Autonomic nervous system involvement in autoimmune encephalitis and paraneoplastic neurological syndromes

In autoimmune neurological diseases, the autonomic nervous system can be the primary target of autoimmunity (e.g. autoimmune autonomic ganglionopathy), or, more frequently, be damaged together with other areas of the nervous system (e.g. Guillain-Barré syndrome). Patients with autoimmune encephalitis and paraneoplastic neurological syndromes (PNS) often develop dysautonomia; however, the frequency and spectrum of autonomic signs and symptoms remain ill defined except for those scenarios in which dysautonomia is a core feature of the disease. Such is the case of Lambert-Eaton myasthenic syndrome, Morvan syndrome or anti-NMDAR encephalitis; in the latter, patients with dysautonomia have been reported to carry a more severe disease and to retain higher disability than those without autonomic dysfunction. Likewise, the presence of autonomic involvement indicates a higher risk of death due to neurological cause in patients with anti-Hu PNS. However, in anti-Hu and other PNS, as well as in the context of immune checkpoint inhibitors' toxicities, the characterization of autonomic involvement is frequently overshadowed by the severity of other neurological symptoms and signs. When evaluated with tests specific for autonomic function, patients with autoimmune encephalitis or PNS usually show a more widespread autonomic involvement than clinically suggested, which may reflect a potential gap of care when it comes to diagnosing dysautonomia. This review aims to revise the autonomic involvement in patients with autoimmune encephalitis and PNS, using for that purpose an antibody-based approach. We also discuss and provide general recommendations for the evaluation and management of dysautonomia in these patients.

Autoimmune and paraneoplastic neurological disorders: A review of relevant neuroimaging findings

INTRODUCTION

Paraneoplastic neurologic syndromes (PNS) and autoimmune encephalitis (AIE) are immune-mediated disorders. PNS is linked to cancer, while AIE may not Their clinical manifestations and imaging patterns need further elucidation.

OBJECTIVE/AIMS

To investigate the clinical profiles, antibody associations, neuroimaging patterns, treatments, and outcomes of PNS and AIE.

METHODS

A systematic review of 379 articles published between 2014 and 2023 was conducted. Of the 55 studies screened, 333 patients were diagnosed with either PNS or AIE and tested positive for novel antibodies. Data on demographics, symptoms, imaging, antibodies, cancer associations, treatment, and outcomes were extracted.

RESULTS

The study included 333 patients (mean age 54 years, 67% males) with PNS and AIE positive for various novel antibodies. 84% had central nervous system issues like cognitive impairment (53%), rhombencephalitis (17%), and cerebellar disorders (24%). Neuroimaging revealed distinct patterns with high-risk antibodies associated with brainstem lesions in 98%, cerebellar in 91%, hippocampal in 98%, basal ganglia in 75%, and spinal cord in 91%, while low/intermediate-risk antibodies were associated with medial temporal lobe lesions in 71% and other cortical/subcortical lesions in 55%. High-risk antibodies were associated with younger males, deep brain lesions, and increased mortality of 61%, while low/intermediate-risk antibodies were associated with females, cortical/subcortical lesions, and better outcomes with 39% mortality. Associated cancers included seminomas (23%), lung (19%), ovarian (2%), and breast (2%). Treatments included IVIG, chemotherapy, and plasmapheresis. Overall mortality was 25% in this cohort.

CONCLUSION

PNS and AIE have distinct clinical and radiological patterns based on antibody profiles. High-risk antibodies are associated with increased mortality while low/intermediate-risk antibodies are associated with improved outcomes. Appropriate imaging and antibody testing are critical for accurate diagnosis.

CV2/CRMP5-antibody-related Paraneoplastic Neurologic Syndrome Associated with Gastrointestinal Stromal Tumor

Paraneoplastic neurological syndrome (PNS) is a heterogeneous group of neurological disorders caused by immune-mediated inflammatory mechanisms. We herein report a 77-year-old man with CV2/CRMP5-antibody-related PNS associated with a gastrointestinal stromal tumor (GIST). He was admitted for forgetfulness and delusional behavior. His neurological symptoms were subacute, and a whole-body examination revealed a gastric GIST. Serology showed CV2/collapsin response mediator protein (CRMP)-5 antibodies. Partial gastrectomy was performed for the GIST, and the neurological symptoms and serum CV2/CRMP5 antibodies disappeared. No relapse has occurred since the surgery. PNS should be considered in patients with subacute neurological disorders.

Paraneoplastic sensorimotor neuropathy and ventral cauda equina nerve root enhancement as initial presentation of small cell lung carcinoma: a case study

BACKGROUND

Paraneoplastic neurologic syndromes (PNS) are rare, however, are important to recognize as oftentimes they precede the detection of an occult malignancy. Our case highlights a rare circumstance of paraneoplastic radiculoneuropathy and the importance of recognizing PNS in antibody negative disease, as is the case in up to 16% of sensory neuronopathies, and the process of excluding other etiologies.

CASE PRESENTATION

We discuss a 51-year-old man who presented with asymmetric subacute sensorimotor deficits in the lower limbs. Initial clinical examination showed weakness throughout the right lower limb and normal strength on the left with objective numbness in a mixed dermatomal and stocking-glove distribution. Electrophysiology was consistent with axonal sensorimotor neuropathy. Cerebrospinal fluid showed pleocytosis and elevated protein. Intravenous immunoglobulin treatment was given with some improvement in pain symptoms but no measurable motor improvement. Following clinical and electrophysiologic deterioration the patient was transferred to a tertiary centre. Magnetic resonance imaging of the spine showed smooth enhancement of the ventral caudal nerve roots. Chest computed tomography revealed left lower vascular scarring. Further positron emission tomography scan imaging identified fluorodeoxyglucose avid right lung lymphadenopathy. Bronchoscopy-guided biopsy revealed small cell lung carcinoma. Onconeural and antiganglioside antibodies were negative. The patient was then transferred to a medical oncology ward where he underwent chemoradiotherapy and subsequently experienced improvement in his motor function, supporting that his neurological condition was indeed secondary to a paraneoplastic process.

CONCLUSIONS

Onconeural negative paraneoplastic radiculoneuropathy can precede diagnosis of small cell lung carcinoma. If considered early and adequately investigated, it can allow earlier diagnosis and treatment of underlying malignancy, improving overall and neurological prognosis.

Simultaneous bilateral optic neuropathy and myelitis revealing paraneoplastic neurological syndrome associated with multiple onconeuronal antibodies

Paraneoplastic neurological syndromes (PNS) are immune-mediated complications of cancer associated with a broad spectrum of clinical manifestations. Optic neuropathy (ON) and myelitis are frequent manifestations of multiple sclerosis and neuromyelitis optic spectrum disorders but are considered as non-classical in PNS. Here, we report a case of PNS revealed by simultaneous bilateral ON and myelitis related to a cluster of three neural autoantibodies, in the setting of small cell lung cancer.

Immunophenotypical characterization of paraneoplastic neurological syndrome patients: a multicentric study

Paraneoplastic neurological syndromes (PNS) are a group of rare and severe immune-mediated disorders that affect the nervous system in patients with cancer. The best way to diagnose a paraneoplastic neurological disorder is to identify anti-onconeural protein antibodies that are specifically associated with various cancers. The aim of this multicentric study was to clinically and immunologically characterize patients with PNS and study their association with cancer. Patients suspected to have PNS were enrolled from various clinical centres and were characterized immunologically. This study population consisted of 112 patients. Onset of PNS was mainly subacute (76 %). PNS patients had various neurological disorders and symptoms. PNS developed before the diagnosis of cancer in 28 definite PNS patients and in six suspected PNS patients. The most frequent autoantibodies detected in PNS patients were anti-Hu and anti-Yo. One definite PNS patient with cerebellar syndrome had anti-Tr antibody and seven patients had atypical antibodies. The literature associates these antibodies with various neurological disorders and cancers. Our observations confirm the important role of autoantibodies in PNS and their importance for the early diagnosis of cancer in PNS patients.

Treatment of Movement Disorder Emergencies in Autoimmune Encephalitis in the Neurosciences ICU

Immune response against neuronal and glial cell surface and cytosolic antigens is an important cause of encephalitis. It may be triggered by activation of the immune system in response to an infection (para-infectious), cancer (paraneoplastic), or due to a patient's tendency toward autoimmunity. Antibodies directed toward neuronal cell surface antigens are directly pathogenic, whereas antibodies with intracellular targets may become pathogenic if the antigen is transiently exposed to the cell surface or via activation of cytotoxic T cells. Immune-mediated encephalitis is well recognized and may require intensive care due to status epilepticus, need for invasive ventilation, or dysautonomia. Patients with immune-mediated encephalitis may become critically ill and display clinically complex and challenging to treat movement disorders in over 80% of the cases (Zhang et al. in Neurocrit Care 29(2):264-272, 2018). Treatment options include immunotherapy and symptomatic agents affecting dopamine or acetylcholine neurotransmission. There has been no prior published guidance for management of these movement disorders for the intensivist. Herein, we discuss the immune-mediated encephalitis most likely to cause critical illness, clinical features and mechanisms of movement disorders and propose a management algorithm.

Paraneoplastic Syndromes in Neuro-ophthalmology

PURPOSE OF REVIEW

This article discusses the varied types of paraneoplastic syndromes that commonly have neuro-ophthalmologic manifestations. Diagnostic considerations and therapeutic options for individual diseases are also discussed.

RECENT FINDINGS

Paraneoplastic syndromes can affect the afferent and efferent visual systems. Paraneoplastic syndromes may result in reduced visual acuity from retinal degeneration, alterations in melanocyte proliferation and uveal thickening, or acquired nystagmus. Ocular motor abnormalities related to paraneoplastic syndromes may present with symptoms from opsoclonus or from neuromuscular junction disease. Diagnosis remains challenging, but serologic identification of some specific antibodies may be helpful or confirmatory. Treatment, in addition to directed therapies against the underlying cancer, often requires systemic corticosteroids, plasma exchange, or immunosuppression, but some specific syndromes improve with use of targeted pharmacologic therapy.

SUMMARY

Diagnosis and therapy of paraneoplastic syndromes presenting with neuro-ophthalmic symptoms remain a challenge, but strategies are evolving and new approaches are on the horizon.

Paraneoplastic movement disorders: phenomenology, diagnosis, and treatment

Paraneoplastic syndromes include, by definition, any symptomatic and non-metastatic condition associated with a neoplasm. Paraneoplastic movement disorders are a heterogeneous group of syndromes encompassing both hyperkinetic and hypokinetic conditions, characterized by acute/sub-acute onset, rapidly progressive evolution, and multifocal localizations with several overlapping features. These movement disorders are immune-mediated, as shown by the rapid onset and by the presence of antineuronal antibodies in biological samples of patients, fundamental for the diagnosis. Antineuronal antibodies could be targeted against intracellular or neuronal surface antigens. Paraneoplastic movement disorders associated with anti-neuronal surface antigens antibodies respond more frequently to immunotherapy. The underlying tumors may be different, according to the clinical presentation, age, and gender of patients. Our search considered articles involving human subjects indexed in PubMed. Abstracts were independently reviewed for eligibility criteria by one author and validated by at least one additional author. In this review, we sought to critically reappraise the clinical features and the pathophysiological mechanisms of paraneoplastic movement disorders, focusing on diagnostic and therapeutic strategies. Our main aim is to make clinicians aware of paraneoplastic movement disorders, and to provide assistance in the early diagnosis and management of these rare but life-threatening conditions.

Paraneoplastic Disorders

PURPOSE OF REVIEW

Paraneoplastic neurologic syndromes target specific areas of the nervous system with pathogenic autoantibodies or T-cell responses. Each syndrome conveys a risk of particular tumors. Expanded paraneoplastic antibody testing has led to improved diagnosis but created challenges involving appropriate interpretation of test results.

RECENT FINDINGS

Peripheral nervous system paraneoplastic disorders such as myasthenia gravis and Lambert-Eaton myasthenic syndrome involve pathogenic autoantibodies. Recently, the pathogenic mechanisms and antigens of these disorders have been further elucidated. Paraneoplastic syndromes associated with onconeuronal antibodies, such as anti-Hu, have strong cancer associations and limited response to treatment. Autoimmunity to central nervous system membrane proteins, such as the N-methyl-D-aspartate (NMDA) receptor or leucine-rich, glioma inactivated 1 (LGI1), defines an expanding group of disorders with better prognosis and more variable cancer associations. In these diseases, the autoantibodies are either proven to be or are potentially pathogenic. An animal model of anti-NMDA receptor encephalitis will allow novel treatments to be developed. Autoantibodies to intracellular synaptic antigens, such as glutamic acid decarboxylase 65 (GAD65), are associated with diverse disorders such as stiff person syndrome, and the pathophysiology of these diseases is unclear.

SUMMARY

Paraneoplastic disorders have diverse clinical manifestations, including weakness, sensory neuronopathy, encephalitis, epilepsy, and psychosis. Proper use of antibody testing may assist with diagnosis. Treatment may require immunotherapy and tumor treatment.

Anti-Ma2-associated limbic encephalitis with coexisting chronic inflammatory demyelinating polyneuropathy in a patient with non-Hodgkin lymphoma: A case report

RATIONALE

We report the rare case of a 74-year-old man with anti-Ma2-associated paraneoplastic neurologic syndrome (PNS), and review and analyze the clinical manifestations, diagnosis, and treatment of the disease.

PATIENT CONCERNS

The patient presented with a 5-month history of muscle weakness, progressive body aches, and weakness and numbness in both lower extremities. Before his hospitalization, he had experienced cognitive function decline; ptosis, inward gaze, and vertical gaze palsy in the right eye; and occasional visual hallucinations. Brain and spinal cord magnetic resonance imaging (MRI) yielded normal results. Anti-Ma2 antibodies were detected in both serum and cerebrospinal fluid. A 4-hour electroencephalogram showed irregular sharp slow waves and δ waves in the temporal region. Electromyography showed peripheral nerve demyelination. Positron-emission tomography/computed tomography (PET-CT) examination revealed hypermetabolism in the lymph nodes of the whole body. Biopsy of the lymph nodes showed non-Hodgkin lymphoma.

DIAGNOSIS

A clinical diagnosis of lymphoma and PNS was made.

INTERVENTIONS

The patient was treated with intravenous dexamethasone (15 mg/day) for 3 days.

LESSONS

We have presented a rare case of a PNS involving both the central and peripheral nervous systems. The clinical features of this case indicated anti-Ma2-associated encephalitis and chronic inflammatory demyelinating polyneuropathy. PET-CT played a critical role in enabling early diagnosis and prompt treatment in this case.

Autoimmune paraneoplastic syndromes associated to lung cancer: A systematic review of the literature Part 4: Neurological paraneoplastic syndromes, involving the peripheral nervous system and the neuromuscular junction and muscles

The development of new immune treatment in oncology and particularly for lung cancer may induce new complications, particularly activation or reactivation of auto-immune diseases. In this context, a systematic review on the auto-immune paraneoplastic syndromes that can complicate lung cancer appears useful. This article is the fourth of a series of five and deals mainly with neurological paraneoplastic syndromes involving the peripheral nervous system and the neuromuscular junction and muscles.

Paraneoplastic epilepsy

Epilepsy can be a manifestation of paraneoplastic syndromes which are the consequence of an immune reaction to neuronal elements driven by an underlying malignancy affecting other organs and tissues. The antibodies commonly found in paraneoplastic encephalitis can be divided into two main groups depending on the target antigen: 1) antibodies against neuronal cell surface antigens, such as against neurotransmitter (N-methyl-d-aspartate (NMDA), alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA), gamma-aminobutyric acid (GABA)) receptors, ion channels (voltage-gated potassium channel (VGKC)), and channel-complex proteins (leucine rich, glioma inactivated-1 glycoprotein (LGI1) and contactin-associated protein-2 (CASPR2)) and 2) antibodies against intracellular neuronal antigens (Hu/antineuronal nuclear antibody-1 (ANNA-1), Ma2/Ta, glutamate decarboxylase 65 (GAD65), less frequently to CV2/collapsin response mediator protein 5 (CRMP5)). In this review, we provide a comprehensive survey of the current literature on paraneoplastic epilepsy indexed by the associated onconeuronal antibodies. While a range of seizure types can be seen with paraneoplastic syndromes, temporal lobe epilepsy is the most common because of the association with limbic encephalitis. Early treatment of the paraneoplastic syndrome with immune modulation/suppression may prevent the more serious potential consequences of paraneoplastic epilepsy.

Paraneoplastic disorders

PURPOSE OF REVIEW

Paraneoplastic disorders are autoimmune diseases associated with risks for specific cancers and marked by specific autoantibodies. They cause diverse clinical syndromes of the central and peripheral nervous systems.

RECENT FINDINGS

In the peripheral nervous system, autoimmunity to synaptic or axonal proteins has long been recognized to associate with specific cancers. In these disorders, typified by myasthenia gravis, the antibodies are directly toxic, and recovery with immunotherapy is the rule. In contrast, the classic paraneoplastic syndromes involve a higher risk of cancer, autoantibodies to intracellular proteins (eg, Hu proteins), T-cell-dependent disease mechanisms targeting the CNS or peripheral nervous system, and a poor response to treatment. Following the discovery of N-methyl-D-aspartate (NMDA) receptor antibodies, a new and expanding group of disorders involving autoantibodies to CNS synaptic and neuronal membrane proteins and a favorable response to immunotherapy emerged. A final group of disorders involves antibodies to intracellular synaptic proteins, such as glutamic acid decarboxylase 65 (GAD65), and it is unclear whether these diseases involve antibody or T-cell mechanisms.

SUMMARY

Neurologists should recognize the clinical syndromes associated with paraneoplastic disorders, utilize autoantibody and other testing to confirm the diagnosis, understand the pathologic basis of the diseases, and promptly give appropriate therapies.

Novel Humoral Prognostic Markers in Small-Cell Lung Carcinoma: A Prospective Study

Purpose

Favourable small cell lung carcinoma (SCLC) survival outcomes have been reported in patients with paraneoplastic neurological disorders (PNDs) associated with neuronal antibodies (Neur-Abs), but the presence of a PND might have expedited diagnosis. Our aim was to establish whether neuronal antibodies, independent of clinical neurological features, correlate with SCLC survival.

Experimental Design

262 consecutive SCLC patients were examined: of these, 24 with neurological disease were excluded from this study. The remaining 238 were tested for a broad array of Neur-Abs at the time of cancer diagnosis; survival time was established from follow-up clinical data.

Results

Median survival of the non-PND cohort (n = 238) was 9.5 months. 103 patients (43%) had one or more antigen-defined Neur-Abs. We found significantly longer median survival in 23 patients (10%) with HuD/anti-neuronal nuclear antibody type 1 (ANNA-1, 13.0 months P = 0.037), but not with any of the other antigen-defined antibodies, including the PND-related SOX2 (n = 56, 24%). An additional 28 patients (12%) had uncharacterised anti-neuronal nuclear antibodies (ANNA-U); their median survival time was longer still (15.0 months, P = 0.0048), contrasting with the survival time in patients with non-neuronal anti-nuclear antibodies (detected using HEp-2 cells, n = 23 (10%), 9.25 months). In multivariate analyses, both ANNA-1 and ANNA-U independently reduced the mortality hazard by a ratio of 0.532 (P = 0.01) and 0.430 (P<0.001) respectively.

Conclusions

ANNAs, including the newly described ANNA-U, may be key components of the SCLC immunome and have a potential role in predicting SCLC survival; screening for them could add prognostic value that is similar in magnitude to that of limited staging at diagnosis.

Anti-Hu Antibody-associated Paraneoplastic Neurological Syndrome Showing Peripheral Neuropathy and Atypical Multifocal Brain Lesions

A 64-year-old Japanese woman presented with a three-month history of progressive numbness and weakness of the lower extremities. A neurological examination and nerve conduction study indicated sensorimotor polyneuropathy. Since the serum anti-Hu antibody titer was remarkably elevated, paraneoplastic neurological syndrome was highly suspected. A thoracoscopic biopsy of the hilar lymph nodes, in which (18)F-fluorodeoxyglucose uptake was obviously increased, revealed pathological findings for small-cell lung cancer (SCLC). Subsequently, the patient presented with generalized tonic-clonic seizures, and cerebral MRI showed reversible multifocal brain lesions, considered to reflect paraneoplastic encephalopathy. After two courses of chemotherapy for SCLC, the brain lesions totally disappeared.

Case report: Paraneoplastic neurologic syndrome associated with squamous cell carcinoma of the tonsil

Paraneoplastic syndromes include a variety of disorders that affect the neurologic, endocrine, mucocutaneous, hematologic, and other systems as a result of neoplastic disease. Although their presentations vary, syndromes occur when tumor antigens exhibit cross-reactivity to similar antigens expressed by these systems. The antigens in the nervous system are called "onconeural" antigens. Although many disorders are associated with a comparatively high incidence of paraneoplastic neurologic syndromes, only a few cases have been associated with squamous cell carcinoma (SCC) of the tonsil. We report the case of a 69-year-old man who initially presented with weakness and spastic gait. He was subsequently found to have a characteristic paraneoplastic tractopathy on thoracic magnetic resonance imaging. The subsequent workup and operative intervention identified a T2N0M0 SCC of the tonsil. Following resection, the patient's overall symptoms were significantly alleviated, and his gait improved. A thorough literature search yielded no other report of a tonsillar SCC with associated paraneoplastic thoracic spine tractopathy.

[2011: What's new in dysimmune neuropathies]

There are strong research activities in the field of dysimmune neuropathies. In Guillain-Barré syndrome, new pathophysiological mechanisms have been demonstrated with the potential development of new therapies, a clinical prediction model is applicable early in the course of disease, and under investigation are new treatment strategies with adapted intravenous Ig dosages. In chronic inflammatory demyelinating polyneuropathies, current diagnostic tests are discussed but biomarkers are needed, such as histological changes or differential gene expression in nerve or skin biopsies. The exploration of novel therapeutic approaches including monoclonal antibodies and oral immunosuppressants, known from multiple sclerosis studies, suggests new approaches to treatment. Changes of the peripheral nerves on MR imaging are better known and the usefulness of serum antibodies is reviewed.

Rhombencephalitis / brainstem encephalitis

Rhombencephalitis (RE) is a syndrome of multiple causes and multiple outcomes. Most authors now use the terms "rhombencephalitis" and "brainstem encephalitis" interchangeably even though anatomically they are slightly different. The etiologic categories of RE include infections, autoimmune diseases, and paraneoplastic syndromes (PNS). Listeria is the most common cause of infectious RE. Listeria RE primary occurs in healthy young adults. It usually occurs as a biphasic time course with a flu-like syndrome followed by brainstem dysfunction; 75% of patients have a cerebrospinal fluid (CSF) pleocytosis, and almost 100% have an abnormal brain MRI scan. Positive CSF and blood cultures are the most specific for diagnosis. Treatment primarily is with ampicillin. Enterovirus 71 is probably the second most common infectious cause of RE; however, 95% of cases have occurred in the Asian-Pacific region and there is no specific treatment. Herpes simplex virus (HSV) is the third most common infectious cause of RE, and about 80% of cases are caused by HSV1 and 20% by HSV2. About 50% only had involvement of the brainstem whereas the other 50% also had supratentorial involvement of the temporal and frontal lobes. Mortality with acyclovir treatment was 22% versus those not on acyclovir 75%. Epstein-Barr virus (EBV) and human herpesvirus 6 (HHV6) have caused a few cases. The most common autoimmune etiology is Behçet disease. Over 90% of those with Behçet RE had abnormal MRI scans and 94% had a CSF pleocytosis. Treatment is with corticosteroids and immunosuppressive agents, but only 25% have complete recovery. Paraneoplastic causes are the third category of RE. Brain MRIs are usually normal; there is usually a CSF pleocytosis but the protein is usually normal. Often anti-neuronal antibodies can be found. Prognosis is poor and treatment is only partially beneficial. Because Listeria and HSV are the most common treatable acute causes of RE, we recommend empiric therapy with ampicillin and acyclovir for all cases after samples have been obtained from CSF and blood for cultures and the polymerase chain reaction (PCR). Antibiotics can be changed based upon MRI, culture results, PCR results, and antibody studies.

[Paraneoplastic neurological syndrome in 64-year-old patient in association with a small cell lung carcinoma]

BACKGROUND

Paraneoplastic neurological syndromes are rare conditions manifest as psychiatric/neurological symptoms. They are caused by autoimmunne cross-reaction leading to destruction of the central nervous system.

CASE

We present the case of a 64-year-old patient hospitalized for 6 months at the Department of Psychiatry for persisting depression. During that time he progressed to delirium. A diagnosis of diffuse encephalopathy was made, but further examination revealed a small cell lung cancer with generalisation. A paraneoplastic syndrome was finally diagnosed after autoptic and histologic examination.

CONCLUSION

Paraneoplastic neurological syndromes can be early signs of malignancy and may considerably precede oncologic diagnosis.

Movement disorders in paraneoplastic and autoimmune disease

PURPOSE OF REVIEW

The most relevant advances in immune-mediated movement disorders are described, with emphasis on the clinical--immunological associations, novel antigens, and treatment.

RECENT FINDINGS

Many movement disorders previously considered idiopathic or degenerative are now recognized as immune-mediated. Some disorders are paraneoplastic, such as anti-CRMP5-associated chorea, anti-Ma2 hypokinesis and rigidity, anti-Yo cerebellar ataxia and tremor, and anti-Hu ataxia and pesudoathetosis. Other disorders such as Sydenham's chorea, or chorea related to systemic lupus erythematosus and antiphospholipid syndrome occur in association with multiple antibodies, are not paraneoplastic, and are triggered by molecular mimicry or unknown mechanisms. Recent studies have revealed a new category of disorders that can be paraneoplastic or not, and associate with antibodies against cell-surface or synaptic proteins. They include anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis, which may cause dyskinesias, chorea, ballismus or dystonia (NMDAR antibodies), the spectrum of Stiff-person syndrome/muscle rigidity (glutamic acid decarboxylase, amphiphysin, GABA(A)-receptor-associated protein, or glycine receptor antibodies), neuromyotonia (Caspr2 antibodies), and opsoclonus--myoclonus--ataxia (unknown antigens).

SUMMARY

Neurologists should be aware that many movement disorders are immune-mediated. Recognition of these disorders is important because it may lead to the diagnosis of an occult cancer, and a substantial number of patients, mainly those with antibodies to cell-surface or synaptic proteins, respond to immunotherapy.

Therapeutic strategies for catatonia in paraneoplastic encephalitis

This report is about a 40-year-old man suffering from fluctuating catatonia as main symptom of long-lasting paraneoplastic encephalitis caused by a testicular neoplasm. With recurrence of a neoplasm initially diagnosed as seminoma after a 7-year symptom-free interval the patient suddenly developed various neurological and psychopathological symptoms including seizures, autonomic dysregulation, continuous anterograde short-term amnesia and predominantly a long-lasting complex catatonic syndrome with on-off phenomena. Repeated MRI scans of the brain showed no pathology; brain FDG-PET scans indicated a hypometabolism of the frontal cortex and the left temporal lobe. Eventually a paraneoplastic encephalitis was diagnosed. Repeated resections of tumour recurrences and plasmapheresis moderately alleviated catatonic symptoms. Haloperidol and lorazepam effectively relieved catatonic symptoms in contrast to various atypical antipsychotic drugs and diazepam. A series of 12 electroconvulsive treatments (ECT) temporarily improved residual catatonic symptoms such as catalepsy, stupor and mutism. Further neoplasm recurrences, however, reinforced catatonia until the tumour was successfully treated and the patient fully recovered. This case report illustrates the potential but also the limitations of various therapeutic approaches in organic catatonia due to paraneoplastic encephalitis.

Limbic encephalitis associated with immature teratoma

Paraneoplastic neurological syndrome (PNS) includes rare manifestations of different forms of cancer, in which the specific syndrome of limbic encephalitis can be found. This report describes a case of a previously healthy young lady who developed severe limbic encephalitis associated with an immature teratoma. After surgical treatment, the patient showed rapid progressive neurological improvement with complete regression of the symptoms during follow-up. Although rare, correct recognition and management of PNS is of great importance especially considering the fact that PNS can carry the risk of permanent disability or even death, even when associated with tumors in which high cure rates are expected.

Paraneoplastic syndromes in patients with nasopharyngeal cancer

Paraneoplastic syndromes (PNS) represent the clinical manifestation of the remote and indirect effects produced by tumor metabolites or other products. Paraneoplastic effects are not directly mediated by tumor invasion of normal tissue, or by the disruption of normal function of the involved organ, or by distant metastases. More than 260 cases of nasopharyngeal carcinoma (NPC) associated with PNS have been reported in the literature. These syndromes can be divided into six main groups: cutaneous or dermatologic, endocrine, hematologic, osteoarticular or rheumatologic, neurologic, and ocular. The most common dermatologic manifestation is dermatomyositis, while the syndrome of inappropriate secretion of antidiuretic hormone and occasionally Cushing's syndrome due to ectopic ACTH production are the endocrinologic manifestations. Tumor fever and leukemoid reaction, osteoarticular or rheumatic syndromes, including clubbing of the fingers and toes, sensory neuropathy and demyelinating motor polyneuropathy, and rarely optic neuritis represent the most prominent examples of the other groups of syndromes. PNS may occur before the NPC is manifest, or while it is in an occult stage, and thus the possibility of NPC should be considered in patients with these various disorders. While some PNS will respond to direct treatment, most often the PNS subsides in parallel to response of the NPC, and thus may be useful for monitoring tumor response or recurrence.

[Mental disorders in paraneoplastic syndromes]

Usually paraneoplastic symptoms precede actual diagnosis of a neoplasm, however, may also be concurrent with it. They do not result from the localization of the primary lesion nor are associated with metastases or with other effects of presence and treatment of the neoplasm. The immunological etiology is assumed. In diagnostics estimation of level of the antionconeuronal antibodies may be helpful. Mental disorders in the course of paraneoplastic syndrome may coexist with neoplasm, but also may precede it (combined with neurological signs or without them). Such mental disorders have diverse clinical pictures and often are characterized by atypical and heavy course. Observed psychopathological symptoms do not form any specific diagnostic profile delineated in ICD 10 and encompass disturbances of consciousness, perception and thinking, as well as affective states. Although psychiatric intervention in paraneoplastic syndromes with psychopathological symptoms is merely symptomatic, one can still expect atypical response. Suspected paraneoplastic syndrome in patients not yet diagnosed as having neoplasm should persuade one to initiate a screening for potential focal change and to introduce targeted treatment should tumor growth be confirmed.

[From psychiatric symptoms to paraneoplastic syndrome]

Two patients, a 38-year-old man and a 32-year-old woman, were admitted to a psychiatric ward. The first patient suffered from a mood disorder, personality changes and complained of several, hitherto unexplained physical symptoms. Finally the patient was diagnosed with paraneoplastic cerebellar degeneration associated with Hodgkin's disease. The second patient presented with psychosis and panic disorders, but the condition was later found to be caused by paraneoplastic limbic encephalitis due to ovarian teratomas. These cases illustrate that patients with paraneoplastic neurological syndromes may present with psychiatric symptoms which can hamper an early diagnosis.

Neurological course of long-term surviving patients with SCLC and anti-Hu syndrome

Patients with small-cell lung cancer (SCLC) have a poor prognosis with a three year survival rate of 4%. Our report concerns three patients with histologically proven SCLC and anti-Hu associated paraneoplastic neurological syndrome who have survived for 11 in two cases and 16 years respectively. The patients showed progressive deterioration which was only partly beneficially modulated by steroid therapy or tumor treatment, even in the cases with complete tumor remission.

Paraneoplastic effects on neurophthalmologic function

OBJECTIVE

Paraneoplastic neurologic syndrome with otoneurophthalmologic manifestations is much less common than direct, metastatic, and treatment-related complications of cancer. Few studies have focused on patients presenting with paraneoplastic syndrome before a cancer is identified.

PATIENT

We describe a case of combined paraneoplastic brainstem/limbic encephalitis and Lambert-Eaton myasthenic syndrome in a patient with small cell lung cancer and positive antiamphiphysin antibodies who initially presented with otoneurophthalmologic signs and symptoms to the ears, nose, and throat clinic. To the best of the authors' knowledge, this combined form of disease, confirmed by both clinical and laboratory tests, is one of the rarest cases ever to be reported. Immunoglobulin G polyclonal antibodies directed against amphiphysin have been detected in a few stiff-person syndrome patients, especially those with breast cancer. This case is again unusual in the sense that the patient was positive for antiamphiphysin antibodies, but negative for anti-Hu antibodies.

CONCLUSION

Patients initially presenting with otoneurophthalmologic signs and symptoms with no detectable lesions in the central nervous system should be promptly and thoroughly investigated and monitored carefully for a possible malignancy elsewhere in their bodies without waiting for the actual malignancy to manifest itself at a later stage, thus increasing the prospect of detecting the malignancy and optimizing the treatment modalities at an earlier stage.

Central hypoventilation as the presenting symptom in Hu associated paraneoplastic encephalomyelitis

Central hypoventilation is usually caused by ischaemic or neoplastic lesions of the medulla and upper cervical spinal cord. An autoimmune disorder is not usually considered in the differential diagnosis of this syndrome. We retrospectively identified 14 patients from our database of 202 patients with Hu antibodies who presented with brainstem symptoms. Three were admitted to hospital because of central hypoventilation. All underwent intubation and mechanical ventilation. They could breathe properly while they were awake but suffered deep apnoeas during sleep. Two died, but one is still alive requiring ventilatory assistance during sleep. Autopsy was performed in one of the patients which showed severe inflammatory infiltrates and neuronal loss in the medulla. All patients had normal brain imaging studies and the cause of central hypoventilation was an unsolved problem until Hu antibodies were determined.

Paraneoplastic vasculitis of central nervous system presenting as recurrent cryptogenic stroke

We report the case of paraneoplastic vasculitis of the central nervous system associated with breast cancer. A 54-year old woman had a complete workup because of recidive seizures. Magnetic resonance imaging (MRI) showed cerebral and medullary cryptogenic lesions, and a diagnosis of encephalomyelitis of unknown origin was made. She was treated with corticosteroids, but because of cognitive impairment and recurrence of epileptic seizures, she was finally transferred to our Neurology Department. The previous diagnosis was then changed, because a poorly differentiated invasive lobular breast cancer was discovered. Thoracic and abdominal computed tomography (CT) scans diagnosed pulmonary, pericardial, adrenal, and renal metastases. Because MRI findings did not fit with the diagnosis of brain metastases, a CT-guided cerebral biopsy was performed, and she was eventually diagnosed with paraneoplastic vasculitis of the central nervous system.

Long-term outcome of ten children with opsoclonus-myoclonus syndrome

Opsoclonus-myoclonus syndrome (OMS) in children is a rare neurological condition with opsoclonus, myoclonus, ataxia and irritability in the first 2 years of life. It can be idiopathic, parainfectious, or paraneoplastic with tumours of the neural crest. Few studies of long-term follow-up after OMS have been published. We investigated the motor, cognitive and behavioural outcome of ten patients (eight girls and two boys) seen between 1987 and 2002. We reviewed the records and reassessed the patients. A ganglioneuroma was found in one patient and a neuroblastoma in another. Tumour resection did not influence the OMS. The age at diagnosis was 10-24 months and the follow-up period 1-17 years (average 6.5 years). The interval between the first signs and symptoms and starting treatment was 2-12 weeks: treatment consisted of different immunosupressants. Remission was achieved within 5 months in seven, and relapses were present in seven of ten. At follow-up, only one child had mild ataxia. IQ testing was performed in nine with scores below 75 in four and above 85 in four. Attention deficit and visuomotor difficulties led to school problems with special needs, also in those three children with normal IQs. Only two children were attending regular schools. Behavioural problems were reported in seven, and speech difficulties were present in five. In conclusion, the long-term outcome in our patients with OMS was dominated by cognitive and behavioural problems and not by ataxia. Compared with previous reports, our patients were treated earlier. Larger studies and uniform treatment protocols are needed to demonstrate whether early and prolonged immunosupressant therapy has a favourable influence on outcome.

Pupil abnormalities in selected autonomic neuropathies

Examination of the pupil provides an opportunity to detect disturbances in the autonomic innervation of the eye. The pupil is frequently affected in patients with generalized autonomic neuropathies. This literature review confirms a high prevalence of sympathetic deficits and parasympathetic deficits in acute or subacute dysautonomia, diabetes, amyloidosis, pure autonomic failure, paraneoplastic syndromes, Sjögren syndrome, familial dysautonomia, and dopamine beta-hydroxylase deficiency. It confirms the relative scarcity of a pupil abnormality in patients with multiple system atrophy. There are difficulties in clinical diagnosis of pupil abnormalities and interpretation of pupil pharmacologic tests, particularly when combined sympathetic and parasympathetic deficits are present.

Current therapies for neuromuscular manifestations of paraneoplastic syndromes

The neuromuscular manifestations of paraneoplastic disorders result in diverse syndromes that may also occur in patients without cancer. In general, treatment of these disorders is the same whether or not there is an underlying malignancy. However, when the disorder is believed to be paraneoplastic, the main concern should be prompt detection and treatment of the tumor, as this has been shown to offer the best chance for neurologic stabilization or improvement. The paraneoplastic neuromuscular disorders can be divided into two main categories: those that are directly mediated by antibodies and those that are believed to result from other immune-mediated mechanisms, including cytotoxic T-cell responses with or without association with specific antibodies. For disorders in which the antibodies are pathogenic, therapy is aimed at removing the antibodies. For the other disorders, adjuvant therapies are for the most part empiric and include a variety of immunosuppressant and immunomodulatory agents.

Functional characterisation of autoantibodies from patients with pediatric opsoclonus–myoclonus-syndrome

Paraneoplastic opsoclonus-myoclonus-syndrome (OMS) both in children and adults is suspected to be the result of an autoimmune response directed against cross-reactive proteins of tumor and neuronal cells. We here characterised the binding and functional activities of anti-neuroblastoma antibodies in IgG fractions from 11 OMS children with and without neuroblastoma. IgG fractions from neuroblastoma without OMS (NB) and healthy children served as controls. Indirect immunofluorescence and Western blot revealed IgG binding to intracellular autoantigens in all OMS patients, but in only one of the controls (p<0.001). Using flow cytometry, we could demonstrate surface binding of IgG fractions in all OMS patients, but only in one of control (p<0.001). Moreover OMS IgG exhibited a significant anti-proliferative and a cytotoxic effect on neuroblastoma cells compared to control IgG (p<0.001 and p<0.01). TUNEL assay revealed increased apoptotic cell death of the neuroblastoma cells after exposure to OMS IgG, but not to NB or control IgG (p<0.01). Preabsorption of membrane binding abandoned the anti-proliferative effect of OMS IgG. These findings indicate that surface-binding autoantibodies are present in OMS patients and these autoantibodies cause inhibition of cell proliferation and induce apoptosis.

Longitudinal neurodevelopmental evaluation of children with opsoclonus-ataxia

OBJECTIVE

We previously reported on children with opsoclonus-ataxia and found pervasive neurodevelopmental deficits, years after onset, without a clear relationship to treatment modality or timing of treatment. A significant negative correlation of functional status with age at testing raised a question of whether opsoclonus-ataxia is a progressive encephalopathy. We attempted to answer this question with serial testing. In addition, we examined the relationship between clinical course and developmental outcome.

METHODS

Thirteen of 17 children with opsoclonus-ataxia, all with neuroblastoma, who were previously reported were reevaluated a second time 2 to 4 years after the initial assessment. One subject who lived out of state was partially reevaluated and is included. Five new subjects (2 with neuroblastoma and 3 without) were also enrolled. Each was evaluated twice at a minimum interval of 1 year between sessions. Intercurrent medical course was recorded, emphasizing medication and relapse history. Cognitive, adaptive behavior, academic, speech and language, and motor abilities were assessed.

RESULTS

For the group as a whole, overall standardized, age-adjusted cognitive scores improved. Generally, younger subjects' cognitive and adaptive behavior scores improved more than older subjects. Although all subjects had gains in speech, language, and motor function, some progressed at a slow pace, and in some instances, standard scores dropped. There was a striking influence of clinical course. Although initial presentation was severe and all subjects required high doses of corticosteroids or corticotropin, 5 had a monophasic course and were able to be weaned from treatment without relapses. Fourteen had multiple relapses over the years, generally with reduction of medication or intercurrent illnesses. Of the 5 children with monophasic course, 4 are currently functioning in the average range with a full-scale IQ of > or =90 and age-appropriate academic and adaptive skills.

CONCLUSIONS

The results continue to raise concern that opsoclonus-ataxia is sometimes a progressive encephalopathy. A minority of children with opsoclonus-ataxia have a monophasic course. Despite initial severity of symptoms, these children may have a more benign prognosis. For the majority of children with opsoclonus-ataxia, the course includes multiple relapses and requires prolonged treatment. Developmental sequelae are significant in these children with chronic course.

Opsoclonus myoclonus syndrome in neuroblastoma a report from a workshop on the dancing eyes syndrome at the advances in neuroblastoma meeting in Genoa, Italy, 2004

Opsoclonus-myoclonus syndrome (OMS) is a rare neurologic syndrome that, in children, associates with neuroblastoma in more than half of the cases. The etiology of this condition is thought to be immune mediated, but, though immunosuppressive therapies may ameliorate the acute symptoms, no effective treatment to prevent the common neuropsychologic sequelae has been established. This paper summarizes the results obtained at the 2004 Advances in Neuroblastoma Research meeting, providing status of the art information on immune pathogenesis, clinical features, acute and chronic neurologic manifestations, current and novel therapeutic approaches. It is emphasized that, due to the rarity of OMS in general and neuroblastoma-associated OMS in particular, international collaborations are needed to better define the pathogenesis and therapy of this disease, propose common evaluation criteria and identify new treatment modalities.

Celiac disease presenting as a paraneoplastic syndrome in a patient with synchronous endometrial and ovarian cancers

OBJECTIVE

Celiac disease is characterized by gluten intolerance and commonly manifests with unexplained diarrhea, abdominal distention and weight loss. Infrequently, patients present with vague, non-specific symptoms which often delay diagnosis and treatment.

CASE

A 52-year-old female with a history of synchronous endometrial and ovarian cancers, previously treated with surgical resection, staging and pelvic irradiation, presented with progressive paresthesias in her extremities. Extent of disease work-up was unremarkable. Neurologic evaluation suggested celiac disease which was later proven by duodenal biopsy.

CONCLUSION

The development of new or worsening neurologic symptoms in the cancer patient requires a thorough evaluation especially to exclude metastatic disease and/or paraneoplastic syndromes. Once neoplastic processes are excluded, celiac disease should be considered in the differential diagnosis of patients with unexplained neurologic dysfunction.

[Opsoclonus myoclonus with ataxia]

Opsoclonus myoclonus with ataxia (OMA) is a rare neurological disorder. The syndrome is characterized by involuntary, conjugate, multidirectional eye movements accompanied by involuntary movements of limb or face, and sometimes ataxia, dysarthria, irritability, dementia, altered level of consciousness and even death. OMA is associated with various etiologies including infectious, toxic, drug-related, vascular and paraneoplastic conditions. Paraneoplastic opsoclonus myoclonus with ataxia (POMA) is more common in patients over 40 years of age and is usually associated with lung (especially small cell), breast and ovarian cancer but has also been reported with many other cancers. The syndrome is thought to be mediated by autoantibodies directed against onconeural antigens that are expressed by the tumor as well as by neurons. Studies from several laboratories were able to demonstrate a role for the cellular response in the pathogenesis of POMA. The results for treatment of this syndrome have been disappointing, although aggressive multimodality immunosuppressive treatments have been used. This is a case study of a patient with POMA who clearly demonstrates the difficulties in the diagnosis and treatment of this syndrome.

Obstipation as a paraneoplastic presentation of small cell lung cancer: case report and literature review

Paraneoplastic symptoms caused by abnormal gastrointestinal motility may be the initial manifestation of small cell lung cancer (SCLC). We report a case of a 63-year-old woman who presented with progressive constipation culminating in obstipation, and associated symptoms of more widespread dysmotility. A paraneoplastic syndrome was suspected. The only abnormality on chest computed tomography was a minimally enlarged paratracheal lymph node. Positron emission tomography demonstrated increased activity in the lymph node. The antinuclear neuronal antibody titer was elevated. Bronchoscopy with transtracheal biopsy confirmed the diagnosis of SCLC. One year after diagnosis, the patient had progressive symptoms of intestinal obstruction, and ultimately feculent vomiting. On abdominal radiography, colonic sitz markers ingested a year earlier were in virtually the same positions as after ingestion. Palliative colectomy with ileostomy was performed. The myenteric plexus in the terminal ileum and colon showed infiltration by a mixture of B-cell and T-cell lymphocytes and plasma cells, and no gross neuronal abnormalities. We review the clinical and pathologic features, clinical course, and management of paraneoplastic pseudoobstruction.

T cell response to Hu-D peptides in patients with anti-Hu syndrome

The anti-Hu syndrome is the most common paraneoplastic neurologic syndrome but the exact mechanism of immune mediated neuronal injury remains unknown. Anti-Hu antibodies do not appear to play a pivotal role in the pathogenesis of the disease. To assess cell-mediated immunity, we selected 51 peptides from the Hu-D sequence and tested their ability to bind to six common HLA class I molecules. Stable complexes with purified HLA molecules were obtained with 19/51 (37%) selected peptides. Subsequently, the ability of the 19 HLA-binding peptides to stimulate T cells from 10 patients and 10 control subjects was evaluated by detecting IFN-gamma secretion. An anti-peptide T-cell response was observed in 7/10 Hu-positive patients but also in 3/10 control subjects. Overall, a significant T-cell activation occurred in response to 74% (14 out of 19) of the selected peptides in the Hu-positive patients vs. 16% (3 out of 19) in the control group (p < 0.001). In addition, T cells of patients tested within 3 months of the onset of anti-Hu syndrome responded to 82% (14 out of 17) of assessed Hu-D peptides vs. 37% (7 out of 19) in patients tested 1 year or more after developing the syndrome (p < 0.01). Thus, the present study suggests a role of cellular immunity during the course of anti-Hu syndrome.

[Anti-Ri paraneoplastic syndrome associated with ophtalmoplegia, blepharospasm and palilalia]

INTRODUCTION

Anti-Hu and anti-Yo are the most well-known anti-neuronal antibodies. The anti-Ri antibodies, which are less common, are generally found in subjects with opsoclonus-myoclonus, often associated with breast cancer.

CASE REPORT

A 54-year-old woman presented anti-Ri antibodies associated with a paraneoplastic syndrome and unusual symptoms of ophthalmoplegia, blepharospasm, palilalia and ataxia. Adenocarcinoma of the breast was also found. After chemotherapy, radiotherapy, and several immunoglobulin infusions, the patient did not improve ten months after tumor surgery.

CONCLUSION

Anti-Ri antibodies associated with paraneoplastic syndrome can be observed in patients who develop a rapidly progressive brainstem tumor. Breast or lung cancer and conduct to search a breast or pulmonary cancer.