Opsoclonus-Myoclonus Syndrome, Neuroblastoma, and Insulin-Dependent Diabetes Mellitus in a Child: A Unique Patient

Faciobrachial Myoclonus as the Presenting Manifestation of Diabetic Keto-Acidosis

Background:

Chorea and ballism are well-recognized acute potentially reversible movement disorders as the presenting manifestation of non-ketotic hyperglycemic states among older type-2 diabetics. Myoclonus as the form of presentation of diabetic keto-acidosis (DKA) in previously undiagnosed type-1 diabetic has never been reported before.

Case report:

We herein report the case of a 36-year-old previously healthy patient who presented with acute onset incessant faciobrachial myoclonus for 10 days. The patient was found to be suffering from DKA and eventually diagnosed as type-1 diabetes mellitus. Myoclonus disappeared with achieving euglycemia and did not recur.

Discussion:

Apart from expanding the spectrum of acute movement disorder among diabetics, this case reiterates the importance of rapid bedside measurement of capillary blood glucose in all patients presenting with acute onset abnormal movements irrespective of their past glycemic status. This simple yet life-saving approach can clinch the diagnosis at the earliest and thus will avoid costly investigations and mismanagement.

The Treatment of Opsoclonus-Myoclonus Syndrome Secondary to Neuroblastic Tumours-Single-Centre Experience and Literature Review

Background and Objectives: The opsoclonus-myoclonus syndrome (OMS) is characterised by opsoclons, myoclons and impaired balance, often concomitant with sleep disorder and behavioural difficulties. The symptoms develop as a result of autoimmune response triggered by a neuroblastic tumour (NT). OMS can also develop secondarily to a viral infection or as an immune response triggered by an unknown agent. This leads to the activation of B- and T-cells, which produce and release autoantibodies or cytokines directly within the central nervous system (CNS), thus damaging the neurons within the cerebellum and the brain stem. The available OMS treatments aim at decreasing lymphocyte, cytokine and autoantibody production or accelerating the utilisation of the latter. Another treatment option for OMS involves using cytostatic agents, which damage T- and B-cells causing their depletion and impaired function, which reduces their ability to produce antibodies and cytokines. Materials and Methods: We present a single-centre experience in treating OMS secondary to NT in 7 children. Results: The combined treatment with cyclophosphamide plus dexamethasone resulted in a complete resolution of OMS symptoms in 4 children, and a significant improvement in the 3 children. Two of them periodically present hyperactivity, and one girl requires an additional support at school due to special educational needs (SEN). Conclusions: NT resection does not resolve OMS in children with OMS secondary to NT. The combined treatment with dexamethasone plus cyclophosphamide seems to be an effective treatment of OMS.

Anti-glutamate Dehydrogenase Antibody Positive Cerebellar Ataxia and Stiff Person Syndrome Responding to Dual Treatment with Steroids and Intravenous Immunoglobulin: A Case Presentation and Literature Review

Anti-glutamic acid decarboxylase (anti-GAD) antibody syndrome (aGAS) has various presentations including cerebellar ataxia (CA) and stiff person syndrome (SPS). This is a treatable cause of CA and SPS. We present a case of a 49-year-old man who developed blurred vision, slurred speech, difficulty walking, unsteady gait, and clumsiness which had progressed over four months. The patient was found to have anti-GAD ab (+) CA and SPS and experienced significant symptomatic improvements after treatment with intravenous (IV) steroids followed by intravenous immunoglobulin (IVIG). The patient’s improvement persisted when he was reevaluated at follow up one month later. Since anti-GAD ab related diseases, including anti-GAD CA and SPS, are rarely diagnosed, there is limited data regarding the treatment of this condition. As there are only a few cases in the literature similar to this one, highlighting the successful treatment of anti-GAD ab cerebellar ataxia and SPS with dual therapy (steroids followed by IVIG) is important.