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Grossman SN, Rucker JC. Opsoclonus and ocular flutter: evaluation and management. Curr Opin Ophthalmol 2023; 34:465-469. [PMID: 37603546 DOI: 10.1097/icu.0000000000000998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
PURPOSE OF REVIEW Opsoclonus and ocular flutter are saccadic intrusions characterized by spontaneous, back-to-back, fast eye movements (saccades) that oscillate about the midline of central visual fixation without intervening inter-saccadic intervals. When this type of movement occurs exclusively in the horizontal plane, it is called ocular flutter. When it occurs in multiple planes (i.e. horizontal, vertical, and torsional) it is called opsoclonus. The most common etiologic categories are parainfectious and paraneoplastic diseases. Less common are toxic-metabolic, traumatic, or idiopathic origins. The mechanism of these movements relates to dysfunction of brainstem and cerebellar machinery involved in the generation of saccades. In this review, we discuss the characteristics of opsoclonus and ocular flutter, describe approaches to clinical evaluation and management of the patient with opsoclonus and ocular flutter, and review approaches to therapeutic intervention. RECENT FINDINGS Recent publications demonstrated eye position-dependent opsoclonus present only in left gaze, which may be related to dysfunction of frontal eye fields or structures in the cerebellar vermis. SUMMARY Opsoclonus and ocular flutter originate from a broad array of neuropathologies and have value from both a neuroanatomic and etiologic perspective.
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Affiliation(s)
| | - Janet C Rucker
- Department of Neurology
- Department of Ophthalmology, New York University Grossman School of Medicine, New York, New York, USA
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2
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Johnston WR, Hwang R, Mattei P. Surgical considerations for neuroblastoma-associated opsoclonus-myoclonus-ataxia syndrome: a series of 14 patients from a single institution. Pediatr Surg Int 2022; 38:249-255. [PMID: 34549330 DOI: 10.1007/s00383-021-05014-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Neuroblastoma is a childhood cancer of neural crest cells occasionally associated with opsoclonus-myoclonus-ataxia syndrome (OMAS), a paraneoplastic process characterized by ataxia, rapid eye movements, and muscle twitching. OMAS treatment and outcomes are well studied, but prior reports do not detail how the presence of OMAS should impact surgical approach, particularly for tumors with image defined risk factors (IDRF). METHODS We reviewed patients with neuroblastoma and OMAS at our institution from January 2009 to December 2020 and recorded tumor characteristics, operative details, OMAS therapies, and outcomes. RESULTS We identified 14 patients with neuroblastoma and OMAS out of 212 patients referred for surgery. There were 11 gross total resections and three partial resections. Two patients with partial resections developed OMAS after initial resection. One patient with gross total resection developed tumor recurrence 10 years later with OMAS redevelopment signaling recurrence. Three patients were positive for IDRFs and the one receiving neoadjuvant therapy achieved a gross total resection. CONCLUSIONS OMAS development after partial resection and OMAS recurrence following tumor recurrence indicates a correlation between tumor bulk and the paraneoplastic process. This justifies an aggressive resection even for low-risk tumors. Neoadjuvant therapy should be considered for potentially unresectable tumors with image defined risk factors. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- William R Johnston
- General, Thoracic, and Fetal Surgery, Department of Surgery, Wood 5, Children's Hospital of Philadelphia, 34th St. and Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Rosa Hwang
- General, Thoracic, and Fetal Surgery, Department of Surgery, Wood 5, Children's Hospital of Philadelphia, 34th St. and Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Peter Mattei
- General, Thoracic, and Fetal Surgery, Department of Surgery, Wood 5, Children's Hospital of Philadelphia, 34th St. and Civic Center Blvd., Philadelphia, PA, 19104, USA.
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3
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Zhu H, Wu W, Chen L, Hou C, Zeng Y, Tian Y, Shen H, Gao Y, Zhang Y, Peng B, Chen WX, Li X. Clinical Analysis of Pediatric Opsoclonus-Myoclonus Syndrome in One of the National Children's Medical Center in China. Front Neurol 2021; 12:744041. [PMID: 34690917 PMCID: PMC8531251 DOI: 10.3389/fneur.2021.744041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/17/2021] [Indexed: 11/17/2022] Open
Abstract
Objective: To study the clinical characteristics and treatment of pediatric opsoclonus-myoclonus syndrome (OMS). Methods: We analyzed the clinical data of nine children OMS between June 2017 and Nov 2020. Results: Nine children (M/F = 3:6, median onset age was 18 months) diagnosed with OMS were included in the study. Before onset, human rhinovirus and respiratory syncytial virus were seen in one patient, respectively. And one patient received Japanese encephalitis vaccination. Three patients had neuroblastoma, and one patient had ganglioneuroblastoma. All patients' symptoms were improved after receiving surgery (for four patients with tumor), intravenous human immunoglobulin and pulsed methylprednisolone. However, four patients without mass relapsed and became relapse free after rituximab treatment. The relapse rate was 44.4% (4/9). The OMS severity score at the last follow-up was significantly lower than the OMS severity score at onset (3.0 ± 1.0 vs. 11.0 ± 2.2, paired-samples t-test, P < 0.001). All patients had at least one item of neurological symptoms or neuropsychological disturbances. Conclusion: For pediatric OMS, human rhinovirus infection and respiratory syncytial virus infection can be seen before onset. Rituximab is effective in reducing relapse. Improving recognition and long-term prognosis in OMS is urgent.
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Affiliation(s)
- Haixia Zhu
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wenlin Wu
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Lianfeng Chen
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Chi Hou
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yiru Zeng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yang Tian
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Huiling Shen
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yuanyuan Gao
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yani Zhang
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Bingwei Peng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wen-Xiong Chen
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Xiaojing Li
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
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Opsoclonus-Myoclonus Syndrome in Children and Adolescents: A Therapeutic Challenge. CHILDREN 2021; 8:children8110965. [PMID: 34828678 PMCID: PMC8625142 DOI: 10.3390/children8110965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/11/2021] [Accepted: 10/22/2021] [Indexed: 11/17/2022]
Abstract
Opsoclonus-myoclonus syndrome (OMS) is a neurological non-fatal disease that usually responds to immunotherapies. However, the real challenge is to counteract the high frequency of relapses and long-term developmental sequelae. Since the OMS is extremely rare, a common consensus regarding therapeutic guidelines is still lacking. The goals of this study were to test whether ACTH was superior to other immunotherapies and to investigate whether an early treatment could improve the outcome. Sixteen children affected by OMS were retrospectively reviewed. Eight children had a neuroblastic tumor. The other eight patients were affected by non-paraneoplastic OMS. Overall, the most commonly used treatment was corticotherapy (n = 11). However, ACTH (n = 10), rituximab (n = 7), immunoglobulins (n = 4), cyclophosphamide (n = 3), and mycophenolate (n = 2) were also administered. ACTH was associated with a high percentage of patients who healed (80%) and, as a first-line therapy, was associated with a lower incidence of relapses. An early treatment was associated with a favorable long-term outcome. Long-term sequelae occurred in 42% of patients who were treated early and in all of those who were treated late. It is advisable for the affected children to be identified at an early time, as they may benefit from an early treatment. ACTH represents an effective treatment with a high probability of recovery and low rate of relapses.
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Patel A, Fischer C, Lin YC, Basu EM, Kushner BH, De Braganca K, Khakoo Y. Treatment and revaccination of children with paraneoplastic opsoclonus-myoclonus-ataxia syndrome and neuroblastoma: The Memorial Sloan Kettering experience. Pediatr Blood Cancer 2020; 67:e28319. [PMID: 32543116 PMCID: PMC8382509 DOI: 10.1002/pbc.28319] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/23/2020] [Accepted: 03/24/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To review the treatment and revaccination of neuroblastoma-associated opsoclonus-myoclonus-ataxia syndrome (OMAS) patients at Memorial Sloan Kettering Cancer Center (MSK). PROCEDURE Institutional Review Board approval was obtained for this retrospective study of patients with neuroblastoma-associated OMAS followed at MSK from 2000 to 2016. RESULTS Fourteen patients (nine female) were 9-21 (median 17) months old at diagnosis of neuroblastoma and OMAS syndrome. They had stage 1 (n = 12), stage 2B, or intermediate-risk stage 4. Tumor histology was favorable in 11 patients, unfavorable in two, and unknown in one patient. No patient had amplified MYCN. All patients underwent tumor resection at diagnosis. Anti-neuroblastoma treatment was limited to chemotherapy in one patient. Overall survival is 100% at 3-16 (median 10) years. For OMAS, 13 patients received intravenous immune globulin (IVIg), adrenocorticotropic hormone (ACTH), and rituximab, and one received ACTH and IVIg. Seven patients experienced OMAS relapse. For these relapses, five patients received low-dose cyclophosphamide and two received rituximab. The mean total OMAS treatment was 20-96 (median 48) months. Seven patients started rituximab ≤3 months from diagnosis and did not relapse. The other six experienced OMAS relapse. To date, six patients have been revaccinated at a minimum of 2 years after completion of OMAS therapy without OMAS recurrence. CONCLUSIONS Patients with neuroblastoma-associated OMAS had excellent overall survival. Early initiation of rituximab, IVIg, and ACTH may reduce risks of OMAS relapse. Revaccination can be resumed without exacerbation of OMAS. Further investigation with a larger cohort of patients is needed.
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Affiliation(s)
- Ami Patel
- New York University School of Medicine, New York, NY, USA
| | - Cheryl Fischer
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yi-Chih Lin
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ellen M. Basu
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brian H. Kushner
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kevin De Braganca
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yasmin Khakoo
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Department of Pediatrics, Weill Medical College of Cornell University, New York, NY USA
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Ko YJ, Shim YK, Kim WJ, Kim SY, Kim H, Hwang H, Chae JH, Choi JE, Kim KJ, Lim BC. The Efficacy and Safety of Rituximab for the Treatment of Pediatric Autoimmune Neuroinflammatory Disorders at a Single Center. ANNALS OF CHILD NEUROLOGY 2020. [DOI: 10.26815/acn.2019.00290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Wilbur C, Yea C, Licht C, Irwin MS, Yeh EA. An upfront immunomodulatory therapy protocol for pediatric opsoclonus-myoclonus syndrome. Pediatr Blood Cancer 2019; 66:e27776. [PMID: 31033188 DOI: 10.1002/pbc.27776] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/19/2019] [Accepted: 04/11/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Treatment of opsoclonus-myoclonus syndrome (OMS) has historically involved corticosteroids and intravenous immunoglobulin (IVIG) for a duration of 6-12 months or longer. This study evaluated whether a brief upfront immunomodulatory therapy protocol with rituximab reduces the duration of OMS therapy without adversely affecting OMS outcomes. PROCEDURE Retrospective chart review was performed for consecutive children diagnosed with OMS from 2006 to 2019 at The Hospital for Sick Children (Toronto, Canada). Children treated within 3 months of diagnosis with a treatment protocol involving pulse methylprednisolone (3-5 days, followed by an oral steroid taper), IVIG and/or plasma exchange, and rituximab (protocol group, n = 7) were compared to a historical group treated primarily with prednisone and IVIG (n = 8). RESULTS The duration of corticosteroid treatment was shorter in the protocol (median 4.5 [range 3-12] months) compared to that in the historical group (median 21.5 [range 6-70] months, P = .005), and subjects in the protocol group received fewer cycles of IVIG (median 1 [range 0-7] cycle vs 7 [range 1-70] cycles, P = .01). The proportion of children with OMS relapse was similar between the protocol and historic groups (2/6 vs 5/8, P = .59). OMS symptom rating scales at 12-month follow-up were similar in the protocol group (median 2.5, range 0-3) compared to that in the historical group (median 1, range 0-7; P = .66). CONCLUSIONS An upfront immunomodulatory therapy protocol with rituximab permits reduction in the duration of corticosteroid and IVIG therapy without a detrimental effect on OMS outcomes. Future studies with longer follow-up will have to determine whether neurocognitive and psychosocial outcomes are improved by this approach.
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Affiliation(s)
- Colin Wilbur
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada.,Division of Neurology, Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Canada
| | - Carmen Yea
- Department of Neurosciences and Mental Health, SickKids Research Institute, Toronto, Canada
| | - Christoph Licht
- Division of Nephrology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Meredith S Irwin
- Division of Hematology-Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada.,Department of Neurosciences and Mental Health, SickKids Research Institute, Toronto, Canada
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8
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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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Mohammad SS, Dale RC. Principles and approaches to the treatment of immune-mediated movement disorders. Eur J Paediatr Neurol 2018; 22:292-300. [PMID: 29289523 DOI: 10.1016/j.ejpn.2017.11.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 11/06/2017] [Accepted: 11/27/2017] [Indexed: 01/18/2023]
Abstract
Immune mediated movement disorders include movement disorders in the context of autoimmune encephalitis such as anti-NMDAR encephalitis, post-infectious autoimmune movement disorders such as Sydenham chorea, paraneoplastic autoimmune movement disorders such as opsoclonus myoclonus ataxia syndrome, and infection triggered conditions such as paediatric acute neuropsychiatric syndrome. This review focuses on the approach to treatment of immune mediated movement disorders, which requires an understanding of the immunopathogenesis, whether the disease is destructive or 'altering', and the natural history of disease. Factors that can influence outcome include the severity of disease, the delay before starting therapy, use of multimodal therapy and whether the course is monophasic or relapsing. Although the four main conditions listed above have different pathophysiological processes, there are general themes that broadly apply including: early diagnosis and treatment is better, minimise the severity of disease, escalate treatment if the patient is not responding to initial treatments, and minimise relapse.
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Affiliation(s)
- Shekeeb S Mohammad
- The Children's Hospital at Westmead Clinical School, Children's Hospital at Westmead, Sydney Medical School, University of Sydney, Australia; TY Nelson Department of Neurology and Neurosurgery, Children's Hospital at Westmead, Sydney, Australia
| | - Russell C Dale
- The Children's Hospital at Westmead Clinical School, Children's Hospital at Westmead, Sydney Medical School, University of Sydney, Australia; Brain and Mind Centre Westmead, University of Sydney, Australia.
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Kushner BH, Khakoo Y. Enigmatic entities: opsoclonus myoclonus ataxia syndrome linked to neuroblastoma. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:3-5. [DOI: 10.1016/s2352-4642(17)30129-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 10/15/2017] [Accepted: 10/16/2017] [Indexed: 01/20/2023]
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Pranzatelli MR, Tate ED, McGee NR. Demographic, Clinical, and Immunologic Features of 389 Children with Opsoclonus-Myoclonus Syndrome: A Cross-sectional Study. Front Neurol 2017; 8:468. [PMID: 28959231 PMCID: PMC5604058 DOI: 10.3389/fneur.2017.00468] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 08/24/2017] [Indexed: 12/17/2022] Open
Abstract
Pediatric-onset opsoclonus-myoclonus syndrome (OMS) is a devastating neuroinflammatory, often paraneoplastic, disorder. The objective was to characterize demographic, clinical, and immunologic aspects in the largest cohort reported to date. Cross-sectional data were collected on 389 children in an IRB-approved, observational study at the National Pediatric Myoclonus Center. Non-parametric statistical analysis was used. OMS manifested in major racial/ethnic groups, paralleling US population densities. Median onset age was 1.5 years (1.2–2 interquartile range), inclusive of infants (14%), toddlers (61%), and youngsters (25%). The higher female sex ratio of 1.2 was already evident in toddlers. Time to diagnosis was 1.2 months (0.7–3); to treatment, 1.4 months (0.4–4). Irritability/crying dominated prodromal symptomatology (60%); overt infections in <35%. Acute cerebellar ataxia was the most common misdiagnosis; staggering appeared earliest among 10 ranked neurological signs (P < 0.0001). Some untreated youngsters had no words (33%) or sentences (73%). Remote neuroblastic tumors were detected in 50%; resection was insufficient OMS treatment (58%). Age at tumor diagnosis related to tumor type (P = 0.004) and stage (P = 0.002). A novel observation was that paraneoplastic frequency varied with patient age—not a mere function of the frequency of neuroblastoma, which was lowest in the first 6 months of life, when that of neuroblastoma without OMS was highest. The cerebrospinal fluid (CSF) leukocyte count was minimally elevated in 14% (≤11/mm3) with normal differential, and commercially screened serum autoantibodies were negative, but CSF oligoclonal bands (OCB) and B cells frequency were positive (58 and 93%). Analysis of patients presenting on immunotherapy revealed a shift in physician treatment practice patterns from monotherapy toward multi-agent immunotherapy (P < 0.001); the number of agents/sequences varied. In sum, a major clinical challenge is to increase OMS recognition, prevent initial misdiagnosis, and shorten time to diagnosis/treatment. The index of suspicion for an underlying tumor must remain high despite symptoms of infection. The disparity in onset age of neuroblastoma frequency with that of neuroblastoma with OMS warrants further studies of potential host/tumor factors. OMS neuroinflammation is best diagnosed by CSF OCB and B cells, not by routine CSF or commercial antibody studies.
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Affiliation(s)
- Michael R Pranzatelli
- National Pediatric Myoclonus Center, Neuroimmunology Laboratory, Orlando, FL, United States.,National Pediatric Neuroinflammation Organization, Inc., Orlando, FL, United States
| | - Elizabeth D Tate
- National Pediatric Myoclonus Center, Neuroimmunology Laboratory, Orlando, FL, United States.,National Pediatric Neuroinflammation Organization, Inc., Orlando, FL, United States
| | - Nathan R McGee
- National Pediatric Myoclonus Center, Neuroimmunology Laboratory, Orlando, FL, United States
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13
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Eberhardt O, Topka H. Myoclonic Disorders. Brain Sci 2017; 7:E103. [PMID: 28805718 PMCID: PMC5575623 DOI: 10.3390/brainsci7080103] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/06/2017] [Accepted: 08/08/2017] [Indexed: 01/17/2023] Open
Abstract
Few movement disorders seem to make a straightforward approach to diagnosis and treatment more difficult and frustrating than myoclonus, due to its plethora of causes and its variable classifications. Nevertheless, in recent years, exciting advances have been made in the elucidation of the pathophysiology and genetic basis of many disorders presenting with myoclonus. Here, we provide a review of all of the important types of myoclonus encountered in pediatric and adult neurology, with an emphasis on the recent developments that have led to a deeper understanding of this intriguing phenomenon. An up-to-date list of the genetic basis of all major myoclonic disorders is presented. Randomized studies are scarce in myoclonus therapy, but helpful pragmatic approaches at diagnosis as well as treatment have been recently suggested.
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Affiliation(s)
- Olaf Eberhardt
- Klinik für Neurologie, Klinikum Bogenhausen, Städt. Klinikum München GmbH, Englschalkinger Str. 77, 81925 München, Germany.
| | - Helge Topka
- Klinik für Neurologie, Klinikum Bogenhausen, Städt. Klinikum München GmbH, Englschalkinger Str. 77, 81925 München, Germany.
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14
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Galstyan A, Wilbur C, Selby K, Hukin J. Opsoclonus-Myoclonus Syndrome: A New Era of Improved Prognosis? Pediatr Neurol 2017; 72:65-69. [PMID: 28479124 DOI: 10.1016/j.pediatrneurol.2017.03.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 03/11/2017] [Accepted: 03/18/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Opsoclonus-myoclonus syndrome is an autoimmune neurological disorder characterized by opsoclonus, myoclonus, ataxia, and behavioral changes. Although long-term outcomes have historically been poor, including motor and cognitive disabilities, the advent of new and more aggressive immunotherapy regimens may be improving prognosis in opsoclonus-myoclonus syndrome. METHODS We retrospectively reviewed the records of all children diagnosed with opsoclonus-myoclonus syndrome at BC Children's Hospital from 2000 to 2010. Neurological outcomes were compared with those previously reported in the literature. RESULTS Twelve children with opsoclonus-myoclonus syndrome were identified, four of whom had an associated neuroblastoma. Two thirds of patients received initial treatment with a combination of corticosteroids, intravenous immunoglobulin (IVIG), and an additional immunosuppressant agent. After a median follow-up of three years from diagnosis, ten patients had no or minimal neurological abnormalities. Two patients had poor outcome with significant cognitive impairment. CONCLUSIONS Most patients in this series were treated with early multimodal immunotherapy, and neurological outcomes were better than those in most historical reports. This finding is consistent with recent studies that suggest multimodal immunotherapy regimens may be improving the prognosis in this challenging disease. However, some individuals did well with less aggressive treatment, and further studies are required to determine optimal treatment approach.
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Affiliation(s)
- Armine Galstyan
- Division of Neurology, Department of Pediatrics, University of British Columbia and BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Colin Wilbur
- Division of Neurology, Department of Pediatrics, University of British Columbia and BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Kathryn Selby
- Division of Neurology, Department of Pediatrics, University of British Columbia and BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Juliette Hukin
- Division of Neurology, Department of Pediatrics, University of British Columbia and BC Children's Hospital, Vancouver, British Columbia, Canada.
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Gadian J, Kirk E, Holliday K, Lim M, Absoud M. Systematic review of immunoglobulin use in paediatric neurological and neurodevelopmental disorders. Dev Med Child Neurol 2017; 59:136-144. [PMID: 27900773 DOI: 10.1111/dmcn.13349] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2016] [Indexed: 01/18/2023]
Abstract
AIM A systematic literature review of intravenous immunoglobulin (IVIG) treatment of paediatric neurological conditions was performed to summarize the evidence, provide recommendations, and suggest future research. METHOD A MEDLINE search for articles reporting on IVIG treatment of paediatric neuroinflammatory, neurodevelopmental, and neurodegenerative conditions published before September 2015, excluding single case reports and those not in English. Owing to heterogeneous outcome measures, meta-analysis was not possible. Findings were combined and evidence graded. RESULTS Sixty-five studies were analysed. IVIG reduces recovery time in Guillain-Barré syndrome (grade B). IVIG is as effective as corticosteroids in chronic inflammatory demyelinating polyradiculoneuropathy (grade C), and as effective as tacrolimus in Rasmussen syndrome (grade C). IVIG improves recovery in acute disseminated encephalomyelitis (grade C), reduces mortality in acute encephalitis syndrome with myocarditis (grade C), and improves function and stabilizes disease in myasthenia gravis (grade C). IVIG improves outcome in N-methyl-d-aspartate receptor encephalitis (grade C) and opsoclonus-myoclonus syndrome (grade C), reduces cataplexy symptoms in narcolepsy (grade C), speeds recovery in Sydenham chorea (grade C), reduces tics in selected cases of Tourette syndrome (grade D), and improves symptoms in paediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (grade B). INTERPRETATION IVIG is a useful therapy in selected neurological conditions. Well-designed, prospective, multi-centre studies with standardized outcome measures are required to compare treatments.
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Affiliation(s)
- Jonathan Gadian
- Evelina London Children's Hospital, St Thomas' Hospital, Children's Neurosciences Centre, London, UK
| | - Emma Kirk
- Evelina London Children's Hospital, St Thomas' Hospital, Paediatric Pharmacy, London, UK
| | | | - Ming Lim
- Evelina London Children's Hospital, St Thomas' Hospital, Children's Neurosciences Centre, London, UK
| | - Michael Absoud
- Evelina London Children's Hospital, St Thomas' Hospital, Children's Neurosciences Centre, London, UK
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Ratner N, Brodeur GM, Dale RC, Schor NF. The "neuro" of neuroblastoma: Neuroblastoma as a neurodevelopmental disorder. Ann Neurol 2016; 80:13-23. [PMID: 27043043 DOI: 10.1002/ana.24659] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/28/2016] [Accepted: 03/28/2016] [Indexed: 12/11/2022]
Abstract
Neuroblastoma is a childhood cancer derived from cells of neural crest origin. The hallmarks of its enigmatic character include its propensity for spontaneous regression under some circumstances and its association with paraneoplastic opsoclonus, myoclonus, and ataxia. The neurodevelopmental underpinnings of its origins may provide important clues for development of novel therapeutic and preventive agents for this frequently fatal malignancy and for the associated paraneoplastic syndromes. Ann Neurol 2016;80:13-23.
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Affiliation(s)
- Nancy Ratner
- Department of Pediatrics, Cincinnati Children's Hospital and University of Cincinnati, Cincinnati, OH
| | - Garrett M Brodeur
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Russell C Dale
- Clinical School, the Children's Hospital at Westmead, University of Sydney, Sydney, New South Wales, Australia
| | - Nina F Schor
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY
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Player B, Harmelink M, Bordini B, Weisgerber M, Girolami M, Croix M. Pediatric Opsoclonus-Myoclonus-Ataxia Syndrome Associated With Anti-N-methyl-D-aspartate Receptor Encephalitis. Pediatr Neurol 2015; 53:456-8. [PMID: 26341674 DOI: 10.1016/j.pediatrneurol.2015.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 07/22/2015] [Accepted: 07/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The full clinical spectrum of anti-N-methyl-D-aspartate receptor encephalitis is unknown in the pediatric population. PATIENT We describe a previously healthy 4-year-old girl presenting with opsoclonus-myoclonus together with ataxia who had NR1-specific, anti-N-methyl-D-aspartate receptor antibodies in the cerebral spinal fluid. CONCLUSION The presence of NR1-specific, anti-N-methyl-D-aspartate receptor antibodies in the setting of opsoclonus-myoclonus and ataxia syndrome may represent an expansion of the clinical presentations of anti-N-methyl-D-aspartate receptor encephalitis.
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Affiliation(s)
- Brittany Player
- Pediatric Hospital Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Matthew Harmelink
- Pediatric Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Brett Bordini
- Pediatric Hospital Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Weisgerber
- Pediatric Hospital Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Girolami
- Medical Education Office, Medical College of Wisconsin, Milwaukee, Wisconsin
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18
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Mitchell WG, Wooten AA, O'Neil SH, Rodriguez JG, Cruz RE, Wittern R. Effect of Increased Immunosuppression on Developmental Outcome of Opsoclonus Myoclonus Syndrome (OMS). J Child Neurol 2015; 30:976-82. [PMID: 25342308 DOI: 10.1177/0883073814549581] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 08/08/2014] [Indexed: 11/17/2022]
Abstract
Opsoclonus myoclonus syndrome (OMS) produces long-term cognitive, behavioral, and motor deficits. Objective was to see if more aggressive treatment improved outcome. Assessment included opsoclonus myoclonus syndrome rating, developmental/cognitive and motor assessment, and adaptive behavior. Fourteen subjects completed testing. Nine had neuroblastoma. Onset was at 10 to 35 months; onset to diagnosis: 2 days to 14 months, and onset to first treatment: 5 days to 15 months. Initial treatment was corticotropin (12), oral steroids (3), plus intravenous immunoglobulin in all. Ten received rituximab, 5 cyclophosphamide. Age at testing ranged from 2.5 to 10.3 years. Adaptive Behavior Score (11 subjects), mean 93.5; estimated Intelligence Quotient/Developmental Quotient mean 93.5; Motor: mean 92.8. Residual opsoclonus myoclonus syndrome symptoms at the time of the evaluation were generally minor; opsoclonus myoclonus syndrome scores ranged from 0 to 6. Comparison to previously reported opsoclonus myoclonus syndrome subjects showed improved outcomes: Adaptive behavior, cognitive and motor scores were significantly higher (P < .001) in new subjects. Outcomes have improved with more aggressive immunosuppression, with most opsoclonus myoclonus syndrome survivors now functioning at or near normal.
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Affiliation(s)
- Wendy G Mitchell
- Neurology Division, Children's Hospital Los Angeles, Los Angeles, CA, USA Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Amelia A Wooten
- Neurology Division, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Sharon H O'Neil
- Clinical Translational Science Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jenny G Rodriguez
- Neurology Division, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Rosa E Cruz
- Neurology Division, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Rachael Wittern
- Clinical Translational Science Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
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Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) syndrome may have a hypothalamus-periaqueductal gray localization. Pediatr Neurol 2015; 52:521-5. [PMID: 25746964 DOI: 10.1016/j.pediatrneurol.2014.11.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 11/27/2014] [Accepted: 11/28/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Anatomical localization of the rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) syndrome has proved elusive. Most patients had neuroimaging after cardiorespiratory collapse, revealing a range of ischemic lesions. PATIENT DESCRIPTION A 15-year-old obese boy with an acute febrile encephalopathy had hypoventilation, autonomic dysfunction, visual hallucinations, hyperekplexia, and disordered body temperature, and saltwater regulation. These features describe the ROHHAD syndrome. Cerebrospinal fluid analysis showed pleocytosis, elevated neopterins, and oligoclonal bands, and serology for systemic and antineuronal antibodies was negative. He improved after receiving intravenous steroids, immunoglobulins, and long-term mycophenolate. Screening for neural crest tumors was negative. CONCLUSION Magnetic resonance imaging of the brain early in his illness showed focal inflammation in the periaqueductal gray matter and hypothalamus. This unique localization explains almost all symptoms of this rare autoimmune encephalitis.
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20
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Beh SC, Frohman TC, Frohman EM. Neuro-ophthalmic Manifestations of Cerebellar Disease. Neurol Clin 2014; 32:1009-80. [DOI: 10.1016/j.ncl.2014.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Shin C Beh
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Teresa C Frohman
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Elliot M Frohman
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA; Department of Ophthalmology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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21
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Singhi P, Sahu JK, Sarkar J, Bansal D. Clinical profile and outcome of children with opsoclonus-myoclonus syndrome. J Child Neurol 2014; 29:58-61. [PMID: 23318697 DOI: 10.1177/0883073812471433] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The opsoclonus-myoclonus syndrome is a distinct disorder characterized by opsoclonus, myoclonus, and ataxia, along with marked irritability and behavioral changes. Worldwide, data on its epidemiology, clinical features, and outcome are scarce. The aim of the study was to determine the clinical profile and outcome of children with this disorder. A retrospective study of all children admitted with a diagnosis of opsoclonus-myoclonus from 2000 to 2012 was done. Outcome was assessed on follow-up by direct assessment and by telephonic interview. Eleven patients with a diagnosis of opsoclonus-myoclonus were admitted over a 12-year period. Of the 11, 4 had paraneoplastic etiology. Children with paraneoplastic opsoclonus had more relapses and a poor outcome as compared to an idiopathic group. Paraneoplastic opsoclonus had a poor outcome in our experience.
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Affiliation(s)
- Pratibha Singhi
- 1Pediatric Neurology Division, Department of Pediatrics, Post-Graduate Institute of Medical Education & Research, Chandigarh, India
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22
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CSF neurofilament light chain is elevated in OMS (decreasing with immunotherapy) and other pediatric neuroinflammatory disorders. J Neuroimmunol 2013; 266:75-81. [PMID: 24342231 DOI: 10.1016/j.jneuroim.2013.11.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 10/15/2013] [Accepted: 11/12/2013] [Indexed: 11/22/2022]
Abstract
Using a panel of seven brain cell-specific biomarkers in cerebrospinal fluid (CSF), pediatric opsoclonus-myoclonus syndrome (OMS) (n=234) was compared to pediatric non-inflammatory neurological controls (n=84) and other inflammatory neurological disorders (OIND) (n=44). Only CSF NFL was elevated in untreated OMS versus controls (+83%). It was 87% higher in OIND than in OMS. On combination treatment with front-loaded ACTH, IVIg, rituximab, median CSF NFL decreased by 60% to control levels. These biochemical data suggest neuronal/axonal injury in some children with OMS without indicators of astrogliosis, and reduction on sufficient immunotherapy.
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Pranzatelli MR, Tate ED, McGee NR, Ransohoff RM. CCR7 signaling in pediatric opsoclonus–myoclonus: Upregulated serum CCL21 expression is steroid-responsive. Cytokine 2013; 64:331-6. [DOI: 10.1016/j.cyto.2013.05.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 05/02/2013] [Accepted: 05/17/2013] [Indexed: 11/25/2022]
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Pranzatelli MR, Tate ED, McGee NR, Colliver JA. Cytokines, cytokine antagonists, and soluble adhesion molecules in pediatric OMS and other neuroinflammatory disorders. J Neurol Sci 2013; 326:53-8. [DOI: 10.1016/j.jns.2013.01.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 01/07/2013] [Accepted: 01/09/2013] [Indexed: 11/26/2022]
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25
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Tate ED, Pranzatelli MR. Response to correspondence on "active comparator-controlled, rater-blinded study of corticotropin-based immunotherapies for opsoclonus-myoclonus syndrome". J Child Neurol 2013; 28:417-8. [PMID: 23400632 DOI: 10.1177/0883073812469054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Elizabeth D. Tate
- National Pediatric Myoclonus Center and Department of Neurology, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Michael R. Pranzatelli
- National Pediatric Myoclonus Center and Department of Neurology, Southern Illinois University School of Medicine, Springfield, IL, USA
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26
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Sahu JK, Singhi P. Conventional versus multimodal corticotropin-based immunotherapies for opsoclonus-myoclonus syndrome: where are we? J Child Neurol 2013; 28:416. [PMID: 23400631 DOI: 10.1177/0883073812469048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Jitendra Kumar Sahu
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pratibha Singhi
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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28
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Pranzatelli MR, Tate ED, McGee NR, Colliver JA, Ransohoff RM. CCR4 Agonists CCL22 and CCL17 are Elevated in Pediatric OMS Sera: Rapid and Selective Down-Regulation of CCL22 by ACTH or Corticosteroids. J Clin Immunol 2013; 33:817-25. [DOI: 10.1007/s10875-013-9867-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 01/10/2013] [Indexed: 01/04/2023]
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Pranzatelli MR, Tate ED, McGee NR, Travelstead AL, Colliver JA, Ness JM, Ransohoff RM. BAFF/APRIL system in pediatric OMS: relation to severity, neuroinflammation, and immunotherapy. J Neuroinflammation 2013; 10:10. [PMID: 23324534 PMCID: PMC3610127 DOI: 10.1186/1742-2094-10-10] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Accepted: 01/08/2013] [Indexed: 01/16/2023] Open
Abstract
Background B-cell dysregulation has been implicated but not fully characterized in pediatric opsoclonus-myoclonus syndrome (OMS), a neuroblastoma-associated neuroinflammatory disorder. Objective To assess the role of B-cell activating factor (BAFF) and a proliferation-inducing ligand (APRIL), two critical B cell-modulating cytokines, as potential biomarkers of disease activity and treatment biomarkers in OMS. Methods Soluble BAFF and APRIL were measured in cerebrospinal fluid (CSF) and serum by ELISA in 433 children (296 OMS, 109 controls, 28 other inflammatory neurological disorders (OIND)). BAFF-R receptors on circulating CD19+ B cells were measured by flow cytometry. A blinded scorer rated motor severity on the OMS Evaluation Scale. Immunotherapies were evaluated cross-sectionally and longitudinally. Results The mean CSF BAFF concentration, which was elevated in untreated OMS and OIND, correlated with OMS severity category (P = 0.006), and reduction by adrenocorticotropic hormone or corticotropin (ACTH) (−61%) or corticosteroids (−38%) was seen at each level of severity. In contrast, CSF APRIL was normal in OMS and OIND and unaffected by immunotherapy. When the entire OMS dataset was dichotomized into ‘high’ versus ‘normal’ CSF BAFF concentration, the phenotype of the high group included greater motor severity and number of CSF oligoclonal bands, and a higher concentration of inflammatory chemokines CXCL13 and CXCL10 in CSF and CXCL9 and CCL21 in serum. Serum APRIL was 6.7-fold higher in the intravenous immunoglobulins (IVIg) group, whereas serum BAFF was 2.6-fold higher in the rituximab group. The frequency of B cell BAFF-R expression was similar in untreated and treated OMS. Longitudinal studies of CSF BAFF revealed a significant decline in ACTH-treated patients (with or without rituximab) (P < 0.0001). Longitudinal studies of serum APRIL showed a 2.9-fold increase after 1 to 2 g/kg IVIg monotherapy (P = 0.0003). Conclusions Striking distinctions in BAFF/APRIL signaling were found. OMS displayed heterogeneity in CSF BAFF expression, which met many but not all criteria as a potential biomarker of disease activity. We speculate that CSF BAFF may have more utility in a biomarker panel than as a stand-alone biomarker, and that the selective upregulation of both serum APRIL by IVIg and BAFF by rituximab, as well as downregulation of CSF BAFF by ACTH/steroids, may have utility as treatment biomarkers.
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Affiliation(s)
- Michael R Pranzatelli
- Department of Neurology, National Pediatric Myoclonus Center and Neuroimmunology Laboratory, and Southern Illinois University School of Medicine, PO Box 19643, Springfield, IL 62794-9643, USA.
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