Opsoclonus-ataxia due to childhood neural crest tumors: a chronic neurologic syndrome

Ophthalmologic Manifestations of Neuroblastoma: A Systemic Review

Neuroblastoma (NBL) is the most common extracranial solid tumor found in pediatric patients. It develops from the sympathetic tract tissue. Although the symptoms are associated with tumor localization, sometimes NBL is manifested as ophthalmologic disorders. In this paper, we describe their incidence and the correlation with the prognosis. We searched 2 databases (PubMed and Web of Science) for papers published before April 2022, and concerned pediatric patients with NBL, which caused ophthalmologic changes. We collected 7 papers assessing the occurrence of ophthalmologic findings in the NBL patients, as well as 68 case reports presenting children with orbital changes and NBL, or with other tumors stemming from the sympathetic ganglia. The statistical analysis was performed to synthetize the data. The ophthalmologic signs occurred in 17.89% of the NBL cases; however, they were observed on presentation in 10.68%. The isolated ocular presentation was found in 2.56% of patients, whereas Horner syndrome was most frequent. The ophthalmologic symptoms correlated with patients' age, primary tumor site, and survival rate. NBL may be challenging to diagnose in cases with isolated ophthalmologic manifestations. Numerous possible ocular signs can be observed, which emphasize the need for multidisciplinary care with regard to the NBL patients.

Clinical Analysis of Pediatric Opsoclonus-Myoclonus Syndrome in One of the National Children's Medical Center in China

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.

Paraneoplastic movement disorders

Paraneoplastic movement disorders are rare, autoimmune-mediated, nonmetastatic complications of malignant neoplasms. Common paraneoplastic movement disorders include paraneoplastic chorea, dystonia, cerebellar degeneration, different types of encephalitis, opsoclonus-myoclonus syndrome, stiff person syndrome, and neuromyotonia. Syndromes usually develop before tumor diagnosis, have subacute onset, and are associated with serum or cerebrospinal fluid antibodies. Two types of antibodies can be distinguished: antibodies against nuclear and cytoplasmic neuronal antigens (anti-Hu, anti-Ri, anti-Yo, anti-Ma, anti-CV2/CRMP5, anti-Gephrin, and anti-GABATRAP) and antibodies recently identified against cell surface and synaptic proteins (anti-NMDAR, anti-LGI1, and anti-Caspr2). These two types differ from each other in a few important aspects. Antibodies against cell surface and synaptic protein disrupt cell-surface antigens. Clinical symptoms are related to the disruption of antigens and potentially can be reversed by immunotherapy. The association between these antibodies and malignancy is much less consistent. On the other hand, antibodies against nuclear and cytoplasmic neuronal antigens seem to be not pathogenic; however, they most likely indicate a T-cell-mediated immune response against neurons. Due to T-cell-mediated neuronal loss, response to immunotherapy is generally disappointing. Early recognition of all these diseases is crucial because it may lead to the disclosure of occult cancer. This review is focused on paraneoplastic movement disorders with emphasis on clinical presentations, investigational findings, and therapeutic results.

Cancer and Autoimmunity: Paraneoplastic Neurological Disorders Associated With Neuroblastic Tumors

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.

Neuroepidemiologic Trends in 105 US Cases of Pediatric Opsoclonus-Myoclonus Syndrome

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.

Update on diagnosis, treatment, and prognosis in opsoclonus-myoclonus-ataxia syndrome

PURPOSE OF REVIEW

Opsoclonus-myoclonus-ataxia syndrome (OMS) is a severe autoimmune central nervous system disorder, which predominantly affects young children and causes lifelong neurological disability. Early recognition and treatment may yield better outcomes.

RECENT FINDINGS

Appreciation of the spectrum of clinical presentations of OMS, awareness of common misdiagnoses, and utilization of diagnostic criteria may facilitate the timely diagnosis of OMS. Approximately 50% of patients have an associated neuroblastoma, which may escape detection by traditional methods and require MRI or computed tomography of the torso for diagnosis. In nonparaneoplastic cases, many associated infections have been reported. Although there has been progress in autoantibody identification and cerebrospinal fluid B cell expansion is a common finding, there is no diagnostic biomarker for OMS currently. Approximately 80% of reported patients, typically treated with conventional therapies such as adrenocorticotropin hormone, corticosteroids, and/or intravenous immunoglobulin, develop long-term neurological morbidity. Newer treatment approaches using early, aggressive therapy with cyclophosphamide or rituximab are promising.

SUMMARY

The diagnosis of OMS requires a high level of suspicion and a systematic approach for diagnostic testing, particularly for neuroblastoma. Future collaborative studies are required to determine whether early, aggressive therapy will improve the typically poor long-term neurological outcome.

Opsoclonus-myoclonus syndrome attributable to hepatitis C infection

Opsoclonus-myoclonus syndrome is a rare neurologic disorder characterized by multidirectional chaotic eye movements, myoclonus in the limbs, and ataxia. We present a 9-year-old boy with opsoclonus-myoclonus syndrome associated with hepatitis C infection. To the best of our knowledge, this is the first report of opsoclonus-myoclonus syndrome associated with hepatitis C infection.

Improvement of neurological status and quality of life in children with opsoclonus myoclonus syndrome at long-term follow-up

BACKGROUND

Kinsbourne syndrome or opsoclonus myoclonus syndrome (OMS) is characterized by rapid, involuntary, irregular conjugate eye movements (opsoclonus), myoclonic jerking of the limbs and trunk, ataxia, and behavioral disturbances. In general, the outcome of neurologic and behavioral symptoms is poor. Studies on quality of life (Qol) and recovery after very long-term follow-up of children with OMS are lacking.

METHODS

We studied long-term cancer survival, neurologic recovery, and Qol of a consecutive series of eight patients with OMS that were treated in our center. Two cross-sectional follow-up evaluations were conducted at a 3-year interval (T1 and T2).

RESULTS

In four out of eight children with OMS a neuroblastoma (NBL) was diagnosed and surgically removed completely. All children received immuno-modulatory therapy, consisting of prednisone (three children), prednisone and ACTH (four children), or prednisone, ACTH, and gammaglobulin (one child). At T1, median follow-up time was 9.5 years (range 3-14 years) after OMS onset and at T2, 11.6 years (range 6-17 years). Neurologic functioning improved in all children, reflected by a significant improvement of the mean Z-score in the motor domain of the Qol questionnaire at T2 as compared to T1. In contrast, seven children continued to have a severe developmental delay at T2. No significant difference in any of the variables was found between NBL survivors and OMS patients without NBL.

CONCLUSION

Cognitive and behavioral impairments and not a motor impairment, such as ataxia, appear to be predominant at long-term in children with OMS.

MR imaging of neuroblastic masses

Neuroblastoma is one of the most common non-central nervous system solid tumors in children. Imaging plays a role in the evaluation of the primary tumor and regional and distant disease. This article reviews the biologic, clinical, and MR imaging features of this tumor.

Chronic relapsing opsoclonus-myoclonus syndrome: combination of cyclophosphamide and dexamethasone pulses

Opsoclonus-myoclonus syndrome (OMS) is a rare and debilitating disorder of unknown etiology affecting children and adults. Outcome is unfavourable; approximately 80% of children with OMS suffer from mild to severe neurological handicaps, mainly cognitive impairment. A standard therapy does not exist. Due to the possible immune-mediated mechanisms, treatment with steroids, ACTH, plasmapheresis and immunoglobulins can be successful. However, some children become steroid dependent and symptoms may reoccur after treatment has been finished. We present two girls with OMS, who had a prolonged clinical course lasting 4 and 9 years with many relapses. Both children developed symptoms around the age of two years. Diagnostic work-up to exclude neuroblastoma was negative. Several treatment modalities including oral steroids, dexamethasone pulses, immunoglobulin and cyclosporine were used without lasting success. In addition, cognitive impairment developed in both children. In order to prevent further clinical and mental deterioration, 6 pulses of cyclophosphamide in combination with dexamethasone pulses every 4 weeks were administered. Both children showed significant improvement of OMS symptoms. One girl is still symptom free 18 months after treatment, mild ataxia developed in the other after 12 months. Both children are mentally handicapped and in special need schools. We conclude that combination of cyclophosphamide pulses and dexamethasone pulse therapy is a therapeutic option even after a long clinical course to improve symptoms of OMS.

Neuroblastoma and other neuroendocrine tumors

Neuroblastoma is the most common extracranial solid tumor of childhood. It commonly presents in children younger than 2 years of age, with 90% being younger than 5 years of age. There is marked variability in clinical behavior ranging from spontaneous regression or differentiation into benign tumors to rapid and progressive fatal disease. Approximately 50% of patients will have metastases at presentation. The management is dependent on age, stage of disease, and biological and biochemical markers. Nuclear medicine plays an important role in the initial staging, as a prognostic indicator, for assessment of response to treatment, and also in therapy. The most common nuclear medicine diagnostic studies are (99m)Tc-disphosphonate bone scintigraphy and (123)I-MIBG (metaiodobenzylguanidine) scintigraphy. Bone scintigraphy has been the main investigational modality to diagnose skeletal metastases. Whole body imaging with (123)I-MIBG has become the preferred diagnostic test because this agent accumulates in neuroblastoma in 90% to 95% of cases and will accumulate in the primary tumor and metastases particularly in bone, bone marrow, lymph nodes, and soft tissues. MIBG can be used to assess therapy response and is a significant prognostic indicator. Other diagnostic techniques include positron emission tomography (PET)/computed tomography, mainly using (18)F-fluorodeoxyglucose. Other more experimental PET agents, as well as radiolabeled antibodies and octreotide, also are being investigated. Therapy has mainly focused on palliation and has been used alone or in combination with chemotherapy in high-risk refractory or relapsed patients. Major attention is being placed on stratification of patients to try and reduce the side effects associated with intensive megatherapy in the low to intermediate risk patients. Neuroendocrine tumors (NETs) are rare in childhood, but nuclear medicine techniques, mainly using MIBG and somatostatin receptor agents, have a role in diagnosis, staging, and a limited role in therapy. Newer radiopharmaceuticals, including PET agents, are being evaluated for the assessment of NET. Nuclear medicine techniques play a major role in the management of neuroblastoma and NET.

An update on opsoclonus

PURPOSE OF REVIEW

The aim of this article is to review opsoclonus, with particular emphasis on its immunopathogenesis and pathophysiology.

RECENT FINDINGS

Infections (West Nile virus, Lyme disease), neoplasms (non-Hodgkin's lymphoma, renal adenocarcinoma), celiac disease, and allogeneic hematopoietic stem cell transplantation can cause opsoclonus. Newly identified autoantibodies include antineuroleukin, antigliadin, antiendomysial, and anti-CV2. Evidence suggests that the autoantigens of opsoclonus reside in postsynaptic density, or on the cell surface of neurons or neuroblastoma cells (where they exert antiproliferative and proapoptotic effects). Most patients, however, are seronegative for autoantibodies. Cell-mediated immunity may also play a role, with B and T-cell recruitment in the cerebrospinal fluid linked to neurological signs. Rituximab, an anti-CD20 monoclonal antibody, seems efficacious as an adjunctive therapy. Although changes in synaptic weighting of saccadic burst neuron circuits in the brainstem have been implicated, disinhibition of the fastigial nucleus in the cerebellum, or damage to afferent projections to the fastigial nucleus, is a more plausible pathophysiologic mechanism which is supported by functional magnetic resonance imaging findings in patients.

SUMMARY

There is increasing recognition that both humoral and cell mediated immune mechanisms are involved in the pathogenesis of opsoclonus. Further studies are needed to further elucidate its immunopathogenesis and pathophysiology in order to develop novel and efficacious therapy.

The role of simple emotion recognition skills among school aged boys at risk of ADHD

Poor social skills and behavioral problems are a major component of ADHD. The different explanations offered so far, such as cognitive deficits and deficient self regulation, have not been able fully to account for the various aspects of the social dysfunction, suggesting that other mechanisms might underlay this impairment. Our study sought to assess the emotion recognition of Israeli boys at risk of ADHD, and to evaluate its associations with their social skills. A group of 111 boys (grades 4 and 5) were assigned to an At-risk (n=50) and a control (n=61) group based on their scores in an ADHD symptoms questionnaire. The two groups were matched on age, socio-economic status and class and school environment. Group comparisons revealed that compared to their non-At-risk counterparts, At-risk boys have impaired emotion recognition. Finally, multiple groups Structural Equation Modeling analyses (SEM) demonstrated that emotion misrecognition plays a significant role in the At-risk children's social functioning and behavioral problems compared to its role in the social competence and behavioral problems among the comparison group. Implications for the understanding and treatment of social skills problems among children at risk of ADHD are proposed.

Delayed, recurrent opsoclonus-myoclonus syndrome responding to plasmapheresis

Opsoclonus-myoclonus syndrome is a distinct neurologic disorder characterized by opsoclonic eye movements, multifocal myoclonus, and ataxia, traditionally described as "dancing eyes, dancing feet." A presenting sign in 2% of children with neuroblastoma, it usually heralds a favorable prognosis for the tumor. Although opsoclonus-myoclonus syndrome usually presents at initial diagnosis or relapse, there are reports of delayed presentation, usually a few months after diagnosis. This report describes a patient with ganglioneuroblastoma who developed recurrent symptoms of opsoclonus-myoclonus syndrome 9 years after completing treatment, without evidence of recurrent tumor. Believed to be autoimmune in origin, opsoclonus-myoclonus syndrome frequently responds to immunomodulatory therapies, such as steroids or intravenous immunoglobulin. This patient did not respond adequately to either agent, so plasmapheresis, a less commonly used modality in opsoclonus-myoclonus syndrome, was attempted. His symptoms resolved after he received therapy with a combination of plasmapheresis and steroids over a 1-year period. After being slowly weaned off all therapy, he has been symptom-free now for over 3 years. Armstrong MB, Robertson PL, Castle VP. Delayed, recurrent opsoclonus-myoclonus syndrome responding to plasmapheresis.

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.

Benign opsoclonus in preterm infants

Opsoclonus is a rare childhood ocular motility disorder characterized by irregular, chaotic, involuntary bursts of high amplitude, back-and-forth oscillations of the eyes,without pause intervals. Although this disorder is associated with neuroblastoma and other neural crest tumors, as well as with other neurologic abnormalities, it was also reported in healthy infants. The purpose of this study was to prospectively investigate the prevalence of opsoclonus in preterm infants, and to find any conditions associated with this disorder. Between August 2000 and April 2003, 528 consecutive preterm infants with gestation of less than 33 weeks or birth weight of less than 1500 gm were examined in accordance with our medical centers' retinopathy of prematurity screening policy. Opsoclonus was identified in three patients (0.6%), who were all otherwise physically and neurologically intact. One patient developed threshold retinopathy of prematurity that resolved after laser treatment. On follow-up examinations, the opsoclonus gradually disappeared by the age of 6 months in all infants,with no other complications. This study suggests that opsoclonus can be a benign, self-limiting phenomenon in preterm infants as was previously reported in term infants. However, because of the risk of severe associated illnesses, it is prudent to perform several diagnostic procedures and to continue careful follow-up until this phenomenon spontaneously resolves.

Neuroblastoma: an unusual presentation with bilateral ptosis

Neuroblastoma, a common tumor of neural crest origin, demonstrates an extremely variable clinical presentation and behavior. Paraspinal tumors may occur anywhere along the spinal column where they may invade the intervertebral foramina and produce cord compression. Cervical involvement may produce Horner's syndrome. Opsoclonus-myoclonus syndrome is also a well-known neuroimmunologic finding of neuroblastoma. We report a 28-month-old female presenting with ptosis and muscle weakness, diagnosed as having a neuroblastoma.

Acute ataxia in childhood

Acute childhood ataxia is a common cause of presentation to the pediatric emergency room or child neurologist. The primary concern on initial assessment is to exclude serious causes of this clinical syndrome, including central nervous system infections and mass lesions, while recognizing the essentially benign nature of acute ataxia in most children. Childhood ataxia can be diagnostically approached by consideration of the temporal course and presence or absence of associated neurologic abnormalities. In all forms of childhood ataxia, outcome is largely determined by etiology. In this review, the various causes and syndromes of acute ataxia in childhood are described, with discussion of diagnostic considerations and an approach to investigation, treatment, and prognosis.

Current Therapies for Paraneoplastic Neurologic Syndromes

Paraneoplastic neurologic syndromes (PNS) comprise an extensive group of heterogeneous disorders that can affect any part of the central and peripheral nervous system. There is evidence that many of these disorders are mediated by immunologic responses triggered by the presence of a cancer. Several immunologic mechanisms and many antigenic targets have been related to these disorders. Some disorders of the neuromuscular junction or peripheral nervous system are directly mediated by antibodies, and they may have a paraneoplastic origin or develop without a tumor association. For these disorders and a few PNS of the central nervous system, immunotherapy may result in neurologic improvement. However, for most PNS of the peripheral and central nervous system the response to any type of therapy is, in general, disappointing. The main concern of the clinician should be to rule out other diagnostic entities and to uncover the presence of the associated neoplasm that often remains elusive to detection. In general, the best approach to treat PNS is to discover and treat the tumor promptly, and provide supportive care for the neurologic deficits with symptomatic treatment and physical therapy. In a few cases, depending on the syndrome and if the patient is in the early stages of the neurologic disease, treatment with immunosuppression may have some effect on the PNS.

Forty-one year follow-up of childhood-onset opsoclonus-myoclonus-ataxia: cerebellar atrophy, multiphasic relapses, and response to IVIG

We report on an adult with opsoclonus-myoclonus-ataxia syndrome experiencing widely spaced neurological relapses, who was followed for 41 years. His responses to treatment are described.

Opsoclonus Myoclonus Syndrome A Case Report of Two Patients and Review of the Literature

Opsoclonus myoclonus syndrome (OMS) is a very rare syndrome which presents with ataxia, opsoclonus and myoclonus. We report the combined treatment of immunoglobulins and prednisolone compared to prednisolone alone in two patients. The diagnosis was based on the clinical findings. Work up for neuroblastoma was negative in both patients. Prednisolone treatment in the first patient was associated with slow response, relapses and toxic side effects. Immunoglobulins combined with prednisolone in the second patient were effective with neither relapse nor drug side effect. The clinical findings, differential diagnosis and the management are discussed. It appears that combined therapy with prednisolone and immunoglobulin gives better results. To the best of our knowledge this is first paper from the Middle East reporting this syndrome.

Remote neurologic manifestations of cancer

Paraneoplastic disorders may affect any part of the central or peripheral nervous systems. Although relatively uncommon, these disorders are a significant cause of neurologic morbidity for cancer patients. At least some paraneoplastic syndromes are believed to be caused by an autoimmune reaction against shared tumor-neural antigens. This article summarizes the clinical features of paraneoplastic disorders, the current evidence for autoimmunity, and guidelines for diagnosis and treatment.

Long-term neurobehavioral outcomes in children with neuroblastoma and opsoclonus-myoclonus-ataxia syndrome: relationship to MRI findings and anti-neuronal antibodies

OBJECTIVES

Opsoclonus-myoclonus-ataxia (OMA) syndrome affects 2% to 3% of patients with neuroblastoma. This study examined relationships between long-term neurobehavioral outcomes and potential biologic markers of OMA, including chronic changes on magnetic resonance imaging (MRI) brain scanning and prevalence of late antineuronal antibodies.

STUDY DESIGN

Children with neuroblastoma and OMA were identified through medical record review of patients treated at the University of California at San Francisco Medical Center from 1979 to 1999. Eleven patients with a mean follow-up time of 7.6 years underwent standard neurologic, neurocognitive, developmental/behavioral, and academic assessments. Consenting patients underwent MRI brain scanning and a blood draw. Sera were analyzed for the presence of antineuronal immunoreactivity.

RESULTS

Two (18%) patients had no observed neurologic abnormalities, 7 (64%) demonstrated mild deficits, and 2 (18%) had severe neurologic deficits. However, on neurocognitive, behavioral, and academic assessments, 6 (55%) children performed within the average range, 1 (9%) was moderately below average and 4 (36%) had severe cognitive and behavioral deficiencies. Brain MRI in 5 of 5 patients was notable for cerebellar atrophy without supratentorial involvement. Antineuronal activity was detected in sera of 0 of 10 children at follow-up.

CONCLUSIONS

Certain patients with neuroblastoma associated OMA may achieve average-range neurobehavioral function in spite of residual neurologic abnormalities, with suggestion of continued improvement over time. Late cerebellar atrophy appears to be a common finding regardless of neurologic outcome, whereas antineuronal immune reactivity does not appear to be a long-term feature of OMA.

Opsoclonus-myoclonus-ataxia syndrome in neuroblastoma: clinical outcome and antineuronal antibodies-a report from the Children's Cancer Group Study

BACKGROUND

Opsoclonus-myoclonus-ataxia (OMA) is a paraneoplastic neurologic syndrome affecting 2-3% of children with neuroblastoma. Although children with OMA and neuroblastoma may have higher survival, many experience a significant amount of late neurologic impairment, which may be immunologically mediated. The aim of this study was to compare the outcome of neuroblastoma patients with and without OMA, relating to prognostic factors, treatment, and the presence or absence of anti-neuronal antibodies.

PROCEDURE

Questionnaires were mailed out requesting information on the current neurologic status of patients who submitted sera at diagnosis to the Children's Cancer Group serum bank from 1980 to 1994. Information was requested on clinical and biological patient characteristics as well as clinical aspects of the patients identified as having OMA syndrome, including presentation and treatment for OMA, late sequelae of OMA, the presence or absence of antineuronal antibodies, and survival. Sera from 16 of the OMA patients and 48 case-controls with neuroblastoma were assayed for anti-neuronal antibodies.

RESULTS

Of the 675 responses received, 21 patients had OMA. Ninety percent of OMA patients presented with non-metastatic disease, vs. 35% of non-OMA patients. Estimated 3-year survival for the OMA patients with nonmetastatic disease (stage I, II, III) greater than 1 year of age was 100% vs. 77% for similar non-OMA patients (P = 0.0222). At follow-up, 14/19 evaluable OMA patients displayed some form of developmental or neurologic abnormality. There was no significant correlation of late sequelae with antineuronal antibodies, age, time between OMA symptoms and diagnosis, or treatment given for tumor or OMA. There was a significant correlation of late sequelae with lower stage disease (I and II) compared to more advanced disease (III and IV).

CONCLUSIONS

Patients with OMA and neuroblastoma have excellent survival but a high risk of neurologic sequelae. Favorable disease stage correlates with a higher risk for development of neurologic sequelae. The role of anti-neuronal antibodies in late sequelae of OMA needs further clarification.

Post-vaccinic opsoclonus-myoclonus syndrome: a case report

The opsoclonus-myoclonus syndrome is a pathological condition characterized mainly by involuntary myoclonic movements involving ocular, trunk and limb muscles associated with ataxia and other neurological signs.We describe the case of a 30-year-old woman who developed this syndrome 15days after anti-Rubella vaccination. This case suggests a possible autoimmune post-vaccinic etiopathogenesis of opsoclonus-myoclonus syndrome, rarely described in the literature.

Neuroblastoma

Neuroblastoma is a malignant tumor of neural crest origin that may arise anywhere along the sympathetic ganglia or within the adrenal medulla. The median age of diagnosis is 2 years; however occurrence is skewed toward younger children, with nearly 35% of cases occurring under 1 year of age and the remainder under 10 years of age. Seventy-five percent of neuroblastomas originate within the abdomen or pelvis, and half of these occur within the adrenal medulla, whereas 20% originate within the posterior mediastinum and 5% within the neck.

[Opsoclonus-myoclonus syndrome associated with non-metastatic neuroblastoma. Long-term survival. Study of the French Society of Pediatric Oncologists]

Opsoclonus-myoclonus is a rare syndrome characterized by multidirectional chaotic eye movements, myoclonus and ataxia. In children, it could be a paraneoplastic syndrome in association with neuroblastoma, usually with a high survival rate, but having a high frequency of neurologic and psychologic sequelae.

OBJECTIVES

The aim of this study was to describe oncologic outcome (prospectively) and neurologic outcome (retrospectively) in children with non-metastatic neuroblastoma, and to determine its best treatment.

PATIENTS AND METHODS

Data were collected on 21 children diagnosed with localized neuroblastoma and opsoclonus-myoclonus between 1990-1999 from the French Society of Pediatric Oncology institutions.

RESULTS

Median age at diagnosis was 18 months. Location of the tumor was abdominal in 14 cases, thoracic in three cases, pelvic in three cases, and cervical in the last case. There was a majority of small tumors with a maximal diameter < 5 cm in 13 cases. Only four tumors were initially considered as unresectable tumors and received first-line chemotherapy. Complete macroscopic resection was performed in 20 cases (four after primary chemotherapy). Nine children received chemotherapy. Twenty children remained in first complete remission, and one relapsed and died (the unique NMYC amplified case). Treatment for opsoclonus-myoclonus varied widely. Only one child received no medical treatment for opsoclonus-myoclonus, because of complete resolution of neurologic symptoms after exclusive surgery. The following agents were used: corticosteroids in 18 cases, intravenously immune globulin in five cases, and antiepileptic drugs in seven cases. Ten patients experienced relapses of opsoclonus-myoclonus symptoms, mainly related to the decrease of steroid therapy (5/10). Ten of 16 assessable children had persistent neurologic deficits including speech delay or cognitive deficits (8/16), ataxia (6/16), motor delay (2/16), and behavioral problems (2/16). There is no correlation between neurologic outcome, and either age at diagnosis or duration of neurologic symptoms, or type of treatment of the tumor, particularly chemotherapy.

CONCLUSION

Persistent neurologic deficits are characteristic for children with neuroblastoma and opsoclonus-myoclonus. Neurologic outcome seems unrelated to the treatment of neuroblastoma, which should exclusively be conducted according to oncological criteria. The treatment of opsoclonus-myoclonus should be standardized, mainly based on high-dose hydrocortisone, with a very low decreasing dosage, associated to intravenously immune globulin in severe cases. A biological immunologic work-up of the disease and cautious neurologic and psychologic standardized follow-up should be performed.

Paraneoplastic Diseases of the Nervous System

Several neurologic paraneoplastic disorders are believed to be caused by an autoimmune reaction against an antigen or antigens coexpressed by tumor cells and neurons. Of the paraneoplastic syndromes, the Lambert-Eaton myasthenic syndrome (LEMS)--in which autoantibodies downregulate voltage-gated calcium channels at the presynaptic nerve terminal--is associated with the strongest evidence of an autoimmune cause. For the other syndromes, including cerebellar degeneration, multifocal encephalomyelitis, sensory neuronopathy, limbic encephalitis, opsoclonus-myoclonus, and retinal degeneration, an autoimmune cause is indicated by the presence of specific anti-neuronal antibodies. These antibodies serve as a useful diagnostic tool, but their actual role in causing neuronal injury and clinical disease remains unclear. A small percentage of patients with paraneoplastic disorders shows major neurologic improvement after successful treatment of the associated tumor. Of patients who require further therapy for the neurologic disorder, those with LEMS have the best outcome. The response to immunosuppression among patients with paraneoplastic central nervous system (CNS) dysfunction is much less favorable. Although exceptions clearly exist, most patients with CNS paraneoplastic disorders do not improve despite tumor treatment and immunosuppressive therapy. It is likely that many patients already have irreversible neuronal injury at the time of diagnosis. The decision to attempt immunosuppressive treatment must be made on an individual basis.

Current aspects of biology, risk assessment, and treatment of neuroblastoma

Neuroblastoma is one of the most intensely studied solid malignancies that affect the pediatric age groups; its clinical presentation, treatment strategies and ultimate prognosis vary greatly. The biologic and genetic character of each tumor has an important impact on disease behavior, and clinical staging now incorporates these factors to generate an overall therapy plan. The clinical presentation of neuroblastoma is related to primary tumor location, production of metabolically active substances, and the presence of metastatic disease. There are also prognostically important associated syndromes including opsoclonus-myoclonus, Horner's syndrome, neurofibromatosis, and a variety of other neurocristopathies. The histologic features of the tumor are of prognostic significance and are utilized in treatment stratification. The International Neuroblastoma Staging System (INSS) has unified classic clinical staging. Features at diagnosis and those determined by initial operation are combined with biologic prognostic factors to achieve risk group assignment for virtually all patients. There are groups of children in which limited therapy is curative and intermediate-risk situations where standard multimodality treatment provides favorable outcomes. Unfortunately, there are many patients with high-risk disease that require intensive strategies, but success is still limited. It is in these most resistant patients that innovative approaches are being undertaken and novel strategies are being investigated.

Dancing eye syndrome and hyperphosphatasemia

An 11-month-old boy with a relapsing dancing eye syndrome associated with elevation of serum alkaline phosphatase, lactate dehydrogenase, and aminotransferase activities is reported. During two clinical episodes the serum alkaline phosphatase activity increased up to four times the upper reference limit, remained elevated for a few weeks and normalized gradually in parallel with clinical improvement under steroid therapy. We found no evidence of liver or bone pathology nor of a neural crest tumor. The association between dancing eye syndrome and hyperphosphatasemia has not yet been described. The beneficial effect of the steroid therapy strengthens the hypothesis of an autoimmune origin.

Neurologic paraneoplastic syndromes

Several neurologic paraneoplastic disorders are believed to be caused by an autoimmune reaction against antigen(s) co-expressed by tumour cells and neurons. Of the paraneoplastic syndromes, the evidence for an autoimmune etiology is strongest for the Lambert-Eaton myasthenic syndrome, in which autoantibodies downregulate voltage-gated calcium channels at the presynaptic nerve terminal. For other syndromes, including cerebellar degeneration, multifocal encephalomyelitis, sensory neuronopathy, limbic encephalitis, opsoclonus-myoclonus, stiff person syndrome, and retinal degeneration, the autoimmune theory is supported by the presence of specific antineuronal antibodies. These antibodies serve as a useful diagnostic tool, but their actual role in causing neuronal injury and clinical disease remains unclear. Further understanding of immunopathogenesis awaits successful experimental models. Among different syndromes, a varied proportion of patients shows neurologic improvement with immunosuppressive treatments; it is likely that many patients have already suffered irreversible neuronal injury at the time of diagnosis.

Long-term neurologic outcome in children with opsoclonus-myoclonus associated with neuroblastoma: a report from the Pediatric Oncology Group

A retrospective data collection was performed on 29 children diagnosed with neuroblastoma and opsoclonus-myoclonus between 1983-1993 from Pediatric Oncology Group institutions. The aim was to describe neurologic outcome in children with neuroblastoma and opsoclonus-myoclonus. Age at diagnosis ranged from one month to 4 years (median age, 18 months). The duration of opsoclonus-myoclonus symptoms prior to the diagnosis of neuroblastoma ranged from 6 days to 17 months (median duration, 6 weeks). There was a prevalence of low stage disease according to the POG staging system: stage A (n = 18), stage B (n = 3), stage C (n = 7), stage D (n = 1). There was a predominance of paraspinal primary tumors. There was no case of Nmyc amplification (0/17), and 2/8 cases were diploid. Treatment for neuroblastoma consisted of surgery alone in 19/29 (18 stage A, 1 stage C in thorax), and surgery plus chemotherapy in 10/ 29. No patient received radiotherapy. Treatment for opsoclonus-myoclonus ranged varied. Six children received no treatment for opsoclonus-myoclonus. The following agents were used ACTH (n = 14), prednisone (n = 12), IV IgG (n = 6), immuran (n = 2), depakote (n = 1), and inderal (n = 1). Eighteen of 29 children (62%) had resolution of opsoclonus-myoclonus symptoms. The range of time for recovery was a few days to 3 years. However the majority recovered over several months. Twenty of 29 children (69%) had persistent neurologic deficits including speech delay, cognitive deficits, motor delay, and behavioral problems. Of the 9 children who had complete recovery of opsoclonus-myoclonus without neurologic sequelae, age at diagnosis and duration of symptoms were not different from the entire group. Interestingly, 6/9 children with complete recovery received chemotherapy as part of their treatment. In conclusion, persistent neurologic deficits are characteristic for children with neuroblastoma and opsoclonus-myoclonus. Treatment with chemotherapy may improve the neurologic outcome.

Neuroblastoma-associated paraneoplastic syndrome with anti-Hu antineuronal antibodies presenting at the time of recurrence

A 27-month-old girl presented with chest pain. Further evaluation confirmed posterior mediastinal neuroblastoma with bone marrow infiltration, which was treated with a combination of chemotherapy and surgery. Four months after completing treatment, she presented with myoclonus and weakness of her right arm. The myoclonus eventually subsided but her right arm weakness progressed to a right hemiplegia. High titers of antineuronal nuclear antibodies identified as anti-Hu were found in both serum and cerebrospinal fluid. One month later she presented with a relapse of her original tumor, from which she died. Identification of anti-Hu antineuronal nuclear antibodies in this neuroblastoma-associated paraneoplastic syndrome supports the hypothesis that the syndrome is due to autoimmune disease.

Neurological sequelae of the dancing eye syndrome

Fifty-four patients with dancing eye syndrome (DES), presenting over a 25-year period, were reviewed retrospectively. One third of them were on active follow up at the time of the study. Malignancy was uncommon, diagnosed in only 4 patients, neuroblastoma in 3 cases and acute lymphoblastic leukaemia (ALL) in 1. An intercurrent illness preceded onset of DES in 51% of the children and was of equivocal significance. There was no clear temporal relationship to immunization. The acute phase of the illness was severe and caused total immobilization in 88% of patients. A favourable initial response to treatment with prednisolone or corticotrophin gel was observed in all patients. Although corticotrophin seemed to produce a more rapid response, overall improvement was similar with both treatments. Long-term neurological morbidity was a major problem with 91% of children suffering either persisting symptoms or repeated relapses. A persisting disability was found in 88% and was considered severe in 61% of patients. No features prognostic of neurological severity or outcome were identified.

CONCLUSION

Demonstrable malignancy is uncommon in the dancing eye syndrome. The neurological legacy of DES is often evident well into adult life.

Neuroblastoma-associated opsoclonus-myoclonus treated with intravenously administered immune globulin G

An 18-month-old black girl had progressive truncal ataxia, opsoclonus, and multifocal myoclonus associated with a nonresectable abdominal ganglioneuroblastoma. Before chemotherapy, she received intravenously administered IgG, 1 gm/kg, for 2 days; within 48 hours of the first dose, there was significant improvement of the opsoclonus-myoclonus and ataxia. She required a 1 gm/kg maintenance dose every 4 to 6 weeks for a total of 12 doses, but is now free of symptomatic after 2 years with no therapy.

Outcome of children with opsoclonus-myoclonus regardless of etiology

Within the past 11 years, 11 patients with opsoclonus and myoclonus, with or without a history of neuroblastoma, have been admitted to Children's Memorial Hospital. Eight of the 11 children had an occult neuroblastoma. Eight children have had subsequent delayed development with motor incoordination and speech delay (7 with neuroblastoma, 1 without). Nine of 11 children initially were treated with ACTH, 1 child was treated with prednisone, and 1 was not treated. Nine of the 10 children who were treated had recurrences of symptoms during the gradual withdrawal or discontinuation of ACTH. Often the ACTH had to be restarted or increased, although several times the episodes were self-limited, not requiring treatment after ACTH was withdrawn. We found prednisone was ineffective in controlling opsoclonus-myoclonus regardless of etiology. The majority of children with opsoclonus-myoclonus, regardless of etiology, have developmental delay, more severe and at a higher rate than previously reported. When a neuroblastoma was present, tumor removal did not improve symptoms. Although limited in size, our study indicates patients with opsoclonus-myoclonus without an associated neuroblastoma have a better chance for normal neurologic development (2/3 versus 1/8).

Myoclonic encephalopathy of infancy: a 10 year review

Myoclonic encephalopathy of infancy (MEI) is a unique cause of acute ataxia in infants and is a rare presentation of neuroblastoma. Five cases presenting to a tertiary referral children's hospital during a 10 year period are reviewed. Two cases were associated with a neuroblastoma. All children were treated with intramuscular injections of adrenocorticotropic hormone, with symptomatic improvement. One child died from an opportunistic infection following chemotherapy for neuroblastoma. The four survivors have mild to moderate clinical and intellectual deficits. Investigation and continuing observation for occult neural crest tumours is emphasized for all cases of MEI, though no underlying cause was found in 60% of children in this study.

Paraneoplastic manifestations in children

Paraneoplastic manifestations are signs and symptoms observed in patients with cancer, distant from the tumour or its metastases and not caused by invasion, obstruction or bulk mass. In children with cancer, paraneoplastic manifestations are rare and distinct from those observed in adults. Knowledge about paraneoplastic manifestations can be of great clinical importance because they may be the presenting sign of a tumour or its recurrence and hence facilitate early diagnosis. In contrast, they sometimes mask the symptoms of a tumour and cause diagnostic delay. In this review, paraneoplastic manifestations in children are described, including hypercalcaemia, Cushing syndrome, precocious puberty, opsoclonus/myoclonus, acquired von Willebrand disease, watery diarrhoea syndrome, and hypertension. The mechanisms causing these manifestations are also discussed.

Idiopathic hypothalamic dysfunction with dilated unresponsive pupils: report of two cases

Idiopathic hypothalamic dysfunction is a rare but well-defined entity in childhood characterized by adipsia-hypernatremia, obesity, poor thermoregulation, and disturbance of pituitary function. Two cases of idiopathic hypothalamic dysfunction are described. There are 10 previously reported cases in the literature, and the clinical features are compared. The present cases are unique in that the patients also had bilaterally dilated unresponsive pupils. In the first case, there was no demonstrable pathology at autopsy; in the second case, lymphocytic infiltration of the hypothalamus and midbrain associated with neuronal loss was present at autopsy. Possible etiologies are discussed.

Anti-Hu antibody in a neuroblastoma-associated paraneoplastic syndrome

A 20-month-old infant with Turner syndrome presented with opsoclonus-myoclonus and tonic pupils in association with an abdominal neuroblastoma. Despite complete removal of the tumor, the child developed progressive hearing loss, areflexia, and seizures. Immunohistochemical and Western blot studies of serum and cerebrospinal fluid revealed the presence of anti-Hu antineuronal antibody, which cross-reacted with areas of the patient's tumor. Treatment with intravenous immunoglobulin coincided with the resolution of opsoclonus-myoclonus and the cessation of new neurologic symptoms. This case provides direct support for the autoimmune basis of paraneoplastic symptoms associated with neuroblastoma and suggests that treatment with intravenous immunoglobulin may be of value.