ASFA Special Issue. The Fourth ASFA Special Issue is significantly modified in comparison to the previous editions. A new concept of a fact sheet has been introduced. The fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis. A detailed description of the fact sheet is provided. The article consists of 53 fact sheets devoted to each disease entity currently categorized by the ASFA. Categories I, II, and III are defined as previously in the Third Special Issue. However, a few new therapeutic apheresis modalities, not yet approved in the United States or are currently in clinical trials, have been assigned category P (pending) by the ASFA Clinical Categories Subcommittee. The diseases assigned to category IV are discussed in a separate article in this issue.

Glutamic acid decarboxylase autoimmunity with brainstem, extrapyramidal, and spinal cord dysfunction

OBJECTIVE

To describe novel neurological manifestations associated with glutamic acid decarboxylase (GAD65) autoimmunity.

PATIENTS AND METHODS

This retrospective study (1987-2003) describes 62 patients Incidentally found to have a serum autoantibody that bound selectively to synapse-rich central nervous system tissues. The immunostaining pattern was determined to be GAD65-specific by radiolmmunoprecipitation assay. These cases were identified among samples submitted for paraneoplastic autoantibody evaluation using indirect immunofluorescence. In no case had GAD65 or any other islet cell antibody testing been requested.

RESULTS

In most cases, the patients' presentations were initially considered neurodegenerative or inflammatory (multiple sclerosis or paraneoplastic). Median age at onset was 50 years, and 77% were women. Of the 44 patients seen at the Mayo Clinic, 23% were African American; in contrast, less than 10% of Mayo Clinic's neurology patients are African American. Median follow-up was 24 months. The radioimmunoprecipitation assay values for GAD65 antibody were extremely high (median, 1429 nmol/L; Interquartile range, 643-3078 nmol/L) and correlated significantly with immunofluorescence titers (median, 3840; interquartile range, 1920-15,360; r = 0.81; P < .001). Neurological manifestations were multifocal in 41 patients and included cerebellar ataxia (63%), brainstem involvement (29%), seizures (27%), stiff-man phenomena (26%), extrapyramidal signs (16%), and myelopathy (8%). One third of the patients had type 1 diabetes mellitus, 53% had thyroid autoantibodies, and 16% had vitiligo. Eleven of 20 patients identified as African American had brainstem involvement. Some patients appeared to benefit from short-term immunosuppression (none received long-term therapy).

CONCLUSIONS

The neurological spectrum of GAD65 autoimmunity includes brainstem, extrapyramidal, and spinal cord syndromes. In our experience, African American patients were disproportionately affected. A patient with a presumed neurodegenerative disorder of new onset, with high levels of GAD65 antibody (>20 nmol/L), merits consideration of immunotherapy.

Le syndrome de l’homme raide : formes cliniques, traitement et profil évolutif

INTRODUCTION

Stiff-Man syndrome (SMS) is a rare neurological disease first described fifty years ago. There are several clinical forms, which are frequently misdiagnosed. The aim of this study is to review three of the main clinical forms.

MATERIAL AND METHODS

Case reports concerning three women suffering from different forms of SMS are presented, giving the main clinical features, their associations with other diseases, and the biological and electrophysiological findings.

RESULTS

The first patient presented a symmetric axial muscle rigidity, painful spasms and contractions of the trunk and limbs associated with anti-GAD antibodies. The common form of SMS was diagnosed and the patient was improved by intravenous immunoglobulin (IVIg). The second patient suffered from contractions and spasms localized to the lower limbs. In this patient, anti-GAD antibodies were absent. The Stiff-Leg syndrome was diagnosed and the patient was improved by intrathecal baclofen. The third patient presented rigidity of limb and trunk muscles associated with signs of encephalitis. In this patient, only anti-amphiphysin antibodies were present. The progressive encephalomyelitis with rigidity was diagnosed and the patient was improved by IVIg associated with corticosteroid.

CONCLUSION

Identifying patients with SMS makes it possible to propose appropriate medical management. There are several forms of the disease, and the severity of the evolution differs in each case. Treatment with GABA-ergic inhibitory drugs, IVIg and corticosteroid improve both the symptomatology and the quality of life of these patients.

Stiff man-like syndrome and generalized myokymia in spinocerebellar ataxia type 3

We describe the novel association of spinocerebellar ataxia type 3/Machado-Joseph disease (SCA3/MJD) phenotype combining classical clinical presentation and semeiology mimicking stiff man syndrome (SMS). The studied pedigree comprises seven affected members in three generations. Their clinical picture consisted of cerebellar ataxia, pyramidal signs, facial myokymia, and ophthalmoplegia. The proband was a 39-year-old man in whom such a clinical picture, 5 years after onset at age 29, evolved to severe SMS and widespread myokymia. Electrophysiological study revealed continuous muscle activity in proximal limb muscles. Molecular study demonstrated the MJD gene mutation in all four examined patients with 73 to 76 CAG repeats in the expanded allele. We conclude that an excess of motor unit activity including stiff man-like syndrome and widespread myokymia may be an integral part of the SCA3 clinical spectrum.

Physical Therapy During In-Patient Rehabilitation for a Patient with Stiff-Person Syndrome

BACKGROUND AND PURPOSE

Patients with Stiff-Person Syndrome (SPS) typically show stiffness and spasms, primarily of the trunk and proximal lower extremities. The purpose of this case report is to provide an overview of SPS and a description of the specific physical therapy management strategies used during a brief inpatient rehabilitation stay for a patient with SPS, illustrating the use of the patient/client management model in the Guide to Physical Therapist Practice.

CASE DESCRIPTION

The patient was a 33-year-old with a 3- year history of SPS. He spent 10 days in an in-patient rehabilitation hospital where he received physical therapy daily. The initial examination revealed impairments of pain, range of motion, reflex integrity, and motor function, along with abnormalities of posture, balance, and function. The procedural interventions included therapeutic exercise and functional retraining. Stretching exercises were categorized according to their priority and level of difficulty to accommodate for the patient's varying symptoms, and relaxation exercises aimed to reduce the severity of the patient's spasms. The functional retraining program included transfer and progressive gait training.

OUTCOMES

The patient showed improvements in ankle range of motion, posture, and gait (distance, speed, and independence), despite continued problems with stiffness, spasms, and pain.

DISCUSSION

Physical therapists working with patients with SPS have challenges related to the paucity of information in the literature. The chronic, progressive, and variable nature of SPS indicates the need for life-long management, with the inclusion of an exercise program that can be adjusted accordingly, given the frequently changing symptoms experienced by the patient. As is shown with this case, it appears that physical therapy can improve function and some of the impairments associated with SPS.

Clinical evidence for the safety of GAD65 immunomodulation in adult-onset autoimmune diabetes

The purpose of this Phase II study was to evaluate if alum-formulated human recombinant GAD65 is safe and does not compromise beta cell function. The study was conducted as a randomized, double blind, placebo-controlled, dose-escalation clinical trial in a total of 47 Latent Autoimmune Diabetes in Adults (LADA) patients who received either placebo or 4, 20, 100, or 500 microg Diamyd subcutaneously at Weeks 1 and 4. Safety evaluations, including neurology, beta cell function tests, diabetes status assessment, hematology, biochemistry, and cellular and humoral immunological markers, were repeatedly assessed over 24 weeks. None of the patients had significant study-related adverse events (AE). Fasting c-peptide levels at 24 weeks were increased compared with placebo (P=.0015) in the 20 microg but not in the other dose groups. In addition, both fasting (P=.0081) and stimulated (P=.0236) c-peptide levels increased from baseline to 24 weeks in the 20 microg dose group. GADA log levels clearly increased (P=.0002) in response to 500 microg Diamyd. The (CD4+)(CD25+)/(CD4+)(CD25-) cell ratio increased (P=.0128) at 24 weeks in the 20 microg group. No sudden increase in HbA1c or plasma glucose or decrease in beta cell function was observed in any of the dose groups. These positive findings for clinical safety further support the clinical development of Diamyd as a therapeutic to prevent autoimmune diabetes.

The role of IVIg in the treatment of patients with stiff person syndrome and other neurological diseases associated with anti-GAD antibodies

INTRODUCTION

High-titre anti-GAD antibodies are characteristically seen in patients with stiff person syndrome (SPS). Other CNS disorders, rarely associated with high anti-GAD antibody titres, include: a) SPS-plus, a syndrome characterised by SPS and cerebellar ataxia; b) Batten's disease; and c) rare patients with epilepsy and idiopathic cerebellar ataxia. Currently, high-titre anti- GAD antibodies serve only as markers of an autoimmune process within the CNS because their pathogenic role in the afore-mentioned disorders has not been established. In SPS, there is evidence of autoimmune pathogenesis based on: the association of the disease with other autoimmune disorders or autoantibodies; immunogenetic background; presence of oligoclonal IgG bands in the CSF with increased intrathecal anti-GAD antibody synthesis and response to immunotherapies. SPS is the only GAD-positive CNS disease where a controlled study with immunotherapy has been conducted.

METHODS

Sixteen anti-GAD antibody-positive patients were randomised to receive IVIg or placebo for 3 months. After a washout, they crossed to the alternative therapy for another three months. Efficacy was based on the difference in scores of the distribution of stiffness index and heightened sensitivity (spasms) from baseline to the second and third month of the infusions. Direct treatment and carry-over effect were compared for both groups.

RESULTS

The stiffness scores in the IVIg-randomised patients declined significantly from month 1 through 4, but rebounded when they crossed to placebo. In contrast, the scores in the placebo-randomised group remained constant from month 1-4 but dropped significantly after crossing to IVIg. Eleven patients who received IVIg became able to walk unassisted, stopped falling and assumed household or work duties. The duration of benefit varied from 6-12 weeks or up to a year. The anti-GAD(65) antibody titres declined after IVIg, but not after placebo.

CONCLUSION

Based on a controlled study, IVIg is a safe and effective therapy for SPS in patients unresponsive to other agents. Whether IVIg has a role in the other GAD-positive patients with neurological disease, or in SPS patients without GAD antibodies, remains unknown.

Systemic diseases that cause movement disorders

The present review is aimed at providing practical assistance to the clinical neurologist in reaching a diagnosis, understanding the pathogenic mechanisms of movement disorders associated with systemic diseases, and determining appropriate therapy. Infectious disease by direct effect or as an acquired autoimmune neurological disease, stroke, hypoxia-ischemia, paraneoplastic syndromes, collagen disorders, endocrine, liver and kidney diseases that may cause hypokinetic or hyperkinetic abnormal movement are considered separately. The type and evolution of abnormal movement caused by systemic disease vary with age and underlying pathology. Therapy for abnormal movements should include a primary treatment for the systemic disease.

Evaluation of hyponatremia: a little physiology goes a long way

Hyponatremia is common in hospitalized patients. By taking a careful and logical approach, one can promptly recognize the causative factor or factors in nearly all cases. Most cases of hyponatremia are due to impaired renal water excretion, and recognizing the cause and pathophysiologic process makes it possible to provide focused individualized care and avoid mistreatment.

Hyperekplexia and stiff-man syndrome: abnormal brainstem reflexes suggest a physiological relationship

BACKGROUND AND OBJECTIVES

Hyperekplexia and the stiff-man syndrome (SMS) are both conditions with exaggerated startle suggesting abnormal brainstem function. Investigation of brainstem reflexes may provide insight into disturbed reflex excitation and inhibition underlying these movement disorders.

PATIENTS AND METHODS

Using four-channel EMG, we examined four trigeminal brainstem reflexes (monosynaptic masseter, masseter inhibitory, glabella, and orbicularis oculi blink reflexes) and their spread into pericranial muscles in five patients with familial hyperekplexia (FH), two with acquired hyperekplexia (AH), 10 with SMS, and 15 healthy control subjects.

RESULTS

Both FH/AH and SMS patients had abnormal propagation of brainstem reflexes into pericranial muscles. All patients with hyperekplexia showed an abnormal short-latency (15-20 ms) reflex in the trapezius muscle with a characteristic clinical appearance ("head retraction jerk") evoked by tactile or electrical stimulation of the trigeminal nerve, but normal monosynaptic masseter reflexes. Inhibitory brainstem reflexes were attenuated in some FH/AH patients. Four of 10 patients with SMS had similar short-latency reflexes in the neck muscles and frequently showed widespread enhancement of other excitatory reflexes, reflex spasms, and attenuation of inhibitory brainstem reflexes.

CONCLUSION

Reflex excitation is exaggerated and inhibition is attenuated in both stiff-man syndrome and familial or acquired hyperekplexia, indicating a physiological relationship. Reflex transmission in the brainstem appears biased towards excitation which may imply dysfunction of inhibitory glycinergic or GABAergic interneurons, or both.

Stiff-person syndromes: motor cortex hyperexcitability correlates with anti-GAD autoimmunity

OBJECTIVE

S: To investigate whether motor cortex excitability is enhanced in both stiff-person syndrome (SPS) and its "plus" variant, progressive encephalomyelitis with rigidity (PER), and related to autoimmunity against glutamic acid decarboxylase (GAD).

METHODS

The authors compared 21 patients with SPS or PER (7 untreated, 14 treated) with 14 age-matched healthy controls and used transcranial magnetic stimulation (TMS, paired-pulse paradigm) to investigate intracortical inhibition (ICI) and intracortical facilitation (ICF). GAD autoantibody levels in serum and CSF were determined by radioimmunoassay.

RESULTS

The authors found significantly enhanced motor cortex excitability in untreated SPS and PER patients. GABAmimetic medication significantly reduced ICF but did not affect ICI. Motor cortex excitability was more enhanced in patients with GAD antibodies than in patients without GAD antibodies and correlated positively with GAD antibody levels in CSF.

CONCLUSIONS

The motor cortex is hyperexcitable in SPS and PER patients. However, hyperexcitability is partly masked by GABAmimetic treatment. Correlation of elevated GAD antibody levels with enhanced ICF suggests that motor cortex hyperexcitability in SPS and PER is related to anti-GAD autoimmunity.

Paraneoplastic "stiff person syndrome" with metastatic adenocarcinoma and anti-Ri antibodies

A 43-year-old woman presented with clinical and electrophysiologic features of stiff person syndrome (SPS), without abdominal or lumbar paraspinal muscle involvement. Investigations revealed metastatic adenocarcinoma of the lung with positive anti-Ri antibodies. Her clinical condition improved with diazepam, baclofen, tizanidine, and palliative chemotherapy. Screening for an underlying malignancy and anti-Ri antibodies should be considered in patients with SPS when clinical presentation is atypical.

Progressive encephalomyelitis with rigidity: a paraneoplastic presentation of oat cell carcinoma of the lung. Case report

Progressive encephalomyelitis with rigidity and myoclonus (PEWR) is a rare neurological disorder, characterised by muscular rigidity, painful spasms, myoclonus, and evidence of brain stem and spinal cord involvement. A 73-year-old white man was admitted with a 10-day history of painful muscle spasms and continuous muscle rigidity on his left lower limb. He had involuntary spasms on his legs and developed encephalopathy with cranial nerves signs and long tract spinal cord symptomatology. Brain CT scan and spinal MRI were normal. The CSF showed lymphocytic pleocytosis and no other abnormalities. EMG showed involuntary muscle activity with 2-6 seconds of duration, interval of 30-50 ms and a frequency of 2/second in the left lower limb. Anti-GAD antibodies were detected in the blood. We detected radiological signs of lung cancer during the follow-up, which proved to be an oat cell carcinoma. The patient died two weeks after the diagnosis of the cancer.

Stiff-Person Syndrome

BACKGROUND

Stiff-person syndrome (SPS) is a rare neurologic disorder with autoimmune features. It is characterized by progressive, severe muscle rigidity or stiffness most prominently affecting the spine and lower extremities.

REVIEW SUMMARY

Superimposed muscle spasms result in simultaneous contraction of agonist and antagonist muscles which are detectable by electromyography (EMG) and relieved by administration of benzodiazepines. The exacerbation of SPS by emotional stressors often results in the referral of these patients for psychiatric assessment although this was more common before the discovery of an association with antibodies to glutamic acid decarboxylase (GAD antibodies). Formerly known as stiff-man syndrome, the female to male ratio is 2:1 and the principle paraneoplastic variant is associated with breast cancer. Although rare, this is a disease of middle age that severely curtails the functional capacity of those it strikes. It is frequently associated with diabetes and other autoimmune diseases. IVIg is recently demonstrated to be effective in the treatment of SPS; diazepam remains useful in managing the symptoms.

CONCLUSIONS

This article summarizes the history of SPS, describes important clinical features, discusses management, touches upon areas of uncertainty, and postulates some avenues for research.

Pregnancy in stiff-limb syndrome

To our knowledge, pregnancy in a patient with stiff-limb-syndrome (SLS) has not been reported. We present the case of a woman with SLS who improved during pregnancy, delivered a normal healthy baby by forceps-assisted vaginal delivery, and suffered a mild postpartum "relapse."

A delayed diagnosis of stiff person syndrome

A 37-year-old industrial designer presented in February 2002 with a 6-week history of thirst, polydipsia and polyuria. Urine dipstick showed glucose and 3+ ketones. Diabetes was diagnosed following fasting glucose of 13 mmol/litre and glycosylated haemoglobin (Hba1c) of 10.3%. He was commenced on insulin therapy.

He had been healthy until 1995 when he described the onset of muscle spasm and pain in upper back and shoulders. There was no obvious precipitating injury. He described the muscle over his left shoulder tightening up like a knot. It subsequently spread to his neck, upper and, later, lower back, giving significant rigidity and pain. Exertion and sporting activities cause his whole back to seize up with extreme pain afterwards. The spasms spread to his legs twice in the last 7 years, but the rigidity was fortunately only short lasting. He sought advice from a chiropractor and various medical specialists including an orthopaedic surgeon, rheumatologist and pain consultant. He had many investigations including isotope bone scan and magnetic resonance imaging (MRI) scan of cervical and thoracic spine which were all normal. There was no explanation for his symptoms and no diagnosis was given. He was prescribed baclofen, which brought some relief.

Clinical examination was normal except for markedly increased tone of muscles over his left shoulder. There was no obvious truncal rigidity or exaggerated lumbar lordosis and no pyramidal or extrapyramidal signs. He was clinically euthyroid.

Antiglutamic acid decarboxylase (GAD) 65 antibody was highly elevated at 220 U/ml (normal range (NR) <1 U/ml; >100 U/ml associated with neurological disease). Thyroid function test showed normal free thyroxine of 16.3 pmol/litre (NR 10–25.0 pmol/litre) with elevated thyroid-stimulating hormone of 8.43 mU/litre (NR 0.4–4 mU/litre) and positive thyroid peroxidase (TPO) antibody at 82 IU/ml (NR <37.0 IU/ml). Nerve conduction studies showed no evidence of neuropathy. Electromyograph studies were not done because of the difficulty of excluding voluntary movement from this quite painful test. Full blood count, renal, liver and bone profile were normal. CSF was not examined.

The typical history of painful muscle spasm and strongly positive anti-GAD 65 antibody suggested the diagnosis of stiff person syndrome. The association with an autoimmune condition, in this case type 1 diabetes, and elevated TPO antibody levels further supports the diagnosis.

Head retraction reflex in stiff-man syndrome and related disorders

The head retraction reflex (HRR) is a vestigial withdrawal reflex of the face and is suppressed in healthy subjects. We investigated the prevalence and electrophysiological patterns of the HRR in patients suffering from stiff-man syndrome (SMS, n = 28) and related disorders, stiff-limb syndrome (SLS, n = 2), and progressive encephalomyelitis with rigidity and myoclonus (PERM, n = 20). In patients with a positive HRR, the electromyographic (EMG) pattern was analyzed with surface recordings from the orbicularis oculi, sternocleidomastoid, trapezius, and the paraspinal extensor muscles at midthoracic and lumbar levels. On clinical testing, 17 of 28 SMS patients, 10 of 20 PERM patients, and 0 of 2 SLS patients had a positive HRR, ranging from a brief contraction of the neck extensors to violent retropulsion of the upper body. In all muscles, EMG reflex patterns elicited by gentle taps to the face or by electrical stimulation of the trigeminal nerve branches consisted of two components: an early, synchronous, brief burst with the shortest latency in trapezius (12.5-20.0 msec) and a late, asynchronous, longer response with latencies between 44 and 70 msec. We conclude that the HRR is an abnormal cutaneomuscular brainstem reflex that occurs in a considerable proportion of patients with SMS and related disorders. Although neither specific nor particularly sensitive for SMS, presence of the HRR in a setting with otherwise unexplained stiffness and spasms might help to avoid the otherwise frequent misdiagnosis of a psychogenic motor disturbance in patients with SMS.

Specific phobia is a frequent non-motor feature in stiff man syndrome

OBJECTIVE

To investigate systematically the rate and type of phobia in stiff man syndrome and its variants, and to compare patients with stiff man syndrome with and without phobia for sociodemographic and neurological characteristics.

METHODS

43 consecutive patients with stiff man syndrome referred to a university department of neurology were assessed using the anxiety disorders interview schedule, revised (ADIS-R), a structured diagnostic interview for anxiety disorders, in addition to a full clinical neurological and psychiatric assessment.

RESULTS

19 patients (44.2%) developed task specific phobia--that is, fear and avoidance of situations difficult to master owing to the motor symptoms of stiff man syndrome (such as crossing streets). Three further patients (7%) had subthreshold phobia--that is, phobic anxiety without avoidance. There were no significant differences between patients with and without phobia in terms of age, illness duration, type of stiff man syndrome, antibody status, or frequency of falls. Patients with phobia were more likely to present with exaggerated startle responses and to have an initial misdiagnosis of psychogenic movement disorder.

CONCLUSIONS

Specific phobia is a frequent non-motor symptom of stiff man syndrome. Early recognition is an important aid to correct diagnosis. The aetiology of phobia in stiff man syndrome is unknown. There is no evidence of a direct pathogenic role of autoantibodies directed against glutamic acid decarboxylase in the development of phobia.

Stiff-person Syndrome

Stiff-person syndrome (SPS) is a progressive neurologic disorder characterized by 1) stiffness that is prominent in axial muscles, with co-contraction of agonist and antagonist muscles; 2) sudden episodic spasms; and 3) absence of another disease that causes similar symptoms. The diagnosis of SPS is based on clinical grounds and requires a high degree of suspicion. The diagnosis is, however, aided by electromyography, which demonstrates motor unit firing at rest simultaneously from the agonist and antagonist muscles, and by high serum titers of antibodies against glutamic acid decarboxylase (GAD), the rate-limiting enzyme for the synthesis of gamma-aminobutyric acid (GABA), which is the brain's main inhibitory neurotransmitter. The reduced GABA level in the brain and cerebrospinal fluid explains the patients' stiffness and justifies the clinical improvement observed by drugs enhancing GABAergic transmission. The association of SPS with other autoimmune disorders or autoantibodies, the intrathecal GAD-specific immunoglobulin G antibody synthesis, and the suppression of GABA by the patient's antibodies supports the autoimmune nature of SPS and justifies the use of immunotherapies. At present, GABA-enhancing agents, such as benzodiazepines, valproate, vigabatrin, tiagabine, gabapentin, and baclofen, provide symptomatic relief. Plasmapheresis, steroids, and periodic intravenous immunoglobulin infusions provide additional and lasting benefit. In this article, the treatment options for patients with SPS are discussed based on the authors' experience and that of others. The beneficial effects from the first controlled study conducted in SPS using intravenous immunoglobulin are presented.

Spinally generated electromyographic oscillations and spasms in a low-thoracic complete paraplegic

We have measured some oscillatory properties of severe lower limb spasms experienced by a low-thoracic complete paraplegic during assisted standing. Electromyograms (EMG) were recorded from the leg muscles while the patient stood passively in a standing frame. The patient also stood using functional electrical stimulation (FES) while ground and handle reaction force vectors were measured together with EMG activity. During passive standing, spasms appeared simultaneously in all leg muscle groups on one side. The interval between spasms varied between 3 and 30 seconds. Within the spasms, there was a tendency of repetitive grouped discharge of motor units as well as a strong 10-Hz component in the EMG that was coherent across ipsilateral muscle groups. Thus, the spasms were inherently oscillatory. During FES-assisted standing, clinically similar spasms were observed. However, the interspasm interval became relatively fixed at around 16 seconds, which may indicate entraining of the spasm cycle by FES. There are similarities between this patient's spasms and the pathological motor activities seen in other movement disorders that may also be of spinal origin.

Diagnosis and differential diagnosis of muscle cramps: a clinical approach

Muscle cramps are one of the most frequently occurring neuromuscular features. They occur normally in healthy persons, can be the manifestation of one of several cramp syndromes, but can also be the expression of various underlying neuromuscular disorders. We review the various types and boundaries of cramps, ranging from true muscle cramps to electromyographic silent muscle contractures (for example, Brody's disease) and cramps associated with dystrophinopathies. In addition, we delineate true muscle cramp from muscle stiffness and muscle twitching. Finally, we propose a workup in a patient suspected of having muscle cramps.

Stiff man syndrome and related conditions

The stiff man syndrome (SMS) and its variants, focal SMS, stiff limb (or leg) syndrome (SLS), jerking SMS, and progressive encephalomyelitis with rigidity and myoclonus (PERM), appear to occur more frequently than hitherto thought. A characteristic ensemble of symptoms and signs allows a tentative clinical diagnosis. Supportive ancillary findings include (1) the demonstration of continuous muscle activity in trunk and proximal limb muscles despite attempted relaxation, (2) enhanced exteroceptive reflexes, and (3) antibodies to glutamic acid decarboxylase (GAD) in both serum and spinal fluid. Antibodies to GAD are not diagnostic or specific for SMS and the role of these autoantibodies in the pathogenesis of SMS/SLS/PERM is the subject of debate and difficult to reconcile on the basis of our present knowledge. Nevertheless, evidence is emerging to suggest that SMS/SLS/PERM are manifestations of an immune-mediated chronic encephalomyelitis and immunomodulation is an effective therapeutic approach.

Stiff-man syndrome: identification of 17 beta-hydroxysteroid dehydrogenase type 4 as a novel 80-kDa antineuronal antigen

Stiff-man syndrome (SMS) is a rare autoimmune disorder of the central nervous system associated with autoantibodies to glutamate decarboxylase (GAD). We isolated five brain-reactive human monoclonal antibodies, with reactivity distinct from GAD, from peripheral blood of a patient newly diagnosed with SMS. Two antibodies reacted with both Purkinje cells and ependymal cells, and precipitated an 80-kDa protein from rat neuronal primary cultures, which was also recognized by 12% (3/25) of SMS sera and 13% (2/15) of SMS cerebrospinal fluid (CSF) samples. The corresponding antigen was identified as 17 beta-hydroxysteroid dehydrogenase type 4 and may represent a possible novel target of autoimmunity in SMS.

Quality of life in stiff-person syndrome

Stiff person syndrome (SPS) is a rare, chronic disorder characterized by painful spasm and stiffness. We investigated the quality of life (QoL) in SPS patients, and identified factors associated with impairment in patients' QoL. Twenty-four SPS patients (10 men, 14 women; mean age +/- S.D., 52.6 +/- 9.5 years) completed the medical outcomes study Short Form health survey (SF-36), the Beck Depression Inventory (BDI), and a questionnaire asking for sociodemographic and clinical details. Extent of the disease was assessed using a distribution of stiffness score. SPS patients showed markedly reduced mean scores for all dimensions of the SF-36 when compared to norms from the general population of the United Kingdom. QoL scores showed a strong correlation with the extent of the disease. Depression was a common finding; 14 of 24 patients had depressive symptoms as evidenced by the BDI. There was a significant and strong correlation between the BDI score and several SF-36 subscores. This is the first study to address QoL in patients with SPS. We have shown that SPS has a significant impact on patients' reported QoL. The association between depression and QoL highlights the importance of recognizing and treating depression in SPS.

Stiffness, spasticity, or both: a case report of stiff-person syndrome

Stiffness and spasticity are common neurologic symptoms that affect limb movements. We describe a patient who presented with ill-defined stiffness and an exaggerated startle response, who on serial examinations had variable degrees of stiffness and marked hyperreflexia but with plantar flexor signs. Stiff-person syndrome (SPS) was considered when axial stiffness became evident and was confirmed with highly elevated anti-GAD antibody titers. A favorable response to a short course of intravenous immunoglobulin treatment was sustained for more than 10 months, an unusual feature to the disease. We review the clinical features, pathologic mechanism, and treatment of this disorder.