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Alsaeed M, Lim CAR, Plecash A, Chen T. Paraneoplastic sensorimotor neuropathy and ventral cauda equina nerve root enhancement as initial presentation of small cell lung carcinoma: a case study. BMC Neurol 2021; 21:374. [PMID: 34579672 PMCID: PMC8474708 DOI: 10.1186/s12883-021-02404-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/16/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Paraneoplastic neurologic syndromes (PNS) are rare, however, are important to recognize as oftentimes they precede the detection of an occult malignancy. Our case highlights a rare circumstance of paraneoplastic radiculoneuropathy and the importance of recognizing PNS in antibody negative disease, as is the case in up to 16% of sensory neuronopathies, and the process of excluding other etiologies. CASE PRESENTATION We discuss a 51-year-old man who presented with asymmetric subacute sensorimotor deficits in the lower limbs. Initial clinical examination showed weakness throughout the right lower limb and normal strength on the left with objective numbness in a mixed dermatomal and stocking-glove distribution. Electrophysiology was consistent with axonal sensorimotor neuropathy. Cerebrospinal fluid showed pleocytosis and elevated protein. Intravenous immunoglobulin treatment was given with some improvement in pain symptoms but no measurable motor improvement. Following clinical and electrophysiologic deterioration the patient was transferred to a tertiary centre. Magnetic resonance imaging of the spine showed smooth enhancement of the ventral caudal nerve roots. Chest computed tomography revealed left lower vascular scarring. Further positron emission tomography scan imaging identified fluorodeoxyglucose avid right lung lymphadenopathy. Bronchoscopy-guided biopsy revealed small cell lung carcinoma. Onconeural and antiganglioside antibodies were negative. The patient was then transferred to a medical oncology ward where he underwent chemoradiotherapy and subsequently experienced improvement in his motor function, supporting that his neurological condition was indeed secondary to a paraneoplastic process. CONCLUSIONS Onconeural negative paraneoplastic radiculoneuropathy can precede diagnosis of small cell lung carcinoma. If considered early and adequately investigated, it can allow earlier diagnosis and treatment of underlying malignancy, improving overall and neurological prognosis.
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Affiliation(s)
- Meshari Alsaeed
- Division of Neurology, Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
| | - Chloe A R Lim
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alyson Plecash
- Division of Neurology, Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Tychicus Chen
- Division of Neurology, Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
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Horiuchi K, Ikeda T, Kida A, Oyamada Y. Bilateral vocal cord paralysis due to direct invasion of right and left recurrent laryngeal nerves in a small cell lung cancer patient. BMJ Case Rep 2021; 14:e245011. [PMID: 34389600 PMCID: PMC8365821 DOI: 10.1136/bcr-2021-245011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 11/03/2022] Open
Affiliation(s)
- Kohei Horiuchi
- Department of Respiratory Medicine, Tokyo Medical Center, Meguro-ku, Japan
- Department of Internal Medicine, Division of Pulmonary Medicine, Keio University School of Medicine, Shinjuku-ku, Japan
| | - Toshiki Ikeda
- Department of Respiratory Medicine, Tokyo Medical Center, Meguro-ku, Japan
| | - Amina Kida
- Department of Otolaryngology, Tokyo Medical Center, Meguro-ku, Japan
| | - Yoshitaka Oyamada
- Department of Respiratory Medicine, Tokyo Medical Center, Meguro-ku, Japan
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Abstract
Autoimmune neurogenic dysphagia refers to manifestation of dysphagia due to autoimmune diseases affecting muscle, neuromuscular junction, nerves, roots, brainstem, or cortex. Dysphagia is either part of the evolving clinical symptomatology of an underlying neurological autoimmunity or occurs as a sole manifestation, acutely or insidiously. This opinion article reviews the autoimmune neurological causes of dysphagia, highlights clinical clues and laboratory testing that facilitate early diagnosis, especially when dysphagia is the presenting symptom, and outlines the most effective immunotherapeutic approaches. Dysphagia is common in inflammatory myopathies, most prominently in inclusion body myositis, and is frequent in myasthenia gravis, occurring early in bulbar-onset disease or during the course of progressive, generalized disease. Acute-onset dysphagia is often seen in Guillain–Barre syndrome variants and slowly progressive dysphagia in paraneoplastic neuropathies highlighted by the presence of specific autoantibodies. The most common causes of CNS autoimmune dysphagia are demyelinating and inflammatory lesions in the brainstem, occurring in patients with multiple sclerosis and neuromyelitis optica spectrum disorders. Less common, but often overlooked, is dysphagia in stiff-person syndrome especially in conjunction with cerebellar ataxia and high anti-GAD autoantibodies, and in gastrointestinal dysmotility syndromes associated with autoantibodies against the ganglionic acetyl-choline receptor. In the setting of many neurological autoimmunities, acute-onset or progressive dysphagia is a potentially treatable condition, requiring increased awareness for prompt diagnosis and early immunotherapy initiation.
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Tolkovsky A, Kipervasser S, Fainmesser Y, Alcalay Y, Gadoth A. A paraneoplastic syndrome misdiagnosed as ALS: What are the red flags? A case report and review of the literature. J Neuroimmunol 2021; 358:577635. [PMID: 34217018 DOI: 10.1016/j.jneuroim.2021.577635] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/31/2021] [Accepted: 06/16/2021] [Indexed: 12/11/2022]
Abstract
Background Paraneoplastic motor neuron disease (PMND) is a rare, non-classical form of paraneoplastic neurological syndrome (PNS). Anti-Hu and anti-CV2/CRMP5 PNS are mostly associated with small-cell lung cancer (SCLC) and consist of highly variable clinical syndromes, including sensory neuronopathy, cerebellar ataxia and/or limbic encephalitis. However, substantial motor impairment is uncommon, particularly when no sensory dysfunction co-exists. Case A 72-year-old man with a recent diagnosis of amyotrophic lateral sclerosis (ALS) was referred to our department of neurology for evaluation. The patient sub-acutely developed progressive neurological dysfunction including erectile dysfunction, behavioral changes, limb weakness, dysphagia, anorexia, as well as worsening stridor that necessitated tracheostomy due to bilateral vocal cord paralysis (BVCP). Neurological examination revealed motor weakness of upper and lower motor neuron origin with autonomic and cognitive dysfunction. Cerebrospinal fluid (CSF) analysis demonstrated pleocytosis, elevated protein, presence of oligoclonal bands (OCB), and neuronal antibody testing was positive for anti-Hu and anti-CV2/CRMP5. Based on these findings a diagnosis of a PNS was made. Evaluation for malignancy was negative, and immunosuppressive/immunomodulatory treatment was initiated but had little effect during fifteen months of follow-up. Conclusions Although PMND is very rare, in an atypical presentation, especially with features that are not usually present in ALS such as autonomic dysfunction, sensory disturbance or cognitive decline, this etiology should be in the differential diagnosis.
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Affiliation(s)
- Assaf Tolkovsky
- Department of Neurology, Tel-Aviv Medical Center, Tel-Aviv, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Svetlana Kipervasser
- Department of Neurology, Tel-Aviv Medical Center, Tel-Aviv, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Epilepsy Unit, Tel-Aviv Medical Center, Tel-Aviv, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaara Fainmesser
- Department of Neurology, Tel-Aviv Medical Center, Tel-Aviv, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Neuromuscular Unit, Tel-Aviv Medical Center, Tel-Aviv, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yifat Alcalay
- Encephalitis Center, Tel-Aviv Medical Center, Tel-Aviv, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Immunology Laboratory, Tel-Aviv Medical Center, Tel-Aviv, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Gadoth
- Department of Neurology, Tel-Aviv Medical Center, Tel-Aviv, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Encephalitis Center, Tel-Aviv Medical Center, Tel-Aviv, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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