Reverse Shapiro's syndrome. A case of agenesis of corpus callosum associated with periodic hyperthermia

The Omnipresence of Autonomic Modulation in Health and Disease

The Autonomic Nervous System (ANS) is a critical part of the homeostatic machinery with both central and peripheral components. However, little is known about the integration of these components and their joint role in the maintenance of health and in allostatic derailments leading to somatic and/or neuropsychiatric (co)morbidity. Based on a comprehensive literature search on the ANS neuroanatomy we dissect the complex integration of the ANS: (1) First we summarize Stress and Homeostatic Equilibrium - elucidating the responsivity of the ANS to stressors; (2) Second we describe the overall process of how the ANS is involved in Adaptation and Maladaptation to Stress; (3) In the third section the ANS is hierarchically partitioned into the peripheral/spinal, brainstem, subcortical and cortical components of the nervous system. We utilize this anatomical basis to define a model of autonomic integration. (4) Finally, we deploy the model to describe human ANS involvement in (a) Hypofunctional and (b) Hyperfunctional states providing examples in the healthy state and in clinical conditions.

Hypothalamic-pituitary dysfunction in alternating hemiplegia of childhood

BACKGROUND

Many central nervous system disorders result in hypothalamic-pituitary (HP) axis dysfunction. Alternating Hemiplegia of Childhood (AHC) is usually caused by mutations in the ATP1A3 subunit of the Na⁺/K⁺ ATPase, predominantly affecting GABAergic interneurons. GABAergic interneurons and the ATP1A3 subunit are both important for function of the hypothalamus. However, whether HP dysfunction occurs in AHC and, if so, how such dysfunction manifests remains to be investigated.

METHODS

We conducted a retrospective review of a cohort of 50 consecutive AHC patients for occurrence of HP related manifestations and analyzed the findings of the 6 patients, from that cohort, with such manifestations.

RESULTS

Six out of 50 AHC patients manifested HP dysfunction. Three of these patients were mutation positive and 3 were mutation negative. Of the 6 patients with HP dysfunction, 3 had central precocious puberty. A fourth had short stature due to growth hormone deficiency. Two other patients had recurrent episodes of fever of unknown origin (FUO) diagnosed, after workups, as being secondary to central fever. All patients were evaluated and co-managed by pediatric neurology and endocrinology or rheumatology.

CONCLUSION

AHC was associated with HP dysfunction in about 12% of patients. Awareness of such dysfunction is important for anticipatory guidance and management particularly in the case of FUO which often presents a diagnostic dilemma. Our findings are also consistent with current understandings of the underlying pathophysiology of AHC and of the HP axis.

[Spontaneous periodic hypothermia syndrome: A systematic review of the literature]

INTRODUCTION

Periodic spontaneous hypothermia syndrome (PSHS), also known as hypersudation-hypothermia syndrome, is a rare condition characterised by the occurrence of paroxysmal attacks of spontaneous hypothermia occurring without age limit. Few studies have attempted to synthesise the available data on PSHS. The objective of this study was to summarize the literature on this condition.

METHODS

A literature review was conducted using the Pubmed and ScienceDirect databases. Cases from a registry of PSHS initiated at the CHU of Saint-Étienne were added to the analysis. For each clinical case, clinical, biological and morphological data as well as therapeutic management and evolution were collected.

RESULTS

Seventy-one cases of PSHS were collected. The median age at symptom onset was 21.5 years. The clinical sign most frequently associated with hypothermia was the presence of hyperhidrosis. The triad of hypothermia-hypersudation-agenesis of the corpus callosum was present in 35.7% of cases.

CONCLUSION

PSHS remains a poorly known cause of hypothermia, without consensual therapeutic options. The need to better describe cases and obtain more long-term data will allow a better definition and knowledge of this syndrome.

Long-term follow-up in pediatric patients with paroxysmal hypothermia (Shapiro's syndrome)

INTRODUCTION

Shapiro syndrome (SS) is characterized by spontaneous recurrent episodes of hypothermia, hyperhidrosis and corpus callosum (CC) agenesis. Less than 60 cases have been reported to date and the pathogenic mechanism as well as the prognosis of this syndrome are still debated. We describe the clinical features and long-term follow-up of a pediatric cohort of SS patients.

METHODS

We collected 13 (10 novel) pediatric cases of SS and report their long-term follow-up and neurological outcome.

RESULTS

All patients experienced recurring hypothermia, with body temperature below 35 °C during the episodes, often accompanied by hyperidrosis. CC agenesis was an inconstant structural feature in the present series (2/13 patients). Seven patients received antiepileptic drugs (AEDs) or other drug therapy for a mean period of 12 months. At long-term follow-up (mean = 61 months, range: 60-96), all individuals were free from episodes of paroxysmal hypothermia independently from previous AED use or other drug therapy.

CONCLUSION

Paroxysmal hypothermia, the core symptom of SS, behaved as a age-dependent feature in our cohort, supporting a good long-term prognosis for SS. A prompt diagnosis of SS is crucial to avoid unnecessary diagnostic investigations.

The combination of thermal dysregulation and agenesis of corpus callosum: Shapiro's or/and reverse Shapiro's syndrome

Shapiro syndrome is an extremely rare condition consisting the clinical triad of recurrent hypothermia, hyperhydrosis and agenesis of the corpus callosum. On the other hand, reverse Shapiro's sydrome is characterized periodic hyperthermia and agenesis of the corpus callosum. Here, we describe a 3.5-year-old girl with complete agenesis of corpus callosum presenting with recurrent fever and vomiting. She also had hypothermia attacks with accompanying diaphoresis. To the best of our knowledge, there is no described case with episodes of hyperthermia, hypothermia, and vomiting associated with agenesis of the corpus callosum. Recurrent vomiting may be a newly defined symptom associated with these syndromes.

A review of paroxysmal sympathetic hyperactivity after acquired brain injury

Severe excessive autonomic overactivity occurs in a subgroup of people surviving acquired brain injury, the majority of whom show paroxysmal sympathetic and motor overactivity. Delayed recognition of paroxysmal sympathetic hyperactivity (PSH) after brain injury may increase morbidity and long-term disability. Despite its significant clinical impact, the scientific literature on this syndrome is confusing; there is no consensus on nomenclature, etiological information for diagnoses preceding the condition is poorly understood, and the evidence base underpinning our knowledge of the pathophysiology and management strategies is largely anecdotal. This systematic literature review identified 2 separate categories of paroxysmal autonomic overactivity, 1 characterized by relatively pure sympathetic overactivity and another group of disorders with mixed parasympathetic/sympathetic features. The PSH group comprised 349 reported cases, with 79.4% resulting from traumatic brain injury (TBI), 9.7% from hypoxia, and 5.4% from cerebrovascular accident. Although TBI is the dominant causative etiology, there was some suggestion that the true incidence of the condition is highest following cerebral hypoxia. In total, 31 different terms were identified for the condition. Although the most common term in the literature was dysautonomia, the consistency of sympathetic clinical features suggests that a more specific term should be used. The findings of this review suggest that PSH be adopted as a more clinically relevant and appropriate term. The review highlights major problems regarding conceptual definitions, diagnostic criteria, and nomenclature. Consensus on these issues is recommended as an essential basis for further research in the area.

Paroxysmal autonomic instability with dystonia

Paroxysmal autonomic instability with dystonia, an under-recognized and poorly understood phenomenon of episodic central dysautonomia is associated with various cerebral insults. Treatment options include benzodiazepines, opioids, and gabapentin. Using an illustrative case, we discuss presentation, pathomechanisms, and management of this condition.

Reverse Shapiro's syndrome--an unusual cause of fever of unknown origin

Reverse Shapiro's syndrome was first described by Hirayama et al. in a girl with periodic hyperthermia associated with complete agenesis of the corpus callosum. Here we report another such case in a 9-month-old girl presenting with fever of unknown origin since the age of 7 months. On examination, she had mild hypotonia with delayed developmental milestones. No other neurological or physical abnormalities were noted. The cause of her prolonged fever of unknown origin was investigated and all results were negative. Her brain magnetic resonance images showed agenesis of the corpus callosum. On the basis of the previous literature, we suggest that the periodic hyperthermia of this girl was caused by dopaminergic denervation of the hypothalamic thermoregulatory center. Treatment with dopamine agonists (levodopa plus carbidopa) failed to control the hyperthermia.

Thermoregulatory dysfunction in neuroleptic malignant syndrome

Hyperthermia is the central feature of neuroleptic malignant syndrome (NMS), but its etiology remains elusive. Two competing hypotheses implicate either hypothalamic dysfunction (inappropriate "set point") or direct myotoxicity (excessive peripheral heat production). These two models have distinct implications for thermoregulatory activity in NMS. The first predicts that the individual should respond as to a hypothermic threat or infection (the hypothalamus signals the body to raise its temperature). The second implies that an excessive heat load is perceived by the hypothalamus, which responds to this hyperthermic threat (it signals the body to lower its temperature). To assess the validity of these two hypotheses the thermoregulatory responses of a series of NMS patients (36 patients, 46 episodes) were examined using standard statistical methods. In contrast to normal mammalian thermoregulatory behavior, thermoeffector responses were not organized into either mode, but appeared to function somewhat independently and paradoxically. We conclude that neither hypothesis is sufficient to explain altered thermoregulation in NMS, and that the loss of integrated thermoeffector activity may be unique to this disorder.