Case 1, 1996: rapidly progressive parkinsonism, incontinence, impotency, and levodopa-induced moaning in a patient with multiple myeloma

Anti- RI antibody associated progressive supranuclear palsy like presentation in a patient with breast carcinoma

Paraneoplastic neurological syndromes (PNS) are well established entities associated with onconeural antibodies. Paraneoplastic parkinsonism is a highly under narrated presentation of PNS. Rapid progression of typical or atypical parkinsonism with red flags like multiaxial involvement, complete gaze palsy and a clinico-radiological mismatch should prompt a clinician to suspect secondary etiologies like infection, metabolic, vascular, metastatic and paraneoplastic causes. We describe a patient with rapidly progressive parkinsonism. Diagnosis of Breast carcinoma associated ANNA-2/ Anti Ri mediated PSP like phenotype was made in this patient based upon clinical examination and investigations. We also present a review of literature on paraneoplastic parkinsonism in this manuscript.

Moaning Phenomenon and Rapidly Progressive Dementia in Anti LGI-1 Associated Progressive Supranuclear Palsy Syndrome

Background:

Immunological causes of atypical parkinsonisms linked to neuronal specific antibodies have been recently reported. As these are potentially treatable disorders, it is desirable to identify which clinical features may suggest an autoimmune etiology.

Case Report:

A 60-year-old-man with progressive supranuclear palsy associated with anti-LGI-1 antibodies presented with rapidly progressive dementia and moaning. Treatment with steroids and immunoglobulin resulted in temporary clinical improvement and disease stabilization.

Discussion:

Anti-LGI-1 antibodies interfere with normal synaptic activity and maturation in the central nervous system. We suggest that an immune-mediated mechanism might be considered in atypical parkinsonisms with unusual features such as rapidly progressive dementia.

Highlights:

We present a case of rapidly evolving progressive supranuclear palsy-like parkinsonism associated with anti-LGI-1 antibodies, suggesting that immune-mediated mechanisms might be involved in rapid progression of some atypical parkinsonisms. This case also contributes to the expanding spectrum of moaning-associated disorders.

Paraneoplastic movement disorders: phenomenology, diagnosis, and treatment

Paraneoplastic syndromes include, by definition, any symptomatic and non-metastatic condition associated with a neoplasm. Paraneoplastic movement disorders are a heterogeneous group of syndromes encompassing both hyperkinetic and hypokinetic conditions, characterized by acute/sub-acute onset, rapidly progressive evolution, and multifocal localizations with several overlapping features. These movement disorders are immune-mediated, as shown by the rapid onset and by the presence of antineuronal antibodies in biological samples of patients, fundamental for the diagnosis. Antineuronal antibodies could be targeted against intracellular or neuronal surface antigens. Paraneoplastic movement disorders associated with anti-neuronal surface antigens antibodies respond more frequently to immunotherapy. The underlying tumors may be different, according to the clinical presentation, age, and gender of patients. Our search considered articles involving human subjects indexed in PubMed. Abstracts were independently reviewed for eligibility criteria by one author and validated by at least one additional author. In this review, we sought to critically reappraise the clinical features and the pathophysiological mechanisms of paraneoplastic movement disorders, focusing on diagnostic and therapeutic strategies. Our main aim is to make clinicians aware of paraneoplastic movement disorders, and to provide assistance in the early diagnosis and management of these rare but life-threatening conditions.

Paraneoplastic movement disorders

Neurologic paraneoplastic syndromes (NPSs) result from damage to the nervous system due to the remote effects of cancer not related to metastasis, infection, or metabolic derangements. NPSs are rare, affecting 1 in 10,000 patients with cancer. Pathogenesis is likely related to the immune mechanisms: normal neural tissue is mistakenly attacked due to the similarity in the onconeural antigens expressed by the tumor cells. Among the various "classic" and other NPSs, this review focuses on paraneoplastic movement disorders, including ataxia due to cerebellar degeneration, stiff-person syndrome, opsoclonus-myoclonus syndrome, chorea, parkinsonism, and tremor. The recently described syndrome of paraneoplastic anti-N-methyl-D-aspartate receptor encephalitis is also included, given that these patients have complex movements such as stereotypies and dyskinesias in addition to psychiatric symptoms, altered sensorium, and other neurologic signs. Although variable, treatment and prognosis of NPSs rely heavily on treatment of the underlying malignancy and immunotherapy.

Paraneoplastic progressive supranuclear palsy syndrome in a patient with B-cell lymphoma

An important component in the diagnosis of atypical parkinsonian disorders is the exclusion of secondary causes. Paraneoplastic causes of parkinsonism are extremely rare. We describe a case which presented initially as probable progressive supranuclear palsy (PSP) but on follow-up displayed a rapidly progressive course, unexplained fever, peripheral neuropathy and an abnormal CSF. We highlight the difficulties faced in formulating a diagnosis for this unusual case prior to the discovery of an occult B-cell lymphoma, and discuss its relevance in the exclusion criteria for PSP. A paraneoplastic cause should be considered if disease progression is unusually rapid.

Paraneoplastic movement disorder in a patient with non-Hodgkin's lymphoma and CRMP-5 autoantibody

The paraneoplastic autoantibody, collapsin response-mediator protein (CRMP)-5 immunoglobulin G (IgG), is specific for neuronal cytoplasmic CRMP-5, and is usually associated with small-cell lung carcinoma or thymoma. We report on details of a movement disorder that followed anti-B-cell therapy in a patient with lymphoma, and was accompanied by CRMP-5 IgG.

Diagnosis and differential diagnosis of Parkinson's disease and parkinsonism

In the clinic setting, most cases represent either Parkinson's disease (PD) or one of the other neurodegenerative disorders that make up the parkinsonism-plus syndromes. The major parkinsonism-plus syndromes include progressive supranuclear palsy, multiple system atrophy, corticobasal degeneration, as well as parkinsonism occurring in the context of Alzheimer's disease or one of the other primary dementing disorders. There are a variety of other conditions, however, that occasionally come into the differential diagnosis. These fall into the categories of secondary parkinsonism (due to drugs, toxins, structural lesions, etc.), another tremor syndrome such as essential tremor, or a hereditary disorder with parkinsonism. This broad differential diagnosis is reviewed.