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Kumar P, Willard VW, Embry L, Naranjo A, LaBarre B, Matthay KK, de Alarcon PA. Late cognitive and adaptive outcomes of patients with neuroblastoma-associated opsoclonus-myoclonus-ataxia-syndrome: A report from the Children's Oncology Group. Pediatr Blood Cancer 2024; 71:e31039. [PMID: 38689540 PMCID: PMC11116037 DOI: 10.1002/pbc.31039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Opsoclonus-myoclonus-ataxia syndrome (OMAS) is a rare autoimmune disorder of the nervous system presenting with abnormal eye and limb movements, altered gait, and increased irritability. Two to four percent of children diagnosed with neuroblastoma have neuroblastoma-associated OMAS (NA-OMAS). These children typically present with non-high-risk neuroblastoma that is cured with surgery, with or without chemotherapy. Despite excellent overall survival, patients with NA-OMAS can have significant persistent neurological and developmental issues. OBJECTIVE This study aimed to describe long-term neurocognitive and adaptive functioning of patients with NA-OMAS treated with multimodal therapy, including intravenous immunoglobulin (IVIG) on Children's Oncology Group (COG) protocol ANBL00P3. METHODS Of 53 children enrolled on ANBL00P3, 25 submitted evaluable neurocognitive data at diagnosis and at least one additional time point within 2 years and were included in the analyses. Adaptive development was assessed via the Vineland Adaptive Behavior Scale, and validated, age-appropriate measures of intellectual function were also administered. RESULTS Twenty-one of the 25 patients in this cohort ultimately received IVIG. Descriptive spaghetti plots suggest that this cohort demonstrated stable long-term cognitive functioning and adaptive development over time. This cohort also demonstrated decreased OMAS scores over time consistent with improved OMAS symptoms. CONCLUSIONS While statistical significance is limited by small sample size and loss to follow-up over 10 years, findings suggest stable long-term cognitive and adaptive functioning over time in this treated cohort.
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Affiliation(s)
- Prerna Kumar
- University of Illinois College of Medicine Peoria, Pediatrics, Peoria, IL
| | - Victoria W. Willard
- St. Jude Children’s Research Hospital, Psychology & Biobehavioral Sciences, Memphis, TN
| | - Leanne Embry
- UT Health San Antonio, Pediatrics, San Antonio, TX
| | - Arlene Naranjo
- University of Florida, Biostatistics, Children’s Oncology Group Statistics & Data Center, Gainesville, FL
| | - Brian LaBarre
- University of Florida, Biostatistics, Children’s Oncology Group Statistics & Data Center, Gainesville, FL
| | - Katherine K. Matthay
- University of California San Francisco School of Medicine and UCSF Benioff Children’s Hospital, Pediatric Oncology, San Francisco, CA
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Feng L, Yang S, Lin Y, Li J, Cao Z, Zheng Q, Wang H, Yang J. Diagnostic value of 18F-fluorodeoxyglucose positron emission tomography/computed tomography imaging in pediatric opsoclonus myoclonus ataxia syndrome presenting with neuroblastoma. Pediatr Radiol 2024; 54:954-964. [PMID: 38613691 DOI: 10.1007/s00247-024-05921-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Early precision diagnosis and effective treatment of opsoclonus myoclonus ataxia syndrome (OMAS) patients presenting with neuroblastoma can prevent serious neurological outcomes. OBJECTIVE To assess the diagnostic value of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) imaging in pediatric OMAS with neuroblastoma. MATERIALS AND METHODS A retrospective evaluation of 45 patients diagnosed with OMAS who underwent 18F-FDG PET/CT was performed. A univariate analysis was performed to compare clinical characteristics between OMAS with and without neuroblastoma. Univariate and multivariate logistic regression analyses were applied to identify independent risk factors for OMAS with neuroblastoma and to develop the clinical model. Finally, independent risk factors and PET/CT were fitted to build the combined model for the diagnosis of OMAS with neuroblastoma and presented as a nomogram. Receiver operating characteristic curve, decision curve, and calibration curve analyses were conducted to evaluate the performance of the models. RESULTS Among 45 patients, 27 were PET/CT-positive, 23/27 lesions were neuroblastoma, and four were false positives. One of the false positive patients was confirmed to be adrenal reactive hyperplasia by postoperative pathology, and the symptoms of OMAS disappeared in the remaining three cases during clinical follow-up. The average maximal standardized uptake value of PET/CT-positive lesions was 2.6. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of PET/CT were 100%, 81.8%, 85.2%, 100%, and 91.1%, respectively. Age at diagnosis, lactate dehydrogenase, and neuron-specific enolase showed statistically significant differences between OMAS with and without neuroblastoma. Lactate dehydrogenase was identified as the independent risk factor to develop the clinical model, and the clinical model demonstrated an area under the curve (AUC) of 0.82 for the diagnosis of OMAS with neuroblastoma, with an AUC as high as 0.91 when combined with PET/CT. The decision curve analysis and calibration curve demonstrated that the nomogram had good consistency and clinical usefulness. CONCLUSION In patients with OMAS, 18F-FDG PET/CT has a high diagnostic accuracy in detecting tumors of the neuroblastoma, especially when combined with the independent risk factor serum lactate dehydrogenase.
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Affiliation(s)
- Lijuan Feng
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Shen Yang
- Department of Surgical Oncology, Beijing Children's Hospital, Beijing, China
| | - Yu Lin
- Department of Surgical Oncology, Beijing Children's Hospital, Beijing, China
| | - Jiuwei Li
- Department of Neurology, Beijing Children's Hospital, Beijing, China
| | - Zhenhua Cao
- Department of Thoracic Surgery and Surgical Oncology, Children's Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Qipeng Zheng
- Department of Thoracic Surgery and Surgical Oncology, Children's Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Huanmin Wang
- Department of Surgical Oncology, Beijing Children's Hospital, Beijing, China
| | - Jigang Yang
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China.
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Almudhry M, Wagner MW, Longoni G, Yea C, Vidarsson L, Ertl-Wagner B, Yeh EA. Brain Volumes in Opsoclonus-Myoclonus Ataxia Syndrome: A Longitudinal Study. J Child Neurol 2024; 39:129-134. [PMID: 38544431 PMCID: PMC11102640 DOI: 10.1177/08830738241240181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/27/2024] [Accepted: 03/03/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Little is known about the longitudinal trajectory of brain growth in children with opsoclonus-myoclonus ataxia syndrome. We performed a longitudinal evaluation of brain volumes in pediatric opsoclonus-myoclonus ataxia syndrome patients compared with age- and sex-matched healthy children. PATIENTS AND METHODS This longitudinal case-control study included brain magnetic resonance imaging (MRI) scans from consecutive pediatric opsoclonus-myoclonus ataxia syndrome patients (2009-2020) and age- and sex-matched healthy control children. FreeSurfer analysis provided automatic volumetry of the brain. Paired t tests were performed on the curvature of growth trajectories, with Bonferroni correction. RESULTS A total of 14 opsoclonus-myoclonus ataxia syndrome patients (12 female) and 474 healthy control children (406 female) were included. Curvature of the growth trajectories of the cerebral white and gray matter, cerebellar white and gray matter, and brainstem differed significantly between opsoclonus-myoclonus ataxia syndrome patients and healthy control children (cerebral white matter, P = .01; cerebral gray matter, P = .01; cerebellar white matter, P < .001; cerebellar gray matter, P = .049; brainstem, P < .01). DISCUSSION/CONCLUSION We found abnormal brain maturation in the supratentorial brain, brainstem, and cerebellum in children with opsoclonus-myoclonus ataxia syndrome.
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Affiliation(s)
- Montaha Almudhry
- Program in Neurosciences and Mental Health, SickKids Research Institute, The Hospital for Sick Children, Canada
| | - Matthias W. Wagner
- Division of Neuroradiology, Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Giulia Longoni
- Program in Neurosciences and Mental Health, SickKids Research Institute, The Hospital for Sick Children, Canada
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Carmen Yea
- Program in Neurosciences and Mental Health, SickKids Research Institute, The Hospital for Sick Children, Canada
| | - Logi Vidarsson
- Division of Neuroradiology, Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Birgit Ertl-Wagner
- Program in Neurosciences and Mental Health, SickKids Research Institute, The Hospital for Sick Children, Canada
- Division of Neuroradiology, Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - E. Ann Yeh
- Program in Neurosciences and Mental Health, SickKids Research Institute, The Hospital for Sick Children, Canada
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Elzomor H, El Menawi S, Elawady H, Elkinaai N, Elshafie M, Refaat A, Ghareeb H, Fawzy M. Neuroblastoma-associated Opsoclonous Myoclonous Ataxia Syndrome: Profile and Outcome Report on 15 Egyptian Patients. J Pediatr Hematol Oncol 2023; 45:e194-e199. [PMID: 35462382 DOI: 10.1097/mph.0000000000002466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 03/08/2022] [Indexed: 11/26/2022]
Abstract
Opsoclonous myoclonous ataxia syndrome (OMAS) is a rare primarily immune-mediated disease in children. The current study aim was to find out the patterns and outcome of OMAS associated with neuroblastoma (NBL) among Children's Cancer Hospital-Egypt patients. Data was reviewed for 15 eligible patients enrolled between 2007 and 2016. OMAS treatment included prednisolone and cyclophosphamide with/without intravenous immunoglobulin; NBL treatment was given according to risk-corresponding protocol. Patients' age ranged from 0.75 to 12 years at presentation with male/female: 1.1/1. Concurrent diagnosis of OMAS and NBL occurred in 6 patients (40%). OMAS preceded NBL within 0.25 to 2 years in 33%, while NBL preceded OMAS within 0.5 to 1.5 years in 27%. Full OMAS picture was present in 10/15 patients, while 20% presented with truncal ataxia and myoclonus, 1 with truncal ataxia and opsoclonus, and 1 had opsoclonus and myoclonus. Median time till improvement of manifestations was 5 months. The 5-year OMAS progression-free survival was 33.3%, where 10 patients needed second-line therapy due to relapse/progression of OMAS. The median time to progression was 28 months measured from OMAS diagnosis. All patients remained alive with NBL 5-year overall survival of 100% and event-free survival of 85.7% for. However, 73% of the patients showed late sequelae ranging from ocular to cognitive, behavioral and motor disorders; rarely seizures and hemolytic anemia.
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Affiliation(s)
- Hossam Elzomor
- Departments of Pediatric Oncology
- National Cancer Institute
| | | | - Heba Elawady
- Neurology
- Pediatrics Department, Fayoum University, Fayoum, Egypt
| | | | | | | | - Hany Ghareeb
- Clinical Pharmacy, Children's Cancer Hospital Egypt
| | - Mohamed Fawzy
- Departments of Pediatric Oncology
- National Cancer Institute
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Muacevic A, Adler JR, Vagha K. Opsoclonus Myoclonus Syndrome in a Case of Severe Acute Malnutrition in Children: A Case Report. Cureus 2022; 14:e32578. [PMID: 36660537 PMCID: PMC9845687 DOI: 10.7759/cureus.32578] [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: 09/15/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
Opsoclonus myoclonus syndrome (OMS) is a rare (1 in 10 million people per year) but nonfatal autoimmune disorder characterized by involuntary oscillating eye movements, multifocal muscular jerky movements, severe ataxia, and neuropsychological and behavioral changes. It usually manifests as a paraneoplastic condition but has other etiologies also. To the best of our knowledge, this is the first case of OMS seen in a patient with severe acute malnutrition (SAM). Parents brought a three-year-old female child with complaints of being unable to sit, stand, and hold her neck for the past 18 months. The patient has had involuntary eyeball movements for three months and has shown regression in milestones. Our study aimed to understand the pathophysiology, etiology, and clinical course of OMS in a child with SAM. However, relapses and long-term developmental sequelae are common due to the lack of a common consensus regarding therapeutic guidelines.
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Du H, Cai W. Opsoclonus-myoclonus syndrome associated with neuroblastoma: Insights into antitumor immunity. Pediatr Blood Cancer 2022; 69:e29949. [PMID: 36094353 DOI: 10.1002/pbc.29949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 07/08/2022] [Accepted: 08/04/2022] [Indexed: 11/08/2022]
Abstract
Opsoclonus-myoclonus syndrome (OMS) is a rare neurological disorder. Half of these cases occur in children with neuroblastoma. Neuroblastoma patients with OMS usually have better oncological outcomes than those without OMS even after stratification by tumor stage and age, indicating that factors mediating OMS may also inhibit tumor cell proliferation. Although the mechanisms underlying OMS remain undefined, the cytokines and lymphocytes alterations in the cerebrospinal fluid support the concept that it is a pattern of neuroinflammation due to an autoimmune effect. The presence of lymphoid follicles consisting of follicular dendritic cells, CD20+ B lymphocytes, CD3+ T lymphocytes, and CD68+ macrophages in the tumor microenvironment in OMS-associated neuroblastoma support the autoimmune nature of this disorder. This review focuses on the clinical and genetic features of OMS-associated neuroblastoma, and we update readers on immune features of neuroblastoma with or without OMS to gain insights into antitumor immunity as it relates to tumor biology and prognosis.
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Affiliation(s)
- Hongmei Du
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Weisong Cai
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China
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Sun Q, Wang Y, Xie Y, Wu P, Li S, Zhao W. Long-term neurological outcomes of children with neuroblastoma with opsoclonus-myoclonus syndrome. Transl Pediatr 2022; 11:368-374. [PMID: 35378965 PMCID: PMC8976687 DOI: 10.21037/tp-21-519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 02/22/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Neuroblastoma with opsoclonus-myoclonus syndrome (OMS-NB) is a rare disease in children. Few studies of long-term outcome of children with OMS-NB were conducted. This study aimed to review the rate of recovery of neurological symptoms and the long-term neurological outcomes of children with OMS-NB. METHODS This study retrospectively assessed 14 children with OMS-NB diagnosed at Peking University First Hospital from May 2011 to November 2019. Demographic data, neurological symptoms, oncological status and treatments were retrospectively reviewed from the records. Neurological sequelae were recorded by clinical and remote follow-up. RESULTS During the acute stage, myoclonus and ataxia were observed in all children while opsoclonus was observed in 10/14 children. The median durations of neurological symptoms were 15 months (range, 5-48 months). Approximately 93% (13/14) children revealed neurological sequelae. Significant correlations were as follows: motor retardation with female gender (P<0.001) and residual tumors (P<0.05); language impairment with non-adrenal-gland-located tumors (P<0.05). There were no obvious factors that had a statistical relationship with cognitive disorder or behavioral changes. CONCLUSIONS Children with OMS-NB have favorable outcomes in terms of neurological symptoms. Neurological sequelae occurred in almost all children. Children with different features tend to reveal different sequalae. Features of female gender and residual tumors tend to reveal motor retardation while that of non-adrenal-gland-located tumors tend to reveal language impairment.
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Affiliation(s)
- Qing Sun
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Yinhao Wang
- Department of Ophthalmology, Peking University Third Hospital, Beijing, China
| | - Yao Xie
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Penghui Wu
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Shuo Li
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Weihong Zhao
- Department of Pediatrics, Peking University First Hospital, Beijing, China
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8
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Foster R, Zheng DJ, Netson-Amore KL, Kadan-Lottick NS. Cognitive Impairment in Survivors of Pediatric Extracranial Solid Tumors and Lymphomas. J Clin Oncol 2021; 39:1727-1740. [PMID: 33886354 DOI: 10.1200/jco.20.02358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Rebecca Foster
- St Louis Children's Hospital, St Louis, MO.,Washington University, St Louis, MO
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Sheridan A, Kapur K, Pinard F, Dietrich Alber F, Camposano S, Pike MG, Klein A, Gorman MP. IQ predictors in pediatric opsoclonus myoclonus syndrome: a large international cohort study. Dev Med Child Neurol 2020; 62:1444-1449. [PMID: 32696984 DOI: 10.1111/dmcn.14628] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/28/2020] [Indexed: 11/29/2022]
Abstract
AIM To determine predictors of full-scale IQ (FSIQ) in an international pediatric opsoclonus myoclonus syndrome (OMS) cohort. METHOD In this retrospective and prospective cohort study at three academic medical centers (2006-2013), the primary outcome measure, FSIQ, was categorized based on z-score: above average (≥+1), average (+1 to -1), mildly impaired (-1 to -2), and impaired (<-2). Univariate analysis and multivariable linear regression modeling using stepwise selection with Akaike's information criterion was performed to understand the relationship between exposures and FSIQ. RESULTS Of 81 participants, 37 with sufficient data had mean FSIQ 84.38 (SD 20.55) and median 90 (40-114) at latest available evaluation (mean age 8y 5mo). Twenty (54%), nine (24.3%), and eight (21.6%) had normal, mildly impaired, and impaired FSIQ respectively. The final multivariable linear regression model included 34 participants with evaluable data: number of relapses occurring before neuropsychological testing (p<0.001) and OMS severity score at last follow-up (p<0.001) predicted FSIQ (adjusted R2 =0.64). There was a mean decrease of 2.4 FSIQ points per OMS relapse. INTERPRETATION Number of relapses negatively correlates with FSIQ in pediatric OMS. Demographic and clinical measures available at OMS onset did not predict FSIQ. Strategies to reduce OMS relapses may improve intellectual outcomes.
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Affiliation(s)
- Andrew Sheridan
- School of Psychological Science, The University of Western Australia, Perth, Australia
| | - Kush Kapur
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ferne Pinard
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Fabienne Dietrich Alber
- Department of Neurology/Neuropsychology, University Children's Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Susana Camposano
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Andrea Klein
- Division of Child Neurology, University Children's Hospital Bern Inselspital, University of Bern, Bern, Switzerland.,Department of Pediatric Neurology, University Children's Hospital Basel, Basel, Switzerland.,Department of Pediatric, Neurology University Children's Hospital Lausanne, Lausanne, Switzerland
| | - Mark P Gorman
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Evolving Cognitive Dysfunction in Children with Neurologically Stable Opsoclonus-Myoclonus Syndrome. CHILDREN-BASEL 2020; 7:children7090103. [PMID: 32824925 PMCID: PMC7552772 DOI: 10.3390/children7090103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/09/2020] [Accepted: 08/13/2020] [Indexed: 11/16/2022]
Abstract
Cognitive and acquired neurodevelopmental deficits have been reported in children with opsoclonus-myoclonus syndrome (OMS) and are known to be associated with more severe and relapsing disease course. However, there is a paucity of data regarding cognitive dysfunction in children with stable neurological disease. We report three children with OMS and evolving cognitive dysfunction in the context of a mild disease course. The children's ages at disease onset were between 17 and 35 months and they were followed up for 4-10 years. Neuroblastoma was identified in one child. OMS severity scores ranged between 8 and 12/15 at presentation. They underwent immunotherapy and all were in remission by 7 months (range 4-13 months), with treatment maintained for 1 year. One child remained relapse-free, while two others had one clinical relapse each and were immunotherapy-responsive again. In all cases, evolving cognitive dysfunction was reported despite being in remission and stable off treatment for a median of 20 months (range of 12-31 months; two OMS scores of 0/15 and one of 2/15). In children with OMS who have completed treatment and have made full or near full neurological recovery, concerns remain regarding long-term outcome in terms of future learning and cognitive development.
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Pranzatelli MR, Allison TJ, Tate ED. Effect of low-dose cyclophosphamide, ACTH, and IVIG combination immunotherapy on neuroinflammation in pediatric-onset OMS: A retrospective pilot study. Eur J Paediatr Neurol 2018; 22:586-594. [PMID: 29555260 DOI: 10.1016/j.ejpn.2018.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 02/17/2018] [Accepted: 02/25/2018] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Flow cytometric cerebrospinal fluid (CSF) lymphocyte subset analysis has improved the diagnosis of neuroinflammation and identified multiple markers of inflammation in opsoclonus-myoclonus syndrome (OMS). The aim of this exploratory, retrospective study was to analyze the effect of immunotherapy on these markers to determine which agents are disease modifying. METHODS Cross-sectional immunological observations were made in an IRB-approved case-control study, and patients were treated empirically. Ten different CSF lymphocyte subpopulations from 18 children with persistent OMS had been measured by flow cytometry before and after clinical treatment with cyclophosphamide/ACTH/IVIG combination (n = 7) or ACTH/IVIG alone (n = 11). Clinical severity of OMS was scored from videotapes by a blinded observer using the OMS Evaluation Scale. RESULTS Only cyclophosphamide combination therapy (mean dose 26 ± 3 mg/kg or 922 ± 176 mg/m2 x 6 cycles) significantly decreased the percentage of CSF B cells. The mean reduction was 65%, with CSF B cell frequency normalized at 7-8 months in 70%. Other abnormalities of the CSF immunophenotype, such as the low CD4/CD8 T cell ratio, persisted, and there were no therapeutic changes in T cell activation/maturation markers. Effects on relative and absolute size of PBMC subsets were similar. Clinical improvement was 70% and 55% in respective treatment groups. The relapse rates of the two groups did not significantly differ. DISCUSSION The main effect of cyclophosphamide combination therapy on neuroinflammation in OMS was moderate reduction in CSF B cell expansion. Though exploratory, it may provide a steroid sparer option in partially-responsive OMS.
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Affiliation(s)
- Michael R Pranzatelli
- National Pediatric Myoclonus Center, Orlando, FL, USA; National Pediatric Neuroinflammation Organization, Inc, Orlando, FL, USA.
| | | | - Elizabeth D Tate
- National Pediatric Myoclonus Center, Orlando, FL, USA; National Pediatric Neuroinflammation Organization, Inc, Orlando, FL, USA.
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13
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Ibáñez-Juliá MJ, Pappa E, Gaymard B, Leclercq D, Hautefort C, Tilikete C, Delattre JY, Hoang-Xuan K, Psimaras D, Alentorn A. Brain volumetric analysis and cortical thickness in adults with saccadic intrusions (ocular flutter or opsoclonus-myoclonus syndrome). Clin Neurol Neurosurg 2017; 163:167-172. [PMID: 29121544 DOI: 10.1016/j.clineuro.2017.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 09/24/2017] [Accepted: 10/28/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Ocular flutter (OF) and opsoclonus are considered a continuum with a similar pathogenesis. Due to the rarity of this disease in the adult population, little is known about the brain morphological changes in the chronic phase of the disease. PATIENTS AND METHODS Six magnetic resonance imaging from adults with previous history of OF/Opsoclonus and 12 healthy patients (paired by age and sex) were analyzed in order to identify the long term cortical thickness pattern in this rare disease by using Freesurfer. RESULTS Patients with OF/Opsoclonus showed reduced cerebellum cortical volume with a subsequent diminution in total cerebellar volume. White mater cerebellum volume was not modified. In addition, we have also identified a significant supratentorial gray matter volume decrease in OF/Opsoclonus patients, involving both the cortical and the subcortical gray matter. CONCLUSIONS OF/Opsoclonus in adults may be associated with cortical and subcortical gray matter atrophy, as well as decreased cerebellar cortical volume. Further larger prospective studies are necessary to confirm these results.
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Affiliation(s)
- María-José Ibáñez-Juliá
- Department of Neurology 2, Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris (AP-HP), 75013, Paris, France; Sorbonne Universités, Université Pierre et Marie Curie, Université Paris VI, 75013, Paris, France; Institut du Cerveau et de la Moelle Epinière, INSERM U1127 and Centre National de la Recherche Scientifique, Unité de Recherche Mixte, 7225, Paris, France
| | - Evangelia Pappa
- Department of Neurology 2, Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris (AP-HP), 75013, Paris, France; Sorbonne Universités, Université Pierre et Marie Curie, Université Paris VI, 75013, Paris, France; Institut du Cerveau et de la Moelle Epinière, INSERM U1127 and Centre National de la Recherche Scientifique, Unité de Recherche Mixte, 7225, Paris, France
| | - Bertrand Gaymard
- Deparment of Clinical Neurophysiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris (AP-HP), 75013, Paris, France
| | - Delphine Leclercq
- Department of Neuro-radiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris (AP-HP), 75013, Paris, France
| | - Charlotte Hautefort
- Otolaryngology - Head and Neck Surgery Department, Hôpital Lariboisière, Assistance Publique Hôpitaux de Paris (AP-HP), 75475, Paris, France
| | - Caroline Tilikete
- Neuro-Ophthalmology Unit, Lyon Civil Hospitals, Neurological Hospital, Lyon 1 University, Bron Cedex, France
| | - Jean-Yves Delattre
- Department of Neurology 2, Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris (AP-HP), 75013, Paris, France; Sorbonne Universités, Université Pierre et Marie Curie, Université Paris VI, 75013, Paris, France; Institut du Cerveau et de la Moelle Epinière, INSERM U1127 and Centre National de la Recherche Scientifique, Unité de Recherche Mixte, 7225, Paris, France
| | - Khê Hoang-Xuan
- Department of Neurology 2, Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris (AP-HP), 75013, Paris, France; Sorbonne Universités, Université Pierre et Marie Curie, Université Paris VI, 75013, Paris, France; Institut du Cerveau et de la Moelle Epinière, INSERM U1127 and Centre National de la Recherche Scientifique, Unité de Recherche Mixte, 7225, Paris, France
| | - Dimitri Psimaras
- Department of Neurology 2, Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris (AP-HP), 75013, Paris, France; Sorbonne Universités, Université Pierre et Marie Curie, Université Paris VI, 75013, Paris, France; Institut du Cerveau et de la Moelle Epinière, INSERM U1127 and Centre National de la Recherche Scientifique, Unité de Recherche Mixte, 7225, Paris, France
| | - Agusti Alentorn
- Department of Neurology 2, Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris (AP-HP), 75013, Paris, France; Sorbonne Universités, Université Pierre et Marie Curie, Université Paris VI, 75013, Paris, France; Institut du Cerveau et de la Moelle Epinière, INSERM U1127 and Centre National de la Recherche Scientifique, Unité de Recherche Mixte, 7225, Paris, France.
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14
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Tate ED, Allison TJ, Pranzatelli MR, Verhulst SJ. Neuroepidemiologic Trends in 105 US Cases of Pediatric Opsoclonus-Myoclonus Syndrome. J Pediatr Oncol Nurs 2016; 22:8-19. [PMID: 15574722 DOI: 10.1177/1043454204272560] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Opsoclonus-myoclonus syndrome (OMS) is a rare, autoimmune neurological disorder that is poorly recognized and undertreated. Neuroblastoma is found in one half of the cases. Because of the high incidence of spontaneous regression of neuroblastoma, it is unknown whether not finding a tumor means there was none. To define demographic trends and the standard of care in the first large series of OMS, 105 children were recruited over a 13-year period in a retrospective questionnaire survey. Children with and without a tumor differed little in viral-like prodrome and neurological symptoms. Earliest neurological symptoms were staggering and falling, leading to a misdiagnosis of acute cerebellitis. Later symptoms included body jerks, drooling, refusal to walk or sit, speech problems, decreased muscle tone, opsoclonus, and inability to sleep. Tumor resection alone did not provide adequate therapy for most. Adrenocorticotropic hormone (ACTH), prednisone, and intravenous immunoglobulin were used with equal frequency, but ACTH was associated with the best early response. More than one half of the children had relapses. Residual behavioral, language, and cognitive problems occurred in the majority. The delay in diagnosis (11 weeks) and initiation of treatment (17 weeks) is unacceptably long.
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Affiliation(s)
- Elizabeth D Tate
- Southern Illinois University, School of Medicine, Division of Child and Adolescent Neurology, PO Box 19643, Springfield, IL 62794-9643, USA.
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15
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Green D, Lim M, Lang B, Pohl K, Turk J. Sensory Processing Difficulties in Opsoclonus-Myoclonus Syndrome: A Pilot Project of Presentation and Possible Prevalence. J Child Neurol 2016; 31:965-70. [PMID: 26994071 DOI: 10.1177/0883073816634856] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 12/13/2015] [Indexed: 11/16/2022]
Abstract
Opsoclonus-myoclonus syndrome is a rare but serious neurological condition resulting in loss of control of eye movements, often accompanied by difficulties in posture and movement control with reports of sensory sensitivities potentially impacting on behavior. This pilot study characterizes the presence of atypical sensory behaviors in opsoclonus-myoclonus syndrome through questionnaire survey of a cohort of families. The Short Sensory Profile, Vineland Adaptive Behavior Scale, and Developmental Behaviour Checklist were distributed to 30 families; 16 were returned anonymously. Atypical sensory behaviors were identified in a large proportion (62.5%). Children reported as being more anxious showed greater sensitivity to auditory stimuli, U(14) 11, P = .026. This is consistent with recent recognition of more extensive disease neurocognitive effects in Opsoclonus-myoclonus syndrome. Further research is needed to increase understanding of the complex pathology of this disease and to provide indicators for sensory and behavioral as well as pharmacological interventions.
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Affiliation(s)
- Dido Green
- Centre for Rehabilitation, Oxford Brookes University, Oxford, UK
| | - Ming Lim
- Paediatric Neurosciences, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Bethan Lang
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Keith Pohl
- Paediatric Neurosciences, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - Jeremy Turk
- Southwark Child & Adolescent Mental Health Neurodevelopmental Service, South London & Maudsley NHS Foundation Trust, London, UK
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16
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Blaes F, Dharmalingam B. Childhood opsoclonus-myoclonus syndrome: diagnosis and treatment. Expert Rev Neurother 2016; 16:641-8. [DOI: 10.1080/14737175.2016.1176914] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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17
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Nisa N, Talawar P, Vasudevan B. Anesthesia in a child with Kinsbourne syndrome: Does anesthesia technique matters? Saudi J Anaesth 2016; 10:468-470. [PMID: 27833499 PMCID: PMC5044740 DOI: 10.4103/1658-354x.179115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Kinsbourne syndrome is a rare neurological paraneoplastic syndrome associated with neuroblastic tumors. There are very few literatures on its anesthetic management and interaction with anesthetic agents. The epileptogenic potential of certain anesthetic agents such as ketamine, etomidate, and meperidine might trigger opsoclonus and myoclonus and have an impact on the long-term neurological outcome. The objective of this case report is to discuss the safety of anesthetic agents and their relationship in a patient with Kinsbourne syndrome. We discuss our experience in the anesthetic management of a child with Kinsbourne syndrome with ganglioneuroblastoma in the thoracic paravertebral space.
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Affiliation(s)
- N Nisa
- Department of Anesthesia, Critical Care and Pain Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - P Talawar
- Department of Anesthesia, Critical Care and Pain Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - B Vasudevan
- Department of Anesthesia, Critical Care and Pain Medicine, All India Institute of Medical Sciences, New Delhi, India
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18
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Opsoclonus-myoclonus syndrome after adenovirus infection. SPRINGERPLUS 2015; 4:636. [PMID: 26543770 PMCID: PMC4628014 DOI: 10.1186/s40064-015-1429-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 10/12/2015] [Indexed: 11/10/2022]
Abstract
Autoimmune and paraneoplastic movement disorders are rare in childhood. Diagnosis often relies on clinical manifestations and clinicians' recognition. A 22-month-old girl at onset of opsoclonus-myoclonus syndrome (OMS) was followed for 8 years. Adenovirus (type C subtype 3) infection coincided with manifestation. Data on treatment, imaging and follow-up are provided. In the spinal fluid, elevated anti-rubella antibodies and oligoclonal bands were detected. An autoimmune process affecting mainly cerebellar neurons was revealed immunohistochemically. Moderately intense long-term immunosuppressive therapy resulted in a favorable clinical outcome. A video demonstrated severe OMS manifestations at onset, followed by nearly complete recovery after treatment. We describe the association of a parainfectious OMS and adenovirus infection; laboratory results indicate a non-specific humoral process affecting mainly cerebellar neurons. Our video documentation will aid to recognize this rare movement disorder and to initiate early treatment.
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19
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Anand G, Bridge H, Rackstraw P, Chekroud AM, Yong J, Stagg CJ, Pike M. Cerebellar and cortical abnormalities in paediatric opsoclonus-myoclonus syndrome. Dev Med Child Neurol 2015; 57:265-72. [PMID: 25290446 DOI: 10.1111/dmcn.12594] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2014] [Indexed: 11/28/2022]
Abstract
AIM Paediatric opsoclonus-myoclonus syndrome (OMS) is a poorly understood condition with long-term cognitive, behavioural, and motor sequelae. Neuroimaging has indicated cerebellar atrophy in the chronic phase, but this alone may not explain the cognitive sequelae seen in many children with OMS. This study aimed to determine the extent of structural change throughout the brain that may underpin the range of clinical outcomes. METHOD Nine participants with OMS (one male, eight females; mean age [SD] 14y, [6y 5mo], range 12-30y) and 10 comparison individuals (three males, seven females; mean age 12y 6mo, [4y 9mo], range 10-23y) underwent magnetic resonance imaging to acquire T1-weighted structural images, diffusion-weighted images, and magnetic resonance spectroscopy scans. Neuroblastoma had been present in four participants with OMS. Voxel-based morphometry was used to determine changes in grey matter volume, tract-based spatial statistics to analyze white matter integrity, and Freesurfer to analyze cortical thickness across visual and motor cortices. RESULTS Whole-brain analysis indicated that cerebellar grey matter was significantly reduced in the patients with OMS, particularly in the vermis and flocculonodular lobe. A region-of-interest analysis indicated significantly lower cerebellar grey matter volume, particularly in patients with the greatest OMS scores. Diffusion-weighted images did not show effects at a whole brain level, but all major cerebellar tracts showed increased mean diffusivity when analysis was restricted to the cerebellum. Cortical thickness was reduced across the motor and visual areas in the OMS group, indicating involvement beyond the cerebellum. INTERPRETATION Across individuals with OMS, there is considerable cerebellar atrophy, particularly in the vermis and flocculonodular lobes with atrophy severity associated with persistent symptomatology. Differences in cerebral cortical thickness indicate disease effects beyond the cerebellum.
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Affiliation(s)
- Geetha Anand
- Department of Paediatric Neurology, Children's Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
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20
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Jasminekalyani P, Saravanan S, V S, M R. Dancing eyes dancing feet syndrome-a report of two cases. J Clin Diagn Res 2014; 8:MD03-5. [PMID: 24995204 DOI: 10.7860/jcdr/2014/7184.4339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 03/10/2014] [Indexed: 11/24/2022]
Abstract
Opsoclonus Myoclonus (OMS) is a rare neurological disorder which appears to be the result of an autoimmune dysfunction. It is an extremely rare condition, affecting as few as 1 in 10,000,000 people every year. It affects 2 to 3% of children. Opsoclonus Myoclonus, which manifests itself as post infectious encephalopathy, occasionally along with HIV infection, post Streptococcal infection, West Nile virus encephalitis and Rickettsial infection, most often presents as a paraneoplastic syndrome, which is especially caused by occult neuroblastoma which is commonly seen in childhood and occurs in adults in relation to breast cancer and small cell lung cancer. In this study, two adult post infectious cases which had rare manifestations, have been presented. The cases were managed by using corticosteroids.
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Affiliation(s)
- P Jasminekalyani
- PG Student (DM Neuro), Department of Neurology, Tirunelveli Medical College , Tirunelveli-627 011, Tamil Nadu, India
| | - S Saravanan
- Professor & HOD, Department of Neurology, Tirunelveli Medical College , Tirunelveli-627 011, Tamil Nadu, India
| | - Sriramakrishnan V
- Assistant Professor, Department of Neurology, Tirunelveli Medical College , Tirunelveli-627 011, Tamil Nadu, India
| | - Radha M
- Assistant Professor, Department of Neurology, Tirunelveli Medical College , Tirunelveli-627 011, Tamil Nadu, India
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21
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Krivochenitser R, Lemma Y, Wynn B, Jones JS. Ophthalmic presentation in the emergency department: a case report of a girl with "shimmering eyes". J Emerg Med 2014; 46:e163-5. [PMID: 24698510 DOI: 10.1016/j.jemermed.2014.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 11/04/2013] [Accepted: 01/31/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Ophthalmic complaints are commonplace in the emergency department (ED) and are often initial presentations of a systemic illness. We present a 2-year-old girl presenting to the ED with ataxia and "shimmering" eyes. CASE REPORT The patient was diagnosed with opsoclonus-myoclonus syndrome (OMS) involving involuntary, multi-vectorial (mostly horizontal), conjugate fast eye movements without intersaccadic intervals. The ophthalmic presentation led to a paraneoplastic work-up, which revealed an abdominal mass measuring 5.3 × 3.3 × 4.3 cm, suggestive of neuroblastoma. The patient's opsoclonus improved after a 5-day course of dexamethasone and intravenous immunoglobulin. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case illustrates the importance of recognizing pathognomonic ophthalmic complaints in the ED. We present an overview of classic ophthalmic presentations associated with systemic illnesses.
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Affiliation(s)
| | - Yonatan Lemma
- Michigan State University Program in Emergency Medicine, Spectrum Health Hospital-Butterworth Campus, Grand Rapids, Michigan
| | - Barbara Wynn
- Michigan State University Program in Emergency Medicine, Spectrum Health Hospital-Butterworth Campus, Grand Rapids, Michigan
| | - Jeffrey S Jones
- Michigan State University Program in Emergency Medicine, Spectrum Health Hospital-Butterworth Campus, Grand Rapids, Michigan
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22
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Blaes F, Fühlhuber V, Preissner KT. Identification of autoantigens in pediatric opsoclonus-myoclonus syndrome. Expert Rev Clin Immunol 2014; 3:975-82. [DOI: 10.1586/1744666x.3.6.975] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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23
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Owens C, Irwin M. Neuroblastoma: the impact of biology and cooperation leading to personalized treatments. Crit Rev Clin Lab Sci 2012; 49:85-115. [PMID: 22646747 DOI: 10.3109/10408363.2012.683483] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Neuroblastoma is the most common extra-cranial solid tumor in children. It is a heterogeneous disease, consisting of neural crest-derived tumors with remarkably different clinical behaviors. It can present in a wide variety of ways, including lesions which have the potential to spontaneously regress, or as an extremely aggressive form of metastatic cancer which is resistant to all forms of modern therapy. They can arise anywhere along the sympathetic nervous system. The median age of presentation is approximately 18 months of age. Urinary catecholamines (HVA and VMA) are extremely sensitive and specific tumor markers and are used in diagnosis, treatment response assessment and post-treatment surveillance. The largest national treatment groups from North America, Europe and Japan have formed the International Neuroblastoma Risk Group Task Force (INRG) to identify prognostic factors, to understand the mechanisms of tumorigenesis in this rare disease and to develop multi-modality therapies to improve outcomes and decrease treatment-related toxicities. This international cooperation has resulted in a significant leap in our understanding of the molecular pathogenesis of neuroblastoma. Lower staged disease can be cured if the lesion is resectable. Treatment of unresectable disease (loco-regional and metastatic) is stratified depending on clinical features (age at presentation, staging investigations) and specific tumor biological markers that include histopathological analyses, chromosomal abnormalities and the quantification of expression of an oncogene (MYCN). Modern treatment of high-risk neuroblastoma is the paradigm for the evolution of therapy in pediatric oncology. Outcomes have improved substantially with multi-modality therapy, including chemotherapy, surgery, radiation therapy, myeloablative therapy with stem cell transplant, immunotherapy and differentiation therapy; these comprise the standard of care worldwide. In addition, newer targeted therapies are being tested in phase I/II trials. If successful these agents will be incorporated into mainstream treatment programs.
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Affiliation(s)
- Cormac Owens
- Division of Haematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
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24
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Tate ED, Pranzatelli MR, Verhulst SJ, Markwell SJ, Franz DN, Graf WD, Joseph SA, Khakoo YN, Lo WD, Mitchell WG, Sivaswamy L. Active comparator-controlled, rater-blinded study of corticotropin-based immunotherapies for opsoclonus-myoclonus syndrome. J Child Neurol 2012; 27:875-84. [PMID: 22378659 DOI: 10.1177/0883073811428816] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
To test the efficacy and safety of corticotropin-based immunotherapies in pediatric opsoclonus-myoclonus syndrome, 74 children received corticotropin alone or with intravenous immunoglobulin (groups 1 and 2, active controls); or both with rituximab (group 3) or cyclophosphamide (group 4); or with rituximab plus chemotherapy (group 5) or steroid sparers (group 6). There was 65% improvement in motor severity score across groups (P < .0001), but treatment combinations were more effective than corticotropin alone (P = .0009). Groups 3, 4, and 5 responded better than group 1; groups 3 and 5 responded better than group 2. The response frequency to corticotropin was higher than to prior corticosteroids (P < .0001). Fifty-five percent had adverse events (corticosteroid excess), more so with multiagents (P = .03); and 10% had serious adverse events. This study demonstrates greater efficacy of corticotropin-based multimodal therapy compared with conventional therapy, greater response to corticotropin than corticosteroid-based therapy, and overall tolerability.
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Affiliation(s)
- Elizabeth D Tate
- National Pediatric Myoclonus Center, and Departments of Neurology and Statistics and Research Consulting, Southern Illinois University School of Medicine, Springfield, IL 62794, USA.
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25
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Morales La Madrid A, Rubin CM, Kohrman M, Pytel P, Cohn SL. Opsoclonus-myoclonus and anti-Hu positive limbic encephalitis in a patient with neuroblastoma. Pediatr Blood Cancer 2012; 58:472-4. [PMID: 21480475 DOI: 10.1002/pbc.23131] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Accepted: 02/24/2011] [Indexed: 11/10/2022]
Abstract
Opsoclonus-myoclonus syndrome (OMS) is seen in 2-3% of children with neuroblastoma and is believed to be caused by an autoimmune process elicited by the tumor. Although long-term neurologic sequelae are common in children with OMS, limbic encephalitis has not previously been reported. We report a child who developed limbic encephalitis associated with anti-Hu antibodies, 6 years after her initial diagnosis of neuroblastoma and OMS. This case demonstrates that patients with neuroblastoma and OMS are at risk for developing new paraneoplastic symptoms years after their original diagnosis and emphasizes the need for careful long-term follow-up.
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26
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Ben-Pazi H, Jaworowski S, Shalev RS. Cognitive and psychiatric phenotypes of movement disorders in children: a systematic review. Dev Med Child Neurol 2011; 53:1077-84. [PMID: 21950517 DOI: 10.1111/j.1469-8749.2011.04134.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM The cognitive and psychiatric aspects of adult movement disorders are well established, but specific behavioural profiles for paediatric movement disorders have not been delineated. Knowledge of non-motor phenotypes may guide treatment and determine which symptoms are suggestive of a specific movement disorder and which indicate medication effects. METHOD The goal of this review is to outline the known cognitive and psychiatric symptoms associated with paediatric movement disorders. We used a systematic approach, via PubMed, and reviewed over 400 abstracts of studies of selected disorders, of which 88 papers reporting paediatric non-motor symptoms are summarized. RESULTS Obsessive-compulsive disorder was manifest in children with paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and Sydenham chorea. Children with opsoclonus-myoclonus syndrome had, for the most part, cognitive and behavioural problems, and attention-deficit-hyperactivity disorder was reported as a major comorbidity in Tourette syndrome, stereotypies, and restless legs syndrome. Symptoms of depression and anxiety were more frequent in individuals with idiopathic dystonia. Affective disorders were suggestive of Wilson disease. Cognitive decline was common in children with juvenile Huntington disease. A limitation of this review was the lack of systematic assessment in paediatric movement disorders for evaluation and uniform definitions. INTERPRETATION Although the literature in non-motor phenomena is still emerging, recognition of salient cognitive and psychiatric phenomena may facilitate management of paediatric movement disorders.
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Affiliation(s)
- Hilla Ben-Pazi
- Neuropediatric Unit, Shaare Zedek Medical Center, Jerusalem, Israel.
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27
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Sadeghian H, Vernino S. Progress in the management of paraneoplastic neurological disorders. Ther Adv Neurol Disord 2011; 3:43-52. [PMID: 21180635 DOI: 10.1177/1756285609349521] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Paraneoplastic neurological disorders (PNDs) are a rare and diverse group of neurological conditions that can involve any part of the nervous system. Diagnosis is facilitated by finding well-recognized autoantibodies directed against neural antigens in the sera and the cerebrospinal fluid. Identifying and eliminating the underlying malignancy is the mainstay of treatment. Immunomodulatory treatment is gaining more acceptance especially, where a malignancy could not be identified, oncology treatment is completed, or along with cancer treatment. Literature review shows only a handful of systematic prospective case series. Multicenter, prospective controlled clinical trials are needed for future therapeutic advances.
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Affiliation(s)
- Hamid Sadeghian
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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28
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Abstract
PURPOSE OF REVIEW Opsoclonus-myoclonus-ataxia syndrome (OMS) is a severe autoimmune central nervous system disorder, which predominantly affects young children and causes lifelong neurological disability. Early recognition and treatment may yield better outcomes. RECENT FINDINGS Appreciation of the spectrum of clinical presentations of OMS, awareness of common misdiagnoses, and utilization of diagnostic criteria may facilitate the timely diagnosis of OMS. Approximately 50% of patients have an associated neuroblastoma, which may escape detection by traditional methods and require MRI or computed tomography of the torso for diagnosis. In nonparaneoplastic cases, many associated infections have been reported. Although there has been progress in autoantibody identification and cerebrospinal fluid B cell expansion is a common finding, there is no diagnostic biomarker for OMS currently. Approximately 80% of reported patients, typically treated with conventional therapies such as adrenocorticotropin hormone, corticosteroids, and/or intravenous immunoglobulin, develop long-term neurological morbidity. Newer treatment approaches using early, aggressive therapy with cyclophosphamide or rituximab are promising. SUMMARY The diagnosis of OMS requires a high level of suspicion and a systematic approach for diagnostic testing, particularly for neuroblastoma. Future collaborative studies are required to determine whether early, aggressive therapy will improve the typically poor long-term neurological outcome.
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29
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Krug P, Schleiermacher G, Michon J, Valteau-Couanet D, Brisse H, Peuchmaur M, Sarnacki S, Martelli H, Desguerre I, Tardieu M. Opsoclonus-myoclonus in children associated or not with neuroblastoma. Eur J Paediatr Neurol 2010; 14:400-9. [PMID: 20110181 DOI: 10.1016/j.ejpn.2009.12.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Revised: 12/07/2009] [Accepted: 12/22/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To compare the clinical data at diagnosis, treatment and neurological outcome in 34 children with opsoclonus-myoclonus syndrome (OMS) associated with a detected neuroblastoma or not. STUDY DESIGN This is a multicentric retrospective study of 34 children presenting with OMS from four pediatric centers diagnosed between 1988 and 2008. RESULTS Twenty-two patients had OMS associated with a neuroblastoma. These patients all had neuroblastomas with favourable prognostic features; all underwent surgery, six received chemotherapy. Twelve children had OMS without a detected neuroblastoma. For OMS, the main treatment in all children was corticotherapy (n=33), but immunoglobulins (n=13), cyclophosphamide (n=4) and rituximab (n=4) were also given. In the 27 OMS patients with or without neuroblastoma whose follow up was greater than two years, the neurological outcome was evaluated: 59.3% had neurological sequelae, including motor, praxic and/or language sequelae (n=9), persistent ataxia (n=6) and moderate motor deficit (n=3). No significant difference in neurological outcome was noted between the two patient groups. CONCLUSION Our retrospective study provides further evidence that OMS with or without a detected neuroblastoma is the same disease, whose major challenges are the neurological sequelae. An international collaboration is required to improve the knowledge about OMS, the treatment and the outcome in this rare disorder.
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Affiliation(s)
- Pauline Krug
- Pediatric Oncology, Institut Curie, 26 rue d'Ulm, 75248 Paris, France
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30
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Smith ML, Thawani N, Johnstone B, Stucky R. Neuropsychological decline/improvement in opsoclonus myoclonus ataxia. Neurocase 2010; 16:352-7. [PMID: 20446170 DOI: 10.1080/13554791003620264] [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: 10/19/2022]
Abstract
Opsoclonus myoclonus ataxia (OMA) is a rare neurological disorder (incidence = approximately 1/5 million) primarily associated with involuntary conjugate saccadic eye movements, involuntary muscle jerks, cerebellar ataxia, and neuropsychological impairments. Unfortunately, there is limited published data regarding the nature and course of neuropsychological impairments following OMA diagnosis and treatment. This study presents neuropsychological data obtained at 1, 4, and 18 months post-diagnosis of a 52-year-old male with OMA. The patient initially demonstrated significant global neurocognitive, psychomotor, and psychological difficulties with substantial improvement over time. Treatment included medication management, physical rehabilitation, and psychological intervention.
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Affiliation(s)
- Marian L Smith
- Department of Health Psychology, University of Missouri, Columbia, MO, USA.
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31
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Sakuma H, Shimizu Y, Saito Y, Sugai K, Inagaki M, Kaga M, Sasaki M. Electrophysiological evidence of cerebral dysfunction in childhood opsoclonus-myoclonus syndrome. Mov Disord 2010; 25:940-5. [DOI: 10.1002/mds.23084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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32
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Pang KK, de Sousa C, Lang B, Pike MG. A prospective study of the presentation and management of dancing eye syndrome/opsoclonus-myoclonus syndrome in the United Kingdom. Eur J Paediatr Neurol 2010; 14:156-61. [PMID: 19423368 DOI: 10.1016/j.ejpn.2009.03.002] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 03/18/2009] [Indexed: 11/24/2022]
Abstract
The incidence, mode of presentation and management of Dancing Eye Syndrome/Opsoclonus-Myoclonus Syndrome (DES/OMS) was prospectively evaluated in 20 United Kingdom (UK) paediatric neurology centres by questionnaire over a 24-month period between 2003 and 2005. Nineteen children were notified, giving an incidence of 0.18 cases per million total population per year. Mean age at presentation was 18 months (range 3-42 months). Fifteen families consented to participate in the study. Atypical features were present in 6/15 cases including very delayed presentation of opsoclonus, dysphagia, and rapid spontaneous improvement without treatment. Only 4/15 cases were associated with neuroblastoma (NB) but current practice in excluding this is diverse and a standardised approach is suggested.
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Affiliation(s)
- K Ki Pang
- Department of Paediatrics, Newcastle General Hospital, Newcastle upon Tyne, UK
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Dancing Eye Syndrome associated with spontaneous recovery and normal neurodevelopment. Eur J Paediatr Neurol 2010; 14:178-81. [PMID: 19541513 DOI: 10.1016/j.ejpn.2009.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 04/29/2009] [Indexed: 11/24/2022]
Abstract
Five patients with spontaneously recovering Dancing Eye Syndrome/Opsoclonus Myoclonus Syndrome are described. Age at presentation ranged from 4 to 19 months. Four had symptoms of fever and a coryzal illness within days to a few weeks prior to the onset. One of the 4 also had varicella zoster 4 weeks before presentation. All had opsoclonus, myoclonus/ataxia and irritability. Associated infective agents identified were Coxsackie virus and rotavirus. Spontaneous improvement of symptoms started within 9 days of presentation and total duration of illness ranged from 10 to 24 days. Developmental progress at follow-up was normal in all cases. A range of immunomodulatory therapies have been advocated for the treatment of Dancing Eye Syndrome/Opsoclonus Myoclonus Syndrome. However, in some children, early spontaneous recovery may occur, an observation which should be borne in mind when designing therapeutic trials in this condition.
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Catsman-Berrevoets CE, Aarsen FK, van Hemsbergen MLC, van Noesel MM, Hakvoort-Cammel FGAJ, van den Heuvel-Eibrink MM. Improvement of neurological status and quality of life in children with opsoclonus myoclonus syndrome at long-term follow-up. Pediatr Blood Cancer 2009; 53:1048-53. [PMID: 19672966 DOI: 10.1002/pbc.22226] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Kinsbourne syndrome or opsoclonus myoclonus syndrome (OMS) is characterized by rapid, involuntary, irregular conjugate eye movements (opsoclonus), myoclonic jerking of the limbs and trunk, ataxia, and behavioral disturbances. In general, the outcome of neurologic and behavioral symptoms is poor. Studies on quality of life (Qol) and recovery after very long-term follow-up of children with OMS are lacking. METHODS We studied long-term cancer survival, neurologic recovery, and Qol of a consecutive series of eight patients with OMS that were treated in our center. Two cross-sectional follow-up evaluations were conducted at a 3-year interval (T1 and T2). RESULTS In four out of eight children with OMS a neuroblastoma (NBL) was diagnosed and surgically removed completely. All children received immuno-modulatory therapy, consisting of prednisone (three children), prednisone and ACTH (four children), or prednisone, ACTH, and gammaglobulin (one child). At T1, median follow-up time was 9.5 years (range 3-14 years) after OMS onset and at T2, 11.6 years (range 6-17 years). Neurologic functioning improved in all children, reflected by a significant improvement of the mean Z-score in the motor domain of the Qol questionnaire at T2 as compared to T1. In contrast, seven children continued to have a severe developmental delay at T2. No significant difference in any of the variables was found between NBL survivors and OMS patients without NBL. CONCLUSION Cognitive and behavioral impairments and not a motor impairment, such as ataxia, appear to be predominant at long-term in children with OMS.
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Ertle F, Behnisch W, Al Mulla NA, Bessisso M, Rating D, Mechtersheimer G, Hero B, Kulozik AE. Treatment of neuroblastoma-related opsoclonus-myoclonus-ataxia syndrome with high-dose dexamethasone pulses. Pediatr Blood Cancer 2008; 50:683-7. [PMID: 17226843 DOI: 10.1002/pbc.21107] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Opsoclonus-myoclonus-ataxia-syndrome (OMS) represents a rare neuroblastoma-associated paraneoplastic syndrome that commonly results in neurologic deficits despite tumor resection and immunosuppressive therapy. We describe the response of five such children to high-dose dexamethasone pulses including two patients in whom previous glucocorticoids, rituximab, and cytostatic drugs were not successful. All patients had MYCN non-amplified tumors that were detected 1 to 7 months after the onset of the OMS or ataxia. This treatment resulted in a good partial response in three and in complete remission in two patients. Our results show that dexamethasone pulses are likely to be useful for both, first-line- and salvage-therapy for OMS-patients.
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Affiliation(s)
- Florian Ertle
- Department of Pediatric Oncology, Hematology and Immunology, University of Heidelberg, Germany
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Abstract
Opsoclonus-myoclonus syndrome (OMS) is a rare paraneoplastic syndrome that occurs in 2%-3% of patients with neuroblastoma. The cause of this syndrome is believed to be immune mediated, but the exact mechanism still remains unclear. There is an urgent need to improve our current strategies for treating patients with OMS, as many patients have significant long-term neurologic deficits and behavior disorders with current treatment approaches. Therapies that have shown to improve symptoms in these patients have ranged from ACTH and corticosteroids, to intravenous gammaglobulin and plasmapheresis. We report our experience with Rituximab in a patient with neuroblastoma and OMS.
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Affiliation(s)
- Michael J Burke
- Division of Hematology/Oncology/Transplant, Children's Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Bell J, Moran C, Blatt J. Response to rituximab in a child with neuroblastoma and opsoclonus-myoclonus. Pediatr Blood Cancer 2008; 50:370-1. [PMID: 16652344 DOI: 10.1002/pbc.20899] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Opsoclonus-myoclonus (OM) is a paraneoplastic syndrome of probable autoimmune origin. Despite current therapies aimed at decreasing autoantibody formation, OM is difficult to control and may impact long-term neurologic outcome. We present a case of a 19-month-old patient who initially presented with OM, neuroblastoma and a constitutional cytogenetic abnormality t(5;12)(q11.2;q15). The patient's OM was recalcitrant to conventional therapies, but showed significant improvement following treatment with rituximab.
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Affiliation(s)
- Jessica Bell
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Wilken B, Baumann M, Bien CG, Hero B, Rostasy K, Hanefeld F. Chronic relapsing opsoclonus-myoclonus syndrome: combination of cyclophosphamide and dexamethasone pulses. Eur J Paediatr Neurol 2008; 12:51-5. [PMID: 17625938 DOI: 10.1016/j.ejpn.2007.05.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2006] [Revised: 05/15/2007] [Accepted: 05/19/2007] [Indexed: 11/20/2022]
Abstract
Opsoclonus-myoclonus syndrome (OMS) is a rare and debilitating disorder of unknown etiology affecting children and adults. Outcome is unfavourable; approximately 80% of children with OMS suffer from mild to severe neurological handicaps, mainly cognitive impairment. A standard therapy does not exist. Due to the possible immune-mediated mechanisms, treatment with steroids, ACTH, plasmapheresis and immunoglobulins can be successful. However, some children become steroid dependent and symptoms may reoccur after treatment has been finished. We present two girls with OMS, who had a prolonged clinical course lasting 4 and 9 years with many relapses. Both children developed symptoms around the age of two years. Diagnostic work-up to exclude neuroblastoma was negative. Several treatment modalities including oral steroids, dexamethasone pulses, immunoglobulin and cyclosporine were used without lasting success. In addition, cognitive impairment developed in both children. In order to prevent further clinical and mental deterioration, 6 pulses of cyclophosphamide in combination with dexamethasone pulses every 4 weeks were administered. Both children showed significant improvement of OMS symptoms. One girl is still symptom free 18 months after treatment, mild ataxia developed in the other after 12 months. Both children are mentally handicapped and in special need schools. We conclude that combination of cyclophosphamide pulses and dexamethasone pulse therapy is a therapeutic option even after a long clinical course to improve symptoms of OMS.
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Affiliation(s)
- B Wilken
- Department of Pediatric Neurology, Klinikum Kassel, Germany.
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Affiliation(s)
- Marc J Dinkin
- Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA
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Badaki OB, Schapiro ES. Dancing eyes, dancing feet: opsoclonus-myoclonus in an 18-month-old child with neuroblastoma. Pediatr Emerg Care 2007; 23:885-8. [PMID: 18091597 DOI: 10.1097/pec.0b013e31815c9d66] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Opsoclonus-myoclonus-ataxia syndrome is a rare disorder frequently associated with neuroblastoma in pediatric patients. We present the case of an 18-month-old child with symptoms classic of the syndrome and review the current literature with the aim of aiding the clinician in the recognition and early management of this disease.
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Affiliation(s)
- Oluwakemi Bukola Badaki
- University of Pennsylvania School of Medicine, and Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA 19104-4399, USA.
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Rutherford GC, Dineen RA, O'Connor A. Imaging in the investigation of paraneoplastic syndromes. Clin Radiol 2007; 62:1021-35. [PMID: 17920860 DOI: 10.1016/j.crad.2007.06.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2007] [Revised: 06/04/2007] [Accepted: 06/08/2007] [Indexed: 01/13/2023]
Abstract
Paraneoplastic syndromes are a heterogeneous group of disease presentations caused by underlying tumours. As they are non-metastatic in nature an intensive diagnostic evaluation is warranted to identify potentially curable lesions. The selection of the appropriate method of imaging is important in these cases, especially when history and physical examination are unrevealing. In this review the important paraneoplastic syndromes and underlying malignancies are discussed along with relevant imaging strategies.
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Affiliation(s)
- G-C Rutherford
- Department of Diagnostic Imaging, Queen's Medical Centre, Nottingham UK.
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Abstract
The clinical hallmark of neuroblastoma is heterogeneity, with the likelihood of cure varying widely according to age at diagnosis, extent of disease, and tumour biology. A subset of tumours will undergo spontaneous regression while others show relentless progression. Around half of all cases are currently classified as high-risk for disease relapse, with overall survival rates less than 40% despite intensive multimodal therapy. This Seminar focuses on recent advances in our understanding of the biology of this complex paediatric solid tumour. We outline plans for the development of a uniform International Neuroblastoma Risk Group (INRG) classification system, and summarise strategies for risk-based therapies. We also update readers on new discoveries related to the underlying molecular pathogenesis of this tumour, with special emphasis on advances that are translatable to the clinic. Finally, we discuss new approaches to treatment, including recently discovered molecular targets that might provide more effective treatment strategies with the potential for less toxicity.
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Affiliation(s)
- John M Maris
- Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, PA 19104-4318, USA.
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Klein A, Schmitt B, Boltshauser E. Long-term outcome of ten children with opsoclonus-myoclonus syndrome. Eur J Pediatr 2007; 166:359-63. [PMID: 17089089 DOI: 10.1007/s00431-006-0247-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Accepted: 07/06/2006] [Indexed: 10/24/2022]
Abstract
Opsoclonus-myoclonus syndrome (OMS) in children is a rare neurological condition with opsoclonus, myoclonus, ataxia and irritability in the first 2 years of life. It can be idiopathic, parainfectious, or paraneoplastic with tumours of the neural crest. Few studies of long-term follow-up after OMS have been published. We investigated the motor, cognitive and behavioural outcome of ten patients (eight girls and two boys) seen between 1987 and 2002. We reviewed the records and reassessed the patients. A ganglioneuroma was found in one patient and a neuroblastoma in another. Tumour resection did not influence the OMS. The age at diagnosis was 10-24 months and the follow-up period 1-17 years (average 6.5 years). The interval between the first signs and symptoms and starting treatment was 2-12 weeks: treatment consisted of different immunosupressants. Remission was achieved within 5 months in seven, and relapses were present in seven of ten. At follow-up, only one child had mild ataxia. IQ testing was performed in nine with scores below 75 in four and above 85 in four. Attention deficit and visuomotor difficulties led to school problems with special needs, also in those three children with normal IQs. Only two children were attending regular schools. Behavioural problems were reported in seven, and speech difficulties were present in five. In conclusion, the long-term outcome in our patients with OMS was dominated by cognitive and behavioural problems and not by ataxia. Compared with previous reports, our patients were treated earlier. Larger studies and uniform treatment protocols are needed to demonstrate whether early and prolonged immunosupressant therapy has a favourable influence on outcome.
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Affiliation(s)
- Andrea Klein
- Department of Neurology, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland.
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Abstract
PURPOSE OF REVIEW The aim of this article is to review opsoclonus, with particular emphasis on its immunopathogenesis and pathophysiology. RECENT FINDINGS Infections (West Nile virus, Lyme disease), neoplasms (non-Hodgkin's lymphoma, renal adenocarcinoma), celiac disease, and allogeneic hematopoietic stem cell transplantation can cause opsoclonus. Newly identified autoantibodies include antineuroleukin, antigliadin, antiendomysial, and anti-CV2. Evidence suggests that the autoantigens of opsoclonus reside in postsynaptic density, or on the cell surface of neurons or neuroblastoma cells (where they exert antiproliferative and proapoptotic effects). Most patients, however, are seronegative for autoantibodies. Cell-mediated immunity may also play a role, with B and T-cell recruitment in the cerebrospinal fluid linked to neurological signs. Rituximab, an anti-CD20 monoclonal antibody, seems efficacious as an adjunctive therapy. Although changes in synaptic weighting of saccadic burst neuron circuits in the brainstem have been implicated, disinhibition of the fastigial nucleus in the cerebellum, or damage to afferent projections to the fastigial nucleus, is a more plausible pathophysiologic mechanism which is supported by functional magnetic resonance imaging findings in patients. SUMMARY There is increasing recognition that both humoral and cell mediated immune mechanisms are involved in the pathogenesis of opsoclonus. Further studies are needed to further elucidate its immunopathogenesis and pathophysiology in order to develop novel and efficacious therapy.
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Affiliation(s)
- Agnes Wong
- Department of Ophthalmology and Vision Sciences, University of Toronto, Hospital For Sick Children, Toronto, Ontario, Canada.
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Vedeler CA, Antoine JC, Giometto B, Graus F, Grisold W, Hart IK, Honnorat J, Sillevis Smitt PAE, Verschuuren JJGM, Voltz R. Management of paraneoplastic neurological syndromes: report of an EFNS Task Force. Eur J Neurol 2006; 13:682-90. [PMID: 16834698 DOI: 10.1111/j.1468-1331.2006.01266.x] [Citation(s) in RCA: 235] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Paraneoplastic neurological syndromes (PNS) are remote effects of cancer on the nervous system. An overview of the management of classical PNS, i.e. paraneoplastic limbic encephalitis, subacute sensory neuronopathy, paraneoplastic cerebellar degeneration, paraneoplastic opsoclonus-myoclonus, Lambert-Eaton myasthenic syndrome and paraneoplastic peripheral nerve hyperexcitability is given. Myasthenia gravis and paraproteinemic neuropathies are not included in this report. No evidence-based recommendations were possible, but good practice points were agreed by consensus. Urgent investigation is indicated, especially in central nervous system (CNS) syndromes, to allow tumour therapy to be started early and prevent progressive neuronal death and irreversible disability. Onconeural antibodies are of great importance in the investigation of PNS and can be used to focus tumour search. PDG-PET is useful if the initial radiological tumour screen is negative. Early detection and treatment of the tumour is the approach that seems to offer the greatest chance for PNS stabilization. Immune therapy usually has no or modest effect on the CNS syndromes, whereas such therapy is beneficial for PNS affecting the neuromuscular junction. Symptomatic therapy should be offered to all patients with PNS.
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Affiliation(s)
- C A Vedeler
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.
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Abstract
Paraneoplastic neurological syndromes (PNS) are remote effects of cancer that are not caused by invasion of the tumor or its metastases. Immunologic factors appear important in the pathogenesis of PNS because antineuronal autoantibodies and T-cell responses against nervous system antigens have been defined for many of these disorders. The immunologic response is elicited by the ectopic expression of neuronal antigens by the tumor. Expression of these so-called "onconeural" antigens is limited to the tumor and the nervous system and sometimes also the testis. At the time of presentation of the neurological symptoms, most patients have not yet been diagnosed with cancer. Detection of paraneoplastic antibodies is extremely helpful in diagnosing an otherwise unexplained and often rapidly progressive neurological syndrome as paraneoplastic. In addition, the paraneoplastic antibodies may also direct the search for an underlying neoplasm. On the other hand, in patients known to have cancer, the presentation of a PNS may herald recurrence of the tumor or a second tumor. The number of paraneoplastic antibodies is still growing, and at least seven of these can now be considered well characterized. Based on the clinical syndrome, the type of antibody, and the presence or absence of cancer, patients are classified as having a "definite" or "possible" PNS. Despite the presumed autoimmune etiology of PNS, the results of various forms of immunotherapy have been disappointing, with some exceptions. Rapid detection and immediate treatment of the underlying tumor appears to offer the best chance of stabilizing the patient and preventing further neurological deterioration.
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Abstract
Paraneoplastic disorders may affect any part of the central or peripheral nervous systems. Although relatively uncommon, these disorders are a significant cause of severe neurological disability among cancer patients. Most, if not all, neurological paraneoplastic disorders are believed to be autoimmune diseases in which an antitumour immune response also attacks neurons that express shared neuronal tumour antigens. Affected patients often have one or more circulating antineuronal antibodies, which serve as a diagnostic marker for the paraneoplastic condition, and in some cases are the direct mediators of neuronal injury. The exact immunopathogenesis and relative contributions of humoral or cellular immune effectors for most paraneoplastic syndromes are not well understood. Some patients have a gratifying neurological response to tumour treatment and/or immunotherapy, especially if the diagnosis is made early and treatment is initiated promptly. Unfortunately, many patients are left with severe and permanent neurological deficits despite aggressive treatment. This review summarises the current understanding of the clinical immunology of paraneoplastic disorders, and outlines immunotherapy options and outcomes.
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Affiliation(s)
- Edward J Dropcho
- Department of Neurology, Indiana University Medical Center, The Indianapolis Veterans Affairs Medical Center, Indianapolis, IN 46202, USA.
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Matthay KK, Blaes F, Hero B, Plantaz D, De Alarcon P, Mitchell WG, Pike M, Pistoia V. Opsoclonus myoclonus syndrome in neuroblastoma a report from a workshop on the dancing eyes syndrome at the advances in neuroblastoma meeting in Genoa, Italy, 2004. Cancer Lett 2005; 228:275-82. [PMID: 15922508 DOI: 10.1016/j.canlet.2005.01.051] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2004] [Accepted: 01/20/2005] [Indexed: 11/28/2022]
Abstract
Opsoclonus-myoclonus syndrome (OMS) is a rare neurologic syndrome that, in children, associates with neuroblastoma in more than half of the cases. The etiology of this condition is thought to be immune mediated, but, though immunosuppressive therapies may ameliorate the acute symptoms, no effective treatment to prevent the common neuropsychologic sequelae has been established. This paper summarizes the results obtained at the 2004 Advances in Neuroblastoma Research meeting, providing status of the art information on immune pathogenesis, clinical features, acute and chronic neurologic manifestations, current and novel therapeutic approaches. It is emphasized that, due to the rarity of OMS in general and neuroblastoma-associated OMS in particular, international collaborations are needed to better define the pathogenesis and therapy of this disease, propose common evaluation criteria and identify new treatment modalities.
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Mutch LS, Johnston DL. Late presentation of opsoclonus-myoclonus-ataxia syndrome in a child with stage 4S neuroblastoma. J Pediatr Hematol Oncol 2005; 27:341-3. [PMID: 15956891 DOI: 10.1097/01.mph.0000170532.76765.df] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Opsoclonus-myoclonus-ataxia syndrome (OMA) in children is most commonly associated with occult neuroblastoma (NB). Although children with OMA and NB have decreased mortality, they suffer from increased neurologic morbidity. The pathogenesis of OMA in NB is not well understood, but current research and treatments support an immune-mediated process. The authors describe an unusual presentation of OMA occurring following 6 months of chemotherapy in a child with stage 4S NB who presented with partial Horner syndrome. Histopathologic examination of his primary cervical tumor showed NB maturation, which may have played a role in precipitating OMA syndrome. Further study of unusual cases of OMA in NB may provide better understanding of the syndrome and additional treatment options for these children.
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Affiliation(s)
- Linsey S Mutch
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada
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