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Romero C, Quijada A, Abudinén G, Céspedes C, Aguilera L. Opercular myoclonic-anarthric status (OMASE) secondary to anti-Hu paraneoplastic neurological syndrome. Epilepsy Behav Rep 2024; 27:100703. [PMID: 39233876 PMCID: PMC11372628 DOI: 10.1016/j.ebr.2024.100703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 08/01/2024] [Accepted: 08/02/2024] [Indexed: 09/06/2024] Open
Abstract
Focal Opercular Myoclonic - Anarthric Status Epilepticus (OMASE) is a rare form of focal motor status epilepticus caused by several etiologies. It is characterized by fluctuating dysarthria and epileptic myoclonus involving the bilateral glossopharyngeal musculature. We present the case of a 52-year-old woman who experienced gradual and progressive paralysis and myoclonus of facial and bulbar muscles; additional tests revealed the presence of right breast ductal adenocarcinoma and positive serum anti-Hu and anti-GAD65 antibodies. High doses of steroid pulses, anti-seizure therapy, and rituximab partially controlled myoclonus; the tumor resection improved dysphagia and dysarthria.
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Affiliation(s)
- César Romero
- Neurology and Neurosurgery Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Alonso Quijada
- Neurology and Neurosurgery Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Gabriel Abudinén
- Neurology and Neurosurgery Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Catherine Céspedes
- Neurology and Neurosurgery Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Ledda Aguilera
- Neurology and Neurosurgery Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
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Zhou J, Jin M, Su Y, Zhuo X, Fu L, Ren X, Ren C, Zhou A, Li J, Zhang W. Clinical Presentation, Management, and Diagnostic Performance of 2021 Criteria for Paraneoplastic Neurologic Syndromes in Childhood. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200242. [PMID: 38657195 PMCID: PMC11087047 DOI: 10.1212/nxi.0000000000200242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/08/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND AND OBJECTIVES Paraneoplastic neurologic syndromes (PNSs) are remote neurologic immune-related effects of tumors. The clinical characteristics of pediatric PNSs remain unclear. We retrospectively examined the clinical characteristics of cases of pediatric PNSs and assessed the performance of the 2021 diagnostic criteria in children. METHODS Patients hospitalized in the Beijing Children's Hospital between June 2015 and June 2023 and fulfilling the description of definite by 2004 diagnostic criteria of PNSs were included. A retrospective analysis of clinical characteristics was conducted, and the 2021 diagnostic criteria were applied to rediagnostic stratification. RESULTS Among the 42 patients included, the most common neurologic syndrome was opsoclonus-myoclonus syndrome (OMS) (62%), followed by rapidly progressive cerebellar syndrome (26%). Most tumors were neuroblastomas (88%), with few being ovarian teratomas (10%). Approximately 71% (30/42) of patients were classified as definite and 24% (10/42) as probable according to the 2021 criteria. All cases judged as probable exhibited rapidly progressive cerebellar ataxia with neuroblastoma. For OMS, chemotherapy was administered based on the tumor's risk stage, accompanied by regular infusion of IV gamma globulin and oral steroids following tumor diagnosis. Twenty-one patients underwent regular follow-ups over 4.92 (0.58-7.58) years. The initial hospitalization recorded a median score of 12 (7-14) on the Mitchell and Pike OMS rating scale, decreasing to 0 (0-5) at the final follow-up. In cases of rapidly progressive cerebellar syndrome, a similar therapeutic regimen was used. Nine patients underwent regular follow-ups over 4.42 (1.17-7.50) years. The mean modified Rankin scale score at first hospitalization was 4 (3-4), reducing to 1 (0-4) at the final follow-up. Only 17% (5/30) of patients across both groups exhibited poor response to this regimen. Among these 5 patients, 4 belonged to the low-risk group (without chemotherapy). DISCUSSION OMS followed by rapidly progressive cerebellar ataxia are the most common forms of PNSs in children and are associated with neuroblastoma. An aggressive approach with multiple immunotherapies may improve the prognosis of neuroblastoma-associated PNSs. The 2021 criteria perform well in pediatric PNSs. However, we propose upgrading the classification of antibody-negative rapidly progressive cerebellar ataxia with neuroblastoma to definite diagnosis. This adjustment aims to further improve the diagnostic efficacy of this diagnostic criterion in childhood.
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Affiliation(s)
- Ji Zhou
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Mei Jin
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Yan Su
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Xiuwei Zhuo
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Libing Fu
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Xiaotun Ren
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Changhong Ren
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Anna Zhou
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Jiuwei Li
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Weihua Zhang
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
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Zeny MS, do Valle DA, Santos MLSF, Bara TS, Cordeiro ML. Characteristics of Opsoclonus-Myoclonus Syndrome in Patients of the Largest Pediatric Hospital in Latin America. Pediatr Neurol 2024; 154:9-14. [PMID: 38430891 DOI: 10.1016/j.pediatrneurol.2023.12.028] [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: 11/29/2022] [Revised: 12/19/2023] [Accepted: 12/30/2023] [Indexed: 03/05/2024]
Abstract
BACKGROUND Opsoclonus-myoclonus syndrome (OMS) is a rare neuroinflammatory disorder characterized by ataxia, opsoclonus, and myoclonus. Clinical diagnosis of OMS has been challenging; therefore, we sought to determine the clinical and treatment profiles of patients with OMS at the largest pediatric hospital in Latin America. METHODS We analyzed the data of patients diagnosed with OMS between 2010 and 2020 at Pequeno Principe Hospital (Brazil) to determine the corresponding clinical profile more accurately. RESULTS Of the approximately 50,000 visitors to our pediatric neurology department from 2010 to 2020, 10 patients with OMS were observed. Five nontumor cases included three parainfectious and two idiopathic cases. The median time from symptom onset to diagnosis was 34 days. All patients with diagnostic OMS criteria in the idiopathic, nontumor group underwent whole-exome sequencing, with potentially pathogenic mutations identified in two cases. Nine patients were treated with methylprednisolone pulse, followed by oral steroids; eight received one or more intravenous immunoglobulin treatments; and six received azathioprine and cyclophosphamide. Complete symptomatic recovery was observed in only one patient. CONCLUSIONS OMS diagnosis remains challenging. Diagnostic suspicion is necessary to improve the management of these patients and allow early immunosuppressive treatment. Paraneoplastic etiology is the most prevalent. In idiopathic patients who do not respond to immunosuppressive treatment, tests, such as whole-exome sequencing, may reveal a differential diagnosis. Genetic alterations that increase the risk of tumors may be an important clue to the pathophysiology of OMS.
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Affiliation(s)
- Michelle Silva Zeny
- Faculdades Pequeno Príncipe, Curitiba, PR, Brazil; Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba, PR, Brazil; Department of Child Neurology Hospital Pequeno Príncipe, Curitiba, PR, Brazil
| | - Daniel Almeida do Valle
- Faculdades Pequeno Príncipe, Curitiba, PR, Brazil; Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba, PR, Brazil; Department of Child Neurology Hospital Pequeno Príncipe, Curitiba, PR, Brazil
| | | | - Tiago S Bara
- Faculdades Pequeno Príncipe, Curitiba, PR, Brazil; Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba, PR, Brazil
| | - Mara L Cordeiro
- Faculdades Pequeno Príncipe, Curitiba, PR, Brazil; Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba, PR, Brazil; Department of Psychiatry and Biological Behavioral Sciences, University of California Los Angeles (UCLA), Los Angeles, California.
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Cabreira V, Ferreira D, Melo C, Rebelo J, Fonseca J, Sousa R, Sampaio M. Child Neurology: Anti-Hu Encephalitis in an Adolescent With a Mediastinal Seminoma. Neurology 2023; 101:e1640-e1645. [PMID: 37527936 PMCID: PMC10585676 DOI: 10.1212/wnl.0000000000207673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 06/06/2023] [Indexed: 08/03/2023] Open
Abstract
Anti-Hu antibodies are associated with autoimmune syndromes, mainly limbic encephalitis, encephalomyelitis, and painful sensory polyneuropathy (Denny-Brown). We report the case of a 15-year-old boy presenting with epilepsia partialis continua (EPC) found to have a right middle frontal gyrus brain lesion without atrophy or contralateral involvement. After partial resection, neuropathology revealed neuronal loss, reactive gliosis and astrocytosis, and perivascular mononuclear inflammatory infiltrate and features of neuronophagia resembling Rasmussen encephalitis. Suboptimal response to antiseizure drugs and surgery prompted further workup with identification of positive serum anti-Hu antibodies and a mediastinal seminoma. The patient was treated with immunotherapy including steroids, IV immunoglobulin, azathioprine, rituximab, plasmapheresis, and mediastinal lesion resection. However, he continued to experience EPC and psychomotor impairment along with left hemiparesis and dysarthria. Given clinical progression with failure to respond to immunotherapy and antiseizure polytherapy, hemispherotomy was attempted and seizure freedom achieved. A review of the literature found only 16 cases of neurologic presentations associated with anti-Hu antibodies in children, confirming the rarity of EPC in these cases. Thus, this report provides a new observation of germ cell mediastinal tumor associated with anti-Hu antibodies in children, broadening the spectrum of anti-Hu-associated neurologic disorders in children and highlighting the importance of considering antineuronal antibody testing in children presenting with EPC and brain lesions suggestive of Rasmussen encephalitis.
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Affiliation(s)
- Veronica Cabreira
- From the Neurology Department (V.C., D.F.), Centro Hospitalar Universitário de São João; Neurosciences and Mental Health Department (V.C., D.F.), Faculty of Medicine, University of Porto; Neuropediatrics Unit (C.M., J.F., R.S., M.S.), Pediatrics Department, Centro Hospitalar Universitário de São João; Department of Pediatrics and Gynecology-Obstetrics (C.M., J.F., R.S., M.S.), Faculty of Medicine, Universidade do Porto; and Pediatric Oncology Department (J.R.), Centro Hospitalar Universitário de São João, Porto, Portugal.
| | - Daniel Ferreira
- From the Neurology Department (V.C., D.F.), Centro Hospitalar Universitário de São João; Neurosciences and Mental Health Department (V.C., D.F.), Faculty of Medicine, University of Porto; Neuropediatrics Unit (C.M., J.F., R.S., M.S.), Pediatrics Department, Centro Hospitalar Universitário de São João; Department of Pediatrics and Gynecology-Obstetrics (C.M., J.F., R.S., M.S.), Faculty of Medicine, Universidade do Porto; and Pediatric Oncology Department (J.R.), Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Cláudia Melo
- From the Neurology Department (V.C., D.F.), Centro Hospitalar Universitário de São João; Neurosciences and Mental Health Department (V.C., D.F.), Faculty of Medicine, University of Porto; Neuropediatrics Unit (C.M., J.F., R.S., M.S.), Pediatrics Department, Centro Hospitalar Universitário de São João; Department of Pediatrics and Gynecology-Obstetrics (C.M., J.F., R.S., M.S.), Faculty of Medicine, Universidade do Porto; and Pediatric Oncology Department (J.R.), Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Joana Rebelo
- From the Neurology Department (V.C., D.F.), Centro Hospitalar Universitário de São João; Neurosciences and Mental Health Department (V.C., D.F.), Faculty of Medicine, University of Porto; Neuropediatrics Unit (C.M., J.F., R.S., M.S.), Pediatrics Department, Centro Hospitalar Universitário de São João; Department of Pediatrics and Gynecology-Obstetrics (C.M., J.F., R.S., M.S.), Faculty of Medicine, Universidade do Porto; and Pediatric Oncology Department (J.R.), Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Jacinta Fonseca
- From the Neurology Department (V.C., D.F.), Centro Hospitalar Universitário de São João; Neurosciences and Mental Health Department (V.C., D.F.), Faculty of Medicine, University of Porto; Neuropediatrics Unit (C.M., J.F., R.S., M.S.), Pediatrics Department, Centro Hospitalar Universitário de São João; Department of Pediatrics and Gynecology-Obstetrics (C.M., J.F., R.S., M.S.), Faculty of Medicine, Universidade do Porto; and Pediatric Oncology Department (J.R.), Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Raquel Sousa
- From the Neurology Department (V.C., D.F.), Centro Hospitalar Universitário de São João; Neurosciences and Mental Health Department (V.C., D.F.), Faculty of Medicine, University of Porto; Neuropediatrics Unit (C.M., J.F., R.S., M.S.), Pediatrics Department, Centro Hospitalar Universitário de São João; Department of Pediatrics and Gynecology-Obstetrics (C.M., J.F., R.S., M.S.), Faculty of Medicine, Universidade do Porto; and Pediatric Oncology Department (J.R.), Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Mafalda Sampaio
- From the Neurology Department (V.C., D.F.), Centro Hospitalar Universitário de São João; Neurosciences and Mental Health Department (V.C., D.F.), Faculty of Medicine, University of Porto; Neuropediatrics Unit (C.M., J.F., R.S., M.S.), Pediatrics Department, Centro Hospitalar Universitário de São João; Department of Pediatrics and Gynecology-Obstetrics (C.M., J.F., R.S., M.S.), Faculty of Medicine, Universidade do Porto; and Pediatric Oncology Department (J.R.), Centro Hospitalar Universitário de São João, Porto, Portugal
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Smith KM, Britton JW, Thakolwiboon S, Chia NH, Gupta P, Flanagan EP, Zekeridou A, Lopez Chiriboga AS, Valencia Sanchez C, McKeon A, Pittock SJ, Dubey D. Seizure characteristics and outcomes in patients with neurological conditions related to high-risk paraneoplastic antibodies. Epilepsia 2023; 64:2385-2398. [PMID: 37366270 DOI: 10.1111/epi.17695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/21/2023] [Accepted: 06/21/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVE Seizures are a common manifestation of paraneoplastic neurologic syndromes. The objective of this study was to describe the seizure characteristics and outcomes in patients with high-risk paraneoplastic autoantibodies (>70% cancer association) and to determine factors associated with ongoing seizures. METHODS Patients from 2000 to 2020 with seizures and high-risk paraneoplastic autoantibodies were retrospectively identified. Factors associated with ongoing seizures at last follow-up were evaluated. RESULTS Sixty patients were identified (34 males, median age at presentation = 52 years). ANNA1-IgG (Hu; n = 24, 39%), Ma2-IgG (n = 14, 23%), and CRMP5-IgG (CV2; n = 11, 18%) were the most common underlying antibodies. Seizures were the initial presenting symptom in 26 (43%), and malignancy was present in 38 (63%). Seizures persisted for >1 month in 83%, and 60% had ongoing seizures, with almost all patients (55/60, 92%) still being on antiseizure medications at last follow-up a median of 25 months after seizure onset. Ongoing seizures at last follow-up were associated with Ma2-IgG or ANNA1-IgG compared to other antibodies (p = .04), highest seizure frequency being at least daily (p = .0002), seizures on electroencephalogram (EEG; p = .03), and imaging evidence of limbic encephalitis (LE; p = .03). Death occurred in 48% throughout the course of follow-up, with a higher mortality in patients with LE than in those without LE (p = .04). Of 31 surviving patients at last follow-up, 55% continued to have intermittent seizures. SIGNIFICANCE Seizures in the setting of high-risk paraneoplastic antibodies are frequently resistant to treatment. Ongoing seizures are associated with ANNA1-IgG and Ma2-IgG, high seizure frequency, and EEG and imaging abnormalities. Although a subset of patients may respond to immunotherapy and achieve seizure freedom, poor outcomes are frequently encountered. Death was more common among patients with LE.
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Affiliation(s)
- Kelsey M Smith
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Nicholas H Chia
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Pranjal Gupta
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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Marion P, Chalus AD, Giorgi L, Bellesme C, Crétien P, Maurey H, Deiva K. Early and Aggressive Treatment May Modify Anti-Hu Associated Encephalitis Prognosis. Neuropediatrics 2023; 54:64-67. [PMID: 35817357 DOI: 10.1055/a-1896-6687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Anti-Hu encephalitis is a paraneoplastic syndrome in adults. In children, rare cases of anti-Hu encephalitis were reported mostly without underlying tumors and clinical outcome are usually severe. Here, we describe a 4-year-old girl who developed cerebellar syndrome with abnormal behavior. The brain magnetic resonance imaging showed several T2/fluid-attenuated inversion recovery bilateral brain lesions and autoimmune assessment showed positive anti-Hu antibodies. Computed tomography scan revealed ganglioneuroblastoma which was surgically removed 3 months after onset. Aggressive immunotherapy including dexamethasone, rituximab, and intravenous immunoglobulins were used and a marked neurological improvement soon after 9 months of onset was observed with the child being able to go back to school. The short delay between diagnosis and start of aggressive immunotherapy demonstrate the paramount importance of early diagnosis and early specific therapy after onset of symptoms.
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Affiliation(s)
- Perrine Marion
- Pediatric Neurology Department, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Saclay, Le Kremlin Bicêtre, France
| | - Aliénor De Chalus
- Pediatric Neurology Department, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Saclay, Le Kremlin Bicêtre, France
| | - Laetitia Giorgi
- Pediatric Neurology Department, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Saclay, Le Kremlin Bicêtre, France
| | - Céline Bellesme
- Pediatric Neurology Department, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Saclay, Le Kremlin Bicêtre, France
| | - Pascale Crétien
- Pediatric Neurology Department, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Saclay, Le Kremlin Bicêtre, France
| | - Hélène Maurey
- Pediatric Neurology Department, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Saclay, Le Kremlin Bicêtre, France.,Pediatric Neurologic Department, National Referral Center for Rare Brain and Spinal Diseases, Le Kremlin-Bicêtre, France
| | - Kumaran Deiva
- Pediatric Neurology Department, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Saclay, Le Kremlin Bicêtre, France.,Pediatric Neurologic Department, National Referral Center for Rare Brain and Spinal Diseases, Le Kremlin-Bicêtre, France.,Inserm UMR 1184, Immunology of Viral Infections and Autoimmune Diseases, CEA, IDMIT, Le Kremlin Bicêtre, France
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Celdrán-Vivancos D, Noval-Martín S, González-Manrique M, Negoita A, Porto-Castro S. Eye oscilations with neurological implications in pediatric age. ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA 2021; 96:366-376. [PMID: 34217474 DOI: 10.1016/j.oftale.2020.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 09/02/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Eye oscillations, both nystagmic and non-nystagic, can occur from birth. Most correspond to infantile nystagmus that dubates in the first six months of life, which include idiopathic, sensory, latent, or overt latent motor nystagmus. Those associated with neurological diseases or syndromes correspond to approximately 33%, their identification and correct evaluation being important given the potential visual and vital complications. MATERIAL AND METHODS We made a systematic review of the literature on supranuclear gaze control mechanisms and the main ocular oscillations with possible neurological implications, both in childhood. With this, we intend to assess if there are already established clinical-anatomical associations, and to propose a protocol on the complementary studies to be carried out in these cases. RESULTS There are still anatomical pathways involved in supranuclear gaze control that are not fully clarified and understood. Besides, except in the case of nystagmus in seesaw and upbeat, we did not find anatomical explanations for their pathogenesis. The need for complete neuro-ophthalmological physical examinations and the request for additional tests in children who present ocular oscillations with neurological characteristics are clear. CONCLUSIONS Supranuclear gaze control follows a complex neurological network that still needs to be studied better. With a better dissection of the same we could try to understand why the ocular oscillations that we studied have these specific forms of presentation. As for the complementary requests, the request for neuroimaging tests is practically constant, making the others according to the specific case before which we find ourselves.
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Affiliation(s)
- D Celdrán-Vivancos
- Servicio de Oftalmología, Hospital Universitario de La Princesa, Madrid, Spain.
| | - S Noval-Martín
- Servicio de Oftalmología, Hospital Universitario La Paz, Madrid, Spain
| | | | - A Negoita
- Servicio de Radiodiagnóstico, Hospital Universitario Príncipe de Asturias, Madrid, Spain
| | - S Porto-Castro
- Servicio de Oftalmología, Hospital Universitario de La Princesa, Madrid, Spain
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Diagnostic Value of Structural and Functional Neuroimaging in Autoimmune Epilepsy. CONTRAST MEDIA & MOLECULAR IMAGING 2020; 2020:8894213. [PMID: 33380947 PMCID: PMC7752299 DOI: 10.1155/2020/8894213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/14/2020] [Accepted: 12/02/2020] [Indexed: 01/15/2023]
Abstract
Epilepsy is a common nervous system disease, which affects about 70 million people all over the world. In 2017, the International League Against Epilepsy (ILAE) considered immune factors as its independent cause, and the concept of autoimmune epilepsy (AE) was widely accepted. Early diagnosis and timely treatment can effectively improve the prognosis of the disease. However, due to the diversity of clinical manifestations, the expensive cost of autoantibody detection, and the increased prevalence in Western China, the difficulty for clinicians in early diagnosis and treatment has increased. Fortunately, convenient and fast imaging examinations are expected to help even more. The imaging manifestations of AE patients were characteristic, especially the combined application of structural and functional neuroimaging, which improved the diagnostic value of imaging. In this paper, several common autoantibodies associated with AE and their structure and function changes in neuroimaging were reviewed to provide help for neurologists to achieve the goal of precision medicine.
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Abstract
PURPOSE OF REVIEW This article offers clinicians a strategic approach for making sense of a symptom complex that contains myoclonus. The article presents an evaluation strategy that highly leverages the two major classification schemes of myoclonus. The goal of this article is to link evaluation strategy with diagnosis and treatment of myoclonus. RECENT FINDINGS The growth of medical literature has helped better define myoclonus etiologies. Physiologic study of myoclonus types and etiologies with electrophysiologic testing has provided greater clarity to the pathophysiology of the myoclonus in various diseases. Although studies have been limited, the role of newer treatment agents and methods has made progress. SUMMARY Myoclonus has hundreds of different etiologies. Classification is necessary to evaluate myoclonus efficiently and pragmatically. The classification of myoclonus etiology, which is grouped by different clinical presentations, helps determine the etiology and treatment of the myoclonus. The classification of myoclonus physiology using electrophysiologic test results helps determine the pathophysiology of the myoclonus and can be used to strategize symptomatic treatment approaches. Both basic ancillary testing (including EEG and imaging) and more comprehensive testing may be necessary. Treatment of the underlying etiology is the ideal approach. However, if such treatment is not possible or is delayed, symptomatic treatment guided by the myoclonus physiology should be considered. More controlled study of myoclonus treatment is needed. Further research on myoclonus generation mechanisms should shed light on future treatment possibilities.
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Frazzini V, Nguyen-Michel VH, Habert MO, Pichit P, Apartis E, Navarro V. Focal status epilepticus in anti-Hu encephalitis. Autoimmun Rev 2019; 18:102388. [PMID: 31520796 DOI: 10.1016/j.autrev.2019.102388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Valerio Frazzini
- AP-HP, Epilepsy Unit, Rare Epilepsies Referral Center, Pitié-Salpêtrière Hospital and Sorbonne Université, Paris, France; ICM, Brain and Spine Institute, INSERM UMRS1127, CNRS UMR7225, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France.
| | - Vi-Huong Nguyen-Michel
- AP-HP, Epilepsy Unit, Rare Epilepsies Referral Center, Pitié-Salpêtrière Hospital and Sorbonne Université, Paris, France
| | - Marie-Odile Habert
- ICM, Brain and Spine Institute, INSERM UMRS1127, CNRS UMR7225, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France; AP-HP, Nuclear Medicine Department, Pitié-Salpêtrière Hospital and Sorbonne Université, CNRS, INSERM, Biomedical Imaging Laboratory, 75013 Paris, France.
| | - Phintip Pichit
- AP-HP, Epilepsy Unit, Rare Epilepsies Referral Center, Pitié-Salpêtrière Hospital and Sorbonne Université, Paris, France.
| | - Emmanuelle Apartis
- ICM, Brain and Spine Institute, INSERM UMRS1127, CNRS UMR7225, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France; AP-HP, Neurophysiology Department, Saint-Antoine Hospital and Sorbonne Université, Paris, France.
| | - Vincent Navarro
- AP-HP, Epilepsy Unit, Rare Epilepsies Referral Center, Pitié-Salpêtrière Hospital and Sorbonne Université, Paris, France; ICM, Brain and Spine Institute, INSERM UMRS1127, CNRS UMR7225, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France.
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Muthusamy K, Thomas M, Yoganathan S, Sudhakar SV. Clinical Profile, Prognostic Indicators, and Therapeutic Outcomes of Pediatric Opsoclonus-Myoclonus-Ataxia Syndrome: A Single-Center Experience from South India. Ann Indian Acad Neurol 2019; 22:295-301. [PMID: 31359941 PMCID: PMC6613420 DOI: 10.4103/aian.aian_101_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Opsoclonus myoclonus syndrome (OMS) is a neuroinflammatory disorder. Indian literature on its clinical profile and outcome is sparse. Objectives: The objective of this study is to describe the clinical profile and analyze outcomes and prognostic predictors in a cohort of children with OMS. Materials and Methods: This was a retrospective study of children with OMS between 2007 and 2017. Results: Twenty-two children were included in the study. The mean age at onset of symptom was 20.9 months (standard deviation [SD]: 7.5). The mean duration of delay in diagnosis was 8.4 months (SD 1.26) with acute cerebellitis being the most common misdiagnosis. Eleven children (50%) were diagnosed with tumor during evaluation and follow-up and 11 children (50%) belonged to idiopathic/postinfectious group. Magnetic resonance imaging brain was normal in all children except for one revealing cerebellar atrophy on follow-up. One child in the paraneoplastic group (neuroblastoma) had a positive PNMA2/Ta onconeural antibody. Children in the tumor group had an earlier age of onset (mean 15.5 vs. 26.3 months), shorter time to onset of opsoclonus from initial symptom (2.54 vs. 7.27 weeks), and higher severity score at presentation (13.7 vs. 11.3) compared to the nontumor group. Children in the nontumor group attained their first remission with treatment earlier (10.9 weeks, SD: 4.5) than the children with tumor (18.72 weeks, SD: 5.8). There was no significant difference in the outcome between the groups. Children with multiple relapses (>3) and late surgical intervention for tumor (>6 months after symptom onset) had a poor outcome. Discussion: A high index of suspicion coupled with early diagnosis and periodic tumor surveillance (even in the initially negative cases) along with aggressive combined multimechanistic immunotherapies is the key in improving outcomes. Conclusion: A high index of suspicion in appropriate clinical circumstances and early aggressive immunomodulation might lead to a better outcome.
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Affiliation(s)
- Karthik Muthusamy
- Department of Neurological Sciences, Pediatric Neurology Division, Christian Medical College, Vellore, Tamil Nadu, India
| | - Maya Thomas
- Department of Neurological Sciences, Pediatric Neurology Division, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sangeetha Yoganathan
- Department of Neurological Sciences, Pediatric Neurology Division, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sniya Valsa Sudhakar
- Department of Radio Diagnosis, Christian Medical College, Vellore, Tamil Nadu, India
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Pranzatelli MR, Tate ED, McGee NR. Demographic, Clinical, and Immunologic Features of 389 Children with Opsoclonus-Myoclonus Syndrome: A Cross-sectional Study. Front Neurol 2017; 8:468. [PMID: 28959231 PMCID: PMC5604058 DOI: 10.3389/fneur.2017.00468] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 08/24/2017] [Indexed: 12/17/2022] Open
Abstract
Pediatric-onset opsoclonus-myoclonus syndrome (OMS) is a devastating neuroinflammatory, often paraneoplastic, disorder. The objective was to characterize demographic, clinical, and immunologic aspects in the largest cohort reported to date. Cross-sectional data were collected on 389 children in an IRB-approved, observational study at the National Pediatric Myoclonus Center. Non-parametric statistical analysis was used. OMS manifested in major racial/ethnic groups, paralleling US population densities. Median onset age was 1.5 years (1.2–2 interquartile range), inclusive of infants (14%), toddlers (61%), and youngsters (25%). The higher female sex ratio of 1.2 was already evident in toddlers. Time to diagnosis was 1.2 months (0.7–3); to treatment, 1.4 months (0.4–4). Irritability/crying dominated prodromal symptomatology (60%); overt infections in <35%. Acute cerebellar ataxia was the most common misdiagnosis; staggering appeared earliest among 10 ranked neurological signs (P < 0.0001). Some untreated youngsters had no words (33%) or sentences (73%). Remote neuroblastic tumors were detected in 50%; resection was insufficient OMS treatment (58%). Age at tumor diagnosis related to tumor type (P = 0.004) and stage (P = 0.002). A novel observation was that paraneoplastic frequency varied with patient age—not a mere function of the frequency of neuroblastoma, which was lowest in the first 6 months of life, when that of neuroblastoma without OMS was highest. The cerebrospinal fluid (CSF) leukocyte count was minimally elevated in 14% (≤11/mm3) with normal differential, and commercially screened serum autoantibodies were negative, but CSF oligoclonal bands (OCB) and B cells frequency were positive (58 and 93%). Analysis of patients presenting on immunotherapy revealed a shift in physician treatment practice patterns from monotherapy toward multi-agent immunotherapy (P < 0.001); the number of agents/sequences varied. In sum, a major clinical challenge is to increase OMS recognition, prevent initial misdiagnosis, and shorten time to diagnosis/treatment. The index of suspicion for an underlying tumor must remain high despite symptoms of infection. The disparity in onset age of neuroblastoma frequency with that of neuroblastoma with OMS warrants further studies of potential host/tumor factors. OMS neuroinflammation is best diagnosed by CSF OCB and B cells, not by routine CSF or commercial antibody studies.
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Affiliation(s)
- Michael R Pranzatelli
- National Pediatric Myoclonus Center, Neuroimmunology Laboratory, Orlando, FL, United States.,National Pediatric Neuroinflammation Organization, Inc., Orlando, FL, United States
| | - Elizabeth D Tate
- National Pediatric Myoclonus Center, Neuroimmunology Laboratory, Orlando, FL, United States.,National Pediatric Neuroinflammation Organization, Inc., Orlando, FL, United States
| | - Nathan R McGee
- National Pediatric Myoclonus Center, Neuroimmunology Laboratory, Orlando, FL, United States
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