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Kern HM, Waugh JL. Expanding Knowledge of the Causes of Childhood Chorea. Semin Pediatr Neurol 2023; 47:101088. [PMID: 37919039 DOI: 10.1016/j.spen.2023.101088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/21/2023] [Indexed: 11/04/2023]
Abstract
INHERITED AND ACQUIRED CHOREAS Paolo Claudio M. de Gusmao, Jeff L. Waugh Seminars in Pediatric Neurology Volume 25, April 2018, Pages 42-53 Chorea is a symptom of a broad array of genetic, structural, and metabolic disorders. While chorea can result from systemic illness and damage to diverse brain structures, injury to the basal ganglia, especially the putamen or globus pallidus, appears to be a uniting features of these diverse neuropathologies. The timing of onset, rate of progression, and the associated neurological or systemic symptoms can often narrow the differential diagnosis to a few disorders. Recognizing the correct etiology for childhood chorea is critical, as numerous disorders in this category are potentially curable, or are remediable, with early treatment.
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Affiliation(s)
- H M Kern
- Division of Pediatric Neurology, Department of Pediatrics, University of Texas Southwestern, Dallas, TX
| | - J L Waugh
- Division of Pediatric Neurology, Department of Pediatrics, University of Texas Southwestern, Dallas, TX.
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Mytinger JR. Reflections and Updates of Contemporary High-Impact Reviews From Seminars in Pediatric Neurology. Semin Pediatr Neurol 2023; 47:101083. [PMID: 37919032 DOI: 10.1016/j.spen.2023.101083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Affiliation(s)
- John R Mytinger
- Director, Infantile Spasms Program, Nationwide Children's Hospital, Associate Professor, The Ohio State University, Columbus, OH.
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Magalhães T, Melo C, Sampaio M, Correia-Costa A, Sousa R. Hyperkinetic Movement Disorder in a Child. Pediatr Rev 2023; 44:e24-e28. [PMID: 37653135 DOI: 10.1542/pir.2021-005247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Affiliation(s)
- Tiago Magalhães
- Department of Pediatrics
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Cláudia Melo
- Pediatric Neurology Unit, Department of Pediatrics, and
- Faculty of Medicine, University of Porto, Porto, Portugal
| | | | - Ana Correia-Costa
- Department of Pediatric Cardiology, Centro Hospitalar Universitário São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Raquel Sousa
- Pediatric Neurology Unit, Department of Pediatrics, and
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Cincotta MC, Walker RH. Diagnostic Uncertainties: Chorea. Semin Neurol 2023; 43:65-80. [PMID: 36882120 DOI: 10.1055/s-0043-1763506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Chorea is a hyperkinetic movement disorder with a multitude of potential etiologies, both acquired and inherited. Although the differential diagnosis for new-onset chorea is extensive, there are often clues in the history, exam, and basic testing that can help to narrow the options. Evaluation for treatable or reversible causes should take priority, as rapid diagnosis can lead to more favorable outcomes. While Huntington's disease is most common genetic cause of chorea, multiple phenocopies also exist and should be considered if Huntington gene testing is negative. The decision of what additional genetic testing to pursue should be based on both clinical and epidemiological factors. The following review provides an overview of the many possible etiologies as well as a practical approach for a patient presenting with new-onset chorea.
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Affiliation(s)
- Molly C Cincotta
- Department of Neurology, Temple University, Philadelphia, Pennsylvania
| | - Ruth H Walker
- Department of Neurology, James J. Peters Veterans Affairs Medical Center and Mount Sinai School of Medicine, Bronx, New York
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Stimming EF, Bega D. Chorea. Continuum (Minneap Minn) 2022; 28:1379-1408. [DOI: 10.1212/con.0000000000001169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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D'hont A, De Wachter M, Driesen Y, Sabato V, Joos R, Ceulemans B. Successful Rituximab Therapy for Pediatric Antiphospholipid-Related Chorea: A Case Report and Review of the Literature. Neuropediatrics 2022; 53:366-369. [PMID: 35388438 DOI: 10.1055/a-1819-1883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Chorea is considered a nonthrombotic manifestation of the antiphospholipid syndrome, often preceding thrombotic events in children. It can be present in up to 5% of pediatric patients with antiphospholipid syndrome. Immunomodulatory treatment regimens seem to be successful in these patients, emphasizing the underlying immunological etiology. Corticosteroids are considered first-line treatment, but chorea tends to be therapy-resistant and guidelines about second-line therapy in children are solely based on small case studies. We present a case of a therapy-resistant chorea, successfully treated with rituximab. Furthermore, we give an overview of the existing literature concerning rituximab for the treatment of chorea in children. Our findings indicate that rituximab can be considered a safe option to treat antiphospholipid syndrome-related chorea in children.
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Affiliation(s)
- Alexia D'hont
- Department of Pediatrics, ZNA Jan Palfijn, University of Antwerp, Antwerp, Belgium
| | - Matthias De Wachter
- Department of Pediatric Neurology, Pediatrics, Antwerp University Hospital, Antwerp University, Edegem, Belgium
| | - Yentl Driesen
- Department of Pediatrics, ZNA Jan Palfijn, Merksem, Belgium
| | - Vito Sabato
- Department of Immunology, Allergology and Rheumatology, Antwerp University Hospital, Antwerp University, Edegem, Belgium
| | - Rik Joos
- Department of Rheumatology, ZNA Jan Palfijn, Merksem, Belgium
| | - Berten Ceulemans
- Department of Pediatric Neurology, Pediatrics, Antwerp University Hospital, Antwerp University, Edegem, Belgium
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Kim MJ, Yum MS, Seo GH, Ko TS, Lee BH. Phenotypic and Genetic Complexity in Pediatric Movement Disorders. Front Genet 2022; 13:829558. [PMID: 35719373 PMCID: PMC9198294 DOI: 10.3389/fgene.2022.829558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 05/06/2022] [Indexed: 11/13/2022] Open
Abstract
The complex and evolving nature of clinical phenotypes have made genetically diagnosing pediatric patients with movement disorders difficult. Here, we describe this diverse complexity in the clinical and genetic features of a pediatric cohort examined by whole-exome sequencing (WES) and demonstrate the clinical benefit of WES as a diagnostic tool in a pediatric cohort. We evaluated 75 patients with diverse single or combined movement phenomenologies using WES. WES identified 42 variants in 37 genes (56.0%). The detection rate was highest in patients with dystonia (11/13, 84.6%), followed by ataxia (21/38, 55.3%), myoclonus (3/6, 50.0%), unspecified dyskinesia (1/4, 25.0%), tremor (1/1, 100%), respectively. Most genetically diagnosed patients (90.5%) were affected by other neurologic or systemic manifestations; congenital hypotonia (66.7%), and epilepsy (42.9%) were the most common phenotypes. The genetic diagnosis changed the clinical management for five patients (6.7%), including treatments targeting molecular abnormalities, and other systemic surveillance such as cancer screening. Early application of WES yields a high diagnostic rate in pediatric movement disorders, which can overcome the limitations of the traditional phenotype-driven strategies due to the diverse phenotypic and genetic complexity. Additionally, this early genetic diagnosis expands the patient’s clinical spectrum and provides an opportunity for tailored treatment.
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Affiliation(s)
- Min-Jee Kim
- Department of Pediatrics, Asan Medical Center Children’s Hospital, Ulsan University College of Medicine, Seoul, South Korea
| | - Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center Children’s Hospital, Ulsan University College of Medicine, Seoul, South Korea
- *Correspondence: Mi-Sun Yum, ; Beom Hee Lee,
| | | | - Tae-Sung Ko
- Department of Pediatrics, Asan Medical Center Children’s Hospital, Ulsan University College of Medicine, Seoul, South Korea
| | - Beom Hee Lee
- Department of Genetics, Asan Medical Center, Ulsan University College of Medicine, Seoul, South Korea
- *Correspondence: Mi-Sun Yum, ; Beom Hee Lee,
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Xian WB, Zhang XS, Shi XC, Luo GH, Yi C, Pei Z. Corticostriatal Hypermetabolism in Moyamoya Disease-Induced Hemichorea: Two Case Reports and a Literature Review. Front Neurol 2021; 12:649014. [PMID: 34248815 PMCID: PMC8266195 DOI: 10.3389/fneur.2021.649014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 05/26/2021] [Indexed: 12/03/2022] Open
Abstract
Moyamoya disease (MMD) is a rare cause of chorea, and its pathophysiological mechanism remains unclear. We explore the use of cerebral positron emission tomography (PET) to study brain functional connectivity in 2 patients with MMD-induced hemichorea. Abnormal metabolism of brain was analyzed by 18F-fluorodeoxyglucose (18F-FDG) PET images. Dopamine transporters (DAT) PET evaluated the integrity of the cerebral dopamine system. A comprehensive systemic literature search of the PubMed database was also conducted. The 18F-FDG imaging of our patients showed no responsible hypometabolism in affected brain areas, while hypermetabolism in the affected caudate nucleus, putamen and fronto-parietal areas could be seen. DAT PET imaging was normal in patient 1 (a 23-year-old woman), while remarkably reduced DAT binding was seen in the left striatum of patient 2 (a 48-year-old woman). The literature review of 9 publications revealed that 11 patients who underwent single photon emission computed tomography (SPECT) showed cerebral hypoperfusion in the cortex and subcortical area; 18F-FDG PET was performed in 3 cases, which revealed hypermetabolism in the affected striatum in 2 cases. These findings suggest that the striatal and cortical hypermetabolism in the first patient result from underactivity in indirect pathway from basal ganglia-thalamocortical circuits, causing increased activity of excitatory glutamatergic thalamostriatal and thalamocortical projection neurons. The collateral vessels in the basal ganglia might lead to disruption of normal basal ganglia signaling. A dominant left hemisphere with corpus callosal connections to the right basal ganglia resulting into left hemichorea is the most probable explanation for the second patient. We have identified abnormal functional connectivity in basal ganglia-thalamocortical circuits in patients with MMD-induced chorea highlighting the corticostriatal pathway plays an important role in the pathogenesis of MMD-induced chorea.
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Affiliation(s)
- Wen-Biao Xian
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Xiang-Song Zhang
- Department of Nuclear Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xin-Chong Shi
- Department of Nuclear Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Gan-Hua Luo
- Department of Nuclear Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chang Yi
- Department of Nuclear Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhong Pei
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
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Movement disorders in systemic autoimmune diseases: Clinical spectrum, ancillary investigations, pathophysiological considerations. Parkinsonism Relat Disord 2021; 88:116-128. [PMID: 34092506 DOI: 10.1016/j.parkreldis.2021.05.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/09/2021] [Accepted: 05/21/2021] [Indexed: 02/08/2023]
Abstract
With the advances in neuroimmunology especially due to the discovery of new neuronal antibodies, the recognition of treatable antibody-related movement disorders has recently received much attention. In contrast, the identification and characterisation of movement disorders associated with systemic autoimmune diseases remains a substantially unexplored area. Beyond the classic few associations such as chorea and antiphospholipid syndrome, or ataxia and coeliac disease, movement disorders have been reported in association with several systemic autoimmune diseases, however a clear image of clinical phenotypes, investigations, and treatment outcomes in these conditions has never been drawn. In this review, we analyse data from approximately 300 cases and summarise the epidemiological, clinical and diagnostic features of movement disorders associated with systemic autoimmune diseases, and the available knowledge about treatment and outcomes. We highlight that movement disorders in systemic autoimmune conditions are frequently the only or among a few presenting manifestations and are mostly treatable disorders responding to immunotherapy or dietary modifications. We point out the pertinent combination of clinical features and investigations which can suggest the underlying autoimmune nature of these movement disorders, and thus address the most appropriate treatment.
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Jain R, Pandey S, Raghav S. Movement Disorders in Children. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2310-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bertamino M, Signa S, Vagelli G, Caorsi R, Zanetti A, Volpi S, Losurdo G, Amico G, Dodi I, Prato G, Ronchetti AB, Di Rocco M, Nagel M, Severino M. An atypical case of post-varicella stroke in a child presenting with hemichorea followed by late-onset inflammatory focal cerebral arteriopathy. Quant Imaging Med Surg 2021; 11:463-471. [PMID: 33392044 DOI: 10.21037/qims-20-628] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Marta Bertamino
- Rehabilitation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Sara Signa
- Department of Neuroscience, Ophthalmology, Genetics and Maternal Infantile Sciences (DINOGMI), University of Genoa, Genoa, Italy.,Autoinflammatory Diseases and Immunodeficiencies Center, IRCCS Istituto Gianina Gaslini, Genoa, Italy
| | - Giulia Vagelli
- Department of Neuroscience, Ophthalmology, Genetics and Maternal Infantile Sciences (DINOGMI), University of Genoa, Genoa, Italy
| | - Roberta Caorsi
- Autoinflammatory Diseases and Immunodeficiencies Center, IRCCS Istituto Gianina Gaslini, Genoa, Italy
| | - Alice Zanetti
- Rehabilitation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Stefano Volpi
- Department of Neuroscience, Ophthalmology, Genetics and Maternal Infantile Sciences (DINOGMI), University of Genoa, Genoa, Italy.,Autoinflammatory Diseases and Immunodeficiencies Center, IRCCS Istituto Gianina Gaslini, Genoa, Italy
| | - Giuseppe Losurdo
- Infectious Diseases Unit, IRCCS Istituto Gianina Gaslini, Genoa, Italy
| | - Giulia Amico
- Department of Neuroscience, Ophthalmology, Genetics and Maternal Infantile Sciences (DINOGMI), University of Genoa, Genoa, Italy.,Laboratory of Genetic and Genomics of Rare Disease, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Icilio Dodi
- Emergency Unit, Pietro Barilla Children Hospital, Parma, Italy
| | - Giulia Prato
- Child Neuropsychiatry Unit, IRCCS Istituto Gianina Gaslini, Genoa, Italy
| | | | - Maja Di Rocco
- Rare Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Maria Nagel
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
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Abstract
Chorea is a movement disorder characterized by ongoing random-appearing sequences of discrete involuntary movements or movement fragments. Chorea results from dysfunction of the complex neuronal networks that interconnect the basal ganglia, thalamus, and related frontal lobe cortical areas. The complexity of basal ganglia circuitry and vulnerability of those circuits to injury explains why chorea results from a wide variety of conditions. Because etiology-specific treatments or effective symptomatic treatments are available for causes of chorea, defining the underlying disease is important. The treatment of chorea can be considered in three main categories: (1) terminating or modifying exposure to the causative agent, (2) symptomatic treatment of chorea, and (3) treatment targeting the underlying etiology. Symptomatic treatment decision of chorea should be based on the functional impact on the child caused by chorea itself. There have been no reported randomized, placebo-controlled trials of symptomatic treatment for chorea in childhood. Thus the recommendations are based on clinical experience, case reports, expert opinions, and small comparative studies. Better knowledge of mechanisms underlying childhood chorea will provide more etiology-based treatments in the future.
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Abstract
PURPOSE OF REVIEW This article provides an overview of the clinical features and disorders associated with movement disorders in childhood. This article discusses movement disorder phenomena and their clinical presentation in infants and children and presents a diagnostic approach to suspected genetic disorders with a focus on treatable conditions. RECENT FINDINGS Technologic advances in molecular genetic testing over the past decade continue to lead to the discovery of new diseases. This article discusses the clinical presentation and early experience with treatment for several recently described genetic forms of infantile-onset and childhood-onset dystonia and chorea. SUMMARY The clinical spectrum of pediatric movement disorders is broad and heterogeneous, ranging from acute or transient self-limited conditions to conditions that cause profound lifelong motor disability. Most movement disorders in childhood are chronic, and the large number of rare, genetic conditions associated with pediatric movement disorders can pose a significant diagnostic challenge. Recognition of distinctive diagnostic clues in the history and examination can facilitate the diagnosis of potentially treatable disorders.
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