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Ishikawa H, Mandel-Brehm C, Shindo A, Cady MA, Mann SA, Niwa A, Miyashita K, Ii Y, Zorn KC, Taniguchi A, Maeda M, Wilson MR, DeRisi JL, Tomimoto H. Long-term MRI changes in a patient with Kelch-like protein 11-associated paraneoplastic neurological syndrome. Eur J Neurol 2021; 28:4261-4266. [PMID: 34561925 DOI: 10.1111/ene.15120] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/13/2021] [Accepted: 09/17/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this study was to identify the long-term radiological changes, autoantibody specificities, and clinical course in a patient with kelch-like protein 11 (KLHL11)-associated paraneoplastic neurological syndrome (PNS). METHODS Serial brain magnetic resonance images were retrospectively assessed. To test for KLHL11 autoantibodies, longitudinal cerebrospinal fluid (CSF) and serum samples were screened by Phage-display ImmunoPrecipitation and Sequencing (PhIP-Seq). Immunohistochemistry was also performed to assess for the presence of KLHL11 in the patient's seminoma tissue. RESULTS A 42-year-old man presented with progressive ataxia and sensorineural hearing loss. Metastatic seminoma was detected 11 months after the onset of the neurological symptoms. Although immunotherapy was partially effective, his cerebellar ataxia gradually worsened over the next 8 years. Brain magnetic resonance imaging revealed progressive brainstem and cerebellar atrophy with a "hot-cross-bun sign", and low-signal intensity on susceptibility-weighted imaging (SWI) in the substantia nigra, red nucleus and dentate nuclei. PhIP-Seq enriched for KLHL11-derived peptides in all samples. Immunohistochemical staining of mouse brain with the patient CSF showed co-localization with a KLHL11 commercial antibody in the medulla and dentate nucleus. Immunohistochemical analysis of seminoma tissue showed anti-KLHL11 antibody-positive particles in cytoplasm. CONCLUSIONS This study suggests that KLHL11-PNS should be included in the differential diagnosis for patients with brainstem and cerebellar atrophy and signal changes not only on T2-FLAIR but also on SWI, which might otherwise be interpreted as secondary to a neurodegenerative disease such as multiple system atrophy.
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Affiliation(s)
| | - Caleigh Mandel-Brehm
- Department of Biochemistry and Biophysics, University of California, San Francisco, California, USA
| | | | - Martha A Cady
- Department of Biochemistry and Biophysics, University of California, San Francisco, California, USA
| | - Sabrina A Mann
- Department of Biochemistry and Biophysics, University of California, San Francisco, California, USA.,Chan Zuckerberg Biohub, San Francisco, California, USA
| | - Atsushi Niwa
- Department of Neurology, Mie University, Mie, Japan
| | | | - Yuichiro Ii
- Department of Neurology, Mie University, Mie, Japan
| | - Kelsey C Zorn
- Department of Biochemistry and Biophysics, University of California, San Francisco, California, USA
| | | | - Masayuki Maeda
- Department of Neuroradiology, Mie University, Mie, Japan
| | - Michael R Wilson
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, California, USA
| | - Joseph L DeRisi
- Department of Biochemistry and Biophysics, University of California, San Francisco, California, USA.,Chan Zuckerberg Biohub, San Francisco, California, USA
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