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Adamaszek M, Langner S, Mehrholz J, Heiinrich A. Opsoclonus-Myoclonus-Ataxia Syndrome Due to Covid-19. CEREBELLUM (LONDON, ENGLAND) 2024; 23:1245-1248. [PMID: 37814146 DOI: 10.1007/s12311-023-01610-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/26/2023] [Indexed: 10/11/2023]
Abstract
Opsoclonus-myoclonus syndrome (OMS) as a rare neurological encephalopathic entity associated with non-specific infections or cancer processes has been repeatedly described in the setting of SARS-CoV-2 infection. We report a case of a 53-year-old man with SARS-CoV-2 infection, who developed clinical features of opsoclonus-myoclonus ataxia syndrome including cognitive impairments with a prolonged course of disease. Of particular note, cerebrospinal fluid (CSF) analysis revealed the production of myelin oligodendrocyte glycoprotein (MOG) antibodies, suggesting an underlying neuroimmunological mechanism associated with infection with the novel SARS-CoV-2 virus.
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Affiliation(s)
- Michael Adamaszek
- Department of Neurological and Neurocognitive Rehabilitation, Klinik Bavaria Kreischa, An der Wolfsschlucht, 1-2 01731, Kreischa, Germany.
| | - Soenke Langner
- Department of Radiology, Rostock University Medical Center, Schillingallee 35, 18057, Rostock, Germany
| | - Jan Mehrholz
- Department of Public Health, Dresden Medical School, Technical University Dresden, Dresden, Germany
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2
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Norrito RL, Puleo MG, Pintus C, Basso MG, Rizzo G, Di Chiara T, Di Raimondo D, Parrinello G, Tuttolomondo A. Paraneoplastic Cerebellar Degeneration Associated with Breast Cancer: A Case Report and a Narrative Review. Brain Sci 2024; 14:176. [PMID: 38391750 PMCID: PMC10887192 DOI: 10.3390/brainsci14020176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/23/2024] [Accepted: 02/07/2024] [Indexed: 02/24/2024] Open
Abstract
Paraneoplastic neurological syndromes (PNSs) are an uncommon complication of cancer, affecting nearby 1/10,000 subjects with a tumour. PNSs can involve all the central and peripheral nervous systems, the muscular system, and the neuromuscular junction, causing extremely variable symptomatology. The diagnosis of the paraneoplastic disease usually precedes the clinical manifestations of cancer, making an immediate recognition of the pathology crucial to obtain a better prognosis. PNSs are autoimmune diseases caused by the expression of common antigens by the tumour and the nervous system. Specific antibodies can help clinicians diagnose them, but unfortunately, they are not always detectable. Immunosuppressive therapy and the treatment of cancer are the cornerstones of therapy for PNSs. This paper reports a case of PNSs associated with breast tumours and focuses on the most common paraneoplastic neurological syndromes. We report a case of a young female with a clinical syndrome of the occurrence of rigidity in the right lower limb with postural instability with walking supported and diplopia, with a final diagnosis of paraneoplastic cerebellar degeneration and seronegative rigid human syndrome associated with infiltrating ductal carcinoma of the breast.
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Affiliation(s)
- Rosario Luca Norrito
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Maria Grazia Puleo
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Chiara Pintus
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Maria Grazia Basso
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Giuliana Rizzo
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Tiziana Di Chiara
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Domenico Di Raimondo
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Gaspare Parrinello
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Antonino Tuttolomondo
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
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Amod F, Holla VV, Ojha R, Pandey S, Yadav R, Pal PK. A review of movement disorders in persons living with HIV. Parkinsonism Relat Disord 2023; 114:105774. [PMID: 37532621 DOI: 10.1016/j.parkreldis.2023.105774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/22/2023] [Accepted: 07/22/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND The human immunodeficiency virus (HIV) causes movement disorders in persons living with HIV (PLH). OBJECTIVES AND METHODS We conducted a systematic review on the spectrum of movement disorders in PLH using standard terms for each of the phenomenologies and HIV. RESULTS Movement disorders in PLH were commonly attributed to opportunistic infections (OI), dopamine receptor blockade reactions, HIV-associated dementia (HAD), presented during seroconversion, developed due to drug reactions or antiretroviral therapy (ART) itself and lastly, movement disorders occurred as a consequence of the HIV-virus. Parkinsonism in ART naïve PLH was associated with shorter survival, however when Parkinsonism presented in PLH on ART, the syndrome was indistinguishable from Idiopathic Parkinson's disease and responded to therapy. Tremor was often postural due to HAD, drugs or OI. Generalized chorea was most frequent in HIV encephalopathy and toxoplasmosis gondii caused most cases of hemichorea. Ataxia was strongly associated with JCV infection, ART efavirenz toxicity or due to HIV itself. Dystonia was reported in HAD, secondary to drugs and atypical facial dystonias. Both cortical/subcortical and segmental/spinal origin myoclonus were noted mainly associated with HAD. In patients with HIV related opsoclonus-myoclonus-ataxia-syndrome, seroconversion illness was the commonest cause of followed by IRIS and CSF HIV viral escape phenomenon. CONCLUSIONS Aetiology of movement disorders in PLH depend on the treatment state. Untreated, PLH are prone to develop OI and HAD and movement disorders. However, as the number of PLH on ART increase and survive longer, the frequency of ART and non-AIDS related complications are likely to increase.
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Affiliation(s)
- Ferzana Amod
- Department of Neurology, University of KwaZulu-Natal, South Africa.
| | - Vikram V Holla
- National Institute of Mental Health and Neuro Sciences, Bengaluru, India.
| | - Rajeev Ojha
- Department of Neurology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal.
| | - Sanjay Pandey
- Department of Neurology and Stroke Medicine, Amrita Hospital, Delhi National Capital Region, India.
| | - Ravi Yadav
- National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India.
| | - Pramod Kumar Pal
- National Institute of Mental Health and Neuro Sciences, Bangalore, India.
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Ene L, Duiculescu D, Radoi R, Lazar M, Tardei G, Ungureanu E, Ruta S, Vinters HV, Letendre S, Grant I, Ellis RJ, Achim CL. Subacute myoclonic measles encephalitis - An opportunistic HIV-associated infection. Front Cell Neurosci 2023; 17:1113935. [PMID: 37082207 PMCID: PMC10110848 DOI: 10.3389/fncel.2023.1113935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/13/2023] [Indexed: 04/07/2023] Open
Abstract
Introduction An unusual cluster of myoclonic epilepsy was observed in a Romanian pediatric HIV cohort concurrent with measles outbreaks. We describe this particular form of subacute measles encephalitis (SME) in a group of HIV-infected children and adolescents with severe immunosuppression. Methods This is a single-center study, starting in 1997 and covering 4 measles outbreaks in Romania. The presumptive diagnosis of subacute myoclonic measles encephalitis (SMME) was based on: (1) epidemiological data, previous measles episode or presumed contact with measles virus (MV), (2) clinical presentation with initial localized myoclonic jerks with rapid extension and subsequent motor deficit with preserved mental status, and (3) neuroimaging studies revealing cortical gray matter lesions. Definitive diagnosis was based on a neuropathological exam and immunohistochemistry of brain tissues, and measles RNA detection in the cerebrospinal fluid (CSF). Results Thirty-six patients were diagnosed with a particular form of SME during consecutive measles outbreaks in Romania: 1996-1998 (22); 2005-2008 (12); 2010-2011 (1) and 2016-2018 (1). Most children were born in the late 80s and had parenterally acquired HIV infection in early childhood. Before the episode of SMME, 11 patients had confirmed measles, while the rest, without typical rash, had a respiratory tract infection and/or presumed previous measles contact. In all patients, the clinical onset was sudden, with unilateral myoclonus. MRI findings revealed mainly focal cortical gray matter lesions. Neurologic symptoms progressed rapidly to coma and death in most patients. Three patients survived SMME, they had higher CD4 count at onset, slower progression of neurological symptoms, and benefit of immune recovery with cART. Immunocytochemistry studies revealed MV in the brain with a pattern suggesting an ascending viral neural infection. MV was isolated from CSF in 7 out of 8 patients. Sequence analysis of MV RNA from both nasopharyngeal swabs and CSF was available for one patient with similar N-450 strain characteristics. Conclusion During an outbreak of measles, neurological manifestations, especially myoclonus in immunosuppressed patients, can be related to measles even in the absence of an acute episode. This particular form of subacute myoclonic measles encephalitis is an opportunistic fatal disease. Immune recovery due to effective antiretroviral treatment might increase survival.
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Affiliation(s)
- Luminita Ene
- “Dr. Victor Babes” Hospital for Infectious and Tropical Diseases, Bucharest, Romania
| | - Dan Duiculescu
- “Dr. Victor Babes” Hospital for Infectious and Tropical Diseases, Bucharest, Romania
| | - Roxana Radoi
- “Dr. Victor Babes” Hospital for Infectious and Tropical Diseases, Bucharest, Romania
| | | | - Gratiela Tardei
- “Dr. Victor Babes” Hospital for Infectious and Tropical Diseases, Bucharest, Romania
| | - Eugenia Ungureanu
- “Dr. Victor Babes” Hospital for Infectious and Tropical Diseases, Bucharest, Romania
| | - Simona Ruta
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Ştefan S. Nicolau Institute of Virology, Bucharest, Romania
| | - Harry V. Vinters
- University of California, Los Angeles, Los Angeles, CA, United States
| | - Scott Letendre
- University of California, San Diego, La Jolla, CA, United States
| | - Igor Grant
- University of California, San Diego, La Jolla, CA, United States
| | - Ronald J. Ellis
- University of California, San Diego, La Jolla, CA, United States
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Koziorowska-Gawron E, Koszewicz M, Bladowska J, Ejma M, Budrewicz S. Opsoclonus-myoclonus syndrome with severe clinical course and beneficial outcome: A case report. Medicine (Baltimore) 2021; 100:e25261. [PMID: 33832088 PMCID: PMC8036019 DOI: 10.1097/md.0000000000025261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/04/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Opsoclonus-myoclonus syndrome (OMS) is a rare immune-mediated movement disorder, mostly of paraneoplastic or idiopathic origin. The disease usually has an acute onset, serious course and leads rapidly to disability in adult patients. To the best of our knowledge, this is the fourth presented case of OMS with a severe course and complete reversibility of neurological symptoms in a pregnant woman. This report includes videos and a literature review. PATIENT CONCERNS A 30-year-old woman in the 12th week of pregnancy developed severe nausea and vomiting, after several days balance and gait disorders appeared. On admission to hospital, neurological examination revealed opsoclonus, dysarthria, myoclonic jerks with ataxia of the trunk and limbs with inability to sit, stand or walk. DIAGNOSIS Well-known causes of OMS were excluded. Although in our patient the idiopathic origin of the disorder was taken under consideration, diagnosis of opsoclonus-myoclonus related to the pregnancy was highly likely. INTERVENTIONS After administration of steroids and benzodiazepines the patient improved. OUTCOMES In the 6th month of pregnancy, after termination of immunotherapy, she recovered completely and was able to sit, stand and walk independently. In the 39th week of pregnancy, she delivered a healthy child. LESSONS We confirm that understanding of clinical symptoms and rare causes of OMS contributes to early diagnosis and therapy, which ensures an optimal outcome. One probable cause of OMS could be a physiological change to immune system regulation during pregnancy. The relationship between OMS and pregnancy remains uncertain and needs further investigation.
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Affiliation(s)
| | | | - Joanna Bladowska
- Department of General, Interventional Radiology and Neuroradiology, Wroclaw Medical University, Wroclaw, Poland
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Ding X, Yang W, Ren Q, Hu J, Yang S, Han W, Wang J, Wang X, Wang H. Serum IgG-induced microglial activation enhances neuronal cytolysis via the NO/sGC/PKG pathway in children with opsoclonus-myoclonus syndrome and neuroblastoma. J Neuroinflammation 2020; 17:190. [PMID: 32546235 PMCID: PMC7298801 DOI: 10.1186/s12974-020-01839-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 05/11/2020] [Indexed: 12/14/2022] Open
Abstract
Background Opsoclonus-myoclonus syndrome (OMS) is a rare neurological disease. Some children with OMS also have neuroblastoma (NB). We and others have previously documented that serum IgG from children with OMS and NB induces neuronal cytolysis and activates several signaling pathways. However, the mechanisms underlying OMS remain unclear. Here, we investigated whether nitric oxide (NO) from activated microglias and its cascade contribute to neuronal cytolysis in pediatric OMS. Methods The activation of cultured cerebral cortical and cerebellar microglias incubated with sera or IgG isolated from sera of children with OMS and NB was measured by the expression of the activation marker, cytokines, and NO. Neuronal cytolysis was determined after exposing to IgG-treated microglia-conditioned media. Using inhibitors and activators, the effects of NO synthesis and its intracellular cascade, namely soluble guanylyl cyclase (sGC) and protein kinase G (PKG), on neuronal cytolysis were evaluated. Results Incubation with sera or IgG from children with OMS and NB increased the activation of cerebral cortical and cerebellar microglias, but not the activation of astrocytes or the cytolysis of glial cells. Moreover, the cytolysis of neurons was elevated by conditioned media from microglias incubated with IgG from children with OMS and NB. Furthermore, the expression of NO, sGC, and PKG was increased. Neuronal cytolysis was relieved by the inhibitors of NO signaling, while neuronal cytolysis was exacerbated by the activators of NO signaling but not proinflammatory cytokines. The cytolysis of neurons was suppressed by pretreatment with the microglial inhibitor minocycline, a clinically tested drug. Finally, increased microglial activation did not depend on the Fab fragment of serum IgG. Conclusions Serum IgG from children with OMS and NB potentiates microglial activation, which induces neuronal cytolysis through the NO/sGC/PKG pathway, suggesting an applicability of microglial inhibitor as a therapeutic candidate.
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Affiliation(s)
- Xu Ding
- Laboratory of Nutrition and Development, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 Nan-li-shi Road, Xi-Cheng District, Beijing, 100045, China.
| | - Wei Yang
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Qinghua Ren
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Jiajian Hu
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Shen Yang
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Wei Han
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Jing Wang
- Department of Neurobiology, School of Basic Medical Sciences, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, 100069, China
| | - Xu Wang
- Department of Neurology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Huanmin Wang
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.
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Figlerowicz M, Mazur-Melewska K, Kemnitz P, Mania A. Pediatric postviral autoimmune disorders of the CNS. Future Virol 2020. [DOI: 10.2217/fvl-2019-0162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Infections caused by various viruses, mainly belonging to the Herpesviridae family, can trigger the autoimmune process in the CNS in children. This can break brain immune tolerance and induce many molecular and cellular pathways of the immune response. This can lead to the appearance of neuronal auto-antibodies to intracellular, cell-surface or extracellular synaptic antigens. Children may also display a wide spectrum of neurological problems from encephalitis to obsessive–compulsive or tic disorders. In these cases, patients rarely respond to traditional treatment, based on antiviral or/and symptomatic drugs, but early immunotherapy is very effective. The implementation of routine immune tests in all children with acute neurological disorders should be recommended.
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Affiliation(s)
- Magdalena Figlerowicz
- Department of Infectious Diseases & Child Neurology, Karol Marcinkowski University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznań, Poland
| | - Katarzyna Mazur-Melewska
- Department of Infectious Diseases & Child Neurology, Karol Marcinkowski University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznań, Poland
| | - Paweł Kemnitz
- Department of Infectious Diseases & Child Neurology, Karol Marcinkowski University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznań, Poland
| | - Anna Mania
- Department of Infectious Diseases & Child Neurology, Karol Marcinkowski University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznań, Poland
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Ding X, Han W, Wang J, Yang W, Chang XF, Zhu ZY, Qin H, Zhang JZ, Wang X, Wang HM. IGF-1 alleviates serum IgG-induced neuronal cytolysis through PI3K signaling in children with opsoclonus-myoclonus syndrome and neuroblastoma. Pediatr Res 2019; 85:885-894. [PMID: 30718793 DOI: 10.1038/s41390-018-0251-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Opsoclonus-myoclonus syndrome (OMS) is a rare neurological disorder, usually accompanied by neuroblastoma (NB). There is no targeted treatment and animal model of OMS. We aimed to investigate whether insulin-like growth factor 1 (IGF-1)/phosphoinositide 3-kinase (PI3K) signaling alleviates neuronal cytolysis in pediatric OMS. METHODS Cultured rat cerebral cortical neurons and cerebellar neurons were incubated with sera or IgG isolated from sera of children with OMS and NB. Cytolysis and PI3K expression were measured by the lactate dehydrogenase assay and enzyme-linked immunosorbent assay, respectively. Using inhibitors and activators, the effects of IGF-1 and PI3K on cytolysis were investigated. RESULTS The incubation of sera or IgG from children with OMS and NB increased cytolysis in not only cerebellar neurons, but also cerebral cortical neurons. Furthermore, the IGF-1 receptor antagonist NVP-AEW541 exaggerated cytolysis in children with OMS and NB. IGF-1 alleviated cytolysis, which was blocked by the PI3K inhibitor LY294002. Additionally, sera or IgG from children with OMS and NB compensatively elevated PI3K expression. LY294002 exacerbated cytolysis; whereas, the PI3K activator 740 Y-P suppressed cytolysis. CONCLUSION IGF-1/PI3K signaling alleviates the cytolysis of cultured neurons induced by serum IgG from children with OMS and NB, which may be innovation therapy targets.
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Affiliation(s)
- Xu Ding
- Nutrition Research Unit, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Wei Han
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jing Wang
- Department of Neurobiology, School of Basic Medical Sciences, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
| | - Wei Yang
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xiao-Feng Chang
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhi-Yun Zhu
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Hong Qin
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jin-Zhe Zhang
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xu Wang
- Department of Neurology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Huan-Min Wang
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
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Oh SY, Kim JS, Dieterich M. Update on opsoclonus-myoclonus syndrome in adults. J Neurol 2018; 266:1541-1548. [PMID: 30483882 DOI: 10.1007/s00415-018-9138-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/17/2018] [Accepted: 11/21/2018] [Indexed: 01/12/2023]
Abstract
Opsoclonus-myoclonus syndrome in adults is a rare and heterogeneous disorder with the clinical features of opsoclonus, myoclonus, ataxia, and behavioral and sleep disturbances. The pathophysiology is thought to be immunological on the basis of paraneoplastic or infectious etiologies. Immunomodulatory therapies should be performed although the response may be incomplete. A number of autoantibodies have been identified against a variety of antigens, but no diagnostic immunological marker has yet been identified. This review focuses on underlying mechanisms of opsoclonus-myoclonus syndrome, including findings that have been identified recently, and provides an update on the clinical features and treatments of this condition.
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Affiliation(s)
- Sun-Young Oh
- Department of Neurology, Chonbuk National University School of Medicine, 20 Geonji-ro, Deokjin-gu, Jeonju, Chonbuk, 561-712, South Korea.
- Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, South Korea.
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
- Department of Neurology, Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Marianne Dieterich
- Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
- German Center for Vertigo and Balance Disorders (IFBLMU), Ludwig-Maximilians University, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
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Guedes BF, Vieira Filho MAA, Listik C, Carra RB, Pereira CB, Silva ERD, Gomes HR, Vidal JE. HIV-associated opsoclonus-myoclonus-ataxia syndrome: early infection, immune reconstitution syndrome or secondary to other diseases? Case report and literature review. J Neurovirol 2017; 24:123-127. [PMID: 29243132 DOI: 10.1007/s13365-017-0603-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/16/2017] [Accepted: 11/09/2017] [Indexed: 11/29/2022]
Abstract
Opsoclonus-myoclonus-ataxia (OMA) syndrome is a debilitating autoimmune neurological disorder. Post-infectious opsoclonus-myoclonus-ataxia syndrome has been described with varying bacterial, spirochetal, and viral infections including several patients with HIV. However, specific immunopathological mechanisms that may lead to opsoclonus-myoclonus in HIV-positive patients are unknown.We report a case of HIV-associated opsoclonus-myoclonus and early HIV infection. A review of published literature shows opsoclonus-myoclonus can occur during early infection, in immune reconstitution syndrome or in association with other infections, especially tuberculosis.
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Affiliation(s)
- Bruno F Guedes
- Department of Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, 5° andar, sala 5084, Cerqueira César, São Paulo, SP, 05403-900, Brazil.
| | - Márcio A A Vieira Filho
- Department of Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, 5° andar, sala 5084, Cerqueira César, São Paulo, SP, 05403-900, Brazil
| | - Clarice Listik
- Department of Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, 5° andar, sala 5084, Cerqueira César, São Paulo, SP, 05403-900, Brazil
| | - Rafael B Carra
- Department of Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, 5° andar, sala 5084, Cerqueira César, São Paulo, SP, 05403-900, Brazil
| | - Cristiane B Pereira
- Department of Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, 5° andar, sala 5084, Cerqueira César, São Paulo, SP, 05403-900, Brazil
| | - Emanuelle R da Silva
- Department of Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, 5° andar, sala 5084, Cerqueira César, São Paulo, SP, 05403-900, Brazil
| | - Hélio R Gomes
- Department of Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, 5° andar, sala 5084, Cerqueira César, São Paulo, SP, 05403-900, Brazil.,Laboratório de Investigação Médica (LIM 14) da FMUSP, São Paulo, Brazil
| | - José E Vidal
- Department of Infectious Diseases, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Laboratório de Investigação Médica (LIM) 49, Instituto de Medicina Tropical da Universidade de São Paulo, São Paulo, Brazil.,Department of Neurology, Instituto de Infectologia Emilio Ribas, São Paulo, Brazil
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Pereira NMD, Shah I, Kulkarni S. Opsoclonus-myoclonus-ataxia syndrome in an HIV-infected child. Oxf Med Case Reports 2016; 2016:omw077. [PMID: 27699054 PMCID: PMC5045539 DOI: 10.1093/omcr/omw077] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 07/22/2016] [Accepted: 08/08/2016] [Indexed: 11/12/2022] Open
Abstract
Opsoclonus–myoclonus–ataxia (OMA) syndrome typically presents with chaotic eye movements and myoclonus with some patients exhibiting ataxia and behavioural disturbances. The pathogenesis may be inflammatory with an infectious or paraneoplastic trigger. We present a 13-year-old HIV-infected girl who was initially started on highly active antiretroviral therapy (HAART) in March 2013 with a CD4 count of 79 cells/cumm. Initially, the patient did not comply with treatment, resulting in a CD4+ count of 77 cells/mm3 in November 2015 and prompting a new HAART scheme comprising lamivudine, tenofovir and ritonavir-boosted atazanavir. Shortly after starting this scheme, she developed OMA syndrome in January 2016. She was treated with intravenous immunoglobulin and methylprednisolone followed by oral steroids along with oral clonazepam and gradually recovered. We suggest immune reconstitution inflammatory syndrome as a possible aetiology of OMA in HIV-infected children.
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Affiliation(s)
- Noella Maria Delia Pereira
- Department of Pediatrics, Pediatric HIV Clinic , Bai Jerbai Wadia Hospital for Children , Dr Acharya Donde Marg , Parel , Mumbai , India
| | - Ira Shah
- Department of Pediatrics, Pediatric HIV Clinic , Bai Jerbai Wadia Hospital for Children , Dr Acharya Donde Marg , Parel , Mumbai , India
| | - Shilpa Kulkarni
- Department of Pediatrics, Division of Pediatric Neurology , Bai Jerbai Wadia Hospital for Children , Dr Acharya Donde Marg, Parel, Mumbai, India
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Armangué T, Sabater L, Torres-Vega E, Martínez-Hernández E, Ariño H, Petit-Pedrol M, Planagumà J, Bataller L, Dalmau J, Graus F. Clinical and Immunological Features of Opsoclonus-Myoclonus Syndrome in the Era of Neuronal Cell Surface Antibodies. JAMA Neurol 2016; 73:417-24. [PMID: 26856612 DOI: 10.1001/jamaneurol.2015.4607] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Most studies on opsoclonus-myoclonus syndrome (OMS) in adults are based on small case series before the era of neuronal cell surface antibody discovery. OBJECTIVE To report the clinical and immunological features of idiopathic OMS (I-OMS) and paraneoplastic OMS (P-OMS), the occurrence of antibodies to cell surface antigens, and the discovery of a novel cell surface epitope. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study and laboratory investigations of 114 adult patients with OMS at a center for autoimmune neurological disorders done between January 2013 and September 2015. MAIN OUTCOMES AND MEASURES Review of clinical records. Immunohistochemistry on rat brain and cultured neurons as well as cell-based assays were used to identify known autoantibodies. Immunoprecipitation and mass spectrometry were used to characterize novel antigens. RESULTS Of the 114 patients (62 [54%] female; median age, 45 years; interquartile range, 32-60 years), 45 (39%) had P-OMS and 69 (61%) had I-OMS. In patients with P-OMS, the associated tumors included lung cancer (n = 19), breast cancer (n = 10), other cancers (n = 5), and ovarian teratoma (n = 8); 3 additional patients without detectable cancer were considered to have P-OMS because they had positive results for onconeuronal antibodies. Patients with I-OMS, compared with those who had P-OMS, were younger (median age, 38 [interquartile range, 31-50] vs 54 [interquartile range, 45-65] years; P < .001), presented more often with prodromal symptoms or active infection (33% vs 13%; P = .02), less frequently had encephalopathy (10% vs 29%; P = .01), and had better outcome (defined by a modified Rankin Scale score ≤ 2 at last visit; 84% vs 39%; P < .001) with fewer relapses (7% vs 24%; P= .04). Onconeuronal antibodies occurred in 13 patients (11%), mostly Ri/ANNA2 antibodies, which were detected in 7 of 10 patients (70%) with breast cancer. Neuronal surface antibodies were identified in 12 patients (11%), mainly glycine receptor antibodies (9 cases), which predominated in P-OMS with lung cancer (21% vs 5% in patients with OMS without lung cancer; P = .02); however, a similar frequency of glycine receptor antibodies was found in patients with lung cancer without OMS (13 of 65 patients [20%]). A novel cell surface epitope, human natural killer 1 (HNK-1), was the target of the antibodies in 3 patients with lung cancer and P-OMS. CONCLUSIONS AND RELEVANCE Patients with I-OMS responded better to treatment and had fewer relapses than those with P-OMS. Older age and encephalopathy, significantly associated with P-OMS, are clinical clues suggesting an underlying tumor. Glycine receptor antibodies occur frequently in P-OMS with lung cancer, but the sensitivity and specificity are low. The HNK-1 epitope is a novel epitope in a subset of patients with P-OMS and lung cancer.
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Affiliation(s)
- Thaís Armangué
- Neuroimmunology Program, Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Lidia Sabater
- Neuroimmunology Program, Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | | | - Eugenia Martínez-Hernández
- Neuroimmunology Program, Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Helena Ariño
- Neuroimmunology Program, Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Mar Petit-Pedrol
- Neuroimmunology Program, Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Jesús Planagumà
- Neuroimmunology Program, Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Luis Bataller
- Service of Neurology, University Hospital Politècnic La Fe, Valencia, Spain
| | - Josep Dalmau
- Neuroimmunology Program, Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain3Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain4Department of Neurology, University of Pennsylva
| | - Francesc Graus
- Neuroimmunology Program, Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain5Service of Neurology, Hospital Clínic, Barcelona, Spain
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Sutter R, Ristic A, Rüegg S, Fuhr P. Myoclonus in the critically ill: Diagnosis, management, and clinical impact. Clin Neurophysiol 2015; 127:67-80. [PMID: 26428447 DOI: 10.1016/j.clinph.2015.08.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/09/2015] [Accepted: 08/20/2015] [Indexed: 12/22/2022]
Abstract
Myoclonus is the second most common involuntary non-epileptic movement in intensive care units following tremor-like gestures. Although there are several types of myoclonus, they remain underappreciated, and their diagnostic and prognostic associations are largely ignored. This review discusses clinical, electrophysiological, neuroanatomical, and neuroimaging characteristics of different types of myoclonus in critically ill adults along with their prognostic impact and treatment options. Myoclonus is characterized by a sudden, brief, and sometimes repetitive muscle contraction of body parts, or a brief and sudden cessation of tonic muscle innervation followed by a rapid recovery of tonus. Myoclonus can resemble physiologic and other pathologic involuntary movements. Neurologic injuries, anesthetics, and muscle relaxants interfere with the typical appearance of myoclonus. Identifying "real myoclonus" and determining the neuroanatomical origin are important, as treatment responses depend on the involved neuroanatomical structures. The identification of the type of myoclonus, the involved neuroanatomical structures, and the associated illnesses is essential to direct treatment. In conclusion, the combined clinical, electrophysiological, and neuroradiological examination reliably uncovers the neuroanatomical sources and the pathophysiology of myoclonus. Recognizing cortical myoclonus is critical, as it is treatable and may progress to generalized convulsive seizures or status epilepticus.
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Affiliation(s)
- Raoul Sutter
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland; Division of Clinical Neurophysiology, Department of Neurology, University Hospital Basel, Basel, Switzerland.
| | - Anette Ristic
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Stephan Rüegg
- Division of Clinical Neurophysiology, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Peter Fuhr
- Division of Clinical Neurophysiology, Department of Neurology, University Hospital Basel, Basel, Switzerland
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Beh SC, Frohman TC, Frohman EM. Neuro-ophthalmic Manifestations of Cerebellar Disease. Neurol Clin 2014; 32:1009-80. [DOI: 10.1016/j.ncl.2014.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Shin C Beh
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Teresa C Frohman
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Elliot M Frohman
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA; Department of Ophthalmology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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Vale TC, Silva RAE, Cunningham MCQES, Maia DP, Camargos ST, Cardoso F. Opsoclonus-myoclonus-ataxia syndrome in an AIDS patient. EINSTEIN-SAO PAULO 2014; 11:533-4. [PMID: 24488398 PMCID: PMC4880396 DOI: 10.1590/s1679-45082013000400023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Accepted: 04/24/2013] [Indexed: 11/22/2022] Open
Abstract
We report the case of a 38-year-old woman with AIDS who developed opsoclonus-myoclonus-ataxia syndrome during a period different from other cases reported in literature. Opsoclonus-myoclonus-ataxia syndrome had already been reported as the initial neurological presentation of AIDS, as well as at the time of HIV-seroconversion and immune reconstitution syndrome. Our case is unique since the patient had an elevated CD4 count and negative viral load in the period when the opsoclonus-myoclonus-ataxia syndrome occurred.
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Cooper CJ, Said S. West nile virus encephalitis induced opsoclonus-myoclonus syndrome. Neurol Int 2014; 6:5359. [PMID: 24987503 PMCID: PMC4077209 DOI: 10.4081/ni.2014.5359] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 02/19/2014] [Indexed: 01/06/2023] Open
Abstract
West Nile virus (WNV) is an arthropod borne neurotropic single stranded RNA flavivirus with <1% developing presenting with neurological disease. Immunocompromised and elderly patients are more prone to developing WNV meningitis or encephalitis. Definitive diagnosis of WNV meningoencephalitis is a combination of clinical suspicion and cerebrospinal fluid (CSF) serology. Forty-eight year old Caucasian female presented with a sudden onset of altered mental status after being found unresponsive. She was confused with intermittent bouts of alertness/lethargy and unintelligible responses to questioning. Her medical problems included endometrial cancer that was in remission after undergoing a total abdominal hysterectomy with bilateral salpingectomy and postoperative chemotherapy with paclitaxel and carboplatin. Pertinent physical examination revealed muscle strength that was significantly decreased, nuchal rigidity and +2 pitting edema of both lower extremities. Computed tomography and magnetic resonance imaging of the brain were negative for any intracranial pathology. CSF analysis was consistent with aseptic meningitis with all CSF serology being negative except for positive WNV antibody. A few days after being admitted she developed involuntary random movements of her eyes and generalized jerking movements (myoclonus). This was determined to be opsoclonus myoclonus syndrome (OMS) induced by the WNV meningoencephalitis. She then received five consecutive days of plasmapheresis with a significant improvement in her neurological status. Opsoclonus-myoclonus syndrome (OMS) is a rare neurological disorder associated with chaotic multidirectional eye movements, myoclonus and less frequently cerebellar ataxia. OMS affects as few as 1 in 10,000,000 people per year. The pathogenesis is not fully understood with the majority of cases of opsoclonus-myoclonus syndrome being idiopathic. According to current medical literature there have only been two previous case reports of opsoclonus myoclonus syndrome associated with WNV encephalitis.
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Affiliation(s)
- Chad J Cooper
- Department of Internal Medicine, Texas Tech University Health Sciences Center , El Paso, TX, USA
| | - Sarmad Said
- Department of Internal Medicine, Texas Tech University Health Sciences Center , El Paso, TX, USA
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Lino AMM, Spera RR, de Campos FPF, Freitas CHDA, Garcia MRT, Lopes LDC, Prokopowitsch AS. Adult-onset opsoclonus-myoclonus-ataxia syndrome as a manifestation of brazilian lyme disease-like syndrome: a case report and review of literature. AUTOPSY AND CASE REPORTS 2014; 4:29-37. [PMID: 28652990 PMCID: PMC5470562 DOI: 10.4322/acr.2014.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 03/09/2014] [Indexed: 11/23/2022] Open
Abstract
Described in 1962, the opsoclonus-myoclonus-ataxia syndrome (OMAS) is a rare, neurologically debilitating disorder with distinct characteristics that may begin in childhood or adult life. Although many cases remain without etiological diagnosis, others are related to neoplasms and infectious diseases. We report a 41-year-old previously healthy male with an 8-day history of headache, vertigo, nausea, vomiting, and nystagmus. After a normal brain computed tomography and lymphocytic pleocytosis in cerebral spinal fluid (CSF), intravenous acyclovir therapy was initiated in the emergency room. On the third day of hospitalization, the diagnosis of OMAS was made based on the presence of chaotic and irregular eye movements, dysarthric speech, gait instability, generalized tremor, and myoclonic jerks. In the face of his neurological worsening, ampicillin followed by nonspecific immunotherapy (methylprednisolone and intravenous immunoglobulin) was prescribed, with mild clinical improvement. After a thorough laboratory workup, the definite diagnosis of neuroborreliosis was established and ceftriaxone (4 g/daily/3 wks) and doxycycline (200 mg/day/2 mo) was administered. Toward the end of the ceftriaxone regimen, the neurologic signs substantially improved. We believe this to be the first case description of OMAS as clinical presentation of Brazilian Lyme disease-like syndrome (Baggio-Yoshinari syndrome).
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Affiliation(s)
- Angelina Maria Martins Lino
- Department of Neurology - Hospital das Clínicas - Faculdade de Medicina - Universidade de São Paulo, São Paulo/SP - Brazil.,Department of Internal Medicine - Hospital Universitário - Universidade de São Paulo, São Paulo/SP - Brazil
| | - Raphael Ribeiro Spera
- Department of Neurology - Hospital das Clínicas - Faculdade de Medicina - Universidade de São Paulo, São Paulo/SP - Brazil
| | | | | | | | - Leonardo da Costa Lopes
- Department of Internal Medicine - Hospital Universitário - Universidade de São Paulo, São Paulo/SP - Brazil
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Bhandari HS. Presentation of opsoclonus myoclonus ataxia syndrome with glutamic acid decarboxylase antibodies. BMJ Case Rep 2012; 2012:bcr2012006339. [PMID: 22878989 PMCID: PMC4543362 DOI: 10.1136/bcr-2012-006339] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
In this rare case, the patient presented with opsoclonus, myoclonus and ataxia. Serological and imaging studies revealed high glutamic acid decarboxylase antibody (GAD-Ab) levels. High-dose corticosteroids were of no benefit and subsequent intravenous immunoglobulin (IVIg) administration proved resolution of the condition. Levetiracetam proved useful in symptomatically controlling the myoclonus. Follow-up GAD-Ab levels were within normal limits.
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Wiersinga WJ, Prins JM, van de Beek D. Therapy-resistant opsoclonus-myoclonus syndrome secondary to HIV-1 infection. Clin Infect Dis 2012; 54:447-8. [PMID: 22247305 DOI: 10.1093/cid/cir711] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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L. Piquet A, Kothari M, Ermak D, Ahmed A. Opsoclonus-Myoclonus Syndrome Post-Vaccination and Viral Illness. ACTA ACUST UNITED AC 2012. [DOI: 10.4236/ijcm.2012.34060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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