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Lin BC, Johal J, Sivakumar K, Romano AE, Yacoub HA. Stiff-person syndrome: an atypical presentation and a review of the literature. Hosp Pract (1995) 2021; 49:384-390. [PMID: 34313523 DOI: 10.1080/21548331.2021.1961456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: Stiff-person syndrome (SPS) is a rare autoimmune neurological disorder associated with muscle rigidity and spasms. A number of antibodies have been associated with disorder, including anti-glutamic acid decarboxylase and anti-amphiphysin.Case report; In this report, we present a rare case of a 79-year-old woman who presented with bilateral lower extremity weakness who was ultimately diagnosed with stiff-limb syndrome, a rare variant of SPS. Extensive laboratory and CSF studies were unrevealing. Electromyography showed significant peroneal motor neuropathy and complex repetitive discharges in the left tibialis anterior muscle. Antibodies to glutamic acid decarboxylase were significantly elevated at 124 units/mL. She was subsequently started on oral diazepam with significant improvement in her symptoms.Conclusion: The presentation of SPS can vary based on epidemiologic factors, clinical symptoms, and associated disorders. These forms can have overlapping features which may make the categorization of patients into one of these forms challenging.
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Affiliation(s)
- Benjamin C Lin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jaspreet Johal
- Department of Neurology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Keithan Sivakumar
- Division of Neurology, Sunnybrook Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Alissa E Romano
- Department of Neurology, Lehigh Valley Health Network, Allentown, PA, USA.,Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Hussam A Yacoub
- Department of Neurology, Lehigh Valley Health Network, Allentown, PA, USA.,Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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Kitazaki Y, Ikawa M, Kishitani T, Kamisawa T, Nakane S, Nakamoto Y, Hamano T. Progressive Encephalomyelitis with Rigidity and Myoclonus (PERM)-like Symptoms Associated with Anti-ganglionic Acetylcholine Receptor Antibodies. Intern Med 2021; 60:2307-2313. [PMID: 33583893 PMCID: PMC8355408 DOI: 10.2169/internalmedicine.6419-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This report describes a 59-year-old woman who presented with progressive encephalomyelitis with rigidity and myoclonus (PERM)-like symptoms and severe dysautonomia, including orthostatic hypotension, sinus bradycardia, dysuria, and prolonged constipation. Her neurological symptoms improved after immunotherapy, but the dysautonomia persisted. Anti-ganglionic acetylcholine receptor (gAChR) α3 subunit antibodies, which are frequently identified in patients with autoimmune autonomic ganglionopathy, were detected in the pre-treatment serum. The central distribution of the nicotinic acetylcholine receptors, a target of anti-gAChR antibodies, and immunotherapeutic efficacy observed in this case indicate that anti-gAChR α3 subunit antibodies are associated with the PERM-like features accompanied by autonomic manifestations.
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Affiliation(s)
- Yuki Kitazaki
- Department of Neurology, Fukui-ken Saiseikai Hospital, Japan
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Masamichi Ikawa
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
- Department of Advanced Medicine for Community Healthcare, Faculty of Medical Sciences, University of Fukui, Japan
| | - Toru Kishitani
- Department of Neurology, Fukui-ken Saiseikai Hospital, Japan
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Tomoko Kamisawa
- Department of Neurology, Fukui-ken Saiseikai Hospital, Japan
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Shunya Nakane
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Yasunari Nakamoto
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Tadanori Hamano
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
- Department of Aging and Dementia, Faculty of Medical Sciences, University of Fukui, Japan
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Sanchez K, Ullah A, Waler AR, Chakfe Y. Improving Ambulation and Minimizing Disability with Therapeutic Plasma Exchange in a Stiff-person Syndrome Patient with Recurrent Falls. Cureus 2019; 11:e6209. [PMID: 31890410 PMCID: PMC6925374 DOI: 10.7759/cureus.6209] [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] [Indexed: 11/10/2022] Open
Abstract
Stiff-person syndrome (SPS) is a rare, autoimmune, neuromuscular disorder that manifests with axial and proximal muscle stiffness, rigidity, and painful muscle spasms, often causing progressive disability due to limited movement. First-line therapies comprise symptomatic management with γ-aminobutyric acid-modulating drugs such as benzodiazepines and baclofen. Patients resistant to these treatments are often given intravenous immunoglobulin (IVIg). Severe disease refractory to first-line therapy and IVIg may be treated with therapeutic plasma exchange (TPE) or immunomodulatory agents such as rituximab. Current evidence derived from case reports and case series has shown that roughly half of SPS patients treated with TPE report benefits. Here, we report the case of a 68-year-old man with a 20-year history of severe SPS and recurrent falls who was admitted to the emergency department for a traumatic hip fracture. He had significant rigidity in the axial and extremity muscles with persistent spasms of the quadriceps femoris muscle. Postoperatively, he was unable to participate in physical therapy (PT) due to these symptoms. He previously failed treatment with diazepam, baclofen, and monthly IVIg. Under our care, he underwent seven TPE treatments. By the end of treatment, he reported significant improvement in mobility with a resolution of muscle spasms and was able to be discharged to inpatient rehabilitation. This suggests that TPE may offer an effective, safe treatment modality for patients with severe refractory SPS that may significantly improve mobility and disability associated with the disease.
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Affiliation(s)
- Kyle Sanchez
- Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Aqsa Ullah
- Neurology, University of Central Florida/Osceola Regional Medical Center, Orlando, USA
| | - Alexandria R Waler
- Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Yassar Chakfe
- Neurology, University of Central Florida/Osceola Regional Medical Center, Orlando, USA
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Nalbantoğlu M, Battal H, Kiziltan ME, Akalin MA, Kiziltan G. Stiff Person Syndrome with Pyramidal Signs. Noro Psikiyatr Ars 2017; 53:188-190. [PMID: 28360797 DOI: 10.5152/npa.2015.11310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 05/19/2015] [Indexed: 01/07/2023] Open
Affiliation(s)
- Mecbure Nalbantoğlu
- Department of Neurology, İstanbul University Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Hasan Battal
- Department of Physical Therapy and Rehabilitation, İstanbul University Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Meral E Kiziltan
- Department of Neurology, İstanbul University Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Mehmet Ali Akalin
- Department of Neurology, İstanbul University Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Güneş Kiziltan
- Department of Neurology, İstanbul University Cerrahpaşa School of Medicine, İstanbul, Turkey
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Bhatti AB, Gazali ZA. Recent Advances and Review on Treatment of Stiff Person Syndrome in Adults and Pediatric Patients. Cureus 2015; 7:e427. [PMID: 26848416 PMCID: PMC4727915 DOI: 10.7759/cureus.427] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Stiff Person Syndrome (SPS) is one of the rarest autoimmune neurological disorders, which is mostly reported in women. It is characterised by fluctuating muscle rigidity and spasms. There are many variants of SPS, these include the classical SPS, Stiff Leg Syndrome (SLS), paraneoplastic variant, gait ataxia, dysarthria, and abnormal eye movements. Studies have shown that the paraneoplastic variant of SPS is more common in patients with breast cancer who harbour amphiphysin antibodies, followed by colon cancer, lung cancer, Hodgkin's disease, and malignant thymoma. Currently, the treatment for SPS revolves around improving the quality of life by reducing the symptoms as far as possible with the use of GABAergic agonists, such as diazepam or other benzodiazepines, steroids, plasmapheresis, and intravenous immunoglobulin (IVIG). There have been random clinical trials with Rituximab, but nothing concrete has been suggested. A treatment approach with standard drugs and cognitive behavioral therapy (CBT) seems to be promising.
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Affiliation(s)
- Adnan Bashir Bhatti
- Department of Medicine, Capital Development Authority Hospital, Islamabad, Pakistan
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Abstract
Isaacs' syndrome is a rare neuromuscular disorder of continuous muscle fibre activity resulting from peripheral nerve hyperexcitability. Symptoms commonly include myokymia (muscle twitching at rest), pseudomyotonia (delayed muscle relaxation), muscle cramps and stiffness. It is caused by voltage-gated potassium channel dysfunction and may be inherited or acquired. Treatment commonly includes anticonvulsants, immunosuppressive therapy and plasma exchange. To date only two cases of Isaacs' syndrome in pregnancy have been reported. We present a case of maternal Isaacs' along with a review of the literature. There are few reports of Isaacs' syndrome in pregnancy, but all are associated with favourable outcomes. Given the autosomal dominant inheritance pattern, genetic counselling of the gravida is recommended. Anticonvulsant may have to be used in pregnancy, and given the potential teratogenicity with several of these agents; preference should be given to newer drugs such as lamotrigine.
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Affiliation(s)
- Brianna Lide
- Texas A&M University College of Medicine, Bryan, Texas, USA
| | - Jasbir Singh
- North Austin Maternal-Fetal Medicine, Austin, Texas, USA
| | - Sina Haeri
- Department of Obstetrics & Gynecology, Baylor College of Medicine, Houston, Texas, USA
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Michaud M, Gaudin C, Brechemier D, Cintas P, Gauchet C, Moulis G, Vellas B, Balardy L. An unusual cause of older adult falls: Stiff Leg Syndrome. Eur Geriatr Med 2013. [DOI: 10.1016/j.eurger.2012.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Rakocevic G, Floeter MK. Autoimmune stiff person syndrome and related myelopathies: understanding of electrophysiological and immunological processes. Muscle Nerve 2012; 45:623-34. [PMID: 22499087 DOI: 10.1002/mus.23234] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Stiff person syndrome (SPS) is a disabling autoimmune central nervous system disorder characterized by progressive muscle rigidity and gait impairment with superimposed painful spasms that involve axial and limb musculature, triggered by heightened sensitivity to external stimuli. Impaired synaptic GABAergic inhibition resulting from intrathecal B-cell-mediated clonal synthesis of autoantibodies against various presynaptic and synaptic proteins in the inhibitory neurons of the brain and spinal cord is believed to be an underlying pathogenic mechanism. SPS is most often idiopathic, but it can occur as a paraneoplastic condition. Despite evidence that anti-GAD and related autoantibodies impair GABA synthesis, the exact pathogenic mechanism of SPS is not fully elucidated. The strong association with several MHC-II alleles and improvement of symptoms with immune-modulating therapies support an autoimmune etiology of SPS. In this review, we discuss the clinical spectrum, neurophysiological mechanisms, and therapeutic options, including a rationale for agents that modulate B-cell function in SPS.
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Affiliation(s)
- Goran Rakocevic
- Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, Pennsylvania 19107, USA.
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Rigor Mortis or Something Else? Am J Forensic Med Pathol 2010; 31:e2. [DOI: 10.1097/paf.0b013e3181ed7882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hijazi J, Bedat-Millet AL, Hannequin D. Le syndrome de l’homme raide et autres maladies neurologiques associées aux anticorps anti-GAD. Rev Med Interne 2010; 31:23-8. [DOI: 10.1016/j.revmed.2009.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Revised: 12/11/2008] [Accepted: 01/22/2009] [Indexed: 11/16/2022]
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Holmøy T, Skorstad G, Røste LS, Scheie D, Alvik K. Stiff person syndrome associated with lower motor neuron disease and infiltration of cytotoxic T cells in the spinal cord. Clin Neurol Neurosurg 2009; 111:708-12. [DOI: 10.1016/j.clineuro.2009.06.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Revised: 06/12/2009] [Accepted: 06/19/2009] [Indexed: 11/29/2022]
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Thompson PD. Muscle cramp syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2007; 86:389-396. [PMID: 18809011 DOI: 10.1016/s0072-9752(07)86019-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Cantiniaux S, Azulay JP, Boucraut J, Pouget J, Attarian S. Le syndrome de l’homme raide : formes cliniques, traitement et profil évolutif. Rev Neurol (Paris) 2006; 162:832-9. [PMID: 17028544 DOI: 10.1016/s0035-3787(06)75086-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Stiff-Man syndrome (SMS) is a rare neurological disease first described fifty years ago. There are several clinical forms, which are frequently misdiagnosed. The aim of this study is to review three of the main clinical forms. MATERIAL AND METHODS Case reports concerning three women suffering from different forms of SMS are presented, giving the main clinical features, their associations with other diseases, and the biological and electrophysiological findings. RESULTS The first patient presented a symmetric axial muscle rigidity, painful spasms and contractions of the trunk and limbs associated with anti-GAD antibodies. The common form of SMS was diagnosed and the patient was improved by intravenous immunoglobulin (IVIg). The second patient suffered from contractions and spasms localized to the lower limbs. In this patient, anti-GAD antibodies were absent. The Stiff-Leg syndrome was diagnosed and the patient was improved by intrathecal baclofen. The third patient presented rigidity of limb and trunk muscles associated with signs of encephalitis. In this patient, only anti-amphiphysin antibodies were present. The progressive encephalomyelitis with rigidity was diagnosed and the patient was improved by IVIg associated with corticosteroid. CONCLUSION Identifying patients with SMS makes it possible to propose appropriate medical management. There are several forms of the disease, and the severity of the evolution differs in each case. Treatment with GABA-ergic inhibitory drugs, IVIg and corticosteroid improve both the symptomatology and the quality of life of these patients.
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Affiliation(s)
- S Cantiniaux
- Service de Neurologie et Maladies Neuromusculaires, CHU de la Timone, Marseille
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Kubo M, Holt KG, Saltzman E, Wagenaar RC. Changes in axial stiffness of the trunk as a function of walking speed. J Biomech 2006; 39:750-7. [PMID: 16439245 DOI: 10.1016/j.jbiomech.2004.12.024] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2003] [Revised: 02/12/2004] [Accepted: 12/10/2004] [Indexed: 11/20/2022]
Abstract
Research suggests that abnormal coordination patterns between the thorax and pelvis in the transverse plane observed in patients with Parkinson's disease and the elderly might be due to alteration in axial trunk stiffness. The purpose of this study was to develop a tool to estimate axial trunk stiffness during walking and to investigate its functional role. Fourteen healthy young subjects participated in this study. They were instructed to walk on the treadmill and kinematic data was collected by 3D motion analysis system. Axial trunk stiffness was estimated from the angular displacement between trunk segments and the amount of torque around vertical axis of rotation. The torque due to arm swing cancelled out the torque due to the axial trunk stiffness during walking and the thoracic rotation was of low amplitude independent of changes in walking speeds within the range used in this study (0.85-1.52 m/s). Estimated axial trunk stiffness increased with increasing walking speed. Functionally, the suppression of axial rotation of thorax may have a positive influence on head stability as well as allowing recoil between trunk segments. Furthermore, the increased stiffness at increased walking speed would facilitate the higher frequency rotation of the trunk in the transverse plane required at the higher walking speeds.
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Affiliation(s)
- Masayoshi Kubo
- Division of Kinesiology, University of Michigan, 3060 CCRB, 401 Washtenaw Ave, Ann Arbor, MI 48109-2214, USA.
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Abstract
The stiff man syndrome (SMS) and its variants, focal SMS, stiff limb (or leg) syndrome (SLS), jerking SMS, and progressive encephalomyelitis with rigidity and myoclonus (PERM), appear to occur more frequently than hitherto thought. A characteristic ensemble of symptoms and signs allows a tentative clinical diagnosis. Supportive ancillary findings include (1) the demonstration of continuous muscle activity in trunk and proximal limb muscles despite attempted relaxation, (2) enhanced exteroceptive reflexes, and (3) antibodies to glutamic acid decarboxylase (GAD) in both serum and spinal fluid. Antibodies to GAD are not diagnostic or specific for SMS and the role of these autoantibodies in the pathogenesis of SMS/SLS/PERM is the subject of debate and difficult to reconcile on the basis of our present knowledge. Nevertheless, evidence is emerging to suggest that SMS/SLS/PERM are manifestations of an immune-mediated chronic encephalomyelitis and immunomodulation is an effective therapeutic approach.
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