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Peng Y, Yang H, Xue YH, Chen Q, Jin H, Liu S, Yao SY, Du MQ. An update on malignant tumor-related stiff person syndrome spectrum disorders: clinical mechanism, treatment, and outcomes. Front Neurol 2023; 14:1209302. [PMID: 37859648 PMCID: PMC10582361 DOI: 10.3389/fneur.2023.1209302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/01/2023] [Indexed: 10/21/2023] Open
Abstract
Stiff person syndrome (SPS) is a rare central nervous system disorder associated with malignancies. In this review, we retrieved information from PubMed, up until August 2023, using various search terms and their combinations, including SPS, stiff person syndrome spectrum disorders (SPSSDs), paraneoplastic, cancer, and malignant tumor. Data from peer-reviewed journals printed in English were organized to explain the possible relationships between different carcinomas and SPSSD subtypes, as well as related autoantigens. From literature searching, it was revealed that breast cancer was the most prevalent carcinoma linked to SPSSDs, followed by lung cancer and lymphoma. Furthermore, classic SPS was the most common SPSSD subtype, followed by stiff limb syndrome and progressive encephalomyelitis with rigidity and myoclonus. GAD65 was the most common autoantigen in patients with cancer and SPSSDs, followed by amphiphysin and GlyR. Patients with cancer subtypes might have multiple SPSSD subtypes, and conversely, patients with SPSSD subtypes might have multiple carcinoma subtypes. The first aim of this review was to highlight the complex nature of the relationships among cancers, autoantigens, and SPSSDs as new information in this field continues to be generated globally. The adoption of an open-minded approach to updating information on new cancer subtypes, autoantigens, and SPSSDs is recommended to renew our database. The second aim of this review was to discuss SPS animal models, which will help us to understand the mechanisms underlying the pathogenesis of SPS. In future, elucidating the relationship among cancers, autoantigens, and SPSSDs is critical for the early prediction of cancer and discovery of new therapeutic modalities.
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Affiliation(s)
- Yong Peng
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ya-hui Xue
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Quan Chen
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Hong Jin
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Shu Liu
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Shun-yu Yao
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Miao-qiao Du
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
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Rezk M, Pittock SJ, Kapadia RK, Knight AM, Guo Y, Gupta P, LaFrance-Corey RG, Zekeridou A, McKeon A, Dasari S, Mills JR, Dubey D. Identification of SKOR2 IgG as a novel biomarker of paraneoplastic neurologic syndrome. Front Immunol 2023; 14:1243946. [PMID: 37795104 PMCID: PMC10546397 DOI: 10.3389/fimmu.2023.1243946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 08/22/2023] [Indexed: 10/06/2023] Open
Abstract
Introduction The development of new autoantigen discovery techniques, like programmable phage immunoprecipitation sequencing (PhIP-Seq), has accelerated the discovery of neural-specific autoantibodies. Herein, we report the identification of a novel biomarker for paraneoplastic neurologic syndrome (PNS), Sloan-Kettering-Virus-Family-Transcriptional-Corepressor-2 (SKOR2)-IgG, utilizing PhIP-Seq. We have also performed a thorough clinical validation using normal, healthy, and disease/cancer control samples. Methods Stored samples with unclassified staining at the junction of the Purkinje cell and the granule cell layers were analyzed by PhIP-Seq for putative autoantigen identification. The autoantigen was confirmed by recombinant antigen-expressing cell-based assay (CBA), Western blotting, and tissue immunofluorescence assay colocalization. Results PhIP-Seq data revealed SKOR2 as the candidate autoantigen. The target antigen was confirmed by a recombinant SKOR-2-expressing, and cell lysate Western blot. Furthermore, IgG from both patient samples colocalized with a commercial SKOR2-specific IgG on cryosections of the mouse brain. Both SKOR2 IgG-positive patients had central nervous system involvement, one presenting with encephalitis and seizures (Patient 1) and the other with cognitive dysfunction, spastic ataxia, dysarthria, dysphagia, and pseudobulbar affect (Patient 2). They had a refractory progressive course and were diagnosed with adenocarcinoma (Patient 1: lung, Patient 2: gallbladder). Sera from adenocarcinoma patients without PNS (n=30) tested for SKOR2-IgG were negative. Discussion SKOR2 IgG represents a novel biomarker for PNS associated with adenocarcinoma. Identification of additional SKOR2 IgG-positive cases will help categorize the associated neurological phenotype and the risk of underlying malignancy.
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Affiliation(s)
- Mohamed Rezk
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Sean J. Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States
| | - Ronak K. Kapadia
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrew M. Knight
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Yong Guo
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Pranjal Gupta
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | | | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States
| | - Surendra Dasari
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - John R. Mills
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States
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Yohannan B, Sridhar A, Kachira JJ, Jafri SH. Glutamic acid decarboxylase (GAD) antibody-positive paraneoplastic stiff person syndrome associated with mediastinal liposarcoma. BMJ Case Rep 2022; 15:e250639. [PMID: 35798497 PMCID: PMC9263943 DOI: 10.1136/bcr-2022-250639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Stiff person syndrome (SPS) is a rare, debilitating neurological illness characterised by rigidity and spasms of the axial muscles, causing severe restrictions to mobility. SPS can be classic, partial or paraneoplastic. We report a case of a young woman who presented with seizures and painful spasms of the thoracolumbar muscles who was subsequently diagnosed with SPS. Serological work revealed glutamic acid decarboxylase (GAD) antibodies and imaging showed a large mediastinal mass. The patient underwent surgical resection of the mediastinal mass and final pathology revealed well-differentiated mediastinal liposarcoma. She received five sessions of plasma exchange and her neurological symptoms gradually improved after surgery. This case highlights a rare case of GAD antibody-positive paraneoplastic SPS associated with mediastinal liposarcoma.
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Affiliation(s)
- Binoy Yohannan
- Hematology and Oncology, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Arthi Sridhar
- Hematology and Oncology, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Johncy John Kachira
- Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Syed H Jafri
- Hematology and Oncology, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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Treatment and Management of Disorders of Neuromuscular Hyperexcitability and Periodic Paralysis. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00018-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Lin BC, Johal J, Sivakumar K, Romano AE, Yacoub HA. Stiff-person syndrome: an atypical presentation and a review of the literature. Hosp Pract (1995) 2021; 49:384-390. [PMID: 34313523 DOI: 10.1080/21548331.2021.1961456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: Stiff-person syndrome (SPS) is a rare autoimmune neurological disorder associated with muscle rigidity and spasms. A number of antibodies have been associated with disorder, including anti-glutamic acid decarboxylase and anti-amphiphysin.Case report; In this report, we present a rare case of a 79-year-old woman who presented with bilateral lower extremity weakness who was ultimately diagnosed with stiff-limb syndrome, a rare variant of SPS. Extensive laboratory and CSF studies were unrevealing. Electromyography showed significant peroneal motor neuropathy and complex repetitive discharges in the left tibialis anterior muscle. Antibodies to glutamic acid decarboxylase were significantly elevated at 124 units/mL. She was subsequently started on oral diazepam with significant improvement in her symptoms.Conclusion: The presentation of SPS can vary based on epidemiologic factors, clinical symptoms, and associated disorders. These forms can have overlapping features which may make the categorization of patients into one of these forms challenging.
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Affiliation(s)
- Benjamin C Lin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jaspreet Johal
- Department of Neurology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Keithan Sivakumar
- Division of Neurology, Sunnybrook Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Alissa E Romano
- Department of Neurology, Lehigh Valley Health Network, Allentown, PA, USA.,Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Hussam A Yacoub
- Department of Neurology, Lehigh Valley Health Network, Allentown, PA, USA.,Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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Bernardo F, Rebordão L, Rêgo A, Machado S, Passos J, Costa C, Cruz S, Pinto AN, Santos M. Stiff person spectrum disorders: An illustrative case series of their phenotypic and antibody diversity. J Neuroimmunol 2020; 341:577192. [PMID: 32087460 DOI: 10.1016/j.jneuroim.2020.577192] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 01/20/2020] [Accepted: 02/12/2020] [Indexed: 12/13/2022]
Abstract
Stiff person spectrum disorders (SPSD) are a broad group of immune-mediated disorders. Clinical presentations include classical stiff person syndrome (SPS), focal SPS, and progressive encephalomyelitis with rigidity and myoclonus (PERM). The most frequently associated antibodies are anti-GAD65, anti-GlyR, anti-amphiphysin, and anti-DPPX. Immunotherapy is the primary treatment modality. We present an illustrative case series of three patients: anti-GlyR antibody-mediated PERM presenting as rapidly progressive dementia; anti-amphiphysin antibody-mediated SPS; and SPS presentation with anti-Zic4 antibodies, spasmodic laryngeal stridor and fluctuating eyelid ptosis. Clinical characteristics, CSF findings, neurophysiological features, adequate immunological assays and a high suspicion index are essential for prompt diagnosis and management.
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Affiliation(s)
- Francisco Bernardo
- Department of Neurology, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal.
| | - Leonor Rebordão
- Department of Neurology, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - André Rêgo
- Department of Neurology, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Sara Machado
- Department of Neurology, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - João Passos
- Department of Neurology, Instituto Português de Oncologia, Lisboa, Portugal
| | - Cristina Costa
- Department of Neurology, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Simão Cruz
- Department of Neurology, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Amélia Nogueira Pinto
- Department of Neurology, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Mariana Santos
- Department of Neurology, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
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Treatment of Possible PERM Underlying Malignant Catatonia and Accompanying Psychotic Symptoms With Modified Electroconvulsive Therapy: A Case Report. J ECT 2019; 35:e3-e4. [PMID: 30113990 DOI: 10.1097/yct.0000000000000536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Paraneoplastic stiff person syndrome with small cell carcinoma of the bladder and anti-Ri antibodies. Clin Neurol Neurosurg 2018; 173:194-195. [PMID: 30165320 DOI: 10.1016/j.clineuro.2018.08.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 07/11/2018] [Accepted: 08/11/2018] [Indexed: 12/16/2022]
Abstract
The stiff person syndrome is a rare neurological disorder, difficult to diagnose and to treat. Paraneoplastic patients usually present amphiphysin antibodies but the association with anti-Ri antibodies is less known. We present a case report of paraneoplastic SPS, small cell carcinoma of the bladder and anti-Ri antibodies.
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9
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Autoimmune paraneoplastic syndromes associated to lung cancer: A systematic review of the literature: Part 5: Neurological auto-antibodies, discussion, flow chart, conclusions. Lung Cancer 2017; 111:164-175. [DOI: 10.1016/j.lungcan.2017.07.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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10
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McKeon A, Tracy JA. GAD65 neurological autoimmunity. Muscle Nerve 2017; 56:15-27. [PMID: 28063151 DOI: 10.1002/mus.25565] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 01/04/2017] [Indexed: 12/11/2022]
Abstract
The glutamic acid decarboxylase 65-kilodalton isoform (GAD65) antibody is a biomarker of autoimmune central nervous system (CNS) disorders and, more commonly, nonneurological autoimmune diseases. Type 1 diabetes, autoimmune thyroid disease, and pernicious anemia are the most frequent GAD65 autoimmune associations. One or more of these disorders coexists in approximately 70% of patients with GAD65 neurological autoimmunity. Neurological phenotypes have CNS localization and include limbic encephalitis, epilepsy, cerebellar ataxia, and stiff-person syndrome (SPS), among others. Classic SPS is a disorder on the spectrum of CNS hyperexcitability which also includes phenotypes that are either more restricted (stiff-limb syndrome) or more widespread (progressive encephalomyelitis with rigidity and myoclonus). GAD65 antibody is not highly predictive of a paraneoplastic cause for neurological disorders, but diverse cancer types have been occasionally reported. For all phenotypes, responses to immunotherapy are variable (approximately 50% improve). GAD65 autoimmunity is important to recognize for both coexisting nonneurological autoimmune associations and potential immunotherapy-response. Muscle Nerve 56: 15-27, 2017.
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Affiliation(s)
- Andrew McKeon
- Department of Neurology, College of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota, 55905, USA.,Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jennifer A Tracy
- Department of Neurology, College of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota, 55905, USA
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Bentea G, Sculier C, Grigoriu B, Meert AP, Durieux V, Berghmans T, Sculier JP. Autoimmune paraneoplastic syndromes associated to lung cancer: A systematic review of the literature: Part 3: Neurological paraneoplastic syndromes, involving the central nervous system. Lung Cancer 2017; 106:83-92. [PMID: 28285700 DOI: 10.1016/j.lungcan.2017.01.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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 third of a series of five and deals mainly with neurological paraneoplastic syndromes involving the central nervous system.
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Affiliation(s)
- Georgiana Bentea
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium
| | - Claudine Sculier
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium
| | - Bogdan Grigoriu
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium
| | - Anne-Pascale Meert
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium; Laboratoire facultaire de Médecine factuelle (ULB), Belgium
| | - Valérie Durieux
- Bibliothèque des Sciences de la Santé, Université libre de Bruxelles (ULB), Belgium; Laboratoire facultaire de Médecine factuelle (ULB), Belgium
| | - Thierry Berghmans
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium; Laboratoire facultaire de Médecine factuelle (ULB), Belgium
| | - Jean-Paul Sculier
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium; Laboratoire facultaire de Médecine factuelle (ULB), Belgium.
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Abstract
Autoimmune movement disorders encapsulate a large and diverse group of neurologic disorders occurring either in isolation or accompanying more diffuse autoimmune encephalitic illnesses. The full range of movement phenomena has been described and, as they often occur in adults, many of the presentations can mimic neurodegenerative disorders, such as Huntington disease. Disorders may be ataxic, hypokinetic (parkinsonism), or hyperkinetic (myoclonus, chorea, tics, and other dyskinetic disorders). The autoantibody targets are diverse and include neuronal surface proteins such as leucine-rich, glioma-inactivated 1 (LGI1) and glycine receptors, as well as antibodies (such as intracellular antigens) that are markers of a central nervous system process mediated by CD8+ cytotoxic T cells. However, there are two conditions, stiff-person syndrome (also known as stiff-man syndrome) and progressive encephalomyelitis with rigidity and myoclonus (PERM), that are always autoimmune movement disorders. In some instances (such as Purkinje cell cytoplasmic antibody-1 (PCA-1) autoimmunity), antibodies detected in serum and cerebrospinal fluid can be indicative of a paraneoplastic cause, and may direct the cancer search. In other instances (such as 65kDa isoform of glutamic acid decarboxylase (GAD65) autoimmunity), a paraneoplastic cause is very unlikely, and early treatment with immunotherapy may promote improvement or recovery. Here we describe the different types of movement disorder and the clinical features and antibodies associated with them, and discuss treatment.
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Affiliation(s)
- Andrew Mckeon
- Departments of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
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13
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Urrea-Mendoza E, Kanter D, Revilla FJ, Dornoff E, Espay AJ. Stiff-arm syndrome. Neurology 2015; 85:1088-9. [PMID: 26391414 DOI: 10.1212/wnl.0000000000001962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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[Stiff man syndrome and variants]. DER NERVENARZT 2013; 84:450-4. [PMID: 23568166 DOI: 10.1007/s00115-012-3604-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Stiff man syndrome (SMS) and its variants are rare neurological disorders with unusual, often awkward motor and psychological symptoms. Misdiagnoses are frequent and differentiation from psychogenic movement disorder may be difficult. Clinical suspicion can be substantiated by neurophysiological and immunological testing. Autoimmunity against certain proteins of inhibitory synapses appears to be a key feature that links SMS to other autoimmune encephalopathies and endocrinopathies. According to retrospective analyses a front-loaded long-term methylprednisolone treatment appears to be most effective.
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Rakocevic G, Floeter MK. Autoimmune stiff person syndrome and related myelopathies: understanding of electrophysiological and immunological processes. Muscle Nerve 2012; 45:623-34. [PMID: 22499087 DOI: 10.1002/mus.23234] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Stiff person syndrome (SPS) is a disabling autoimmune central nervous system disorder characterized by progressive muscle rigidity and gait impairment with superimposed painful spasms that involve axial and limb musculature, triggered by heightened sensitivity to external stimuli. Impaired synaptic GABAergic inhibition resulting from intrathecal B-cell-mediated clonal synthesis of autoantibodies against various presynaptic and synaptic proteins in the inhibitory neurons of the brain and spinal cord is believed to be an underlying pathogenic mechanism. SPS is most often idiopathic, but it can occur as a paraneoplastic condition. Despite evidence that anti-GAD and related autoantibodies impair GABA synthesis, the exact pathogenic mechanism of SPS is not fully elucidated. The strong association with several MHC-II alleles and improvement of symptoms with immune-modulating therapies support an autoimmune etiology of SPS. In this review, we discuss the clinical spectrum, neurophysiological mechanisms, and therapeutic options, including a rationale for agents that modulate B-cell function in SPS.
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Affiliation(s)
- Goran Rakocevic
- Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, Pennsylvania 19107, USA.
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An uncommon paraneoplastic Ri-positive opsoclonus-myoclonus-like syndrome and Stiff-Person syndrome with elevated glutamate/GABA ratio in the cerebrospinal fluid after breast cancer. J Neurol 2010; 257:1215-7. [DOI: 10.1007/s00415-010-5501-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Revised: 02/02/2010] [Accepted: 02/04/2010] [Indexed: 12/30/2022]
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Katoh N, Matsuda M, Ishii W, Morita H, Ikeda SI. Successful treatment with rituximab in a patient with stiff-person syndrome complicated by dysthyroid ophthalmopathy. Intern Med 2010; 49:237-41. [PMID: 20118602 DOI: 10.2169/internalmedicine.49.2821] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report a patient with stiff-person syndrome and insulin-dependent diabetes mellitus with anti-glutamic acid decarboxylase (GAD) antibody, who suddenly complained of diplopia due to dysthyroid ophthalmopathy. Therapeutic efficacy of plasmapheresis and high-dose intravenous immunoglobulin was transient. After starting administration of rituximab, the patient showed obvious improvement of muscle spasms due to stiff-person syndrome and ophthalmoplegia following quick depletion of CD20-positive cells in peripheral blood. The anti-GAD and anti-thyroid antibodies decreased slowly. This drug might be a potent therapeutic option for refractory patients with stiff-person syndrome, particularly in those associated with dysthyroid ophthalmopathy.
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Affiliation(s)
- Nagaaki Katoh
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto
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Abstract
Neurologic paraneoplastic syndromes (NPSs) result from damage to the nervous system due to the remote effects of cancer not related to metastasis, infection, or metabolic derangements. NPSs are rare, affecting 1 in 10,000 patients with cancer. Pathogenesis is likely related to the immune mechanisms: normal neural tissue is mistakenly attacked due to the similarity in the onconeural antigens expressed by the tumor cells. Among the various "classic" and other NPSs, this review focuses on paraneoplastic movement disorders, including ataxia due to cerebellar degeneration, stiff-person syndrome, opsoclonus-myoclonus syndrome, chorea, parkinsonism, and tremor. The recently described syndrome of paraneoplastic anti-N-methyl-D-aspartate receptor encephalitis is also included, given that these patients have complex movements such as stereotypies and dyskinesias in addition to psychiatric symptoms, altered sensorium, and other neurologic signs. Although variable, treatment and prognosis of NPSs rely heavily on treatment of the underlying malignancy and immunotherapy.
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Misra UK, Maurya PK, Kalita J, Gupta RK. Stiff limb syndrome: end of spectrum or a separate entity? PAIN MEDICINE 2009; 10:594-7. [PMID: 19302441 DOI: 10.1111/j.1526-4637.2009.00578.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Stiff-person syndrome is a rare disorder characterized by rigidity of axial or limb muscles with episodes of co-contraction of agonist and antagonist muscles during the spasms. In some patients axial or limb involvement may predominate and may have unusual manifestations. DESIGN Case report. SETTING Tertiary care teaching hospital. PATIENT A 42-year-old farmer presented with seasonal occurrence of hiccup and vomiting during summer months for the last 3 years. He had painful lower limb spasms lasting for 2-3 minutes every 10-15 minutes for the past 20 days. His neurological examination was normal, erythrocyte sedimentation rate (ESR) was 50 mm at 1st hour, and cerebrospinal fluid protein 78 mg/dL without pleocytosis. Radiograph of chest, abdominal ultrasound, and craniospinal magnetic resonance imaging were normal. The patient improved on diazepam. CONCLUSION Our patient is a forme fruste of stiff person syndrome with hiccups and vomiting due to diaphragmatic spasm.
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Affiliation(s)
- Usha K Misra
- Department of Neurology and Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
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Abstract
BACKGROUND Paraneoplastic neurologic syndromes (PNS) constitute a rare group of disorders resulting from damage to the nervous system in the setting of cancer physically unrelated to the tumor site. PNS are believed to result from an autoimmune attack of normal neuronal tissue, spurred by similar neuronal antigens ectopically expressed by tumor cells. REVIEW SUMMARY The most common PNS are reviewed and also their association with specific onconeural antibodies, some directly pathogenic, others whose role in the disease process is less clear-cut. This diversity in pathogenesis is likely due to the relative role of humoral versus cellular immunity in PNS. Virtually any cancer may result in PNS but certain tumors, small cell lung cancer, gynecologic cancers (breast and ovarian), thymoma, and plasma cell tumors are more frequently encountered. In most instances, immunosuppressive therapy is unhelpful and outcome is poor. CONCLUSIONS PNS have diverse presentations, affecting both the central and peripheral nervous system and commonly, it is the PNS, not cancer that is the presenting symptom. Only subsequently, after onconeural antibodies are discovered or cancer is found, is PNS diagnosed. Neurologists should familiarize themselves with these rare syndromes and treatment principles, as rapid detection and treatment of the underlying tumor offer the best chance for recovery or prevention of further neurologic deterioration.
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Affiliation(s)
- Thomas B Toothaker
- Department of Neurology and Neuroscience, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY 10021, USA.
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Clow EC, Couban S, Grant IA. Stiff-person syndrome associated with multiple myeloma following autologous bone marrow transplantation. Muscle Nerve 2009; 38:1649-52. [PMID: 18932204 DOI: 10.1002/mus.21153] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Stiff-person syndrome (SPS) is an immunologically mediated central nervous system disorder that is infrequently associated with malignancy. We report a 31-year-old woman who developed SPS after autologous bone marrow transplantation and subsequent interferon treatment for multiple myeloma. Anti-glutamic acid decarboxylase (anti-GAD) antibody serology was positive. The myeloma remains in remission 10 years posttransplant. SPS has been described in association with lung cancer and breast cancer, thymoma, and Hodgkin lymphoma. This is the second report of SPS in a patient with myeloma and the first description of SPS following autologous transplantation. Aberrant immune reconstitution is known to occur following hematopoietic progenitor cell transplantation. Interferon is also known to augment the immune response posttransplant. We speculate that an aberrant posttransplant immune response may have caused both the SPS and an autologous graft-versus-myeloma effect, resulting in prolonged remission posttransplant.
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Affiliation(s)
- Erin C Clow
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia B3H 3A7, Canada
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Musunuru K, Kesari S. Paraneoplastic opsoclonus-myoclonus ataxia associated with non-small-cell lung carcinoma. J Neurooncol 2008; 90:213-6. [PMID: 18618225 DOI: 10.1007/s11060-008-9650-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2007] [Accepted: 06/23/2008] [Indexed: 02/06/2023]
Abstract
We report a case of the paraneoplastic opsoclonus-myoclonus ataxia syndrome in a patient with non-small cell lung carcinoma, which represents a highly unusual association. The patient simultaneously manifested both severe neurologic symptoms and widely metastatic disease, complicating her treatment.
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Affiliation(s)
- Kiran Musunuru
- Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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Launay M, Bozzolo E, Venissac N, Delmont E, Fredenrich A, Thomas P. [Paraneoplastic limbic encephalitis with positive anti-RI antibodies and mediastinal seminoma]. Rev Neurol (Paris) 2008; 164:612-9. [PMID: 18565362 DOI: 10.1016/j.neurol.2008.02.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2007] [Revised: 02/09/2008] [Accepted: 02/20/2008] [Indexed: 12/31/2022]
Abstract
We report the case of a 49-year-old man who was admitted for progressive behaviorial disorders with frontal elements. There was no sensorial nor motor deficiency. Clinical examination revealed android obesity, cutaneous and mucous paleness, pubic and axillary depilation and gynecomastia. Encephalic MRI found a lesion of the left amygdalian region with high T2 intensity and low T1 intensity associated with gadolinium-enhancement. Cerebrospinal fluid analysis showed a lymphocytic meningitis. Panhypopituitarism was found on the endocrine investigations. Anti-RI antibodies were positive, leading to the diagnosis of paraneoplastic limbic encephalitis. The CT-scan showed a node of the lower part of the thymic area. Surgical resection revealed an ectopic mediastinal seminoma. The evolution consisted of paraneoplastic fever and crossed-syndrome with right hemiparesia and left common oculomotor nerve paralysis. Treatment was completed by two cycles of carboplatin, corticosteroids and substitutive opotherapy. Paraneoplastic fever disappeared, but behavioral disorders and palsy remain unchanged. The patient died two years later in a bedridden state. This case of paraneoplastic limbic encephalitis associated with positive anti-RI antibodies and mediastinal seminoma is exceptional and has not to our knowledge been described in the literature. Cancers usually associated with anti-RI antibody are breast and lung cancer. Paraneoplastic limbic encephalitis is not the classical clinical presentation, which usually is brainstem encephalitis. Hypothalamic involvement, uncommon in paraneoplastic limbic encephalitis is mainly associated with positive antineuronal anti-Ma2 antibodies. Finally, the gadolinium enhancement on encephalic MRI is unusual in paraneoplastic limbic encephalitis.
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Affiliation(s)
- M Launay
- Service de neurologie, pavillon F, hôpital Pasteur, 30, voie Romaine, B.P. 69, 06002 Nice, France.
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McHugh JC, Murray B, Renganathan R, Connolly S, Lynch T. GAD antibody positive paraneoplastic stiff person syndrome in a patient with renal cell carcinoma. Mov Disord 2008; 22:1343-6. [PMID: 17486640 DOI: 10.1002/mds.21374] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Stiff person syndrome (SPS) is an unusual cause of muscle rigidity and spasms. It is believed to have an autoimmune pathogenesis and is associated with autoantibodies to glutamic acid decarboxylase (GAD). Paraneoplastic SPS (PSPS) has been described mainly in relation to breast cancer and is associated with antibodies to amphiphysin. Few reports of PSPS document the finding of GAD autoantibodies. We present the first reported case of anti-GAD positive PSPS in a 53-year-old male with occult renal carcinoma. Clinical benefit was marked following nephrectomy and intravenous immunoglobulin treatment. Renal carcinoma should be considered in patients with SPS.
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Affiliation(s)
- John C McHugh
- Department of Neurology, Mater Misericordiae University Hospital, Dublin, Ireland.
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Jarius S, Stich O, Rasiah C, Voltz R, Rauer S. Qualitative evidence of Ri specific IgG-synthesis in the cerebrospinal fluid from patients with paraneoplastic neurological syndromes. J Neurol Sci 2007; 268:65-8. [PMID: 18096187 DOI: 10.1016/j.jns.2007.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2007] [Revised: 10/31/2007] [Accepted: 11/02/2007] [Indexed: 10/22/2022]
Abstract
The presence of Ri-specific oligoclonal IgG bands in the CSF was investigated in five patients with paraneoplastic anti-Ri associated neurological syndromes (PNS) and six controls. In 4/5 CSF samples reactivity of IgG bands with recombinant Ri antigen was found using isoelectrofocusing combined with affinity blotting; in one patient with absence of oligoclonal bands of total IgG in CSF Ri-specific oligoclonal bands were detected with the same sample, indicating a higher sensitivity of Ri-specific affinity blotting as compared to affinity blotting with anti-human IgG antibodies. Our results confirm previous studies demonstrating IgG synthesis against onconeuronal antigens by intrathecal B-cell clones in PNS and extend this observation to patients with anti-Ri syndrome. The pathogenic relevance of these antibodies, however, is further challenged by the finding that specific intrathecal IgG synthesis might not be a prerequisite of CNS involvement, because it was missed in one of our patients.
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Affiliation(s)
- S Jarius
- Institute of Clinical Neuroimmunology, Ludwig Maximilians University, Munich, Germany
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Essalmi L, Meaux-Ruault N, Hafsaoui C, Gil H, Curlier E, Dupond JL. Syndrome de la personne raide associé à un thymome: efficacité de la thymectomie. Rev Med Interne 2007; 28:627-30. [PMID: 17624641 DOI: 10.1016/j.revmed.2007.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2007] [Accepted: 05/04/2007] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Stiff person syndrome is a rare autoimmune neurologic disorder characterized by axial muscular rigidity and intermittent painful spasms. Three distinct forms are described: auto-immune, paraneoplastic and idiopathic. EXEGESIS We report the case of a 51-year-old man with an history of Stiff Person Syndrome with typical clinical, electrophysiological and immunological findings. Anti-glutamic acid decarboxylase antibodies were present, as well as anti-amphiphysin antibodies, commonly reported in the paraneoplastic syndrome. CT scan revealed a thymoma. Surgical resection was followed by reduction of the neurologic symptoms, without lowering the auto antibodies titer. CONCLUSIONS The association between Stiff Person Syndrome and thymoma is exceptional. Thymectomy is an effective treatment and may act without change of the autoantibodies titer. Patients with Stiff Person Syndrome should be systematically tested for thymoma.
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Affiliation(s)
- L Essalmi
- Service de médecine interne et immunologie clinique, hôpital Jean-Minjoz, CHU de Besançon, 2, boulevard Fleming, 25030 Besançon cedex, France
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Espay AJ, Chen R. Rigidity and spasms from autoimmune encephalomyelopathies: stiff-person syndrome. Muscle Nerve 2007; 34:677-90. [PMID: 16969837 DOI: 10.1002/mus.20653] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Stiff-person syndrome (SPS) is a disorder characterized by progressive muscle rigidity with superimposed painful muscle spasms and gait impairment due to continuous motor activity. Evidence has accumulated in favor of SPS representing an autoimmune, predominantly encephalomyelopathic disorder resulting from B-cell-mediated clonal production of autoantibodies against presynaptic inhibitory epitopes on the enzyme glutamic acid decarboxylase (GAD) and the synaptic membrane protein amphiphysin. Recognition of the clinical spectrum of SPS is important, particularly the upper-limb, cervical, and cranial nerve involvement that occurs in paraneoplastic variants. The correlation between antibody levels and severity of disease offers evidence for a pathogenic role for the anti-GAD and anti-amphiphysin autoantibodies. The scarcity of neuropathological correlates stand in sharp contrast with the severity of the disability in affected individuals and suggests that functional impairment of inhibitory circuits without structural damage is sufficient to develop the full clinical spectrum of SPS. The rarity of this condition limits the feasibility of controlled clinical trials in the treatment of SPS, but the available evidence suggest that drugs that increase cortical and spinal inhibition such as benzodiazepines and drugs that provide immune modulation such as intravenous immunoglobulin, plasmapheresis, and prednisone are effective treatments.
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Affiliation(s)
- Alberto J Espay
- Department of Neurology, Neuroscience Institute, Movement Disorders Center, University of Cincinnati, Cincinnati, Ohio, USA
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Cantiniaux S, Azulay JP, Boucraut J, Pouget J, Attarian S. Le syndrome de l’homme raide : formes cliniques, traitement et profil évolutif. Rev Neurol (Paris) 2006; 162:832-9. [PMID: 17028544 DOI: 10.1016/s0035-3787(06)75086-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Stiff-Man syndrome (SMS) is a rare neurological disease first described fifty years ago. There are several clinical forms, which are frequently misdiagnosed. The aim of this study is to review three of the main clinical forms. MATERIAL AND METHODS Case reports concerning three women suffering from different forms of SMS are presented, giving the main clinical features, their associations with other diseases, and the biological and electrophysiological findings. RESULTS The first patient presented a symmetric axial muscle rigidity, painful spasms and contractions of the trunk and limbs associated with anti-GAD antibodies. The common form of SMS was diagnosed and the patient was improved by intravenous immunoglobulin (IVIg). The second patient suffered from contractions and spasms localized to the lower limbs. In this patient, anti-GAD antibodies were absent. The Stiff-Leg syndrome was diagnosed and the patient was improved by intrathecal baclofen. The third patient presented rigidity of limb and trunk muscles associated with signs of encephalitis. In this patient, only anti-amphiphysin antibodies were present. The progressive encephalomyelitis with rigidity was diagnosed and the patient was improved by IVIg associated with corticosteroid. CONCLUSION Identifying patients with SMS makes it possible to propose appropriate medical management. There are several forms of the disease, and the severity of the evolution differs in each case. Treatment with GABA-ergic inhibitory drugs, IVIg and corticosteroid improve both the symptomatology and the quality of life of these patients.
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Affiliation(s)
- S Cantiniaux
- Service de Neurologie et Maladies Neuromusculaires, CHU de la Timone, Marseille
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Abstract
The paraneoplastic neurologic disorders (PND) are a diverse group of diseases characterized by the presence of neurologic dysfunction in the setting of a remote cancer. PND can affect almost any part of the nervous system, and are most commonly associated with lung cancer (small cell) and gynecologic tumors. Laboratory studies have demonstrated that an autoimmune response links the neurologic disorder and the cancer, and established a model whereby the cancer is believed to initiate the syndrome by expressing a protein antigen normally expressed in the nervous system, leading to anti-tumor immune response followed by autoimmune neurologic symptoms. We review the currently known PND and their pathogenesis.
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Affiliation(s)
- Robert B Darnell
- Howard Hughes Medical Institute and Laboratory of Molecular Neuro-Oncology, The Rockefeller University, New York, NY 10021, USA.
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What's in the Literature? J Clin Neuromuscul Dis 2004; 6:13-21. [PMID: 19078748 DOI: 10.1097/01.cnd.0000138206.12280.d1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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