Paraneoplastic neurologic syndromes: Clinical presentation and management

Resolution of Paraneoplastic Lumbosacral Plexopathy in a Patient With Stage III Rectal Cancer after Curative Resection

Paraneoplastic syndromes are rare but possible manifestations of colorectal cancer. We present THE CASE of a 51-year-old female diagnosed with cT3N2 rectal adenocarcinoma who developed back pain and progressive muscle weakness during preoperative treatment. She had a rapid worsening in mobility and was ultimately ambulating with a wheelchair, despite physical therapy and conservative treatments. Extensive laboratory workup including onconeural antibodies was negative and her lower extremity electromyogram was suggestive of a subacute demyelinating lumbosacral plexopathy. After multidisciplinary discussion, the decision was made to proceed with curative resection. She had significant improvement in her weakness following resection, suggesting a paraneoplastic etiology. One year after resection, she remains free of disease and is ambulating comfortably. Onconeural antibodies can be a helpful diagnostic tool, but their absence does not rule out paraneoplastic disease. A high index of suspicion is necessary when assessing patients with atypical symptoms, particularly with the rise of colorectal cancer in young adults.

Secondary Psychosis Following Neoadjuvant AC-T Chemotherapy for Triple-Negative Breast Cancer: Case Report and Literature Review of Psychosis Postchemotherapy

Triple-negative breast cancer is a unique subtype among breast cancers. Management includes a neoadjuvant chemotherapy regimen. Psychiatric complications of the regimen have not been reported before. We present a case of acute psychosis after the second cycle of chemotherapy in a 42-year-old woman with triple-negative breast cancer. The patient presented with sudden irritability, agitation, disorganization in speech and behavior, and paranoia involving her coworkers conspiring against her and causing her trouble with the law for 4 days. She was in her usual state of health until after her second cycle of chemotherapy. This was the first presentation of psychotic symptoms in her life. She was conscious and oriented. There were no neurologic deficits. She denied any change in her mood and any features of hallucinations. She was uncooperative, restless, had flight of ideas, and persecutory delusions. The remainder of the examination was normal. An autoimmune process, nervous system infection, or psychosis secondary to the chemotherapy were suspected. Serum electrolytes and other biochemical parameters were normal. Imaging of the brain showed no signs of acute brain insults or intracranial metastasis. Cerebrospinal fluid analysis and culture showed no abnormality or growth. The work-up revealed that neurologic, infectious, or autoimmune causes of her psychotic symptoms were less likely. Thus, a diagnosis of psychosis secondary to chemotherapy was considered. Treatment was with paliperidone, risperidone, clonazepam, and sertraline. Over the course of treatment, she showed substantial improvement and completed all of the chemotherapy sessions without adverse effects. In summary, we report a case of a patient whose initial chemotherapy course was complicated by psychosis. Since the neurotoxic and psychiatric effects of chemotherapeutics are not yet sufficiently elucidated, our case emphasizes that early signs of behavioral changes in patients receiving chemotherapy should trigger comprehensive psychiatric evaluation and monitoring of the patient’s mental state.

Seronegative Paraneoplastic Limbic Encephalitis Associated with Thymoma

Paraneoplastic limbic encephalitis is an autoimmune syndrome characterized by the acute or subacute onset of encephalopathy, memory loss, confusion, temporal lobe seizures, and behavioral and mood changes. Although most patients with paraneoplastic limbic encephalitis have antineuronal antibodies, advances in the field now permit the diagnosis without autoantibody test results. In this case illustrating the new diagnostic criteria, we report a 70-year-old woman who was brought to the emergency room after the acute onset of cognitive impairment, altered mental status, and choreoathetoid movements. Brain magnetic resonance imaging showed hyperintense signals in both temporal lobes, and a chest computed tomogram revealed a thymoma. Because the patient met current diagnostic criteria for autoimmune limbic encephalitis, we were able to start treatment before her antibody tests were processed. The patient received immunotherapy and her tumor was resected. Her choreoathetoid movements disappeared and her other neurologic symptoms improved. Her cerebrospinal fluid proved to be negative for paraneoplastic limbic encephalitis antibodies. Most but not all patients with paraneoplastic limbic encephalitis associated with thymoma have evidence of paraneoplastic antibodies. Prompt management of the underlying malignancy determines whether patients survive and may minimize future cognitive and functional impairment. Practicing neurologists and psychiatrists should be aware of this diagnosis.

Management of neuro-oncologic emergencies

Patients with brain tumors and systemic malignancies are subject to diverse neurologic complications that require urgent evaluation and treatment. These neurologic conditions are commonly due to the tumor's direct effects on the nervous system, such as cerebral edema, increased intracranial pressure, seizures, spinal cord compression, and leptomeningeal metastases. In addition, neurologic complications can develop as a result of thrombocytopenia, coagulopathy, hyperviscosity syndromes, infection, immune-related disorders, and adverse effects of treatment. Patients may present with typical disease syndromes. However, it is not uncommon for patients to have more subtle, nonlocalizing manifestations, such as alteration of mental status, that could be attributed to other systemic, nonneurologic complications. Furthermore, neurologic complications are at times the initial manifestations of an undiagnosed malignancy. Therefore a high index of suspicion is essential for rapid assessment and management. Timely intervention may prolong survival and improve quality of life. In this chapter, we will discuss the common neuro-oncologic emergencies, including epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment.

Cohort study of mesenteric panniculitis and its relationship to malignancy

Background

Mesenteric panniculitis (MP) is a rare condition that historically has been associated with the presence of malignancy. Paraneoplastic phenomena in general regress with cure and in most cases with treatment of the cancer. This study was undertaken to determine whether MP regressed with cancer treatment and cure.

Methods

This was a retrospective review of a database of all patients with MP confirmed on CT between 2003 and August 2015 at Christchurch Hospital. Patients were categorized as having malignant or non-malignant disease, and follow-up scans were assessed for remission of MP. Patients with malignancy were further categorized as having malignancy cured or not cured.

Results

A total of 308 patients were identified with possible MP; 135 were excluded as radiological appearances were not typical of MP (43 patients) or there was no follow-up CT (92). Of 173 patients (131 men) included, 75 (43·4 per cent) were diagnosed with malignancy. Follow-up imaging showed that 33 patients (19·1 per cent) had remission of MP, whereas 140 (80·9 per cent) had no remission. There was no difference in the rates of MP remission in the malignancy versus no malignancy groups (P = 1·000), or between groups in which malignancy was cured or not cured (P = 0·572). Nor was there any difference in the rates of MP remission in malignancy cured versus no malignancy groups (P = 0·524).

Conclusion

MP does not behave like a paraneoplastic phenomenon. The association with malignancy is most likely an epiphenomenon of the many CT images acquired for staging of cancer.

A Rare Case of Childhood Stiff Person Syndrome Associated With Pleuropulmonary Blastoma

INTRODUCTION

Stiff person syndrome is a rare autoimmune, neurological disorder characterized by progressive rigidity and episodic painful spasms, predominantly affecting the proximal limbs and axial muscles, and leading to progressive disability. We report the case of a child who developed symptoms compatible with stiff person syndrome during treatment for pleuropulmonary blastoma.

PATIENT DESCRIPTION

A 3-year, 5-month-old girl was admitted for gradually worsening postural tremor, painful spasms, and generalized stiffness. Since the age of 3 years, she had been on adjuvant chemotherapy for pleuropulmonary blastoma before surgical resection. Brain magnetic resonance imaging and electroencephalographic findings were normal. Although serologic tests for autoimmune disease, including paraneoplastic antibodies and antiglutamic acid decarboxylase antibodies, were unremarkable, her findings were attributed to a paraneoplastic syndrome based on her clinical features and medical history. However, following the planned pulmonary lobectomy, her symptoms were paradoxically aggravated, with continuous motor unit potential at rest on electromyography, which occurs in stiff person syndrome. She gradually improved during postadjuvant chemotherapy with simultaneous immunotherapy including intravenous immunoglobulins and methylprednisolone, and she had recovered completely when evaluated at the 22-month follow-up visit after completion of her treatment for pleuropulmonary blastoma.

CONCLUSION

We present the first documented child with stiff person syndrome associated with pleuropulmonary blastoma. The marked clinical improvement following chemotherapy for pleuropulmonary blastoma was yet more proof of the pleuropulmonary blastoma-related stiff person syndrome. In children with a malignancy and stiff person syndrome, a paraneoplastic syndrome should be considered and the treatment for the malignancy must be undertaken.