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Yiannopoulou K, Vakrakou AG, Anastasiou A, Nikolopoulou G, Sourdi A, Tzartos JS, Kilidireas C, Dimitrakopoulos A. Cerebrospinal Fluid Anti-Neuronal Autoantibodies in COVID-19-Associated Limbic Encephalitis with Acute Cerebellar Ataxia and Myoclonus Syndrome: Case Report and Literature Review. Diagnostics (Basel) 2023; 13:2055. [PMID: 37370950 DOI: 10.3390/diagnostics13122055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Since the outbreak of coronavirus (COVID-19) in 2019, various rare movement disorders and cognitive changes have been recognized as potential neurological complications. The early treatment of some of these allows rapid recovery; therefore, we must diagnose these manifestations in a timely way. We describe the case of a 76-year-old man infected with severe acute respiratory syndrome coronavirus-2 who presented with confusion and hallucinations and was admitted to our hospital 14 days after the onset of symptoms. One day later, he developed generalized myoclonus, dysarthria and ataxia, and tonic clonic seizures and was admitted to the intensive care unit. A diagnosis of COVID-19-associated autoimmune encephalitis with characteristics of limbic encephalitis and immune-mediated acute cerebellar ataxia and myoclonus syndrome was supported by alterations in the limbic system shown in magnetic resonance imaging, lateralized discharges shown in electroencephalography, a slightly elevated protein level in the cerebrospinal fluid (CSF), and indirect immunofluorescence in the CSF with autoantibody binding to anatomical structures of the cerebellum and hippocampus. The patient improved with 2 weeks of corticosteroid treatment and four sessions of plasmapheresis. Our current case study describes a rare case of COVID-19-related limbic encephalitis with immune-mediated acute cerebellar ataxia and myoclonus syndrome (ACAM syndrome) and strengthens the need for tissue-based assays (TBAs) to screen the serum and/or CSF of patients highly suspected to have autoimmune encephalitis. We believe that the timely diagnosis and targeted aggressive immunotherapy were mainly responsible for the patient's total recovery.
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Affiliation(s)
| | - Aigli G Vakrakou
- 1st Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, Vas. Sofias 72-74, 11528 Athens, Greece
| | - Aikaterini Anastasiou
- REHAB Basel, Clinic for Neurorehabilitation and Paraplegiology, 4055 Basel, Switzerland
| | - Georgia Nikolopoulou
- Second Neurological Department, Henry Dunant Hospital Center, 115 26 Athens, Greece
| | - Athina Sourdi
- Third Department of Internal Medicine, Henry Dunant Hospital Center, 115 26 Athens, Greece
| | - John S Tzartos
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, 124 62 Athens, Greece
| | - Constantinos Kilidireas
- Second Neurological Department, Henry Dunant Hospital Center, 115 26 Athens, Greece
- 1st Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, Vas. Sofias 72-74, 11528 Athens, Greece
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Abstract
Background The outbreak of coronavirus disease 2019 (COVID-19) has been widely reported to cause symptoms such as fever, cough, sore throat, fatigue, and shortness of breath. Neurologic complications have not been widely reported without associated respiratory symptoms. These neurologic manifestations have been found mostly in the elderly. There has been no report of ataxia or COVID-19 cerebellitis in the young adult population without associated respiratory symptoms. Case Report Here we report the case of a 30-year-old patient who presented with isolated cerebellar symptoms and was diagnosed with COVID-19 cerebellitis. Why Should an Emergency Physician Be Aware of This? It is important for emergency physicians to know that COVID-19 can have many clinical manifestations and to have a high level of suspicion with acute neurologic symptoms.
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Affiliation(s)
- Adriana Povlow
- Department of Emergency Medicine, UT Health-San Antonio, San Antonio, Texas
| | - Andrew J Auerbach
- Department of Emergency Medicine, UT Health-San Antonio, San Antonio, Texas
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Yu J, Fan Y, Wang L, Huang Y, Xia J, Ding L, Wu CF, Lu X, Ma G, Kim S, Zheng G, Guo H, Zhang G. Intestinal Surgery Contributes to Acute Cerebellar Ataxia Through Gut Brain Axis. Front Neurol 2019; 10:995. [PMID: 31616359 PMCID: PMC6764330 DOI: 10.3389/fneur.2019.00995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/02/2019] [Indexed: 12/20/2022] Open
Abstract
Introduction: Acute cerebellar ataxia (ACA) is the most common form of pediatric ataxia. Changes in gut flora can modulate the nervous system, influencing brain function via the gut-brain axis (GBA). This study aimed to illustrate the relationship between intestinal microbiota and ACA. Method: A total of 30 and 12 children were randomly sampled from history of intestinal surgery (HOIS) and no intestinal surgery groups (NHOIS), respectively. In addition, 10 healthy children who sought physical examination in Children's Hospital of Nanjing Medical University were recruited as a control group. The stool samples were 16S rRNA detected. Results: We observed that many ACA children had intestinal surgery history prior to the onset of ACA. The 16S rRNA sequencing indicated that HOIS and control groups were well-distinguished by principal component analysis. The discrepancy between HOIS and NHOIS groups were also displayed by principal component analysis score plot. However, no differences were found between NHOIS and control groups. The results of student's t-test were consistent with principal component analysis. A total of nine different genera were identified between HOIS and control groups. Five genera and a phylum showed significant differences between HOIS and NHOIS groups. Conclusion: Altered genera and phyla associated with ACA were identified. Our findings provide new insight into treating and preventing ACA.
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Affiliation(s)
- Jie Yu
- Department of Neurology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yuanming Fan
- Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Li Wang
- Department of Neurology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yanjuan Huang
- Department of Neurology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jingyi Xia
- Department of Neurology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Le Ding
- Department of Neurology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Chun-Feng Wu
- Department of Neurology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaopeng Lu
- Department of Neurology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Gaoxiang Ma
- Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Samuel Kim
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Guo Zheng
- Department of Neurology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Hu Guo
- Department of Neurology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Gang Zhang
- Department of Neurology, Children's Hospital of Nanjing Medical University, Nanjing, China
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Suardi LR, Di Lauria N, Pozzi M, Rogasi PG, Barilaro A, Azzolini F, Prestipino E, Colao MG, Rossolini GM, Bartoloni A. Acute cerebellar ataxia: a rare Toscana Virus (TOSV) meningoencephalitis complication. Int J Neurosci 2019; 130:276-278. [PMID: 31554442 DOI: 10.1080/00207454.2019.1673748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose: Arbovirosis, viral infection transmitted by arthropods, is a widespread health problem. In Italy, as well for all Mediterranean basin, from late spring to the end of summer, Toscana Virus (TOSV), a sandfly borne virus, accounts for the majority of aseptic meningitis/meningoencephalitis cases. TOSV meningitis/meningoencephalitis has usually a self-extinguishing benign course. Our aim is to report a case of a young healthy women diagnosed with Toscana Virus meningoencephalitis with a complicated clinical course.Materials and methods/results: Case report of a 33-years old woman, admitted to the Infectious Diseases Unit at Careggi General Hospital (Florence-Italy), with a diagnosis of Toscana Virus meningoencephalitis. Seventy-two hours after the admission, she developed typical symptoms, as impaired legs coordination, slurred speech, stumbling and dysmetria, of acute cerebellar ataxia (ACA). Urgent neurological assessment was provided performing an electroencephalography study followed by a brain and brainstem magnetic resonance imaging. In the meanwhile, bilateral nystagmus arised. Through neurologist consultation ACA clinical diagnosis was then made and intravenous steroid therapy was administered with prompt symptoms resolution. The patient was finally discharged at day 10 since the ACA onset in good clinical conditions.Conclusions: To raise awareness among physicians about possible neurological complications during Toscana Virus meningoencephalitis.
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Affiliation(s)
| | - Nicoletta Di Lauria
- Dipartimento di Medicina Sperimentale e Clinica, Università di Firenze, Florence, Italy
| | - Marco Pozzi
- SOD Malattie Infettive e Tropicali, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Pier Giorgio Rogasi
- SOD Malattie Infettive e Tropicali, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Alessandro Barilaro
- Dipartimento NEUROFARBA, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | | | - Elio Prestipino
- Dipartimento NEUROFARBA, Università di Firenze, Florence, Italy
| | - Maria Grazia Colao
- SOD Microbiologia e Virologia, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Gian Maria Rossolini
- Dipartimento di Medicina Sperimentale e Clinica, Università di Firenze, Florence, Italy.,SOD Microbiologia e Virologia, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Alessandro Bartoloni
- Dipartimento di Medicina Sperimentale e Clinica, Università di Firenze, Florence, Italy.,SOD Malattie Infettive e Tropicali, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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Abstract
Acute cerebellar ataxia is the most common cause of acute ataxia in children and it usually runs a self-limiting and ultimately benign clinical course. A small proportion of children have evidence of inflammatory swelling in the cerebellum. Many of these children suffer more severe and potentially life-threatening forms of cerebellar ataxia and may need more intensive treatments including urgent neurosurgical treatments. This more severe form of acute cerebellar ataxia is often termed acute cerebellitis. Many children with acute cerebellitis have long-term neurological sequela and evidence of structural cerebellar changes on follow-up imaging. Several patterns of cerebellar inflammation have been described. The authors describe the variabilities in the clinical and radiological patterns of disease in the cases that have been described in the literature.
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Affiliation(s)
- John Amaechi Emelifeonwu
- 1 Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.,2 Department of Clinical Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK
| | - Jay Shetty
- 2 Department of Clinical Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK
| | | | - Pasquale Gallo
- 2 Department of Clinical Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK
| | - Drahoslav Sokol
- 2 Department of Clinical Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK
| | - Hamza Soleiman
- 1 Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - Jegajothy Kandasamy
- 2 Department of Clinical Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK
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Kawamura R, Nagata E, Mukai M, Ohnuki Y, Matsuzaki T, Ohiwa K, Nakagawa T, Kohno M, Masuda R, Iwazaki M, Takizawa S. Acute Cerebellar Ataxia Induced by Nivolumab. Intern Med 2017; 56:3357-3359. [PMID: 29249765 PMCID: PMC5790727 DOI: 10.2169/internalmedicine.8895-17] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
A 54-year-old woman with adenocarcinoma of the lung and lymph node metastasis experienced nystagmus and cerebellar ataxia 2 weeks after initiating nivolumab therapy. An evaluation for several autoimmune-related antibodies and paraneoplastic syndrome yielded negative results. We eventually diagnosed the patient with nivolumab-induced acute cerebellar ataxia, after excluding other potential conditions. Her ataxic gait and nystagmus resolved shortly after intravenous steroid pulse therapy followed by the administration of decreasing doses of oral steroids. Nivolumab, an immune checkpoint inhibitor, is known to induce various neurological adverse events. However, this is the first report of acute cerebellar ataxia associated with nivolumab treatment.
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Affiliation(s)
- Reina Kawamura
- Department of Neurology, Tokai University School of Medicine, Japan
| | - Eiichiro Nagata
- Department of Neurology, Tokai University School of Medicine, Japan
| | - Masako Mukai
- Department of Neurology, Tokai University School of Medicine, Japan
| | - Yoichi Ohnuki
- Department of Neurology, Tokai University School of Medicine, Japan
| | - Tomohiko Matsuzaki
- Department of Thoracic Surgery, Tokai University School of Medicine, Japan
| | - Kana Ohiwa
- Department of Thoracic Surgery, Tokai University School of Medicine, Japan
| | - Tomoki Nakagawa
- Department of Thoracic Surgery, Tokai University School of Medicine, Japan
| | - Mitsutomo Kohno
- Department of Thoracic Surgery, Tokai University School of Medicine, Japan
| | - Ryota Masuda
- Department of Thoracic Surgery, Tokai University School of Medicine, Japan
| | - Masayuki Iwazaki
- Department of Thoracic Surgery, Tokai University School of Medicine, Japan
| | - Shunya Takizawa
- Department of Neurology, Tokai University School of Medicine, Japan
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