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Miraclin AT, Mani AM, Sivadasan A, Nair A, Christina M, Gojer AR, Milton S, Jude Prakash JA, Benjamin RN, Prabhakar AT, Mathew V, Aaron S. Opsoclonus myoclonus ataxia syndrome, ovarian teratoma and anti-NMDAR antibody: an 'unresolved' mystery. BMJ Neurol Open 2023; 5:e000414. [PMID: 37396795 PMCID: PMC10314564 DOI: 10.1136/bmjno-2023-000414] [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] [Accepted: 05/20/2023] [Indexed: 07/04/2023] Open
Abstract
Background Opsoclonus-myoclonus-ataxia syndrome (OMAS) is characterised by the combination of opsoclonus and arrhythmic action myoclonus with axial ataxia and dysarthria. In adults, a majority are paraneoplastic secondary to solid organ tumours and could harbour antibodies against intracellular epitopes; however, certain proportions have detectable antibodies to various neuronal cell surface antigens. Anti-N-methyl-D-aspartate (NMDAR) antibodies and ovarian teratomas have been implicated in OMAS. Methods Report of two cases and review of literature. Results Two middle-aged women presented with subacute-onset, rapidly progressive OMAS and behavioural changes consistent with psychosis. The first patient had detectable antibodies to NMDAR in the cerebrospinal fluid (CSF) alone. Evaluation for ovarian teratoma was negative. The second patient had no detectable antibodies in serum or CSF; however, she had an underlying ovarian teratoma. Patient A was treated with pulse steroids, therapeutic plasma exchange (TPE) followed by bortezomib (BOR) and dexamethasone, while patient B was treated with steroids, TPE followed by surgical resection of ovarian teratoma. Both patients had favourable outcomes and were asymptomatic at the 6 monthly follow-up. Conclusions With coexistent neuropsychiatric manifestations, OMAS can be considered a distinct entity of autoimmune encephalitis, pathogenesis being immune activation against known/unknown neuronal cell surface antigens. The observation of absence of anti-NMDAR antibody in patients with teratoma-associated OMAS and vice versa is intriguing. Further research on the potential role of ovarian teratoma in evoking neuronal autoimmunity and its targets is required. The management challenge in both cases including the potential use of BOR has been highlighted.
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Affiliation(s)
- Angel T Miraclin
- Department of Neurosciences, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Arun Mathai Mani
- Department of Neurosciences, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Ajith Sivadasan
- Department of Neurosciences, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Aditya Nair
- Department of Neurosciences, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Munagapati Christina
- Department of Psychiatry, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Abigail Ruth Gojer
- Department of Psychiatry, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Sharon Milton
- Department of Clinical Pathology, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - John A Jude Prakash
- Department of Clinical Microbiology, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Rohit N Benjamin
- Department of Neurosciences, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | | | - Vivek Mathew
- Department of Neurosciences, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Sanjith Aaron
- Department of Neurosciences, Christian Medical College Vellore, Vellore, Tamil Nadu, India
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Du H, Cai W. Opsoclonus-myoclonus syndrome associated with neuroblastoma: Insights into antitumor immunity. Pediatr Blood Cancer 2022; 69:e29949. [PMID: 36094353 DOI: 10.1002/pbc.29949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 07/08/2022] [Accepted: 08/04/2022] [Indexed: 11/08/2022]
Abstract
Opsoclonus-myoclonus syndrome (OMS) is a rare neurological disorder. Half of these cases occur in children with neuroblastoma. Neuroblastoma patients with OMS usually have better oncological outcomes than those without OMS even after stratification by tumor stage and age, indicating that factors mediating OMS may also inhibit tumor cell proliferation. Although the mechanisms underlying OMS remain undefined, the cytokines and lymphocytes alterations in the cerebrospinal fluid support the concept that it is a pattern of neuroinflammation due to an autoimmune effect. The presence of lymphoid follicles consisting of follicular dendritic cells, CD20+ B lymphocytes, CD3+ T lymphocytes, and CD68+ macrophages in the tumor microenvironment in OMS-associated neuroblastoma support the autoimmune nature of this disorder. This review focuses on the clinical and genetic features of OMS-associated neuroblastoma, and we update readers on immune features of neuroblastoma with or without OMS to gain insights into antitumor immunity as it relates to tumor biology and prognosis.
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Affiliation(s)
- Hongmei Du
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Weisong Cai
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China
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Noguchi K, Ikawa Y, Takenaka M, Sakai Y, Fujiki T, Kuroda R, Ikeda H, Nakada S, Nomura K, Sakai S, Fukuda M, Araki R, Takahashi Y, Wada T. Presence of identical B-cell clone in both cerebrospinal fluid and tumor tissue in a patient with opsoclonus-myoclonus syndrome associated with neuroblastoma. Pediatr Hematol Oncol 2022; 40:363-370. [PMID: 36125271 DOI: 10.1080/08880018.2022.2109784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Opsoclonus-myoclonus syndrome associated with neuroblastoma (OMS-NB) is a refractory paraneoplastic syndrome which often remain neurological sequelae, and detailed pathogenesis has remained elusive. We encountered a pediatric patient with OMS-NB treated by immunosuppressed therapy who showed anti-glutamate receptor δ2 antibody and increased B-cells in cerebrospinal fluid (CSF), and multiple lymphoid follicles containing abundant Bcells in tumor tissue. Unbiased B-cell receptor repertoire analysis revealed identical B-cell clone was identified as the dominant clone in both CSF and tumor tissue. These identical B-cell clone may contribute to the pathogenesis of OMS-NB. Our results could facilitate the establishment of pathogenesis-based treatment strategies for OMS-NB.
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Affiliation(s)
- Kazuhiro Noguchi
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Yasuhiro Ikawa
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Mika Takenaka
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Yuta Sakai
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Toshihiro Fujiki
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Rie Kuroda
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Hiroko Ikeda
- Department of Diagnostic Pathology, Kanazawa University Hospital, Kanazawa, Japan
| | - Satoko Nakada
- Department of Diagnostic Pathology, Kanazawa University Hospital, Kanazawa, Japan
| | - Kozo Nomura
- Department of Pediatric Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Seisho Sakai
- Department of Pediatric Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Masaki Fukuda
- Department of Pediatrics, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Raita Araki
- Department of Pediatrics, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Yukitoshi Takahashi
- National Epilepsy Center, NHO, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Taizo Wada
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
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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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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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Anand S, Agarwala S, Jain V, Bakhshi S, Dhua A, Gulati S, Seth R, Srinivas M, Jana M, Kandasamy D, Bhatnagar V. Neuroblastoma With Opsoclonus-Myoclonus-Ataxia Syndrome: Role of Chemotherapy in the Management: Experience From a Tertiary Care Center in a Resource-limited Setting. J Pediatr Hematol Oncol 2021; 43:e924-e929. [PMID: 33769388 DOI: 10.1097/mph.0000000000002131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 01/15/2021] [Indexed: 11/27/2022]
Abstract
Children with neuroblastoma (NB) and opsoclonus-myoclonus-ataxia syndrome (OMAS) have a favorable oncologic outcome and overall survival. In contrast, despite intensive multidrug immunomodulation, the neurologic outcome is complicated by the relapsing nature of the neurologic symptoms and long-term neurobehavioral sequelae. Being associated with low-risk NB, there exists an ambiguity in the current literature regarding the administration of chemotherapy in these children. We reviewed our archives for children with NB-OMAS over a 22-year (January 1996 to January 2018) period. Eighteen children (10 female) with a median age at diagnosis of 23 months had NB-OMAS and were included. They had stage 1 (9/18; 50%), 2 (1/18; 5.5%), 3 (7/18; 39%), and 4 (1/18; 5.5%) disease according to the International Neuroblastoma Staging System. Multimodality therapy included surgery (16/18; 89%), chemotherapy (11/18; 61%), and immunomodulatory therapy (10/18; 55%). Complete oncologic remission was achieved in all children. Relapse of OMAS and presence of neurologic sequelae were observed in 1 (5.5%) and 5 (28%) cases, respectively. Presence of neurologic sequelae was significantly associated with low-tumor stage (P=0.036) and treatment without chemotherapy (P=0.003). Chemotherapy administration was the only variable significantly predicting a favorable neurologic outcome (95% confidence interval: 0.26-1.40, P=0.01). To conclude, our study including a limited cohort of patients highlights a favorable neurologic outcome associated with chemotherapy administration in children with NB-OMAS. However, further studies with larger sample size need to be conducted before drawing any definite conclusions.
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Affiliation(s)
| | | | | | - Sameer Bakhshi
- Department of Medical Oncology, BRAIRCH, AIIMS, New Delhi, India
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Santoro JD, Kerr LM, Codden R, Casper TC, Greenberg BM, Waubant E, Kong SW, Mandl KD, Gorman MP. Increased Prevalence of Familial Autoimmune Disease in Children With Opsoclonus-Myoclonus Syndrome. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/6/e1079. [PMID: 34475249 PMCID: PMC8422990 DOI: 10.1212/nxi.0000000000001079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/08/2021] [Indexed: 11/25/2022]
Abstract
Background and Objectives Opsoclonus-myoclonus syndrome (OMS) is a rare autoimmune disorder associated with neuroblastoma in children, although idiopathic and postinfectious etiologies are present in children and adults. Small cohort studies in homogenous populations have revealed elevated rates of autoimmunity in family members of patients with OMS, although no differentiation between paraneoplastic and nonparaneoplastic forms has been performed. The objective of this study was to investigate the prevalence of autoimmune disease in first-degree relatives of pediatric patients with paraneoplastic and nonparaneoplastic OMS. Methods A single-center cohort study of consecutively evaluated children with OMS was performed. Parents of patients were prospectively administered surveys on familial autoimmune disease. Rates of autoimmune disease in first-degree relatives of pediatric patients with OMS were compared using Fisher exact t test and χ2 analysis: (1) between those with and without a paraneoplastic cause and (2) between healthy and disease (pediatric multiple sclerosis [MS]) controls from the United States Pediatric MS Network. Results Thirty-five patients (18 paraneoplastic, median age at onset 19.0 months; 17 idiopathic, median age at onset 25.0 months) and 68 first-degree relatives (median age 41.9 years) were enrolled. One patient developed systemic lupus erythematosus 7 years after OMS onset. Paraneoplastic OMS was associated with a 50% rate of autoimmune disease in a first-degree relative compared with 29% in idiopathic OMS (p = 0.31). The rate of first-degree relative autoimmune disease per OMS case (14/35, 40%) was higher than healthy controls (86/709, 12%; p < 0.001) and children with pediatric MS (101/495, 20%; p = 0.007). Discussion In a cohort of pediatric patients with OMS, there were elevated rates of first-degree relative autoimmune disease, with no difference in rates observed between paraneoplastic and idiopathic etiologies, suggesting an autoimmune genetic contribution to the development of OMS in children.
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Affiliation(s)
- Jonathan D Santoro
- From the Department of Neurology (J.D.S.), Massachusetts General Hospital, Boston; Department of Neurology (J.D.S., J.M.K., M.P.G.), Boston Children's Hospital, MA; Harvard Medical School (J.D.S., K.D.M.), Boston, MA; Division of Neurology (J.D.S.), Department of Pediatrics, Children's Hospital of Los Angeles, CA; Department of Neurology (J.D.S.), Keck School of Medicine at the University of Southern California, Los Angeles; Department of Pediatrics (R.C., T.C.C.), University of Utah School of Medicine, Salt Lake City; Department of Neurology and Neurotherapeutics (B.M.G.), The University of Texas Southwestern Medical Center at Dallas, TX; UCSF Weill Institute for Neurosciences (E.W.), Department of Neurology, University of California San Francisco, CA; Computational Health Informatics Program (S.W.K., K.D.M.), Boston Children's Hospital, MA; and Department of Pediatrics (S.W.K., K.D.M.), Boston Children's Hospital, MA.
| | - Lauren M Kerr
- From the Department of Neurology (J.D.S.), Massachusetts General Hospital, Boston; Department of Neurology (J.D.S., J.M.K., M.P.G.), Boston Children's Hospital, MA; Harvard Medical School (J.D.S., K.D.M.), Boston, MA; Division of Neurology (J.D.S.), Department of Pediatrics, Children's Hospital of Los Angeles, CA; Department of Neurology (J.D.S.), Keck School of Medicine at the University of Southern California, Los Angeles; Department of Pediatrics (R.C., T.C.C.), University of Utah School of Medicine, Salt Lake City; Department of Neurology and Neurotherapeutics (B.M.G.), The University of Texas Southwestern Medical Center at Dallas, TX; UCSF Weill Institute for Neurosciences (E.W.), Department of Neurology, University of California San Francisco, CA; Computational Health Informatics Program (S.W.K., K.D.M.), Boston Children's Hospital, MA; and Department of Pediatrics (S.W.K., K.D.M.), Boston Children's Hospital, MA
| | - Rachel Codden
- From the Department of Neurology (J.D.S.), Massachusetts General Hospital, Boston; Department of Neurology (J.D.S., J.M.K., M.P.G.), Boston Children's Hospital, MA; Harvard Medical School (J.D.S., K.D.M.), Boston, MA; Division of Neurology (J.D.S.), Department of Pediatrics, Children's Hospital of Los Angeles, CA; Department of Neurology (J.D.S.), Keck School of Medicine at the University of Southern California, Los Angeles; Department of Pediatrics (R.C., T.C.C.), University of Utah School of Medicine, Salt Lake City; Department of Neurology and Neurotherapeutics (B.M.G.), The University of Texas Southwestern Medical Center at Dallas, TX; UCSF Weill Institute for Neurosciences (E.W.), Department of Neurology, University of California San Francisco, CA; Computational Health Informatics Program (S.W.K., K.D.M.), Boston Children's Hospital, MA; and Department of Pediatrics (S.W.K., K.D.M.), Boston Children's Hospital, MA
| | - Theron Charles Casper
- From the Department of Neurology (J.D.S.), Massachusetts General Hospital, Boston; Department of Neurology (J.D.S., J.M.K., M.P.G.), Boston Children's Hospital, MA; Harvard Medical School (J.D.S., K.D.M.), Boston, MA; Division of Neurology (J.D.S.), Department of Pediatrics, Children's Hospital of Los Angeles, CA; Department of Neurology (J.D.S.), Keck School of Medicine at the University of Southern California, Los Angeles; Department of Pediatrics (R.C., T.C.C.), University of Utah School of Medicine, Salt Lake City; Department of Neurology and Neurotherapeutics (B.M.G.), The University of Texas Southwestern Medical Center at Dallas, TX; UCSF Weill Institute for Neurosciences (E.W.), Department of Neurology, University of California San Francisco, CA; Computational Health Informatics Program (S.W.K., K.D.M.), Boston Children's Hospital, MA; and Department of Pediatrics (S.W.K., K.D.M.), Boston Children's Hospital, MA
| | - Benjamin M Greenberg
- From the Department of Neurology (J.D.S.), Massachusetts General Hospital, Boston; Department of Neurology (J.D.S., J.M.K., M.P.G.), Boston Children's Hospital, MA; Harvard Medical School (J.D.S., K.D.M.), Boston, MA; Division of Neurology (J.D.S.), Department of Pediatrics, Children's Hospital of Los Angeles, CA; Department of Neurology (J.D.S.), Keck School of Medicine at the University of Southern California, Los Angeles; Department of Pediatrics (R.C., T.C.C.), University of Utah School of Medicine, Salt Lake City; Department of Neurology and Neurotherapeutics (B.M.G.), The University of Texas Southwestern Medical Center at Dallas, TX; UCSF Weill Institute for Neurosciences (E.W.), Department of Neurology, University of California San Francisco, CA; Computational Health Informatics Program (S.W.K., K.D.M.), Boston Children's Hospital, MA; and Department of Pediatrics (S.W.K., K.D.M.), Boston Children's Hospital, MA
| | - Emmanuelle Waubant
- From the Department of Neurology (J.D.S.), Massachusetts General Hospital, Boston; Department of Neurology (J.D.S., J.M.K., M.P.G.), Boston Children's Hospital, MA; Harvard Medical School (J.D.S., K.D.M.), Boston, MA; Division of Neurology (J.D.S.), Department of Pediatrics, Children's Hospital of Los Angeles, CA; Department of Neurology (J.D.S.), Keck School of Medicine at the University of Southern California, Los Angeles; Department of Pediatrics (R.C., T.C.C.), University of Utah School of Medicine, Salt Lake City; Department of Neurology and Neurotherapeutics (B.M.G.), The University of Texas Southwestern Medical Center at Dallas, TX; UCSF Weill Institute for Neurosciences (E.W.), Department of Neurology, University of California San Francisco, CA; Computational Health Informatics Program (S.W.K., K.D.M.), Boston Children's Hospital, MA; and Department of Pediatrics (S.W.K., K.D.M.), Boston Children's Hospital, MA
| | - Sek Won Kong
- From the Department of Neurology (J.D.S.), Massachusetts General Hospital, Boston; Department of Neurology (J.D.S., J.M.K., M.P.G.), Boston Children's Hospital, MA; Harvard Medical School (J.D.S., K.D.M.), Boston, MA; Division of Neurology (J.D.S.), Department of Pediatrics, Children's Hospital of Los Angeles, CA; Department of Neurology (J.D.S.), Keck School of Medicine at the University of Southern California, Los Angeles; Department of Pediatrics (R.C., T.C.C.), University of Utah School of Medicine, Salt Lake City; Department of Neurology and Neurotherapeutics (B.M.G.), The University of Texas Southwestern Medical Center at Dallas, TX; UCSF Weill Institute for Neurosciences (E.W.), Department of Neurology, University of California San Francisco, CA; Computational Health Informatics Program (S.W.K., K.D.M.), Boston Children's Hospital, MA; and Department of Pediatrics (S.W.K., K.D.M.), Boston Children's Hospital, MA
| | - Kenneth D Mandl
- From the Department of Neurology (J.D.S.), Massachusetts General Hospital, Boston; Department of Neurology (J.D.S., J.M.K., M.P.G.), Boston Children's Hospital, MA; Harvard Medical School (J.D.S., K.D.M.), Boston, MA; Division of Neurology (J.D.S.), Department of Pediatrics, Children's Hospital of Los Angeles, CA; Department of Neurology (J.D.S.), Keck School of Medicine at the University of Southern California, Los Angeles; Department of Pediatrics (R.C., T.C.C.), University of Utah School of Medicine, Salt Lake City; Department of Neurology and Neurotherapeutics (B.M.G.), The University of Texas Southwestern Medical Center at Dallas, TX; UCSF Weill Institute for Neurosciences (E.W.), Department of Neurology, University of California San Francisco, CA; Computational Health Informatics Program (S.W.K., K.D.M.), Boston Children's Hospital, MA; and Department of Pediatrics (S.W.K., K.D.M.), Boston Children's Hospital, MA
| | - Mark P Gorman
- From the Department of Neurology (J.D.S.), Massachusetts General Hospital, Boston; Department of Neurology (J.D.S., J.M.K., M.P.G.), Boston Children's Hospital, MA; Harvard Medical School (J.D.S., K.D.M.), Boston, MA; Division of Neurology (J.D.S.), Department of Pediatrics, Children's Hospital of Los Angeles, CA; Department of Neurology (J.D.S.), Keck School of Medicine at the University of Southern California, Los Angeles; Department of Pediatrics (R.C., T.C.C.), University of Utah School of Medicine, Salt Lake City; Department of Neurology and Neurotherapeutics (B.M.G.), The University of Texas Southwestern Medical Center at Dallas, TX; UCSF Weill Institute for Neurosciences (E.W.), Department of Neurology, University of California San Francisco, CA; Computational Health Informatics Program (S.W.K., K.D.M.), Boston Children's Hospital, MA; and Department of Pediatrics (S.W.K., K.D.M.), Boston Children's Hospital, MA
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Bhatia P, Heim J, Cornejo P, Kane L, Santiago J, Kruer MC. Opsoclonus-myoclonus-ataxia syndrome in children. J Neurol 2021; 269:750-757. [PMID: 33779841 DOI: 10.1007/s00415-021-10536-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/24/2021] [Accepted: 03/25/2021] [Indexed: 12/31/2022]
Abstract
Opsoclonus-myoclonus-ataxia syndrome is a rare neuroimmunologic disorder typically presenting in previously healthy infants and toddlers. It is characterized by a clinical triad of (1) erratic saccadic intrusions; (2) myoclonus and/or ataxia; (3) behavioral features, typified by developmental plateauing, irritability and insomnia. About half of cases are associated with an underlying neuroblastoma and diagnostic imaging is essential once OMAS is suspected. A thorough workup, including serum, urine, and cerebrospinal fluid studies is critical to identify underlying biomarkers of OMAS itself or neuroblastoma. Historically, many children had relatively poor long-term outcomes, with residual neurologic and/or neuropsychiatry sequelae typical. More recent concepts have emphasized combined immunotherapy regimens that offer hope for better outcomes in children with this remarkable, challenging disease.
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Affiliation(s)
- Poonam Bhatia
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA.,Department of Radiology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Jennifer Heim
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA
| | - Patricia Cornejo
- Department of Radiology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Lauren Kane
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA.,Pediatric Neuroimmunology Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Jason Santiago
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA
| | - Michael C Kruer
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA. .,Pediatric Neuroimmunology Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, USA. .,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA.
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NK Cell-mediated Neuroblastoma Cell Lysis is Enhanced by IgG From Patients With Pediatric Opsoclonus-Myoclonus Syndrome. J Pediatr Hematol Oncol 2021; 43:e176-e179. [PMID: 33060390 DOI: 10.1097/mph.0000000000001953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 08/26/2020] [Indexed: 11/26/2022]
Abstract
Pediatric opsoclonus-myoclonussyndrome (OMS) is a rare autoimmune disorder of which 50% are associated with neuroblastoma (NB). We investigated whether surface-binding autoantibodies in OMS can enhance natural killer (NK) cell-mediated cytotoxicity in these patients. OMS immunoglobulin G (IgG) bound to NB cell lines and NK cell-mediated cytotoxicity to NB cells was enhanced after preincubation with OMS-IgG, but not IgG from NB without OMS or healthy controls. Activation of NK cells by surface-binding autoantibodies may be an additional mechanism of antitumor immunity in children with NB and OMS.
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11
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Opsoclonus myoclonus syndrome in a postpartum period. Mult Scler Relat Disord 2021; 50:102862. [PMID: 33662860 DOI: 10.1016/j.msard.2021.102862] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 02/13/2021] [Accepted: 02/22/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Opsoclonus-myoclonus syndrome (OMS) is a rare neuroimmunologic disorder characterized by opsoclonus, myoclonic jerks mostly in the face and limbs, cerebellar ataxia, tremors, and encephalopathy. OMS is rare in adults and exceedingly rarer in pregnancy, as only a few cases in pregnancy have been reported. We present what we understand is the first case of postpartum OMS. METHODS AND RESULTS We report and discuss a challenging case of OMS which started 6 weeks postpartum. Despite extensive infectious and malignancy evaluation, an underlying etiology was not readily apparent thus we treated her with high dose intravenous steroids and intravenous immunoglobulin (IVIG) for presumed idiopathic autoimmune OMS. She relapsed and additional workup identified new enhancing lesion on MRI brain, positive MOG-IgG, and CSF negative for oligoclonal bands. She was transitioned to maintenance IVIG and ultimately to rituximab with better results. At 2 year follow up her exam was improved and without objective evidence of abnormal movement or opsoclonus on maintenance Rituximab infusion 1,000 mg every 6 months. CONCLUSION In OMS, an autoimmune response is usually thought to occur by molecular mimicry with neuronal cell surface antigens in association with infections. Since a preceding infection was absent in this case, we propose that the immune response here was initiated due to immunological changes in pregnancy and postpartum period possibly due to fetal tissue exposure (fetal microchimerism). The presence of the MOG antibody raises the possibility that OMS is another clinical manifestation of MOG-associated disease (MOG-AD), which in our case is supported by characteristic CSF and radiographic findings of MOG-AD.
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12
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Mitoma H, Manto M, Hadjivassiliou M. Immune-Mediated Cerebellar Ataxias: Clinical Diagnosis and Treatment Based on Immunological and Physiological Mechanisms. J Mov Disord 2021; 14:10-28. [PMID: 33423437 PMCID: PMC7840241 DOI: 10.14802/jmd.20040] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/04/2020] [Indexed: 12/24/2022] Open
Abstract
Since the first description of immune-mediated cerebellar ataxias (IMCAs) by Charcot in 1868, several milestones have been reached in our understanding of this group of neurological disorders. IMCAs have diverse etiologies, such as gluten ataxia, postinfectious cerebellitis, paraneoplastic cerebellar degeneration, opsoclonus myoclonus syndrome, anti-GAD ataxia, and primary autoimmune cerebellar ataxia. The cerebellum, a vulnerable autoimmune target of the nervous system, has remarkable capacities (collectively known as the cerebellar reserve, closely linked to plasticity) to compensate and restore function following various pathological insults. Therefore, good prognosis is expected when immune-mediated therapeutic interventions are delivered during early stages when the cerebellar reserve can be preserved. However, some types of IMCAs show poor responses to immunotherapies, even if such therapies are introduced at an early stage. Thus, further research is needed to enhance our understanding of the autoimmune mechanisms underlying IMCAs, as such research could potentially lead to the development of more effective immunotherapies. We underscore the need to pursue the identification of robust biomarkers.
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Affiliation(s)
- Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, Tokyo, Japan
| | - Mario Manto
- Service de Neurologie, Médiathèque Jean Jacquy, CHU-Charleroi, Charleroi, Belgium.,Service des Neurosciences, University of Mons, Mons, Belgium
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13
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Hadjivassiliou M. Advances in Therapies of Cerebellar Disorders: Immune-mediated Ataxias. CNS & NEUROLOGICAL DISORDERS-DRUG TARGETS 2020; 18:423-431. [PMID: 29268693 DOI: 10.2174/1871527317666171221110548] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 12/12/2017] [Accepted: 12/14/2017] [Indexed: 01/30/2023]
Abstract
The identification of an increasing number of immune mediated ataxias suggests that the cerebellum is often a target organ for autoimmune insults. The diagnosis of immune mediated ataxias is challenging as there is significant clinical overlap between immune mediated and other forms of ataxia. Furthermore the classification of immune mediated ataxias requires further clarification particularly for those ataxias where no specific antigenic trigger and associated antibodies have been identified. Recognition of immune mediated ataxias remains imperative as therapeutic interventions can be effective, although given the relative rarity of this entity, large-scale treatment trials may not be feasible. This review will discuss advances in therapies for immune mediated ataxias based on what is currently available in the literature.
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Affiliation(s)
- Marios Hadjivassiliou
- Academic Department of Neurosciences, Royal Hallamshire Hospital, Sheffield, United Kingdom
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14
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Evolving Cognitive Dysfunction in Children with Neurologically Stable Opsoclonus-Myoclonus Syndrome. CHILDREN-BASEL 2020; 7:children7090103. [PMID: 32824925 PMCID: PMC7552772 DOI: 10.3390/children7090103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/09/2020] [Accepted: 08/13/2020] [Indexed: 11/16/2022]
Abstract
Cognitive and acquired neurodevelopmental deficits have been reported in children with opsoclonus-myoclonus syndrome (OMS) and are known to be associated with more severe and relapsing disease course. However, there is a paucity of data regarding cognitive dysfunction in children with stable neurological disease. We report three children with OMS and evolving cognitive dysfunction in the context of a mild disease course. The children's ages at disease onset were between 17 and 35 months and they were followed up for 4-10 years. Neuroblastoma was identified in one child. OMS severity scores ranged between 8 and 12/15 at presentation. They underwent immunotherapy and all were in remission by 7 months (range 4-13 months), with treatment maintained for 1 year. One child remained relapse-free, while two others had one clinical relapse each and were immunotherapy-responsive again. In all cases, evolving cognitive dysfunction was reported despite being in remission and stable off treatment for a median of 20 months (range of 12-31 months; two OMS scores of 0/15 and one of 2/15). In children with OMS who have completed treatment and have made full or near full neurological recovery, concerns remain regarding long-term outcome in terms of future learning and cognitive development.
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15
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Cantarín-Extremera V, Jiménez-Legido M, Aguilera-Albesa S, Hedrera-Fernández A, Arrabal-Fernández L, Gorría-Redondo N, Martí-Carrera I, Yoldi-Pedtri ME, Sagaseta-De Ilúrdoz M, González-Gutiérrez-Solana L. Opsoclonus-myoclonus syndrome: clinical characteristics, therapeutic considerations, and prognostic factors in a Spanish paediatric cohort. Neurologia 2020; 38:S0213-4853(20)30137-7. [PMID: 32653103 DOI: 10.1016/j.nrl.2020.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 03/05/2020] [Accepted: 04/01/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Opsoclonus-myoclonus-ataxia syndrome is a rare neuroinflammatory disorder with onset during childhood; aetiology may be paraneoplastic, para-infectious, or idiopathic. No biomarkers have yet been identified, and diagnosis is clinical. Better cognitive prognosis appears to be related to early onset of immunomodulatory therapy. METHODS We describe the epidemiological, clinical, therapeutic, and long-term prognostic characteristics of a cohort of 20 Spanish patients. RESULTS The mean age of onset was 21 months (range, 2-59). Ataxia and opsoclonus were the most frequent symptoms both at disease onset and throughout disease progression. The mean time from onset to diagnosis was 1.1 months. Neuroblast lineage tumours were detected in 45% of patients; these were treated with surgical resection in 7 cases and chemotherapy in 2. Cerebrospinal fluid analysis revealed pleocytosis in 4 cases (25%) and neither antineuronal antibodies nor oligoclonal bands were detected in any patient. Immunomodulatory drugs were used in all cases. Nine patients started combined immunomodulatory treatment at the time of diagnosis, and 5 patients after a mean of 2.2 months. In the long term, 6 of the 10 patients followed up for more than 5 years presented mild or moderate cognitive sequelae. Four patients presented relapses, generally coinciding with the decrease of corticosteroid doses. CONCLUSIONS Early initiation of immunotherapy, as well as triple combination therapy, where needed, was associated with a lower frequency of cognitive impairment 2 years after onset.
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Affiliation(s)
- V Cantarín-Extremera
- Sección de Neuropediatría. Servicio de Pediatría. Hospital Infantil Universitario Niño Jesús, Madrid, España; Grupo Clínico vinculado (GCV14/ER/6) al Centro de Investigación Biomédica en Red para Enfermedades Raras (CIBERER). Instituto de Salud Carlos III, Madrid, España.
| | - M Jiménez-Legido
- Sección de Neuropediatría. Servicio de Pediatría. Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - S Aguilera-Albesa
- Unidad de Neuropediatría. Servicio de Pediatría. Complejo Hospitalario de Navarra. Servicio Navarro de Salud, Pamplona, España; Navarrabiomed-Fundación Miguel Servet, Pamplona, España
| | - A Hedrera-Fernández
- Unidad de Neuropediatría. Servicio de Pediatría. Hospital Universitario Río Hortega, Valladolid, España
| | - L Arrabal-Fernández
- Unidad de Neuropediatría. Servicio de Pediatría. Hospital Universitario Virgen de las Nieves, Granada, España
| | - N Gorría-Redondo
- Unidad de Neuropediatría. Servicio de Pediatría. Hospital Universitario Araba. Servicio Vasco de Salud, Vitoria-Gasteiz, España
| | - I Martí-Carrera
- Unidad de Neuropediatría. Servicio de Pediatría. Hospital Universitario Donostia. Servicio Vasco de Salud, Donosti, España
| | - M E Yoldi-Pedtri
- Unidad de Neuropediatría. Servicio de Pediatría. Complejo Hospitalario de Navarra. Servicio Navarro de Salud, Pamplona, España; Navarrabiomed-Fundación Miguel Servet, Pamplona, España
| | - M Sagaseta-De Ilúrdoz
- Unidad de Oncología Infantil. Servicio de Pediatría. Complejo Hospitalario de Navarra. Servicio Navarro de Salud, Pamplona, España
| | - L González-Gutiérrez-Solana
- Sección de Neuropediatría. Servicio de Pediatría. Hospital Infantil Universitario Niño Jesús, Madrid, España; Grupo Clínico vinculado (GCV14/ER/6) al Centro de Investigación Biomédica en Red para Enfermedades Raras (CIBERER). Instituto de Salud Carlos III, Madrid, España
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16
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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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Muthusamy K, Thomas M, Yoganathan S, Sudhakar SV. Clinical Profile, Prognostic Indicators, and Therapeutic Outcomes of Pediatric Opsoclonus-Myoclonus-Ataxia Syndrome: A Single-Center Experience from South India. Ann Indian Acad Neurol 2019; 22:295-301. [PMID: 31359941 PMCID: PMC6613420 DOI: 10.4103/aian.aian_101_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Opsoclonus myoclonus syndrome (OMS) is a neuroinflammatory disorder. Indian literature on its clinical profile and outcome is sparse. Objectives: The objective of this study is to describe the clinical profile and analyze outcomes and prognostic predictors in a cohort of children with OMS. Materials and Methods: This was a retrospective study of children with OMS between 2007 and 2017. Results: Twenty-two children were included in the study. The mean age at onset of symptom was 20.9 months (standard deviation [SD]: 7.5). The mean duration of delay in diagnosis was 8.4 months (SD 1.26) with acute cerebellitis being the most common misdiagnosis. Eleven children (50%) were diagnosed with tumor during evaluation and follow-up and 11 children (50%) belonged to idiopathic/postinfectious group. Magnetic resonance imaging brain was normal in all children except for one revealing cerebellar atrophy on follow-up. One child in the paraneoplastic group (neuroblastoma) had a positive PNMA2/Ta onconeural antibody. Children in the tumor group had an earlier age of onset (mean 15.5 vs. 26.3 months), shorter time to onset of opsoclonus from initial symptom (2.54 vs. 7.27 weeks), and higher severity score at presentation (13.7 vs. 11.3) compared to the nontumor group. Children in the nontumor group attained their first remission with treatment earlier (10.9 weeks, SD: 4.5) than the children with tumor (18.72 weeks, SD: 5.8). There was no significant difference in the outcome between the groups. Children with multiple relapses (>3) and late surgical intervention for tumor (>6 months after symptom onset) had a poor outcome. Discussion: A high index of suspicion coupled with early diagnosis and periodic tumor surveillance (even in the initially negative cases) along with aggressive combined multimechanistic immunotherapies is the key in improving outcomes. Conclusion: A high index of suspicion in appropriate clinical circumstances and early aggressive immunomodulation might lead to a better outcome.
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Affiliation(s)
- Karthik Muthusamy
- Department of Neurological Sciences, Pediatric Neurology Division, Christian Medical College, Vellore, Tamil Nadu, India
| | - Maya Thomas
- Department of Neurological Sciences, Pediatric Neurology Division, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sangeetha Yoganathan
- Department of Neurological Sciences, Pediatric Neurology Division, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sniya Valsa Sudhakar
- Department of Radio Diagnosis, Christian Medical College, Vellore, Tamil Nadu, India
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Mitoma H, Manto M, Hampe CS. Immune-mediated Cerebellar Ataxias: Practical Guidelines and Therapeutic Challenges. Curr Neuropharmacol 2019; 17:33-58. [PMID: 30221603 PMCID: PMC6341499 DOI: 10.2174/1570159x16666180917105033] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 07/06/2018] [Accepted: 09/03/2018] [Indexed: 12/11/2022] Open
Abstract
Immune-mediated cerebellar ataxias (IMCAs), a clinical entity reported for the first time in the 1980s, include gluten ataxia (GA), paraneoplastic cerebellar degenerations (PCDs), antiglutamate decarboxylase 65 (GAD) antibody-associated cerebellar ataxia, post-infectious cerebellitis, and opsoclonus myoclonus syndrome (OMS). These IMCAs share common features with regard to therapeutic approaches. When certain factors trigger immune processes, elimination of the antigen( s) becomes a priority: e.g., gluten-free diet in GA and surgical excision of the primary tumor in PCDs. Furthermore, various immunotherapeutic modalities (e.g., steroids, immunoglobulins, plasmapheresis, immunosuppressants, rituximab) should be considered alone or in combination to prevent the progression of the IMCAs. There is no evidence of significant differences in terms of response and prognosis among the various types of immunotherapies. Treatment introduced at an early stage, when CAs or cerebellar atrophy is mild, is associated with better prognosis. Preservation of the "cerebellar reserve" is necessary for the improvement of CAs and resilience of the cerebellar networks. In this regard, we emphasize the therapeutic principle of "Time is Cerebellum" in IMCAs.
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Affiliation(s)
- Hiroshi Mitoma
- Address correspondence to this author at the Medical Education Promotion Center, Tokyo Medical University, Tokyo, Japan;, E-mail:
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19
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Oh SY, Kim JS, Dieterich M. Update on opsoclonus-myoclonus syndrome in adults. J Neurol 2018; 266:1541-1548. [PMID: 30483882 DOI: 10.1007/s00415-018-9138-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/17/2018] [Accepted: 11/21/2018] [Indexed: 01/12/2023]
Abstract
Opsoclonus-myoclonus syndrome in adults is a rare and heterogeneous disorder with the clinical features of opsoclonus, myoclonus, ataxia, and behavioral and sleep disturbances. The pathophysiology is thought to be immunological on the basis of paraneoplastic or infectious etiologies. Immunomodulatory therapies should be performed although the response may be incomplete. A number of autoantibodies have been identified against a variety of antigens, but no diagnostic immunological marker has yet been identified. This review focuses on underlying mechanisms of opsoclonus-myoclonus syndrome, including findings that have been identified recently, and provides an update on the clinical features and treatments of this condition.
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Affiliation(s)
- Sun-Young Oh
- Department of Neurology, Chonbuk National University School of Medicine, 20 Geonji-ro, Deokjin-gu, Jeonju, Chonbuk, 561-712, South Korea.
- Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, South Korea.
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
- Department of Neurology, Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Marianne Dieterich
- Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
- German Center for Vertigo and Balance Disorders (IFBLMU), Ludwig-Maximilians University, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
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20
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Pranzatelli MR, Tate ED, McGee NR. Multifactorial analysis of opsoclonus-myoclonus syndrome etiology ("Tumor" vs. "No tumor") in a cohort of 356 US children. Pediatr Blood Cancer 2018; 65:e27097. [PMID: 29727049 DOI: 10.1002/pbc.27097] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 03/14/2018] [Accepted: 03/17/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pediatric opsoclonus-myoclonus syndrome (OMS) presents a paradox of etiopathogenesis: A neuroblastic tumor (NB) is found in only one half of the cases, the others are ascribed to infections or designated as idiopathic. METHOD From an IRB-approved observational study of 356 US children with OMS, secondary analysis of "etiology" and related factors was performed on a well-characterized cohort. The "Tumor" (n = 173) and "No Tumor" groups (n = 183), as defined radiologically, were compared according to multiple factors considered potentially differentiating. Data were analyzed retrospectively using parametric and nonparametric tests as indicated. RESULTS Patients with NB were not distinguishable by prodromal symptoms, OMS onset age, gender, race/ethnicity, OMS severity, rank order of neurological sign appearance, or geographic distribution. Various CSF immunologic biomarker abnormalities of OMS did not vary in the presence or absence of a detectable tumor: frequency of six lymphocyte subsets, or concentrations of 18 cytokines/chemokines, cytokine antagonists, chemokine receptors, cell adhesion molecules, or neuronal/glial markers. Prior responsiveness to conventional immunotherapy was not contingent on tumor/no tumor designation. CONCLUSIONS Multiple convergent factors provide compelling empirical evidence and rationalize the concept that OMS is one neurological disorder, regardless of apparent etiology. Limitations to the current clinical etiologic classifications as paraneoplastic, parainfectious/post-infectious, and idiopathic etiology require antigen-based biological solutions to tease out the molecular pathophysiology of viral/tumoral mechanisms. Systematic studies, regardless of presumed etiology, will be necessary to find the highest-yield combination of imaging approaches, screening for infectious agents, and new biomarkers. Two testable hypotheses for future research are presented.
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Affiliation(s)
- Michael R Pranzatelli
- National Pediatric Myoclonus Center, National Pediatric Neuroinflammation Organization, Inc., Orlando, Florida, USA
| | - Elizabeth D Tate
- National Pediatric Myoclonus Center, National Pediatric Neuroinflammation Organization, Inc., Orlando, Florida, USA
| | - Nathan R McGee
- National Pediatric Myoclonus Center, National Pediatric Neuroinflammation Organization, Inc., Orlando, Florida, USA
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21
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Pranzatelli MR, Tate ED, McGee NR, MacArthur CA. Evaluation of Responsiveness to Reduced-Dose Rituximab in Corticotropin/Intravenous Immunoglobulin/Rituximab Combination Immunotherapy for Opsoclonus-Myoclonus Syndrome. Pediatr Neurol 2018; 85:71-75. [PMID: 30197220 DOI: 10.1016/j.pediatrneurol.2018.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 05/06/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Rituximab (anti-CD20) has been used as B-cell-targeted intervention to treat opsoclonus-myoclonus syndrome. Due to isolated reports of chronic hypogammaglobulinemia and B lymphopenia following rituximab in several disorders, and rapid B-cell depletion after a few doses, we reduced the dosage 20% in our clinical practice. METHODS In this Institutional Review Board-approved retrospective study, 32 children with opsoclonus-myoclonus syndrome and cerebrospinal fluid B-cell expansion had received front-loaded adrenocorticotropic hormone, intravenous immunoglobulin, and rituximab combination immunotherapy for de novo opsoclonus-myoclonus syndrome. Parametric statistical analysis compared 10 children receiving 1200 mg/m2 of rituximab (300 mg/m2 × 4) and 22 receiving 1500 mg/m2 (375 mg/m2 × 4). Clinical response had been video documented and scored by a blinded observer. RESULTS In both groups, motor severity (total score) lessened by ≥76% and cerebrospinal fluid B cells were similarly depleted (≥95%) six months after treatment. None of the treated patients remained unable to walk independently. Serum IgM depletion was analogous in the 1200 mg/m2 (-73%) and 1500 mg/m2 group (-64%). The relapse frequency was similar in both groups. Side effects were principally steroidal, tolerable, and transient. Circulating B-cell repopulation was comparable. CONCLUSIONS The reduced-dose of rituximab in rituximab combination immunotherapy was as effective and well tolerated as the standard dose, and provided rapid, early therapeutic intervention in opsoclonus-myoclonus syndrome. Pending a long-term prospective study, these are proof-of-concept data in support of challenging the dose of rituximab in various disorders, which may have different dose requirements.
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Affiliation(s)
- Michael R Pranzatelli
- National Pediatric Myoclonus Center and National Pediatric Neuroinflammation Organization, Inc, Orlando, Florida.
| | - Elizabeth D Tate
- National Pediatric Myoclonus Center and National Pediatric Neuroinflammation Organization, Inc, Orlando, Florida.
| | - Nathan R McGee
- National Pediatric Myoclonus Center and National Pediatric Neuroinflammation Organization, Inc, Orlando, Florida.
| | - Craig A MacArthur
- Department of Pediatric Hematology/Oncology, Golisano Children's Hospital of Southwest Florida, Lee Memorial Health Care System, Fort Myers, Florida.
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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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23
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Abstract
Neuroblastomas are characterized by heterogeneous clinical behavior, from spontaneous regression or differentiation into a benign ganglioneuroma, to relentless progression despite aggressive, multimodality therapy. Indeed, neuroblastoma is unique among human cancers in terms of its propensity to undergo spontaneous regression. The strongest evidence for this comes from the mass screening studies conducted in Japan, North America and Europe and it is most evident in infants with stage 4S disease. This propensity is associated with a pattern of genomic change characterized by whole chromosome gains rather than segmental chromosome changes but the mechanism(s) underlying spontaneous regression are currently a matter of speculation. There is evidence to support several possible mechanisms of spontaneous regression in neuroblastomas: (1) neurotrophin deprivation, (2) loss of telomerase activity, (3) humoral or cellular immunity and (4) alterations in epigenetic regulation and possibly other mechanisms. It is likely that a better understanding of the mechanisms of spontaneous regression will help to identify targeted therapeutic approaches for these tumors. The most easily targeted mechanism is the delayed activation of developmentally programmed cell death regulated by the tropomyosin receptor kinase A (TrkA) pathway. Pan-Trk inhibitors are currently in clinical trials and so Trk inhibition might be used as the first line of therapy in infants with biologically favorable tumors that require treatment. Alternative approaches consist of breaking immune tolerance to tumor antigens but approaches to telomere shortening or epigenetic regulation are not easily druggable. The different mechanisms of spontaneous neuroblastoma regression are reviewed here, along with possible therapeutic approaches.
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Affiliation(s)
- Garrett M Brodeur
- Division of Oncology, Department of Pediatrics, the Children's Hospital of Philadelphia, University of Pennsylvania/Perelman School of Medicine, Philadelphia, PA, 19104, USA.
- Oncology Research, The Children's Hospital of Philadelphia, CTRB Rm. 3018, 3501 Civic Center Blvd., Philadelphia, PA, 19104-4302, USA.
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24
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Pranzatelli MR, Allison TJ, McGee NR, Tate ED. Cerebrospinal fluid γδ T cell frequency is age-related: a case-control study of 435 children with inflammatory and non-inflammatory neurological disorders. Clin Exp Immunol 2018; 193:103-112. [PMID: 29485697 DOI: 10.1111/cei.13122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2018] [Indexed: 11/29/2022] Open
Abstract
Studies of cerebrospinal fluid (CSF) γδ T cells in children are limited, due especially to the lack of control data. In adults, gamma/delta T cells (TCR-γδ) residing in the intrathecal space are sometimes involved in neuroinflammation. To evaluate the possible role of γδ T cells in paediatric neuroinflammation, we immunophenotyped cerebrospinal fluid (CSF) and blood lymphocytes using flow cytometry in a case-control study of 100 children with non-inflammatory neurological disorders (NIND), 312 with opsoclonus-myoclonus (OMS) and 23 with other inflammatory neurological disorders (OIND). In NIND, the negative correlation between CSF γδ T cell frequency and patient age was striking: median frequency of 27% in infants and 3·3% in teens. Interindividual variations were largest in the youngest. There was no gender effect. In all OMS, after correcting for age, only a small effect of OMS severity remained. Measurement of markers for γδ T cell activation [human leucocyte antigen D-related (HLA-DR)], maturation (CD45RA, CD45RO) or intracellular cytokine staining [interleukin (IL)-4, interferon (IFN)-γ] failed to discriminate OMS and NIND groups. Of seven OMS immunotherapies/combinations, none altered the frequency of total CSF γδ T cells or subsets significantly. In OIND, the CSF γδ T cell frequency was < 10% for single samples of other paraneoplastic disorders [anti-neuronal nuclear antibody (ANNA)-1, PCA-1, teratoma-associated syndrome], cerebellar ataxia (post-infectious, ataxia-telangiectasia), acute disseminated encephalomyelitis, neuroborreliosis and encephalitis. This study provides new insights into CSF γδ T cells in the paediatric population. Although their role in CSF remains elusive, the negative age correlation, resistance to immunotherapy and our age cut-off references for NIND are important findings for the design of future paediatric studies.
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Affiliation(s)
- M R Pranzatelli
- National Pediatric Myoclonus Center, Orlando, FL, USA.,National Pediatric Neuroinflammation Organization, Inc., Orlando, FL, USA
| | - T J Allison
- National Pediatric Myoclonus Center, Orlando, FL, USA
| | - N R McGee
- National Pediatric Myoclonus Center, Orlando, FL, USA
| | - E D Tate
- National Pediatric Myoclonus Center, Orlando, FL, USA.,National Pediatric Neuroinflammation Organization, Inc., Orlando, FL, USA
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25
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Abstract
Opsoclonus myoclonus syndrome (OMS), often called "dancing eyed syndrome," is a rare neurological condition associated with neuroblastoma in the majority of all childhood cases. Genomic copy number profiles have shown to be of prognostic significance for neuroblastoma patients. The aim of this retrospective multicenter study was to analyze the genomic copy number profiles of tumors from children with neuroblastoma presenting with OMS at diagnosis. In 44 cases of neuroblastoma associated with OMS, overall genomic profiling by either array-comparative genomic hybridization or single nucleotide polymorphism array proved successful in 91% of the cases, distinguishing tumors harboring segmental chromosome alterations from those with numerical chromosome alterations only. A total of 23/44 (52%) tumors showed an segmental chromosome alterations genomic profile, 16/44 (36%) an numerical chromosome alterations genomic profile, and 1 case displayed an atypical profile (12q amplicon). No recurrently small interstitial copy number alterations were identified. With no tumor relapse nor disease-related deaths, the overall genomic profile was not of prognostic impact with regard to the oncological outcome in this series of patients. Thus, the observation of an excellent oncological outcome, even for those with an unfavorable genomic profile of neuroblastoma, supports the hypothesis that an immune response might be involved in tumor control in these patients with OMS.
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26
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Ibáñez-Juliá MJ, Pappa E, Gaymard B, Leclercq D, Hautefort C, Tilikete C, Delattre JY, Hoang-Xuan K, Psimaras D, Alentorn A. Brain volumetric analysis and cortical thickness in adults with saccadic intrusions (ocular flutter or opsoclonus-myoclonus syndrome). Clin Neurol Neurosurg 2017; 163:167-172. [PMID: 29121544 DOI: 10.1016/j.clineuro.2017.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 09/24/2017] [Accepted: 10/28/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Ocular flutter (OF) and opsoclonus are considered a continuum with a similar pathogenesis. Due to the rarity of this disease in the adult population, little is known about the brain morphological changes in the chronic phase of the disease. PATIENTS AND METHODS Six magnetic resonance imaging from adults with previous history of OF/Opsoclonus and 12 healthy patients (paired by age and sex) were analyzed in order to identify the long term cortical thickness pattern in this rare disease by using Freesurfer. RESULTS Patients with OF/Opsoclonus showed reduced cerebellum cortical volume with a subsequent diminution in total cerebellar volume. White mater cerebellum volume was not modified. In addition, we have also identified a significant supratentorial gray matter volume decrease in OF/Opsoclonus patients, involving both the cortical and the subcortical gray matter. CONCLUSIONS OF/Opsoclonus in adults may be associated with cortical and subcortical gray matter atrophy, as well as decreased cerebellar cortical volume. Further larger prospective studies are necessary to confirm these results.
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Affiliation(s)
- María-José Ibáñez-Juliá
- Department of Neurology 2, Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris (AP-HP), 75013, Paris, France; Sorbonne Universités, Université Pierre et Marie Curie, Université Paris VI, 75013, Paris, France; Institut du Cerveau et de la Moelle Epinière, INSERM U1127 and Centre National de la Recherche Scientifique, Unité de Recherche Mixte, 7225, Paris, France
| | - Evangelia Pappa
- Department of Neurology 2, Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris (AP-HP), 75013, Paris, France; Sorbonne Universités, Université Pierre et Marie Curie, Université Paris VI, 75013, Paris, France; Institut du Cerveau et de la Moelle Epinière, INSERM U1127 and Centre National de la Recherche Scientifique, Unité de Recherche Mixte, 7225, Paris, France
| | - Bertrand Gaymard
- Deparment of Clinical Neurophysiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris (AP-HP), 75013, Paris, France
| | - Delphine Leclercq
- Department of Neuro-radiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris (AP-HP), 75013, Paris, France
| | - Charlotte Hautefort
- Otolaryngology - Head and Neck Surgery Department, Hôpital Lariboisière, Assistance Publique Hôpitaux de Paris (AP-HP), 75475, Paris, France
| | - Caroline Tilikete
- Neuro-Ophthalmology Unit, Lyon Civil Hospitals, Neurological Hospital, Lyon 1 University, Bron Cedex, France
| | - Jean-Yves Delattre
- Department of Neurology 2, Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris (AP-HP), 75013, Paris, France; Sorbonne Universités, Université Pierre et Marie Curie, Université Paris VI, 75013, Paris, France; Institut du Cerveau et de la Moelle Epinière, INSERM U1127 and Centre National de la Recherche Scientifique, Unité de Recherche Mixte, 7225, Paris, France
| | - Khê Hoang-Xuan
- Department of Neurology 2, Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris (AP-HP), 75013, Paris, France; Sorbonne Universités, Université Pierre et Marie Curie, Université Paris VI, 75013, Paris, France; Institut du Cerveau et de la Moelle Epinière, INSERM U1127 and Centre National de la Recherche Scientifique, Unité de Recherche Mixte, 7225, Paris, France
| | - Dimitri Psimaras
- Department of Neurology 2, Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris (AP-HP), 75013, Paris, France; Sorbonne Universités, Université Pierre et Marie Curie, Université Paris VI, 75013, Paris, France; Institut du Cerveau et de la Moelle Epinière, INSERM U1127 and Centre National de la Recherche Scientifique, Unité de Recherche Mixte, 7225, Paris, France
| | - Agusti Alentorn
- Department of Neurology 2, Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris (AP-HP), 75013, Paris, France; Sorbonne Universités, Université Pierre et Marie Curie, Université Paris VI, 75013, Paris, France; Institut du Cerveau et de la Moelle Epinière, INSERM U1127 and Centre National de la Recherche Scientifique, Unité de Recherche Mixte, 7225, Paris, France.
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de Alarcon PA, Matthay KK, London WB, Naranjo A, Tenney SC, Panzer JA, Hogarty MD, Park JR, Maris JM, Cohn SL. Intravenous immunoglobulin with prednisone and risk-adapted chemotherapy for children with opsoclonus myoclonus ataxia syndrome associated with neuroblastoma (ANBL00P3): a randomised, open-label, phase 3 trial. THE LANCET CHILD & ADOLESCENT HEALTH 2017; 2:25-34. [PMID: 29376112 PMCID: PMC5783315 DOI: 10.1016/s2352-4642(17)30130-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose No previous clinical trial has been conducted for patients with neuroblastoma
associated opsoclonus myoclonus ataxia syndrome (OMA), and current treatment is based on
case reports. To evaluate the OMA response to prednisone and risk-adapted chemotherapy
and determine if the addition of intravenous gammaglobulin (IVIG) further improves
response, the Children’s Oncology Group designed a randomized therapeutic
trial. Patient and Methods Eligible subjects were randomized to receive twelve cycles of IVIG
(IVIG+) or no IVIG (NO-IVIG) in addition to prednisone and neuroblastoma
risk-adapted chemotherapy. All low-risk patients were treated with cyclophosphamide. The
severity of OMA symptoms was evaluated at 2, 6, and 12 months using a scale developed by
Mitchell and Pike and baseline versus best response scores were compared. A single
patient who did not undergo neurologic assessment was excluded from OMA response
analysis. This study is registered with Clinical Trials.gov (identifier
NCT00033293). Results Of the 53 patients enrolled in the study, 62% (33/53) were female.
There were 44 low-risk, 7 intermediate-risk, and 2 high-risk neuroblastoma patients.
Twenty-six subjects were randomized to receive IVIG+ and 27 were randomized to
NO-IVIG. The neuroblastoma 3-year event-free survival (95% confidence interval
(CI)) was 94.1% (87.3%, 100%) and overall survival was
98.0% (94.1%, 100%). Significantly higher rates of OMA response
were observed in patients randomized to IVIG+ compared to NO-IVIG
[21/26=80.8% for IVIG+; 11/27=40.7% for
NO-IVIG (odds ratio=6.1; 95% CI: (1.5, 25.9),
p=0.0029)]. For the majority of patients, the IVIG+ OMA regimen
combined with cytoxan or other risk-based chemotherapy was well tolerated, although
there was one toxic death in a high-risk subject. Conclusion This is the only randomized prospective therapeutic clinical trial in children
with neuroblastoma-associated OMA. The addition of IVIG to prednisone and risk-adapted
chemotherapy significantly improves OMA response rate. IVIG+ constitutes a
back-bone upon which to build additional therapy.
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Affiliation(s)
- Pedro A. de Alarcon
- Department of Pediatrics, University of Illinois College of Medicine at
Peoria, Peoria IL
| | - Katherine K. Matthay
- Department of Pediatrics, University of California, San Francisco School of
Medicine, San Francisco, CA
| | - Wendy B. London
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center,
Harvard Medical School, Boston, MA
| | - Arlene Naranjo
- Department of Biostatistics, Children’s Oncology Group Statistics
and Data Center, University of Florida, Gainesville, FL
| | - Sheena C. Tenney
- Department of Biostatistics, Children’s Oncology Group Statistics
and Data Center, University of Florida, Gainesville, FL
| | - Jessica A. Panzer
- Departments of Pediatrics and Neurology, University of Pennsylvania,
Philadelphia, PA
| | | | - Julie R. Park
- Seattle Children’s Hospital and University of Washington Department
of Pediatrics, Seattle WA
| | - John M. Maris
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA
| | - Susan L. Cohn
- Department of Pediatrics, University of Chicago, Chicago, IL
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Fukushima H, Inoue T, Takama Y, Ishii N, Okuno T, Kobayashi Y, Yoneda A, Nakamura T, Kuki I, Hara J. Clinicopathological features of neuroblastic tumors with opsoclonus-myoclonus-ataxia syndrome: Follicular structure predicts a better neurological outcome. Pathol Int 2017; 67:503-509. [PMID: 28971571 DOI: 10.1111/pin.12591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 08/24/2017] [Indexed: 10/18/2022]
Abstract
Neuroblastic tumors (NT) with opsoclonus-myoclonus syndrome (OMS) display characteristic histological features, such as lymphocytic infiltration with lymphoid follicles, indicating an underlying immune response. We retrospectively assessed NT patients from 2001 to 2016. Five cases of NT with OMS and 76 cases of NT without OMS were histopathologically reviewed in this study. The grade of lymphocytic infiltration was evaluated. The number of follicles was counted and the presence or absence of lymphoid follicles was recorded for each case. We also confirmed the presence or absence of follicular dendritic cells (FDCs). We investigated the relationship between the histopathological and clinical findings of NT with OMS. Lymphocytic infiltration was observed in all cases; however, the precise follicular structure was occasionally unclear. Patients with clear follicular structures displayed germinal centers including tingible body macrophages and FDCs. All patients without neurological sequelae demonstrated a clear follicular structure with a FDC meshwork pattern. The interval between OMS onset and the detection and initial treatment of NT was typically longer in patients with neurological sequelae compared to those without neurological sequelae. Early detection and treatment of NT with OMS at the phase of a clear follicular formation with multiple FDC may provide favorable neurological outcomes.
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Affiliation(s)
- Hiroko Fukushima
- Department of Pathology, Osaka City General Hospital, Miyakojima-ku, Osaka, Japan
| | - Takeshi Inoue
- Department of Pathology, Osaka City General Hospital, Miyakojima-ku, Osaka, Japan
| | - Yuichi Takama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Naomi Ishii
- Department of Pathology, Osaka City General Hospital, Miyakojima-ku, Osaka, Japan
| | - Takahiro Okuno
- Department of Pathology, Osaka City General Hospital, Miyakojima-ku, Osaka, Japan.,Department of Molecular Pathology, Osaka City University Medical School, Abeno-ku, Osaka, Japan
| | - Yasutsugu Kobayashi
- Department of Pathology, Minami Osaka General Hospital, Suminoe-ku, Osaka, Japan
| | - Akihiro Yoneda
- Department of Pediatric Surgery, Osaka City General Hospital, Miyakojima-ku, Osaka, Japan
| | - Tetsuro Nakamura
- Department of Pediatric Surgery, Osaka City General Hospital, Miyakojima-ku, Osaka, Japan.,Department of Pediatric Surgery, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Ichiro Kuki
- Department of Pediatric Neurology, Osaka City General Hospital, Miyakojima-ku, Osaka, Japan
| | - Junichi Hara
- Department of Pediatric Hematology and Oncology, Osaka City General Hospital, Miyakojima-ku, Osaka, Japan
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29
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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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30
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Pranzatelli MR, Tate ED, Allison TJ. 6-Mercaptopurine modifies cerebrospinal fluid T cell abnormalities in paediatric opsoclonus-myoclonus as steroid sparer. Clin Exp Immunol 2017; 190:217-225. [PMID: 28710878 DOI: 10.1111/cei.13015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2017] [Indexed: 11/26/2022] Open
Abstract
The purpose of this study was to evaluate the capacity of 6-mercaptopurine (6-MP), a known immunosuppressant, to normalize cerebrospinal fluid (CSF) lymphocyte frequencies in opsoclonus-myoclonus syndrome (OMS) and function as a steroid sparer. CSF and blood lymphocytes were immunophenotyped in 11 children with OMS (without CSF B cell expansion) using a comprehensive panel of cell surface adhesion, activation and maturation markers by flow cytometry, and referenced to 18 paediatric controls. Drug metabolites, lymphocyte counts and liver function tests were used clinically to monitoring therapeutic range and toxicity. In CSF, adjunctive oral 6-MP was associated with a 21% increase in the low percentage of CD4+ T cells in OMS, restoring the CD4/CD8 ratio. The percentage of CD4+ T cells that were interferon (IFN)-γ+ was reduced by 66%, shifting the cytokine balance away from T helper type 1 (Th1) (proinflammatory) predominance. The percentage of natural killer (NK) cells decreased significantly in CSF (-32%) and blood (-67 to -82%). Low blood absolute lymphocyte count was more predictive of improvement in CSF lymphocyte proportions (correlated with % CD4+ T cells) than the 6-thioguanine level (no correlation). 6-MP was difficult to titrate: 50% achieved the target absolute lymphocyte count (< 1·5 K/mm); 20%, the 'therapeutic' 6-thioguanine level; and 40% the non-toxic 6-methylmercaptopurine level. Side effects and transaminase elevation were mild and reversible. Clinical steroid-sparing properties and lowered relapse frequency were demonstrated. 6-MP displayed unique pharmacodynamic properties that may be useful in OMS and other autoimmune disorders. Its steroid sparer capacity is limited to children in whom the therapeutic window can be reached without limiting pharmacokinetic factors or side effects.
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Affiliation(s)
- M R Pranzatelli
- National Pediatric Neuroinflammation Organization, Inc., the National Pediatric Myoclonus Center, Orlando, FL, USA
| | - E D Tate
- National Pediatric Neuroinflammation Organization, Inc., the National Pediatric Myoclonus Center, Orlando, FL, USA
| | - T J Allison
- National Pediatric Neuroinflammation Organization, Inc., the National Pediatric Myoclonus Center, Orlando, FL, USA
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31
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Abstract
Despite longstanding perceptions, robust innate and adaptive immune responses occur within the central nervous system (CNS) in response to infection and tissue damage. Although necessary to control infection, immune responses can lead to severe CNS pathology in the context of both viral infection and autoimmunity. Research into how the central nervous and immune systems communicate has accelerated over the past 20 years leading to a better understanding of pathways controlling immune activation and neuroinflammation that have guided the approval of new disease-modifying therapies to treat CNS immunopathology, particularly the inflammatory demyelinating disease multiple sclerosis. This article provides an introduction into the basic principles underlying immune responses within the CNS that developed from experimental animal models of both neurotropic virus infection and autoimmune T cell-mediated CNS demyelination.
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32
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Pranzatelli MR, Tate ED. Dexamethasone, Intravenous Immunoglobulin, and Rituximab Combination Immunotherapy for Pediatric Opsoclonus-Myoclonus Syndrome. Pediatr Neurol 2017; 73:48-56. [PMID: 28651977 DOI: 10.1016/j.pediatrneurol.2017.04.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 04/28/2017] [Accepted: 04/29/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Although pulse-dose dexamethasone is increasingly favored for treating pediatric opsoclonus-myoclonus syndrome (OMS), and multimodal immunotherapy is associated with improved clinical response, there have been no neuroimmunologic studies of dexamethasone-based multimodal disease-modifying therapy. METHODS In this observational retrospective study, 19 children with OMS (with or without associated neuroblastoma) underwent multibiomarker evaluation for neuroinflammation. Nine children of varying OMS severity, duration, and treatment status were treated empirically with pulse dexamethasone, intravenous immunoglobulin (IVIg), and rituximab combination immunotherapy (DEXIR-CI). Another 10 children on dexamethasone alone or with IVIg at initial evaluation only provided a comparison group. Motor severity (total score) was scored rater-blinded via videotapes using the validated OMS Evaluation Scale. RESULTS DEXIR-CI was associated with a 69% reduction in group total score (P = 0.004) and was clinically well tolerated. Patients given the dexamethasone combination exhibited significantly lowered B cell frequencies in cerebrospinal fluid (-94%) and blood (-76%), normalizing the cerebrospinal fluid B cell percentage. The number of patients with positive inflammatory markers dropped 87% (P = 0.002) as did the number of markers. Cerebrospinal fluid oligoclonal bands were positive in four of nine pretreatment patients but zero of six post-treatment patients. In the comparison group, partial response to dexamethasone alone or with IVIg was associated with multiple positive markers for neuroinflammation despite an average of seven months of treatment. CONCLUSIONS Multimechanistic dexamethasone-based combination immunotherapy increases the therapeutic armamentarium for OMS, providing a viable option for less severely affected individuals. Partial response to dexamethasone with or without IVIg is indicative of ongoing neuroinflammation and should be treated promptly and accordingly.
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Affiliation(s)
- Michael R Pranzatelli
- National Pediatric Myoclonus Center, National Pediatric Neuroinflammation Organization, Inc, Orlando, Florida.
| | - Elizabeth D Tate
- National Pediatric Myoclonus Center, National Pediatric Neuroinflammation Organization, Inc, Orlando, Florida
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Promise, Progress, and Pitfalls in the Search for Central Nervous System Biomarkers in Neuroimmunological Diseases: A Role for Cerebrospinal Fluid Immunophenotyping. Semin Pediatr Neurol 2017; 24:229-239. [PMID: 29103430 PMCID: PMC5697729 DOI: 10.1016/j.spen.2017.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Biomarkers are central to the translational medicine strategic focus, though strict criteria need to be applied to their designation and utility. They are one of the most promising areas of medical research, but the "biomarker life-cycle" must be understood to avoid false-positive and false-negative results. Molecular biomarkers will revolutionize the treatment of neurological diseases, but the rate of progress depends on a bold, visionary stance by neurologists, as well as scientists, biotech and pharmaceutical industries, funding agencies, and regulators. One important tool in studying cell-specific biomarkers is multiparameter flow cytometry. Cerebrospinal fluid immunophenotyping, or immune phenotypic subsets, captures the biology of intrathecal inflammatory processes, and has the potential to guide personalized immunotherapeutic selection and monitor treatment efficacy. Though data exist for some disorders, they are surprisingly lacking in many others, identifying a serious deficit to be overcome. Flow cytometric immunophenotyping provides a valuable, available, and feasible "window" into both adaptive and innate components of neuroinflammation that is currently underutilized.
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Mitchell WG, Blaes F. Cancer and Autoimmunity: Paraneoplastic Neurological Disorders Associated With Neuroblastic Tumors. Semin Pediatr Neurol 2017; 24:180-188. [PMID: 29103425 DOI: 10.1016/j.spen.2017.08.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Cancer and autoimmunity come together in paraneoplastic syndromes (PNS), which reflect the remote, not direct, effects of cancer. In the pediatric population, a variety of PNS have been described, but the most common of these rare disorders are instigated by neuroblastic tumors, such as neuroblastoma, ganglioneuroblastoma, and ganglioneuroma. The main pediatric-onset neurological PNS are ROHHAD syndrome, anti-ANNA1 (anti-Hu), and opsoclonus-myoclonus syndrome. They manifest distinctive neurological features, which aid the diagnosis, though under-recognition still poses serious challenges and risks. In each clinical syndrome, a large subgroup of patients had no demonstrated tumor. Most neurological PNS are immunologically mediated, and CSF neuroimmunological studies show common elements of immune involvement in PNS as well as important differences. Future immunotherapy strategies may be able to take advantage of these abnormalities.
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Affiliation(s)
- Wendy G Mitchell
- Neurology Department, University of Southern California Keck School of Medicine, Attending Physician, Children's Hospital Los Angeles, Los Angeles, CA.
| | - Franz Blaes
- Department of Neurology Kreiskrankenhaus Gummersbach, Gummersbach, Germany
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Pranzatelli MR, Tate ED, Allison TJ. Case-control, exploratory study of cerebrospinal fluid chemokines/cytokines and lymphocyte subsets in childhood Tourette syndrome with positive streptococcal markers. Cytokine 2017; 96:49-53. [PMID: 28288328 DOI: 10.1016/j.cyto.2017.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/28/2017] [Accepted: 03/02/2017] [Indexed: 11/18/2022]
Abstract
A longstanding question is whether neuroinflammation is present in children symptomatic for Tourette syndrome (TS) with positive streptococcal serology and throat cultures. The objective was to directly test for it using modern hypothesis-driven approaches. Profiling studies for 14 immune cell types (flow cytometry), 7 chemokines/cytokines (ELISA), oligoclonal bands, and other immunoglobulins were performed in this IRB-approved study of 5 children with TS and streptococcal markers compared to data from 26 non-inflammatory pediatric neurological controls. Subjects were well-characterized clinically and with standardized scales for tics and obsessions/compulsions. Three subjects with TS (60%) had positive throat cultures for Group A beta-hemolytic strep, five had elevated anti-deoxyribonuclease-B titers (mean=444), and 4 (80%) had elevated anti-streptolysin O titers (981). There were no significant differences between groups in the frequency of CSF B and T cell subsets or NK cells; the proportion of intracellularly-stained T helper type 1 (IFN-γ) or type 2 (IL-4) cells; the concentrations of B cell chemoattractants CXCL13, CXCL10; the B cell proliferation/survival cytokines BAFF and APRIL, or other chemokines (CCL19, CCL21, CCL22). None of the patients had positive CSF oligoclonal bands or an abnormal IgG index/synthesis rate. Parallel blood studies were negative. This novel study found no group CSF lymphocyte phenotypic abnormalities or elevated inflammatory mediators in childhood TS despite positive serology and throat cultures for Group A beta-hemolytic streptococci. It demonstrates feasibility of the methodology, and should serve as the basis for a larger study of putative streptococcal-associated neuroimmunological disorders.
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Affiliation(s)
- Michael R Pranzatelli
- National Pediatric Myoclonus Center and National Pediatric Neuroinflammation Organization, Inc., Orlando, FL, USA.
| | - Elizabeth D Tate
- National Pediatric Myoclonus Center and National Pediatric Neuroinflammation Organization, Inc., Orlando, FL, USA.
| | - Tyler J Allison
- National Pediatric Myoclonus Center and National Pediatric Neuroinflammation Organization, Inc., Orlando, FL, USA.
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Tate ED, Allison TJ, Pranzatelli MR, Verhulst SJ. Neuroepidemiologic Trends in 105 US Cases of Pediatric Opsoclonus-Myoclonus Syndrome. J Pediatr Oncol Nurs 2016; 22:8-19. [PMID: 15574722 DOI: 10.1177/1043454204272560] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Opsoclonus-myoclonus syndrome (OMS) is a rare, autoimmune neurological disorder that is poorly recognized and undertreated. Neuroblastoma is found in one half of the cases. Because of the high incidence of spontaneous regression of neuroblastoma, it is unknown whether not finding a tumor means there was none. To define demographic trends and the standard of care in the first large series of OMS, 105 children were recruited over a 13-year period in a retrospective questionnaire survey. Children with and without a tumor differed little in viral-like prodrome and neurological symptoms. Earliest neurological symptoms were staggering and falling, leading to a misdiagnosis of acute cerebellitis. Later symptoms included body jerks, drooling, refusal to walk or sit, speech problems, decreased muscle tone, opsoclonus, and inability to sleep. Tumor resection alone did not provide adequate therapy for most. Adrenocorticotropic hormone (ACTH), prednisone, and intravenous immunoglobulin were used with equal frequency, but ACTH was associated with the best early response. More than one half of the children had relapses. Residual behavioral, language, and cognitive problems occurred in the majority. The delay in diagnosis (11 weeks) and initiation of treatment (17 weeks) is unacceptably long.
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Affiliation(s)
- Elizabeth D Tate
- Southern Illinois University, School of Medicine, Division of Child and Adolescent Neurology, PO Box 19643, Springfield, IL 62794-9643, USA.
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Pranzatelli MR, Tate ED. Trends and tenets in relapsing and progressive opsoclonus-myoclonus syndrome. Brain Dev 2016; 38:439-48. [PMID: 26786246 DOI: 10.1016/j.braindev.2015.11.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Revised: 11/20/2015] [Accepted: 11/25/2015] [Indexed: 10/22/2022]
Abstract
Despite advances in inducing remission in pediatric opsoclonus-myoclonus syndrome (OMS), relapse remains a challenge. By definition, relapse is not a characteristic of monophasic OMS, but occurs at any time in the course of multiphasic OMS. Due to variability and heterogeneity, patients are best approached and treated on a case-by-case basis, using precepts derived from clinical and scientific studies. Treatment of provocations, such as infection or immunotherapy tapering, is the short-term goal, but discovering unresolved neuroinflammation and re-configuring disease-modifying agents is crucial in the long-term. The working hypothesis is that much of the injury in OMS results from neuroinflammation involving dysregulated B cells, which may cause loss of tolerance and autoantibody production. Biomarkers of disease activity include cerebrospinal fluid (CSF) B cell frequency, oligoclonal bands (OCB), B cell attractants (CXCL13) and activating factors (BAFF). Measuring these markers comprises modern detection and characterization of neuroinflammation or verifies 'no evidence of disease activity'. The decision making process is three-tiered: deciding if the relapse is bone fide, identifying its etiology, and formulating a therapeutic plan. Relapsing-remitting OMS is treatable, and combination multimodal/multi-mechanistic immunotherapy is improving the outcome. However, some patients progress to a refractory state with cognitive impairment and disability from failure to go into remission, multiple relapses, or more aggressive disease. This report provides new insights on underappreciated risks and pitfalls inherent in relapse, pro-active efforts to avoid progression, the need for early and sufficient treatment beyond corticosteroids and immunoglobulins, and utilization of disease activity biomarkers to identify high-risk patients and safely withdraw immunotherapy.
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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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Blaes F, Dharmalingam B. Childhood opsoclonus-myoclonus syndrome: diagnosis and treatment. Expert Rev Neurother 2016; 16:641-8. [DOI: 10.1080/14737175.2016.1176914] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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40
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Opsoclonus-myoclonus syndrome after adenovirus infection. SPRINGERPLUS 2015; 4:636. [PMID: 26543770 PMCID: PMC4628014 DOI: 10.1186/s40064-015-1429-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 10/12/2015] [Indexed: 11/10/2022]
Abstract
Autoimmune and paraneoplastic movement disorders are rare in childhood. Diagnosis often relies on clinical manifestations and clinicians' recognition. A 22-month-old girl at onset of opsoclonus-myoclonus syndrome (OMS) was followed for 8 years. Adenovirus (type C subtype 3) infection coincided with manifestation. Data on treatment, imaging and follow-up are provided. In the spinal fluid, elevated anti-rubella antibodies and oligoclonal bands were detected. An autoimmune process affecting mainly cerebellar neurons was revealed immunohistochemically. Moderately intense long-term immunosuppressive therapy resulted in a favorable clinical outcome. A video demonstrated severe OMS manifestations at onset, followed by nearly complete recovery after treatment. We describe the association of a parainfectious OMS and adenovirus infection; laboratory results indicate a non-specific humoral process affecting mainly cerebellar neurons. Our video documentation will aid to recognize this rare movement disorder and to initiate early treatment.
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Bank I, Marcu-Malina V. Quantitative peripheral blood perturbations of γδ T cells in human disease and their clinical implications. Clin Rev Allergy Immunol 2015; 47:311-33. [PMID: 24126758 DOI: 10.1007/s12016-013-8391-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Human γδ T cells, which play innate and adaptive, protective as well as destructive, roles in the immune response, were discovered in 1986, but the clinical significance of alterations of the levels of these cells in the peripheral blood in human diseases has not been comprehensively reviewed. Here, we review patterns of easily measurable changes of this subset of T cells in peripheral blood from relevant publications in PubMed and their correlations with specific disease categories, specific diagnoses within disease categories, and prognostic outcomes. These collective data suggest that enumeration of γδ T cells and their subsets in the peripheral blood of patients could be a useful tool to evaluate diagnosis and prognosis in the clinical setting.
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Affiliation(s)
- Ilan Bank
- Department of Medicine F, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, 52621, Israel,
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42
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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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43
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Kachanov DY, Shamanskaya TV, Malevich OB, Varfolomeeva SR. Opsoclonus-myoclonus syndrome and neuroblastoma (a review of literature). ACTA ACUST UNITED AC 2015. [DOI: 10.17650/2311-1267-2014-0-1-62-69] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- D. Yu. Kachanov
- Federal Research Center of Pediatric Hematology, Oncology and Immunology named after Dmitriy Rogachev, Ministry of Health of Russia
| | - T. V. Shamanskaya
- Federal Research Center of Pediatric Hematology, Oncology and Immunology named after Dmitriy Rogachev, Ministry of Health of Russia
| | - O. B. Malevich
- Federal Research Center of Pediatric Hematology, Oncology and Immunology named after Dmitriy Rogachev, Ministry of Health of Russia
| | - S. R. Varfolomeeva
- Federal Research Center of Pediatric Hematology, Oncology and Immunology named after Dmitriy Rogachev, Ministry of Health of Russia
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44
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Anand G, Bridge H, Rackstraw P, Chekroud AM, Yong J, Stagg CJ, Pike M. Cerebellar and cortical abnormalities in paediatric opsoclonus-myoclonus syndrome. Dev Med Child Neurol 2015; 57:265-72. [PMID: 25290446 DOI: 10.1111/dmcn.12594] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2014] [Indexed: 11/28/2022]
Abstract
AIM Paediatric opsoclonus-myoclonus syndrome (OMS) is a poorly understood condition with long-term cognitive, behavioural, and motor sequelae. Neuroimaging has indicated cerebellar atrophy in the chronic phase, but this alone may not explain the cognitive sequelae seen in many children with OMS. This study aimed to determine the extent of structural change throughout the brain that may underpin the range of clinical outcomes. METHOD Nine participants with OMS (one male, eight females; mean age [SD] 14y, [6y 5mo], range 12-30y) and 10 comparison individuals (three males, seven females; mean age 12y 6mo, [4y 9mo], range 10-23y) underwent magnetic resonance imaging to acquire T1-weighted structural images, diffusion-weighted images, and magnetic resonance spectroscopy scans. Neuroblastoma had been present in four participants with OMS. Voxel-based morphometry was used to determine changes in grey matter volume, tract-based spatial statistics to analyze white matter integrity, and Freesurfer to analyze cortical thickness across visual and motor cortices. RESULTS Whole-brain analysis indicated that cerebellar grey matter was significantly reduced in the patients with OMS, particularly in the vermis and flocculonodular lobe. A region-of-interest analysis indicated significantly lower cerebellar grey matter volume, particularly in patients with the greatest OMS scores. Diffusion-weighted images did not show effects at a whole brain level, but all major cerebellar tracts showed increased mean diffusivity when analysis was restricted to the cerebellum. Cortical thickness was reduced across the motor and visual areas in the OMS group, indicating involvement beyond the cerebellum. INTERPRETATION Across individuals with OMS, there is considerable cerebellar atrophy, particularly in the vermis and flocculonodular lobes with atrophy severity associated with persistent symptomatology. Differences in cerebral cortical thickness indicate disease effects beyond the cerebellum.
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Affiliation(s)
- Geetha Anand
- Department of Paediatric Neurology, Children's Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
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45
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Abstract
Recent genomic and biological studies of neuroblastoma have shed light on the dramatic heterogeneity in the clinical behaviour of this disease, which spans from spontaneous regression or differentiation in some patients, to relentless disease progression in others, despite intensive multimodality therapy. This evidence also suggests several possible mechanisms to explain the phenomena of spontaneous regression in neuroblastomas, including neurotrophin deprivation, humoral or cellular immunity, loss of telomerase activity and alterations in epigenetic regulation. A better understanding of the mechanisms of spontaneous regression might help to identify optimal therapeutic approaches for patients with these tumours. Currently, the most druggable mechanism is the delayed activation of developmentally programmed cell death regulated by the tropomyosin receptor kinase A pathway. Indeed, targeted therapy aimed at inhibiting neurotrophin receptors might be used in lieu of conventional chemotherapy or radiation in infants with biologically favourable tumours that require treatment. Alternative approaches consist of breaking immune tolerance to tumour antigens or activating neurotrophin receptor pathways to induce neuronal differentiation. These approaches are likely to be most effective against biologically favourable tumours, but they might also provide insights into treatment of biologically unfavourable tumours. We describe the different mechanisms of spontaneous neuroblastoma regression and the consequent therapeutic approaches.
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Affiliation(s)
- Garrett M Brodeur
- Division of Oncology, The Children's Hospital of Philadelphia, 3501 Civic Center Boulevard, Philadelphia, PA 19104-4302, USA
| | - Rochelle Bagatell
- Division of Oncology, The Children's Hospital of Philadelphia, 3501 Civic Center Boulevard, Philadelphia, PA 19104-4302, USA
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46
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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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Kwak M, Kim DJ, Lee MR, Wu Y, Han L, Lee SK, Fan R. Nanowire array chips for molecular typing of rare trafficking leukocytes with application to neurodegenerative pathology. NANOSCALE 2014; 6:6537-50. [PMID: 24705924 PMCID: PMC4048658 DOI: 10.1039/c3nr06465d] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Despite the presence of the blood-brain barrier (BBB) that restricts the entry of immune cells and mediators into the central nervous system (CNS), a small number of peripheral leukocytes can traverse the BBB and infiltrate into the CNS. The cerebrospinal fluid (CSF) is one of the major routes through which trafficking leukocytes migrate into the CNS. Therefore, the number of leukocytes and their phenotypic compositions in the CSF may represent important sources to investigate immune-to-brain interactions or diagnose and monitor neurodegenerative diseases. Due to the paucity of trafficking leucocytes in the CSF, a technology capable of efficient isolation, enumeration, and molecular typing of these cells in the clinical settings has not been achieved. In this study, we report on a biofunctionalized silicon nanowire array chip for highly efficient capture and multiplexed phenotyping of rare trafficking leukocytes in small quantities (50 microliters) of clinical CSF specimens collected from neurodegenerative disease patients. The antibody coated 3D nanostructured materials exhibited vastly improved rare cell capture efficiency due to high-affinity binding and enhanced cell-substrate interactions. Moreover, our platform creates multiple cell capture interfaces, each of which can selectively isolate specific leukocyte phenotypes. A comparison with the traditional immunophenotyping using flow cytometry demonstrated that our novel silicon nanowire-based rare cell analysis platform can perform rapid detection and simultaneous molecular characterization of heterogeneous immune cells. Multiplexed molecular typing of rare leukocytes in CSF samples collected from Alzheimer's disease patients revealed the elevation of white blood cell counts and significant alterations in the distribution of major leukocyte phenotypes. Our technology represents a practical tool for potentially diagnosing and monitoring the pathogenesis of neurodegenerative diseases by allowing an effective hematological analysis of the CSF from patients.
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Affiliation(s)
- Minsuk Kwak
- Department of Biomedical Engineering, Yale University, New Haven, CT 06520, USA.
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48
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Krivochenitser R, Lemma Y, Wynn B, Jones JS. Ophthalmic presentation in the emergency department: a case report of a girl with "shimmering eyes". J Emerg Med 2014; 46:e163-5. [PMID: 24698510 DOI: 10.1016/j.jemermed.2014.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 11/04/2013] [Accepted: 01/31/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Ophthalmic complaints are commonplace in the emergency department (ED) and are often initial presentations of a systemic illness. We present a 2-year-old girl presenting to the ED with ataxia and "shimmering" eyes. CASE REPORT The patient was diagnosed with opsoclonus-myoclonus syndrome (OMS) involving involuntary, multi-vectorial (mostly horizontal), conjugate fast eye movements without intersaccadic intervals. The ophthalmic presentation led to a paraneoplastic work-up, which revealed an abdominal mass measuring 5.3 × 3.3 × 4.3 cm, suggestive of neuroblastoma. The patient's opsoclonus improved after a 5-day course of dexamethasone and intravenous immunoglobulin. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case illustrates the importance of recognizing pathognomonic ophthalmic complaints in the ED. We present an overview of classic ophthalmic presentations associated with systemic illnesses.
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Affiliation(s)
| | - Yonatan Lemma
- Michigan State University Program in Emergency Medicine, Spectrum Health Hospital-Butterworth Campus, Grand Rapids, Michigan
| | - Barbara Wynn
- Michigan State University Program in Emergency Medicine, Spectrum Health Hospital-Butterworth Campus, Grand Rapids, Michigan
| | - Jeffrey S Jones
- Michigan State University Program in Emergency Medicine, Spectrum Health Hospital-Butterworth Campus, Grand Rapids, Michigan
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Lino AMM, Spera RR, de Campos FPF, Freitas CHDA, Garcia MRT, Lopes LDC, Prokopowitsch AS. Adult-onset opsoclonus-myoclonus-ataxia syndrome as a manifestation of brazilian lyme disease-like syndrome: a case report and review of literature. AUTOPSY AND CASE REPORTS 2014; 4:29-37. [PMID: 28652990 PMCID: PMC5470562 DOI: 10.4322/acr.2014.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 03/09/2014] [Indexed: 11/23/2022] Open
Abstract
Described in 1962, the opsoclonus-myoclonus-ataxia syndrome (OMAS) is a rare, neurologically debilitating disorder with distinct characteristics that may begin in childhood or adult life. Although many cases remain without etiological diagnosis, others are related to neoplasms and infectious diseases. We report a 41-year-old previously healthy male with an 8-day history of headache, vertigo, nausea, vomiting, and nystagmus. After a normal brain computed tomography and lymphocytic pleocytosis in cerebral spinal fluid (CSF), intravenous acyclovir therapy was initiated in the emergency room. On the third day of hospitalization, the diagnosis of OMAS was made based on the presence of chaotic and irregular eye movements, dysarthric speech, gait instability, generalized tremor, and myoclonic jerks. In the face of his neurological worsening, ampicillin followed by nonspecific immunotherapy (methylprednisolone and intravenous immunoglobulin) was prescribed, with mild clinical improvement. After a thorough laboratory workup, the definite diagnosis of neuroborreliosis was established and ceftriaxone (4 g/daily/3 wks) and doxycycline (200 mg/day/2 mo) was administered. Toward the end of the ceftriaxone regimen, the neurologic signs substantially improved. We believe this to be the first case description of OMAS as clinical presentation of Brazilian Lyme disease-like syndrome (Baggio-Yoshinari syndrome).
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Affiliation(s)
- Angelina Maria Martins Lino
- Department of Neurology - Hospital das Clínicas - Faculdade de Medicina - Universidade de São Paulo, São Paulo/SP - Brazil.,Department of Internal Medicine - Hospital Universitário - Universidade de São Paulo, São Paulo/SP - Brazil
| | - Raphael Ribeiro Spera
- Department of Neurology - Hospital das Clínicas - Faculdade de Medicina - Universidade de São Paulo, São Paulo/SP - Brazil
| | | | | | | | - Leonardo da Costa Lopes
- Department of Internal Medicine - Hospital Universitário - Universidade de São Paulo, São Paulo/SP - Brazil
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50
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Blaes F, Fühlhuber V, Preissner KT. Identification of autoantigens in pediatric opsoclonus-myoclonus syndrome. Expert Rev Clin Immunol 2014; 3:975-82. [DOI: 10.1586/1744666x.3.6.975] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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