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Wijnand A, Verhelst H. Anti-SOX1 Antibodies in a 3-Year-old Girl, Post-Varicella. Child Neurol Open 2023; 10:2329048X231200613. [PMID: 37745634 PMCID: PMC10517599 DOI: 10.1177/2329048x231200613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/04/2023] [Accepted: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
Anti-SRY-related HMG-box gene 1 (SOX1) antibodies were initially described in adults with paraneoplastic neurological disorders, where they are considered high-risk onconeural autoantibodies. Only two pediatric cases of anti-SOX1 antibodies have been reported: a 17-year-old adolescent presenting with paraneoplastic limbic encephalitis due to Hodgkin lymphoma and a 12-year-old girl presenting with non-paraneoplastic encephalitis. We present a unique case of anti-SOX1 antibodies in a 3-year-old girl, post-varicella infection. Initially, she presented with ataxia and dysmetria, with subsequent reports from parents of urinary incontinence and significant behavior changes. Additionally, reflexes in the lower limbs were absent. Anti-SOX1 antibodies tested positive in both serum and cerebrospinal fluid. Oncological screening at presentation and a seven-month follow-up showed no malignancies. The patient exhibited favorable clinical progress without requiring treatment. At the seven-month follow-up, serum antibodies tested negative. This case report broadens the known clinical spectrum, being the first description of post-varicella anti-SOX1 antibodies.
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Affiliation(s)
- Aline Wijnand
- Department of Child and Adolescent Psychiatry, Ghent University Hospital, Ghent, Belgium
| | - Helene Verhelst
- Department of Pediatrics, Division of Pediatric Neurology, Ghent University Hospital, Ghent, Belgium
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Hampe CS, Mitoma H. A Breakdown of Immune Tolerance in the Cerebellum. Brain Sci 2022; 12:brainsci12030328. [PMID: 35326284 PMCID: PMC8946792 DOI: 10.3390/brainsci12030328] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/22/2022] [Accepted: 02/25/2022] [Indexed: 11/21/2022] Open
Abstract
Cerebellar dysfunction can be associated with ataxia, dysarthria, dysmetria, nystagmus and cognitive deficits. While cerebellar dysfunction can be caused by vascular, traumatic, metabolic, genetic, inflammatory, infectious, and neoplastic events, the cerebellum is also a frequent target of autoimmune attacks. The underlying cause for this vulnerability is unclear, but it may be a result of region-specific differences in blood–brain barrier permeability, the high concentration of neurons in the cerebellum and the presence of autoantigens on Purkinje cells. An autoimmune response targeting the cerebellum—or any structure in the CNS—is typically accompanied by an influx of peripheral immune cells to the brain. Under healthy conditions, the brain is protected from the periphery by the blood–brain barrier, blood–CSF barrier, and blood–leptomeningeal barrier. Entry of immune cells to the brain for immune surveillance occurs only at the blood-CSF barrier and is strictly controlled. A breakdown in the barrier permeability allows peripheral immune cells uncontrolled access to the CNS. Often—particularly in infectious diseases—the autoimmune response develops because of molecular mimicry between the trigger and a host protein. In this review, we discuss the immune surveillance of the CNS in health and disease and also discuss specific examples of autoimmunity affecting the cerebellum.
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Affiliation(s)
- Christiane S. Hampe
- Department of Medicine, University of Washington, Seattle, WA 98195, USA
- Correspondence: ; Tel.: +1-206-554-9181
| | - Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, Tokyo 160-0023, Japan;
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Zhu Z, Jiang W, Li W, Zhang J, Lv X, Lu C, Chen H, Li H, Xie H, Tang J, Du C, Chen G, Geng Q, Tang W. Risk factors for the occurrence and recurrence of acute cerebellar ataxia: a retrospective observational study. Neurol Sci 2021; 43:1067-1070. [PMID: 34089111 DOI: 10.1007/s10072-021-05362-4] [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: 02/18/2021] [Accepted: 05/28/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE There is little evidence to support a correlation between abdominal surgery and acute cerebellar ataxia (ACA). We reviewed the records of children with ACA treated at our institution to analyze risk factors for ACA. METHODS Clinical data of 442 children with ACA treated at Children's Hospital of Nanjing Medical University between November 2015 and June 2019 were retrospectively analyzed. Univariate and multivariate analyses were performed to determine risk factors for the occurrence and recurrence of ACA. RESULTS In total, 442 children with ACA were included in this study. Multivariate logistic regression analysis showed age (p = 0.009), infection (p < 0.001), vaccination (p < 0.001), head trauma (p < 0.001), intussusception surgery (IS) (p < 0.001), operation for indirect inguinal hernia (p < 0.001), and operation for congenital gastrointestinal malformation (p < 0.001) were independent risk factors for ACA occurrence. Univariate analysis showed that only IS (p < 0.001) was associated with ACA recurrence. CONCLUSIONS Surgeons should be aware that age, infection, vaccination, head trauma, and history of abdominal surgery are associated with ACA, while IS is a risk factor for ACA recurrence.
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Affiliation(s)
- Zhongxian Zhu
- Department of Neonatal Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Weiwei Jiang
- Department of Neonatal Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Wei Li
- Department of Neonatal Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Jie Zhang
- Department of Neonatal Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Xiaofeng Lv
- Department of Neonatal Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Changgui Lu
- Department of Neonatal Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Huan Chen
- Department of Neonatal Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Hongxing Li
- Department of Neonatal Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Hua Xie
- Department of Neonatal Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Jie Tang
- Department of Neonatal Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Chunxia Du
- Department of Neonatal Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Guanglin Chen
- Department of Neonatal Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Qiming Geng
- Department of Neonatal Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Weibing Tang
- Department of Neonatal Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China.
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Figlerowicz M, Mazur-Melewska K, Kemnitz P, Mania A. Pediatric postviral autoimmune disorders of the CNS. Future Virol 2020. [DOI: 10.2217/fvl-2019-0162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Infections caused by various viruses, mainly belonging to the Herpesviridae family, can trigger the autoimmune process in the CNS in children. This can break brain immune tolerance and induce many molecular and cellular pathways of the immune response. This can lead to the appearance of neuronal auto-antibodies to intracellular, cell-surface or extracellular synaptic antigens. Children may also display a wide spectrum of neurological problems from encephalitis to obsessive–compulsive or tic disorders. In these cases, patients rarely respond to traditional treatment, based on antiviral or/and symptomatic drugs, but early immunotherapy is very effective. The implementation of routine immune tests in all children with acute neurological disorders should be recommended.
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Affiliation(s)
- Magdalena Figlerowicz
- Department of Infectious Diseases & Child Neurology, Karol Marcinkowski University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznań, Poland
| | - Katarzyna Mazur-Melewska
- Department of Infectious Diseases & Child Neurology, Karol Marcinkowski University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznań, Poland
| | - Paweł Kemnitz
- Department of Infectious Diseases & Child Neurology, Karol Marcinkowski University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznań, Poland
| | - Anna Mania
- Department of Infectious Diseases & Child Neurology, Karol Marcinkowski University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznań, Poland
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Wang S, Meng Y, Huang Z, Hu J, Niu Q, Zhang J, Yan B, Wu Y. Anti-centrosome antibodies: Prevalence and disease association in Chinese population. Scand J Immunol 2019; 90:e12803. [PMID: 31267615 DOI: 10.1111/sji.12803] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 06/19/2019] [Accepted: 06/26/2019] [Indexed: 02/05/2023]
Abstract
Anti-centrosome antibodies are rare findings with undefined clinical significance in clinical research. We aimed at investigating the prevalence and clinical significance of anti-centrosome antibodies in Chinese population. Testing results of total of 281,230 ANA-positive sera were retrospectively obtained from West China Hospital Sichuan University in China between 2008 and 2017. We retrospectively collected and analysed the clinical and laboratory data of the patients with positive anti-centrosome antibody. Of the 356 453 patients tested, 281 230 patients had positive antinuclear antibodies (ANAs, 78.9%), but only 78 patients with positive anti-centrosome antibodies (0.022%), of which 74.4% are females. Diagnoses were established in 69 of 78 patients: 37 cases were autoimmune diseases, mainly including undifferentiated connective tissue diseases (UCTD, 9/37), rheumatoid arthritis (RA, 6/37), Sjögren's syndrome (SS, 5/37) and primary biliary cirrhosis (PBC, 5/37), and the remaining were other autoimmune conditions. The most frequent clinical symptoms of the anti-centrosome-positive patients were arthralgia and eyes and mouth drying. Additionally, 86.7% of anti-centrosome antibodies were not associated with other ANA profiles; however, when associated, the most frequent ANA was anti-U1RNP. Anti-centrosome antibodies are featured by a low prevalence and female gender predominance. They are correlated with some specific diseases, both autoimmune diseases, especially UCTD, RA, SS and PBC, and non-autoimmune diseases, such as infection and cancer, which suggests that they might be potential supporting serological markers of these diseases.
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Affiliation(s)
- Shengjie Wang
- Department of Laboratory Medicine, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Yanming Meng
- Department of Laboratory Medicine, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Zhuochun Huang
- Department of Laboratory Medicine, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Hu
- Department of Laboratory Medicine, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Qian Niu
- Department of Laboratory Medicine, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Junlong Zhang
- Department of Laboratory Medicine, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Bing Yan
- Department of Rheumatology, West China Hospital, Sichuan University, Chengdu, China
| | - Yongkang Wu
- Department of Laboratory Medicine, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
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García-Iñiguez J, López-Pisón F, Madurga Revilla P, Montejo Gañán I, Domínguez Cajal M, Monge Galindo L, Sánchez Marco S, García Jiménez M. Acute cerebellitis in paediatric patients: Our experience. NEUROLOGÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.nrleng.2018.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Damoiseaux J, Andrade LEC, Carballo OG, Conrad K, Francescantonio PLC, Fritzler MJ, Garcia de la Torre I, Herold M, Klotz W, Cruvinel WDM, Mimori T, von Muhlen C, Satoh M, Chan EK. Clinical relevance of HEp-2 indirect immunofluorescent patterns: the International Consensus on ANA patterns (ICAP) perspective. Ann Rheum Dis 2019; 78:879-889. [PMID: 30862649 PMCID: PMC6585284 DOI: 10.1136/annrheumdis-2018-214436] [Citation(s) in RCA: 184] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 01/23/2019] [Indexed: 12/21/2022]
Abstract
The indirect immunofluorescence assay (IIFA) on HEp-2 cells is widely used for detection of antinuclear antibodies (ANA). The dichotomous outcome, negative or positive, is integrated in diagnostic and classification criteria for several systemic autoimmune diseases. However, the HEp-2 IIFA test has much more to offer: besides the titre or fluorescence intensity, it also provides fluorescence pattern(s). The latter include the nucleus and the cytoplasm of interphase cells as well as patterns associated with mitotic cells. The International Consensus on ANA Patterns (ICAP) initiative has previously reached consensus on the nomenclature and definitions of HEp-2 IIFA patterns. In the current paper, the ICAP consensus is presented on the clinical relevance of the 29 distinct HEp-2 IIFA patterns. This clinical relevance is primarily defined within the context of the suspected disease and includes recommendations for follow-up testing. The discussion includes how this information may benefit the clinicians in daily practice and how the knowledge can be used to further improve diagnostic and classification criteria.
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Affiliation(s)
- Jan Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Orlando Gabriel Carballo
- Department of Immunology, Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.,Laboratory of Immunology, Hospital General de Agudos Carlos G Durand, Buenos Aires, Argentina
| | - Karsten Conrad
- Immunology, Medical Faculty TU Dresden, Dresden, Germany
| | | | | | | | - Manfred Herold
- Rheumatology Unit, Clinical Department of General Internal Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Werner Klotz
- Department of Internal Medicine II, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Tsuneyo Mimori
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate school of Medicine, Kyoto, Japan
| | | | - Minoru Satoh
- Department of Clinical Nursing, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Edward K Chan
- Department of Oral Biology, University of Florida, Gainesville, Florida, USA
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8
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Emelifeonwu JA, Shetty J, Kaliaperumal C, Gallo P, Sokol D, Soleiman H, Kandasamy J. Acute Cerebellitis in Children: A Variable Clinical Entity. J Child Neurol 2018; 33:675-684. [PMID: 29888646 DOI: 10.1177/0883073818777673] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute cerebellar ataxia is the most common cause of acute ataxia in children and it usually runs a self-limiting and ultimately benign clinical course. A small proportion of children have evidence of inflammatory swelling in the cerebellum. Many of these children suffer more severe and potentially life-threatening forms of cerebellar ataxia and may need more intensive treatments including urgent neurosurgical treatments. This more severe form of acute cerebellar ataxia is often termed acute cerebellitis. Many children with acute cerebellitis have long-term neurological sequela and evidence of structural cerebellar changes on follow-up imaging. Several patterns of cerebellar inflammation have been described. The authors describe the variabilities in the clinical and radiological patterns of disease in the cases that have been described in the literature.
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Affiliation(s)
- John Amaechi Emelifeonwu
- 1 Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.,2 Department of Clinical Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK
| | - Jay Shetty
- 2 Department of Clinical Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK
| | | | - Pasquale Gallo
- 2 Department of Clinical Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK
| | - Drahoslav Sokol
- 2 Department of Clinical Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK
| | - Hamza Soleiman
- 1 Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - Jegajothy Kandasamy
- 2 Department of Clinical Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK
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9
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Acute cerebellitis in children: an eleven year retrospective multicentric study in Italy. Ital J Pediatr 2017; 43:54. [PMID: 28606112 PMCID: PMC5469162 DOI: 10.1186/s13052-017-0370-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 05/29/2017] [Indexed: 11/25/2022] Open
Abstract
Background Acute cerebellitis (AC) and acute cerebellar ataxia (ACA) are the principal causes of acute cerebellar dysfunction in childhood. Nevertheless. there is no accepted consensus regarding the best management of children with AC/ACA: the aim of the study is both to assess clinical, neuroimaging and electrophysiologic features of children with AC/ACA and to evaluate the correlation between clinical parameters, therapy and outcome. Methods A multicentric retrospective study was conducted on children ≤ 18 years old admitted to 12 Italian paediatric hospitals for AC/ACA from 01/01/2003 to 31/12/2013. A score based on both cerebellar and extracerebellar signs/symptoms was computed for each patient. One point was given for each sign/symptom reported. Severity was divided in three classes: low, moderate, severe. Results A total of 124 children were included in the study. Of these, 118 children received a final diagnosis of ACA and 6 of AC. The most characteristic finding of AC/ACA was a broad-based gait disturbance. Other common symptoms included balance disturbances, slurred speech, vomiting, headache and fever. Neurological sequelae were reported in 6 cases (5%) There was no correlation among symptoms, cerebrospinal fluid findings, clinical outcome. There was no correlation between clinical manifestations and clinical score on admission and length of hospital stay, sex, age and EEG findings with sequelae (P > 0.05). Children with pathological magnetic resonance imaging (MRI) or computed tomography (CT) had a higher probability of having clinical sequelae. Treatment was decided independently case by case. Patients with a higher clinical score on admission had a higher probability of receiving intravenous steroids. Conclusions We confirmed the literature data about the benign course of AC/ACA in most cases but we also highlighted a considerable rate of patients with neurological sequelae (5%). Pathological MRI or CT findings at admission correlate to neurological sequelae. These findings suggest the indication to perform an instrumental evaluation in all patients with AC/ACA at admission to identify those at higher risk of neurological outcome. These patients may benefit from a more aggressive therapeutic strategy and should have a closer follow-up. Randomized controlled trials are needed to confirm these observations. The ultimate goal of these studies could be to develop a standardized protocol on AC/ACA. The MRI/CT data, associated with the clinical manifestations, may allow us to define the class risk of patients for a neurological outcome.
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García-Iñiguez JP, López-Pisón FJ, Madurga Revilla P, Montejo Gañán I, Domínguez Cajal M, Monge Galindo L, Sánchez Marco SB, García Jiménez MC. Acute cerebellitis in paediatric patients: Our experience. Neurologia 2017; 34:291-299. [PMID: 28318729 DOI: 10.1016/j.nrl.2017.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 12/22/2016] [Accepted: 01/01/2017] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Acute cerebellitis is a rare inflammatory disease with a highly variable clinical course that ranges from benign self-limiting symptoms to a fulminant presentation associated with a high risk of death due to compression of the posterior fossa, acute hydrocephalus, and intracranial hypertension. METHODS We reviewed clinical, laboratory, and radiological findings from children diagnosed with acute cerebellitis between May 2007 and November 2016. We analysed treatments and clinical and radiological progression. RESULTS Nine children met the diagnostic criteria for cerebellitis. Headache, vomiting, and drowsiness were the most frequent initial symptoms; ataxia, dysarthria, and dysmetria were the most common cerebellar signs. Cerebellitis was diagnosed with magnetic resonance imaging, which revealed cerebellar involvement (unilateral or bilateral); computerised tomography images either were normal or showed indirect signs such as triventricular hydrocephalus due to extrinsic compression of the aqueduct of Sylvius. Corticosteroids were the most commonly used treatment (6 patients). One patient required surgery due to triventricular hydrocephalus. Eight patients recovered completely, whereas the ninth displayed neurological sequelae. CONCLUSIONS Cerebellitis is a medical and surgical emergency; diagnosis requires a high level of suspicion and an emergency brain magnetic resonance imaging study. It is a clinical-radiological syndrome characterised by acute or subacute encephalopathy with intracranial hypertension and cerebellar syndrome associated with T2-weighted and FLAIR hyperintensities in the cerebellar cortex (unilaterally or bilaterally) and possible triventricular dilatation. Treatment is based on high-dose corticosteroids and may require external ventricular drain placement and decompressive surgery.
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Affiliation(s)
- J P García-Iñiguez
- Unidad de Cuidados Intensivos Pediátricos, Hospital Infantil Universitario Miguel Servet, Zaragoza, España.
| | - F J López-Pisón
- Neuropediatría, Hospital Infantil Universitario Miguel Servet, Zaragoza, España
| | - P Madurga Revilla
- Unidad de Cuidados Intensivos Pediátricos, Hospital Infantil Universitario Miguel Servet, Zaragoza, España
| | - I Montejo Gañán
- Radiología, Hospital Infantil Universitario Miguel Servet, Zaragoza, España
| | - M Domínguez Cajal
- Unidad de Cuidados Intensivos Pediátricos, Hospital Infantil Universitario Miguel Servet, Zaragoza, España
| | - L Monge Galindo
- Neuropediatría, Hospital Infantil Universitario Miguel Servet, Zaragoza, España
| | - S B Sánchez Marco
- Neuropediatría, Hospital Infantil Universitario Miguel Servet, Zaragoza, España
| | - M C García Jiménez
- Neuropediatría, Hospital Infantil Universitario Miguel Servet, Zaragoza, España
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Acute Ataxia in Children: A Review of the Differential Diagnosis and Evaluation in the Emergency Department. Pediatr Neurol 2016; 65:14-30. [PMID: 27789117 DOI: 10.1016/j.pediatrneurol.2016.08.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 08/26/2016] [Indexed: 11/21/2022]
Abstract
Acute ataxia in a pediatric patient poses a diagnostic dilemma for any physician. While the most common etiologies are benign, occasional individuals require urgent intervention. Children with stroke, toxic ingestion, infection, and neuro-inflammatory disorders frequently exhibit ataxia as an essential-if not the only-presenting feature. The available retrospective research utilize inconsistent definitions of acute ataxia, precluding the ability to pool data from these studies. No prospective data exist that report on patients presenting to the emergency department with ataxia. This review examines the reported causes of ataxia and attempts to group them into distinct categories: post-infectious and inflammatory central and peripheral phenomena, toxic ingestion, neurovascular, infectious and miscellaneous. From there, we synthesize the existing literature to understand which aspects of the history, physical exam, and ancillary testing might aid in narrowing the differential diagnosis. MRI is superior to CT in detecting inflammatory or vascular insults in the posterior fossa, though CT may be necessary in emergent situations. Lumbar puncture may be deferred until after admission in most instances, with suspicion for meningitis being the major exception. There is insufficient evidence to guide laboratory evaluation of serum, testing should be ordered based on clinical judgement-recommended studies include metabolic profiles and screening labs for metabolic disorders (lactate and ammonia). All patients should be reflexively screened for toxic ingestions.
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Thakkar K, Maricich SM, Alper G. Acute Ataxia in Childhood: 11-Year Experience at a Major Pediatric Neurology Referral Center. J Child Neurol 2016; 31:1156-60. [PMID: 27071467 DOI: 10.1177/0883073816643407] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 03/10/2016] [Indexed: 11/15/2022]
Abstract
We categorized the causes of acute ataxia in the pediatric population-referred to the Division of Neurology-at a large, urban pediatric medical center. Of the 120 cases identified over the past 11 years, post-infectious cerebellar ataxia was the most commonly diagnosed (59%), followed by drug intoxication, opsoclonus-myoclonus ataxia syndrome, episodic ataxia, acute cerebellitis, cerebellar stroke, ADEM, meningitis, cerebral vein thrombosis, Leigh's disease, Miller-Fisher syndrome, and concussion. Among the patients with post-infectious cerebellar ataxia, 85% were 1-6 years old and all had a history of antecedent viral illness. CSF pleocytosis was present in 40% of patients; all had normal brain MRIs. The majority (91%) recovered within 30 days. We conclude that post-infectious cerebellar ataxia remains the most common cause of acute ataxia in childhood and that it carries a good prognosis. We also differentiate acute post-infectious cerebellar ataxia from other causes with similar presentations.
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Affiliation(s)
- Kavita Thakkar
- Department of Pediatrics, Division of Child Neurology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Stephen M Maricich
- Department of Pediatrics, Division of Child Neurology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA Richard King Mellon Foundation Institute for Pediatric Research, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gulay Alper
- Department of Pediatrics, Division of Child Neurology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
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13
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Jarius S, Wildemann B. 'Medusa-head ataxia': the expanding spectrum of Purkinje cell antibodies in autoimmune cerebellar ataxia. Part 1: Anti-mGluR1, anti-Homer-3, anti-Sj/ITPR1 and anti-CARP VIII. J Neuroinflammation 2015; 12:166. [PMID: 26377085 PMCID: PMC4574226 DOI: 10.1186/s12974-015-0356-y] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 07/02/2015] [Indexed: 01/09/2023] Open
Abstract
Serological testing for anti-neural autoantibodies is important in patients presenting with idiopathic cerebellar ataxia, since these autoantibodies may indicate cancer, determine treatment and predict prognosis. While some of them target nuclear antigens present in all or most CNS neurons (e.g. anti-Hu, anti-Ri), others more specifically target antigens present in the cytoplasm or plasma membrane of Purkinje cells (PC). In this series of articles, we provide a detailed review of the clinical and paraclinical features, oncological, therapeutic and prognostic implications, pathogenetic relevance, and differential laboratory diagnosis of the 12 most common PC autoantibodies (often referred to as 'Medusa-head antibodies' due to their characteristic somatodendritic binding pattern when tested by immunohistochemistry). To assist immunologists and neurologists in diagnosing these disorders, typical high-resolution immunohistochemical images of all 12 reactivities are presented, diagnostic pitfalls discussed and all currently available assays reviewed. Of note, most of these antibodies target antigens involved in the mGluR1/calcium pathway essential for PC function and survival. Many of the antigens also play a role in spinocerebellar ataxia. Part 1 focuses on anti-metabotropic glutamate receptor 1-, anti-Homer protein homolog 3-, anti-Sj/inositol 1,4,5-trisphosphate receptor- and anti-carbonic anhydrase-related protein VIII-associated autoimmune cerebellar ataxia (ACA); part 2 covers anti-protein kinase C gamma-, anti-glutamate receptor delta-2-, anti-Ca/RhoGTPase-activating protein 26- and anti-voltage-gated calcium channel-associated ACA; and part 3 reviews the current knowledge on anti-Tr/delta notch-like epidermal growth factor-related receptor-, anti-Nb/AP3B2-, anti-Yo/cerebellar degeneration-related protein 2- and Purkinje cell antibody 2-associated ACA, discusses differential diagnostic aspects and provides a summary and outlook.
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Affiliation(s)
- S Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Otto Meyerhof Center, Im Neuenheimer Feld 350, D-69120, Heidelberg, Germany.
| | - B Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Otto Meyerhof Center, Im Neuenheimer Feld 350, D-69120, Heidelberg, Germany.
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Jarius S, Wildemann B. 'Medusa head ataxia': the expanding spectrum of Purkinje cell antibodies in autoimmune cerebellar ataxia. Part 3: Anti-Yo/CDR2, anti-Nb/AP3B2, PCA-2, anti-Tr/DNER, other antibodies, diagnostic pitfalls, summary and outlook. J Neuroinflammation 2015; 12:168. [PMID: 26377319 PMCID: PMC4573944 DOI: 10.1186/s12974-015-0358-9] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 07/02/2015] [Indexed: 01/23/2023] Open
Abstract
Serological testing for anti-neural autoantibodies is important in patients presenting with idiopathic cerebellar ataxia, since these autoantibodies may indicate cancer, determine treatment and predict prognosis. While some of them target nuclear antigens present in all or most CNS neurons (e.g. anti-Hu, anti-Ri), others more specifically target antigens present in the cytoplasm or plasma membrane of Purkinje cells (PC). In this series of articles, we provide a detailed review of the clinical and paraclinical features, oncological, therapeutic and prognostic implications, pathogenetic relevance, and differential laboratory diagnosis of the 12 most common PC autoantibodies (often referred to as 'Medusa head antibodies' due to their characteristic somatodendritic binding pattern when tested by immunohistochemistry). To assist immunologists and neurologists in diagnosing these disorders, typical high-resolution immunohistochemical images of all 12 reactivities are presented, diagnostic pitfalls discussed and all currently available assays reviewed. Of note, most of these antibodies target antigens involved in the mGluR1/calcium pathway essential for PC function and survival. Many of the antigens also play a role in spinocerebellar ataxia. Part 1 focuses on anti-metabotropic glutamate receptor 1-, anti-Homer protein homolog 3-, anti-Sj/inositol 1,4,5-trisphosphate receptor- and anti-carbonic anhydrase-related protein VIII-associated autoimmune cerebellar ataxia (ACA); part 2 covers anti-protein kinase C gamma-, anti-glutamate receptor delta-2-, anti-Ca/RhoGTPase-activating protein 26- and anti-voltage-gated calcium channel-associated ACA; and part 3 reviews the current knowledge on anti-Tr/delta notch-like epidermal growth factor-related receptor-, anti-Nb/AP3B2-, anti-Yo/cerebellar degeneration-related protein 2- and Purkinje cell antibody 2-associated ACA, discusses differential diagnostic aspects and provides a summary and outlook.
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Affiliation(s)
- S Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Otto Meyerhof Center, Im Neuenheimer Feld 350, D-69120, Heidelberg, Germany.
| | - B Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Otto Meyerhof Center, Im Neuenheimer Feld 350, D-69120, Heidelberg, Germany.
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Bozzola E, Bozzola M, Tozzi AE, Calcaterra V, Longo D, Krzystofiak A, Villani A. Acute cerebellitis in varicella: a ten year case series and systematic review of the literature. Ital J Pediatr 2014; 40:57. [PMID: 24942129 PMCID: PMC4079178 DOI: 10.1186/1824-7288-40-57] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 06/11/2014] [Indexed: 12/11/2022] Open
Abstract
Background Acute cerebellitis (AC) is the most common neurological complication of varicella. Nevertheless, it has been scarcely studied. The objective of this study were to asses the occurrence of AC among children hospitalized for varicella and to analyze its specific clinical picture and outcome. Methods We retrospectively reviewed the medical records of children admitted to the hospital for varicella between 1st October 2003 and 1st June 2013 and we compared our results with literature. Children were all unvaccinated for varicella. Results In our case series, AC was found out in 48 out of 457 patients (10.5%). The highest frequency of AC was observed in children from 1 to 5 years of age (60.9%). The most characteristic symptom of AC was a broad-based gait disturbance that progressed gradually over the course of a few days (95.8%). Other common symptoms included slurred speech (37.5%), vomiting (31.25%), headache (29.16%), dysmetry (25%) and tremor (22.91%). After a long hospitalization (median of 11 days), all but one children were dismissed without invalidating sequelae. Conclusions Data from this study may help to better address the problem of varicella cerebellar complications in hospitalized children and to monitor changes over time caused by an increase in vaccination coverage.
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Affiliation(s)
- Elena Bozzola
- Department of Pediatric, Bambino Gesù Children's Hospital, Pediatric and Infectious Diseases Unit, IRCCS, Rome, Italy.
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16
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Carceller Lechón F, Duat Rodríguez A, Sirvent Cerdá SI, Khabra K, de Prada I, García-Peñas JJ, Madero López L. Hemicerebellitis: Report of three paediatric cases and review of the literature. Eur J Paediatr Neurol 2014; 18:273-81. [PMID: 24423631 DOI: 10.1016/j.ejpn.2013.12.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 12/09/2013] [Accepted: 12/10/2013] [Indexed: 10/25/2022]
Abstract
Acute inflammation of a single cerebellar hemisphere (hemicerebellitis) is a rare disorder of unknown origin. The clinical presentation is mainly characterized by headache, ataxia, dysmetria, and vomiting. In addition, some children may develop severe intracranial hypertension. The neuroimaging of hemicerebellitis raises a challenging differential diagnosis, particularly with posterior fossa tumours. Although there is no standard treatment for hemicerebellitis, its outcome is usually favourable. However, ipsilateral hemicerebellar atrophy develops in up to half of cases, and a minority of children may show persisting fine motor and/or neurocognitive sequelae. In this article, we contribute with three new reports and review a total of 35 cases of hemicerebellitis.
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Affiliation(s)
| | | | | | - Komel Khabra
- Department of Statistics, Royal Marsden Hospital, Sutton, Surrey, United Kingdom
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Kloc M, Kubiak JZ, Li XC, Ghobrial RM. The newly found functions of MTOC in immunological response. J Leukoc Biol 2013; 95:417-30. [DOI: 10.1189/jlb.0813468] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Whelan HT, Verma S, Guo Y, Thabet F, Bozarth X, Nwosu M, Katyayan A, Parachuri V, Spangler K, Ruggeri BE, Srivatsal S, Zhang G, Ashwal S. Evaluation of the child with acute ataxia: a systematic review. Pediatr Neurol 2013; 49:15-24. [PMID: 23683541 DOI: 10.1016/j.pediatrneurol.2012.12.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 12/17/2012] [Indexed: 11/25/2022]
Abstract
Evaluation of acute ataxia in a child poses a dilemma for the clinician in determining the extent and timing of initial screening tests. This article reviews the evidence concerning the diagnostic yield of commonly ordered tests in evaluating the child with acute ataxia. The literature revealed the following frequencies of laboratory screening abnormalities in children with acute ataxia: CT (∼2.5%), MRI (∼5%), lumbar puncture (43%), EEG (42%), and toxicology (49%). In most studies, abnormalities detected by these screening tests were nondiagnostic. There are insufficient data to assess yields of testing for autoimmune disorders or inborn errors of metabolism. A toxicology screen should be considered in all children presenting with acute ataxia. Neuroimaging should be considered in all children with new onset ataxia. Cerebrospinal fluid analysis has limited diagnostic specificity unless clinically indicated. Studies to examine neurophysiology testing did have sufficient evidence to support their use. There is insufficient evidence to establish a role for autoantibody testing or for routine screening for inborn error of metabolism in children presenting with acute ataxia. Finally, in a child presenting with ataxia and opsoclonus myoclonus, urine catecholamine testing for occult neuroblastoma is recommended. Nuclear scan may be considered, however, there is insufficient evidence for additional body imaging.
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Affiliation(s)
- Harry T Whelan
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Desai J, Mitchell WG. Acute cerebellar ataxia, acute cerebellitis, and opsoclonus-myoclonus syndrome. J Child Neurol 2012; 27:1482-8. [PMID: 22805251 DOI: 10.1177/0883073812450318] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute cerebellar ataxia and acute cerebellitis represent a process characterized by parainfectious, postinfectious, or postvaccination cerebellar inflammation. There is considerable overlap between these entities. The mildest cases of acute cerebellar ataxia represent a benign condition that is characterized by acute truncal and gait ataxia, variably with appendicular ataxia, nystagmus, dysarthria, and hypotonia. It occurs mostly in young children, presents abruptly, and recovers over weeks. Neuroimaging is normal. Severe cases of cerebellitis represent the other end of the spectrum, presenting with acute cerebellar signs often overshadowed by alteration of consciousness, focal neurological deficits, raised intracranial pressure, hydrocephalus, and even herniation. Neuroimaging is abnormal and the prognosis is less favorable than in acute cerebellar ataxia. Acute disseminated encephalomyelitis may be confused with acute cerebellitis when the clinical findings are predominantly cerebellar, but lesions on neuroimaging are usually widespread. Paraneoplastic opsoclonus-myoclonus syndrome is often initially misdiagnosed as acute cerebellar ataxia, but has very specific features, course, and etiopathogensis.
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Affiliation(s)
- Jay Desai
- Division of Neurology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA
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Camacho-Badilla K, Méndez I, Soriano-Fallas A, Ulloa-Gutiérrez R, Avila-Aguero ML. [Postvaricella cerebellar ataxia in children in Costa Rica]. An Pediatr (Barc) 2008; 68:49-53. [PMID: 18194628 DOI: 10.1157/13114471] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Postvaricella cerebellar ataxia (PVCA) and meningoencephalitis are the most common acute neurological complications of chickenpox. The objective of this study was to describe the clinical presentation, management, and outcome of children hospitalized with PVCA in the only pediatric hospital of this developing country, where routine varicella immunization is not yet available. METHODS We performed a retrospective chart review of children aged 1-12 years old admitted to the National Children's Hospital of Costa Rica from January 1997 to June 2004 with a diagnosis of PVCA. RESULTS Among the 441 immunocompetent patients admitted for varicella zoster virus-associated complications during this period, 37 (8.4%) had PVCA. Twenty-four of the 37 (64.9%) patients were boys. The mean (range) age was 5 (1-10) years. The median (range) interval from rash onset to admission was 2 (1-3) days. Cerebrospinal fluid analysis was available in 22 (59.5%) patients and was normal in all. Head computed tomography showed cerebral edema in six out of 18 patients (33.3%). Intravenous acyclovir was administered to 23 patients but no significant differences in clinical manifestations or outcomes were observed in treated versus untreated patients. The mean (range) length of ataxia was 4 (1-10) days, and seven (19%) patients were still ataxic on discharge. The mean (range) length of hospital stay was 4.4 (2-11) days. Minor sequelae were documented in 13 out of 24 (54.2%) patients during follow-up visits and telephone contacts. CONCLUSIONS PVCA is usually associated with a favorable prognosis; however, neurological sequelae can occur. The real utility of acyclovir treatment and brain imaging studies in these children remains controversial.
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Affiliation(s)
- K Camacho-Badilla
- Servicio de Infectología, Hospital Nacional de Niños Dr. Carlos Sáenz Herrera, San José, Costa Rica.
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Shiihara T, Kato M, Konno A, Takahashi Y, Hayasaka K. Acute cerebellar ataxia and consecutive cerebellitis produced by glutamate receptor delta2 autoantibody. Brain Dev 2007; 29:254-6. [PMID: 17049194 DOI: 10.1016/j.braindev.2006.09.004] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2006] [Revised: 09/06/2006] [Accepted: 09/07/2006] [Indexed: 12/01/2022]
Abstract
Acute cerebellar ataxia is usually a self-limited benign disease, which may develop in children after certain viral infections or vaccinations. There are several reports of acute cerebellar ataxia associated with autoantibodies. Glutamate receptor delta2, a member of the glutamate receptor family, is predominantly expressed in cerebellar Purkinje cells and plays a crucial role in cerebellar functions. To date anti-GluRdelta2 autoantibody was detected in a patient with chronic cerebellitis. Herein, an 18-month-old boy presented with cerebellar ataxia 9 days following a mild respiratory tract infection. Although cerebellar ataxia gradually improved, it worsened yet again following mumps and varicella virus infection. Cerebro-spinal fluid examination and magnetic resonance imaging of the brain demonstrated pleocytosis and meningeal enhancement, respectively. Furthermore, glutamate receptor delta2 autoantibody was detected in serum and cerebro-spinal fluid. Thus, we believe that the glutamate receptor delta2 autoantibody may play a role in cerebellar ataxia and consecutive cerebellitis.
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Affiliation(s)
- Takashi Shiihara
- Department of Pediatrics, Yamagata University School of Medicine, 2-2-2 Iida-nishi, Yamagata 990-9585, Japan.
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Roselli F, Russo I, Fraddosio A, Aniello MS, De Mari M, Lamberti P, Livrea P, Defazio G. Reversible Parkinsonian syndrome associated with anti-neuronal antibodies in acute EBV encephalitis: a case report. Parkinsonism Relat Disord 2006; 12:257-60. [PMID: 16459123 DOI: 10.1016/j.parkreldis.2005.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2005] [Revised: 09/20/2005] [Accepted: 11/07/2005] [Indexed: 11/25/2022]
Abstract
We report a case of subacute-onset isolated parkinsonian syndrome in a 16 years old patient. Epstein-Barr infection was diagnosed according to serologic evidences. Parkinson-like syndrome completely recovered after 60 days. Autoantibodies reacting against a 130 Kda antigens expressed in human neuroblastoma cell line were detected. Pathogenesis and differential diagnosis are briefly discussed. EBV testing could be worthwhile in juvenile, acute-onset, parkinsonism.
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Affiliation(s)
- Francesco Roselli
- Department of Neurologic and Psychiatric Sciences-University of Bari, p.za Giulio Cesare, 2 70124 Bari (BA), Italy.
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