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Chávez-Nomberto RE, Díaz-Gambini MDA, Ramos Diaz KJ. An unusual case of early onset opsoclonus-myoclonus syndrome: Case report and literature review. SAGE Open Med Case Rep 2024; 12:2050313X241281250. [PMID: 39253590 PMCID: PMC11382242 DOI: 10.1177/2050313x241281250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 08/21/2024] [Indexed: 09/11/2024] Open
Abstract
Opsoclonus-myoclonus syndrome is a rare neurological condition characterized by opsoclonus, myoclonus, ataxia, irritability, and sleep disturbances. In pediatric patients, symptoms usually start between 16 and 18 months of age; opsoclonus-myoclonus syndrome presentation in children under 6 months is rare. Approximately 50% of cases are associated with neuroblastoma. We report an early onset presentation of opsoclonus-myoclonus syndrome in a previously healthy, 3-month-old female infant. The diagnostic workup revealed no abnormalities. The patient underwent monthly cycles of dexamethasone pulses and intravenous immunoglobulin with a favorable response. After a few months, the patient presented intermittent opsoclonus before the next scheduled pulse so from the 9th cycle onwards, the intravenous immunoglobulin dose was increased to 2 g/kg. After 9 months of treatment, she was diagnosed with a latent Mycobacterium tuberculosis infection. Due to this infection, dexamethasone pulses were discontinued, and intravenous immunoglobulin treatment was maintained with clinical improvement The patient received 18 intravenous immunoglobulin cycles, leaving her with a score of one on the Mitchell-Pike scale. Developmental milestones have been attained according to age. Despite the range of therapeutic options for managing opsoclonus-myoclonus syndrome described in the literature, the efficacy of these available therapies needs to be better established. A modified upfront approach with dexamethasone and intravenous immunoglobulin could be an option in settings where rituximab is unavailable.
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Pai V, Kang H, Suthiphosuwan S, Gao A, Mandell D, Shroff M. Autoimmune Encephalitis: Insights Into Immune-Mediated Central Nervous System Injury. Korean J Radiol 2024; 25:807-823. [PMID: 39197826 PMCID: PMC11361799 DOI: 10.3348/kjr.2023.1307] [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] [Received: 12/29/2023] [Revised: 04/23/2024] [Accepted: 06/10/2024] [Indexed: 09/01/2024] Open
Abstract
Autoimmune encephalitis (AE) is a category of immune-mediated disorders of the central nervous system (CNS) affecting children and adults. It is characterized by the subacute onset of altered mentation, neurocognitive issues, refractory seizures/drug-resistant epilepsy, movement disorders, and/or autonomic dysfunction. AE is mediated by autoantibodies targeting specific surface components or intracytoplasmic antigens in the CNS, leading to functional or structural alterations. Multiple triggers that induce autoimmunity have been described, which are mainly parainfectious and paraneoplastic. The imaging features of AE often overlap with each other and with other common causes of encephalitis/encephalopathy (infections and toxic-metabolic etiologies). Limbic encephalitis is the most common imaging finding shared by most of these entities. Cortical, basal ganglia, diencephalon, and brainstem involvement may also be present. Cerebellar involvement is rare and is often a part of paraneoplastic degeneration. Owing to an improved understanding of AE, their incidence and detection have increased. Hence, in an appropriate setting, a high degree of suspicion is crucial when reporting clinical MRIs to ensure prompt treatment and better patient outcomes. In this review, we discuss the pathophysiology of AE and common etiologies encountered in clinical practice.
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Affiliation(s)
- Vivek Pai
- Division of Neuroradiology, Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Toronto, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Heejun Kang
- Department of Medical Imaging, University of Toronto, Toronto, Canada
- Division of Neuroradiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Suradech Suthiphosuwan
- Department of Medical Imaging, University of Toronto, Toronto, Canada
- Division of Neuroradiology, St. Michael's Hospital-Unity Health Toronto, Toronto, Canada
| | - Andrew Gao
- Laboratory Medicine Program, University Health Network, Toronto, Canada
| | - Daniel Mandell
- Department of Medical Imaging, University of Toronto, Toronto, Canada
- Joint Department of Medical Imaging (JDMI), Toronto Western Hospital, Toronto, Canada
| | - Manohar Shroff
- Division of Neuroradiology, Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Toronto, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Canada.
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Jimenez Giraldo S, Michaelis M, Kerr L, Cortina C, Zhang B, Gorman MP. Inaugural Patient-Reported Registry of Pediatric Opsoclonus-Myoclonus-Ataxia Syndrome: Presentation, Diagnosis, and Treatment of 194 Patients. Pediatr Neurol 2024; 158:128-134. [PMID: 39042987 DOI: 10.1016/j.pediatrneurol.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 05/28/2024] [Accepted: 06/16/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Opsoclonus-myoclonus-ataxia syndrome (OMAS) is a rare neuroimmune disease with peak onset at 18 months, associated with neural crest tumors in 50% of patients. In part due to its rarity, misdiagnosis at onset is common, can delay treatment, and may contribute to adverse outcomes. Patient-reported registries may overcome some of these challenges in rare disease research. In this context, the OMSLife Foundation collaborated with the National Organization of Rare Diseases to create a patient-reported registry in OMAS. METHODS Retrospective analysis was performed of data entered by parents of patients with OMAS into nine online surveys assessing demographics, symptoms at onset, triggers, time of diagnosis, treatment, and additional therapies. RESULTS A total of 194 patients were enrolled. There was a female predominance (54%) and high rate of parental autoimmunity (31%). Age at onset peaked between 12 and 18 months overall. The age of onset was older in female patients (median [interquartile range]: females 22 [15 to 31] vs males 18 [14 to 23], P = 0.0223, P = 0.0223). Symptoms at onset most commonly included ataxia (84%) and were typically severe. Initial misdiagnosis occurred in nearly 50% and tumor discovery was delayed in 18 patients, but overall median time to correct diagnosis was 25 days. Most patients (56%) received combination immunomodulatory therapies, and nearly all underwent supportive therapies. CONCLUSIONS Patient- and parent-powered research is feasible in OMAS and created the second largest published cohort of pediatric patients with OMAS. Results were similar to other large cohorts and also validated findings from prior case reports and smaller case series.
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Affiliation(s)
- Sandra Jimenez Giraldo
- Division of Child Neurology, Department of Pediatrics, Hasbro Children's Hospital, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | | | - Lauren Kerr
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher Cortina
- Biostatistics and Research Design Center, Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bo Zhang
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Biostatistics and Research Design Center, Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Mark P Gorman
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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Kravljanac R, Golubovic A, Tadic BV, Ostojic S, Cerovic I, Savkic J. "The Red Flags" in Clinical Approach to Acute Ataxia-the Experience in Cohort of 76 Children. CEREBELLUM (LONDON, ENGLAND) 2024; 23:1321-1327. [PMID: 38008790 DOI: 10.1007/s12311-023-01639-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/18/2023] [Indexed: 11/28/2023]
Abstract
The aim of our study is to define the most frequent etiology, clinical presentation, and predictive factors of outcome in children with acute ataxia (AA) and to determine "the red flags" in the diagnostic approach to children with AA. The retrospective study included the patients with AA treated in the institute from 2015 to 2021. The inclusion criteria were children aged 1-18 years, evolution time of ataxia within 72 h, and diagnosis made by a physician. The exclusion criteria were anamnestic data about ataxia without confirmation by any physician, chronic/persistent ataxia, and psychogenic or postictal ataxia. Clinical presentation was divided into two categories: (1) isolated cerebellar signs (CS): ataxic gait, dysmetria, dysdiadochokinesia, intention tremor, dysarthria, and nystagmus; (2) CS-plus symptoms which included CS associated with any of other symptoms such as encephalopathy (GCS < 15), awareness disturbances, vomiting, headache, a new onset limb or facial paresis, torticollis, hypotonia, and opsoclonus. The outcome was assessed at the end of hospitalization and was defined as complete or incomplete recovery. The study included 76 children, with a mean age of 5.7 years (IQR 2.1-8.3). The most frequent causes of AA were immune-mediated/infective cerebellar ataxia in 27 (35.5%), and intoxication in 24 (31.6%) cases, followed by vestibular ataxia, opsoclonus-myoclonus-ataxia syndrome, and intracranial expansive process. Forty-two (56%) cases experienced isolated CS, and 35 (46%) cases had CS-plus. Complete recovery was experienced by 62 (81.6%) patients. Analysis of some risk factors (sex, age, presence of previous infection, "cerebellar plus symptoms," and structural abnormalities/neuroimaging abnormalities) and their relation to outcome was performed. Analysis showed that presence of additional symptoms to ataxia, so called "cerebellar plus symptoms" (p = 0.002) and structural abnormalities (p < 0.001), had statistically higher frequency of poor outcome. Statistical significance remained in the univariate analysis. Significant data was included in multivariate logistic regression analysis which also showed that presence of "cerebellar plus symptoms" (p = 0.021) and structural abnormalities (p = 0.002) is related to a poor outcome. Most of the children with AA have "benign" etiology such as intoxication and post/parainfectious cerebellar ataxia with favorable outcomes. On the other hand, AA might be the first manifestation of CNS neoplasm or paraneoplastic phenomena. "The red flags" associated with cerebellar signs are limbs or facial palsy, hypotonia, GCS < 15, vomiting, opsoclonus, headache, myoclonus, visual impairment, torticollis, and vertigo. The presence of those signs and/or structural brain abnormalities was related to poor outcomes in children with AA.
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Affiliation(s)
- R Kravljanac
- Pediatric Clinic, Institute for Mother and Child Healthcare of Serbia, Belgrade, Serbia.
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.
| | - A Golubovic
- Institute for Pulmonology, University Clinical Center of Serbia, Belgrade, Serbia
| | - B Vucetic Tadic
- Pediatric Clinic, Institute for Mother and Child Healthcare of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - S Ostojic
- Pediatric Clinic, Institute for Mother and Child Healthcare of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - I Cerovic
- Pediatric Clinic, Institute for Mother and Child Healthcare of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - J Savkic
- Pediatric Clinic, Institute for Mother and Child Healthcare of Serbia, Belgrade, Serbia
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Hacohen Y. Pediatric Autoimmune Neurologic Disorders. Continuum (Minneap Minn) 2024; 30:1160-1188. [PMID: 39088292 DOI: 10.1212/con.0000000000001464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
OBJECTIVE This article discusses common principles in diagnosing and managing autoimmune neurologic conditions in children. LATEST DEVELOPMENTS The key to improving outcomes in all patients with autoimmune neurologic diseases is making an early diagnosis, promptly initiating treatment, and identifying patients who will benefit from long-term maintenance treatment. Some neuroinflammatory syndromes can be diagnosed with an antibody biomarker (eg, aquaporin-4 antibodies, N-methyl-d-aspartate [NMDA] receptor antibodies), whereas others require clinical diagnostic criteria (eg, multiple sclerosis, opsoclonus-myoclonus syndrome). A proportion of children will be labeled as seronegative, and further investigations for other inflammatory or monogenetic etiologies need to be carried out in parallel with treating the central nervous system inflammation. Time to treatment and treatment escalation were shown to correlate with outcomes in many patients with these disorders. The choice and duration of treatment should be evaluated considering side effects and risks in the short and long terms. The presence of a highly inflammatory disease process in children supports the use of highly effective disease-modifying therapies in pediatrics. ESSENTIAL POINTS The phenotypes of pediatric autoimmune neurologic conditions may change across different age groups, as the brain is still actively developing. In general, the presentation in children is more inflammatory, but overall disability is lower, likely because of better neuroplasticity and repair. Convincing evidence has increasingly emerged to support the biological rationale that effective immunosuppressive therapies used in adult neuroimmunology are equally effective in children.
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Kumar P, Willard VW, Embry L, Naranjo A, LaBarre B, Matthay KK, de Alarcon PA. Late cognitive and adaptive outcomes of patients with neuroblastoma-associated opsoclonus-myoclonus-ataxia-syndrome: A report from the Children's Oncology Group. Pediatr Blood Cancer 2024; 71:e31039. [PMID: 38689540 PMCID: PMC11116037 DOI: 10.1002/pbc.31039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Opsoclonus-myoclonus-ataxia syndrome (OMAS) is a rare autoimmune disorder of the nervous system presenting with abnormal eye and limb movements, altered gait, and increased irritability. Two to four percent of children diagnosed with neuroblastoma have neuroblastoma-associated OMAS (NA-OMAS). These children typically present with non-high-risk neuroblastoma that is cured with surgery, with or without chemotherapy. Despite excellent overall survival, patients with NA-OMAS can have significant persistent neurological and developmental issues. OBJECTIVE This study aimed to describe long-term neurocognitive and adaptive functioning of patients with NA-OMAS treated with multimodal therapy, including intravenous immunoglobulin (IVIG) on Children's Oncology Group (COG) protocol ANBL00P3. METHODS Of 53 children enrolled on ANBL00P3, 25 submitted evaluable neurocognitive data at diagnosis and at least one additional time point within 2 years and were included in the analyses. Adaptive development was assessed via the Vineland Adaptive Behavior Scale, and validated, age-appropriate measures of intellectual function were also administered. RESULTS Twenty-one of the 25 patients in this cohort ultimately received IVIG. Descriptive spaghetti plots suggest that this cohort demonstrated stable long-term cognitive functioning and adaptive development over time. This cohort also demonstrated decreased OMAS scores over time consistent with improved OMAS symptoms. CONCLUSIONS While statistical significance is limited by small sample size and loss to follow-up over 10 years, findings suggest stable long-term cognitive and adaptive functioning over time in this treated cohort.
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Affiliation(s)
- Prerna Kumar
- University of Illinois College of Medicine Peoria, Pediatrics, Peoria, IL
| | - Victoria W. Willard
- St. Jude Children’s Research Hospital, Psychology & Biobehavioral Sciences, Memphis, TN
| | - Leanne Embry
- UT Health San Antonio, Pediatrics, San Antonio, TX
| | - Arlene Naranjo
- University of Florida, Biostatistics, Children’s Oncology Group Statistics & Data Center, Gainesville, FL
| | - Brian LaBarre
- University of Florida, Biostatistics, Children’s Oncology Group Statistics & Data Center, Gainesville, FL
| | - Katherine K. Matthay
- University of California San Francisco School of Medicine and UCSF Benioff Children’s Hospital, Pediatric Oncology, San Francisco, CA
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Barahman M, Shamsaei G, Kashipazha D, Bahadoram M, Akade E. Paraneoplastic neurological syndromes of small cell lung cancer. POSTEPY PSYCHIATRII NEUROLOGII 2024; 33:80-92. [PMID: 39119541 PMCID: PMC11304241 DOI: 10.5114/ppn.2024.141157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 03/29/2024] [Indexed: 08/10/2024]
Abstract
Purpose This article reviews the relevant literature on paraneoplastic neurological syndromes of small cell lung cancer and discusses the clinical presentation, pathophysiology, and diagnosis of these syndromes. It also includes a summary of the current treatment options for the management of them. Views Paraneoplastic syndromes are a group of signs and symptoms that develop due to cancer in a remote site, mainly triggered by an autoantibody produced by the tissues involved or lymphocytes during anti-cancer defense. Among the cancers associated with paraneoplastic syndromes, lung cancers are the most common type, with small cell lung cancer being the most common subtype. The most common antibody associated with paraneoplastic syndromes is anti-Hu. Neurological and neuroendocrine syndromes comprise the majority of small cell lung cancer-related paraneoplastic syndromes. Classical paraneoplastic neurological syndromes include inappropriate antidiuretic hormone secretion, Cushing's syndrome, myasthenia gravis, Lambert-Eaton myasthenic syndrome, limbic encephalitis, paraneoplastic cerebellar degeneration, opsoclonus myoclonus ataxia, sensory neuropathy, and chorea. Conclusions Antibodies mediate paraneoplastic syndromes, and antibody detection is a crucial part of diagnosing these entities. Managing the underlying tumor is the best treatment approach for most paraneoplastic syndromes. Therefore, early diagnosis of small cell lung cancer may significantly improve the prognosis of paraneoplastic syndromes associated with it.
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Affiliation(s)
- Maedeh Barahman
- Department of Radiation Oncology, Firoozgar Hospital, Firoozgar Clinical Research Development Center (FCRDC), Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Gholamreza Shamsaei
- Department of Neurology, School of Medicine, Musculoskeletal Rehabilitation Research Center, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Davood Kashipazha
- Department of Neurology, School of Medicine, Musculoskeletal Rehabilitation Research Center, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohammad Bahadoram
- Department of Neurology, School of Medicine, Musculoskeletal Rehabilitation Research Center, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Esma’il Akade
- Department of Medical Virology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Zhou J, Jin M, Su Y, Zhuo X, Fu L, Ren X, Ren C, Zhou A, Li J, Zhang W. Clinical Presentation, Management, and Diagnostic Performance of 2021 Criteria for Paraneoplastic Neurologic Syndromes in Childhood. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200242. [PMID: 38657195 PMCID: PMC11087047 DOI: 10.1212/nxi.0000000000200242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/08/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND AND OBJECTIVES Paraneoplastic neurologic syndromes (PNSs) are remote neurologic immune-related effects of tumors. The clinical characteristics of pediatric PNSs remain unclear. We retrospectively examined the clinical characteristics of cases of pediatric PNSs and assessed the performance of the 2021 diagnostic criteria in children. METHODS Patients hospitalized in the Beijing Children's Hospital between June 2015 and June 2023 and fulfilling the description of definite by 2004 diagnostic criteria of PNSs were included. A retrospective analysis of clinical characteristics was conducted, and the 2021 diagnostic criteria were applied to rediagnostic stratification. RESULTS Among the 42 patients included, the most common neurologic syndrome was opsoclonus-myoclonus syndrome (OMS) (62%), followed by rapidly progressive cerebellar syndrome (26%). Most tumors were neuroblastomas (88%), with few being ovarian teratomas (10%). Approximately 71% (30/42) of patients were classified as definite and 24% (10/42) as probable according to the 2021 criteria. All cases judged as probable exhibited rapidly progressive cerebellar ataxia with neuroblastoma. For OMS, chemotherapy was administered based on the tumor's risk stage, accompanied by regular infusion of IV gamma globulin and oral steroids following tumor diagnosis. Twenty-one patients underwent regular follow-ups over 4.92 (0.58-7.58) years. The initial hospitalization recorded a median score of 12 (7-14) on the Mitchell and Pike OMS rating scale, decreasing to 0 (0-5) at the final follow-up. In cases of rapidly progressive cerebellar syndrome, a similar therapeutic regimen was used. Nine patients underwent regular follow-ups over 4.42 (1.17-7.50) years. The mean modified Rankin scale score at first hospitalization was 4 (3-4), reducing to 1 (0-4) at the final follow-up. Only 17% (5/30) of patients across both groups exhibited poor response to this regimen. Among these 5 patients, 4 belonged to the low-risk group (without chemotherapy). DISCUSSION OMS followed by rapidly progressive cerebellar ataxia are the most common forms of PNSs in children and are associated with neuroblastoma. An aggressive approach with multiple immunotherapies may improve the prognosis of neuroblastoma-associated PNSs. The 2021 criteria perform well in pediatric PNSs. However, we propose upgrading the classification of antibody-negative rapidly progressive cerebellar ataxia with neuroblastoma to definite diagnosis. This adjustment aims to further improve the diagnostic efficacy of this diagnostic criterion in childhood.
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Affiliation(s)
- Ji Zhou
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Mei Jin
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Yan Su
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Xiuwei Zhuo
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Libing Fu
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Xiaotun Ren
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Changhong Ren
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Anna Zhou
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Jiuwei Li
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Weihua Zhang
- From the Department of Neurology (J.Z., X.Z., X.R., C.R., A.Z., J.L., W.Z.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Medical Oncology Department (M.J., Y.S.), Pediatric Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children; and Department of Pathology (L.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
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Feng L, Yang S, Lin Y, Li J, Cao Z, Zheng Q, Wang H, Yang J. Diagnostic value of 18F-fluorodeoxyglucose positron emission tomography/computed tomography imaging in pediatric opsoclonus myoclonus ataxia syndrome presenting with neuroblastoma. Pediatr Radiol 2024; 54:954-964. [PMID: 38613691 DOI: 10.1007/s00247-024-05921-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Early precision diagnosis and effective treatment of opsoclonus myoclonus ataxia syndrome (OMAS) patients presenting with neuroblastoma can prevent serious neurological outcomes. OBJECTIVE To assess the diagnostic value of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) imaging in pediatric OMAS with neuroblastoma. MATERIALS AND METHODS A retrospective evaluation of 45 patients diagnosed with OMAS who underwent 18F-FDG PET/CT was performed. A univariate analysis was performed to compare clinical characteristics between OMAS with and without neuroblastoma. Univariate and multivariate logistic regression analyses were applied to identify independent risk factors for OMAS with neuroblastoma and to develop the clinical model. Finally, independent risk factors and PET/CT were fitted to build the combined model for the diagnosis of OMAS with neuroblastoma and presented as a nomogram. Receiver operating characteristic curve, decision curve, and calibration curve analyses were conducted to evaluate the performance of the models. RESULTS Among 45 patients, 27 were PET/CT-positive, 23/27 lesions were neuroblastoma, and four were false positives. One of the false positive patients was confirmed to be adrenal reactive hyperplasia by postoperative pathology, and the symptoms of OMAS disappeared in the remaining three cases during clinical follow-up. The average maximal standardized uptake value of PET/CT-positive lesions was 2.6. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of PET/CT were 100%, 81.8%, 85.2%, 100%, and 91.1%, respectively. Age at diagnosis, lactate dehydrogenase, and neuron-specific enolase showed statistically significant differences between OMAS with and without neuroblastoma. Lactate dehydrogenase was identified as the independent risk factor to develop the clinical model, and the clinical model demonstrated an area under the curve (AUC) of 0.82 for the diagnosis of OMAS with neuroblastoma, with an AUC as high as 0.91 when combined with PET/CT. The decision curve analysis and calibration curve demonstrated that the nomogram had good consistency and clinical usefulness. CONCLUSION In patients with OMAS, 18F-FDG PET/CT has a high diagnostic accuracy in detecting tumors of the neuroblastoma, especially when combined with the independent risk factor serum lactate dehydrogenase.
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Affiliation(s)
- Lijuan Feng
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Shen Yang
- Department of Surgical Oncology, Beijing Children's Hospital, Beijing, China
| | - Yu Lin
- Department of Surgical Oncology, Beijing Children's Hospital, Beijing, China
| | - Jiuwei Li
- Department of Neurology, Beijing Children's Hospital, Beijing, China
| | - Zhenhua Cao
- Department of Thoracic Surgery and Surgical Oncology, Children's Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Qipeng Zheng
- Department of Thoracic Surgery and Surgical Oncology, Children's Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Huanmin Wang
- Department of Surgical Oncology, Beijing Children's Hospital, Beijing, China
| | - Jigang Yang
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China.
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10
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Delap S, Shah N, Kuns O, Franklin B, Skeens MA. Successful use of tacrolimus for treatment-refractory neuroblastoma-associated opsoclonus-myoclonus-ataxia syndrome: A case series. Pediatr Blood Cancer 2024; 71:e30903. [PMID: 38321586 DOI: 10.1002/pbc.30903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 01/17/2024] [Accepted: 01/21/2024] [Indexed: 02/08/2024]
Abstract
Opsoclonus-myoclonus-ataxia syndrome (OMAS) is an autoimmune central nervous system disorder, primarily manifesting as a paraneoplastic sequalae to neuroblastoma, and characterized by motor disorders and behavioral disturbances. OMAS is typified by aberrant B-cell and T-cell activation. Current treatment involves immunosuppression using corticosteroids, intravenous immunoglobulin, and rituximab. However, these approaches often lead to treatment-related toxicities and symptomatic recurrences with chronic neurocognitive impairment. We treated three children with refractory neuroblastoma-associated OMAS with tacrolimus, a T-cell-targeting calcineurin inhibitor, effectively controlling symptoms within a month and enabling the discontinuation of immunosuppression with minimal side effects. Tacrolimus shows promise as a therapeutic option for refractory OMAS.
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Affiliation(s)
- Sara Delap
- Department of Hospital Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatrics, Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Nilay Shah
- Department of Pediatrics, Ohio State University College of Medicine, Columbus, Ohio, USA
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Olivia Kuns
- Center for Biobehavioral Health, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Bianca Franklin
- Center for Biobehavioral Health, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Micah A Skeens
- Department of Pediatrics, Ohio State University College of Medicine, Columbus, Ohio, USA
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Biobehavioral Health, Nationwide Children's Hospital, Columbus, Ohio, USA
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11
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Almudhry M, Wagner MW, Longoni G, Yea C, Vidarsson L, Ertl-Wagner B, Yeh EA. Brain Volumes in Opsoclonus-Myoclonus Ataxia Syndrome: A Longitudinal Study. J Child Neurol 2024; 39:129-134. [PMID: 38544431 PMCID: PMC11102640 DOI: 10.1177/08830738241240181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/27/2024] [Accepted: 03/03/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Little is known about the longitudinal trajectory of brain growth in children with opsoclonus-myoclonus ataxia syndrome. We performed a longitudinal evaluation of brain volumes in pediatric opsoclonus-myoclonus ataxia syndrome patients compared with age- and sex-matched healthy children. PATIENTS AND METHODS This longitudinal case-control study included brain magnetic resonance imaging (MRI) scans from consecutive pediatric opsoclonus-myoclonus ataxia syndrome patients (2009-2020) and age- and sex-matched healthy control children. FreeSurfer analysis provided automatic volumetry of the brain. Paired t tests were performed on the curvature of growth trajectories, with Bonferroni correction. RESULTS A total of 14 opsoclonus-myoclonus ataxia syndrome patients (12 female) and 474 healthy control children (406 female) were included. Curvature of the growth trajectories of the cerebral white and gray matter, cerebellar white and gray matter, and brainstem differed significantly between opsoclonus-myoclonus ataxia syndrome patients and healthy control children (cerebral white matter, P = .01; cerebral gray matter, P = .01; cerebellar white matter, P < .001; cerebellar gray matter, P = .049; brainstem, P < .01). DISCUSSION/CONCLUSION We found abnormal brain maturation in the supratentorial brain, brainstem, and cerebellum in children with opsoclonus-myoclonus ataxia syndrome.
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Affiliation(s)
- Montaha Almudhry
- Program in Neurosciences and Mental Health, SickKids Research Institute, The Hospital for Sick Children, Canada
| | - Matthias W. Wagner
- Division of Neuroradiology, Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Giulia Longoni
- Program in Neurosciences and Mental Health, SickKids Research Institute, The Hospital for Sick Children, Canada
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Carmen Yea
- Program in Neurosciences and Mental Health, SickKids Research Institute, The Hospital for Sick Children, Canada
| | - Logi Vidarsson
- Division of Neuroradiology, Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Birgit Ertl-Wagner
- Program in Neurosciences and Mental Health, SickKids Research Institute, The Hospital for Sick Children, Canada
- Division of Neuroradiology, Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - E. Ann Yeh
- Program in Neurosciences and Mental Health, SickKids Research Institute, The Hospital for Sick Children, Canada
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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12
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Rossor T, Lim M. Immune-mediated encephalitis. Dev Med Child Neurol 2024; 66:307-316. [PMID: 37438863 DOI: 10.1111/dmcn.15694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 07/14/2023]
Abstract
A neurological deterioration in a child presents a significant worry to the family and often a diagnostic challenge to the clinician. A dysregulated immune response is implicated in a wide and growing spectrum of neurological conditions. In this review we consider the current paradigms in which immune-mediated encephalopathies are considered; the development of paediatric specific diagnostic criteria that facilitate early consideration and treatment of immune-mediated conditions and the limitations and potential developments in diagnostic testing. We consider the expanding phenotype of myelin oligodendrocyte glycoprotein antibody, the spectrum of virus-associated encephalopathy syndromes, and the strategies that have been employed to build an evidence base for the management of these rare conditions. Looking forward we explore the potential for advanced molecular investigations to improve our understanding of immune-mediated encephalitides and guide future treatment strategies. Recently characterized immune-mediated central nervous system disorders include new antibodies causing previously recognized phenotypes. Aggregation of conditions with similar clinical triggers, and characterization of unique imaging features in virus-associated encephalopathy syndromes. Immune treatment iscurrently guided by meta-analysis of individualized patient data and/or multi-national consensus.
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Affiliation(s)
- Thomas Rossor
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, London, UK
- Department Women and Children's Health, School of Life Course Sciences, King's College London, UK
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13
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Prabaharan H, Chandrasekaran S, Shetty N, Nayak K P. Benign paraspinal ganglioneuroma with paraneoplastic opsoclonus myoclonus syndrome. BMJ Case Rep 2024; 17:e256846. [PMID: 38417946 PMCID: PMC10900366 DOI: 10.1136/bcr-2023-256846] [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: 03/01/2024] Open
Abstract
Opsoclonus-myoclonus-ataxia syndrome (OMAS) is a rare immune-mediated movement disorder occurring as a paraneoplastic manifestation of neuroblastic tumours (NTs), especially neuroblastoma in infancy. Ganglioneuroma (GN), the benign tumour in the spectrum, is rarely associated with OMAS. We report the case of a child in her second year of life presenting with acute onset of progressive paraplegia and OMAS. MRI showed diffuse and infiltrating left paraspinal mass from T3-T9 levels with differentials of neuroblastoma or ganglioneuroblastoma. Histopathological and immunohistochemistry examination of the excised tumour showed maturing GN. The OMAS was managed with intravenous immunoglobulin and steroids. In the 6-month follow-up, the child has a residual motor weakness with myelomalacia in neuroimaging. The case report substantiates the occurrence of OMAS as paraneoplastic manifestation in NTs, including benign, in children younger than 2 years with a female predilection.
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Affiliation(s)
- Haritha Prabaharan
- Pediatrics, NITTE (Deemed to be University), Mangalore, Karnataka, India
| | | | - Niharika Shetty
- Pediatrics, KS Hegde Medical Academy, Mangalore, Karnataka, India
| | - Praveen Nayak K
- Pediatrics, KS Hegde Medical Academy, Mangalore, Karnataka, India
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14
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Aktekin EH, Gezer HÖ, Yazıcı N, Erol İ, Erbay A, Sarıalioğlu F. Five Years Follow-up of Opsoclonus-Myoclonus-Ataxia Syndrome-Associated Neurogenic Tumors in Children. Neuropediatrics 2024; 55:57-62. [PMID: 37019145 DOI: 10.1055/s-0043-1768143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
AIM Opsoclonus-myoclonus-ataxia syndrome (OMAS) is a rare autoimmune disorder. Approximately half of the cases are associated with neuroblastoma in children. This study's aim is to review management of our cases with OMAS-associated neuroblastoma for treatment approach as well as long-term follow-up. METHODS Age at onset of symptoms and tumor diagnosis, tumor location, histopathology, stage, chemotherapy, OMAS protocol, surgery, and follow-up period were evaluated retrospectively in six patients between 2007 and 2022. RESULTS Mean age of onset of OMAS findings was 13.5 months and mean age at tumor diagnosis was 15.1 months. Tumor was located at thorax in three patients and surrenal in others. Four patients underwent primary surgery. Histopathological diagnosis was ganglioneuroblastoma in three, neuroblastoma in two, and undifferentiated neuroblastoma in one. One patient was considered as stage 1 and rest of them as stage 2. Chemotherapy was provided in five cases. The OMAS protocol was applied to five patients. Our protocol is intravenous immunoglobulin (IVIG) 1 g/kg/d for 2 consecutive days once a month and dexamethasone for 5 days (20 mg/m2/d for 1-2 days, 10 mg/m2/d for 3-4 days, and 5 mg/m2/d for the fifth day) once a month, alternatively by 2-week intervals. Patients were followed up for a mean of 8.1 years. Neuropsychiatric sequelae were detected in two patients. CONCLUSION In tumor-related cases, alternating use of corticosteroid and IVIG for suppression of autoimmunity as the OMAS protocol, total excision of the tumor as soon as possible, and chemotherapeutics in selected patients seem to be related to resolution of acute problems, long-term sequelae, and severity.
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Affiliation(s)
- Elif Habibe Aktekin
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Baskent University, Adana, Turkey
| | | | - Nalan Yazıcı
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Baskent University, Adana, Turkey
| | - İlknur Erol
- Division of Pediatric Neurology, Department of Pediatrics, Baskent University, Adana, Turkey
| | - Ayşe Erbay
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Baskent University, Adana, Turkey
| | - Faik Sarıalioğlu
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Baskent University, Adana, Turkey
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15
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Holla VV, Pal PK. Overview of management of infection-related movement disorders with focus on specific-infections. Clin Park Relat Disord 2024; 10:100233. [PMID: 38304096 PMCID: PMC10831291 DOI: 10.1016/j.prdoa.2024.100233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 12/09/2023] [Accepted: 01/05/2024] [Indexed: 02/03/2024] Open
Abstract
Infections are important treatable causes of secondary movement disorders (MD) that can have heterogeneous presentations. According to various studies, infection-related movement disorders (IRMD) account for around 10-20% of secondary MD. Certain infections have a predilection for causing various MD, and some MD phenomenologies, such as acute cerebellar ataxia and opsoclonus-myoclonus-ataxia syndromes (OMAS), suggest a strong possibility of an underlying infectious cause. The underlying pathophysiology is multifaceted, including direct neuronal damage due to neurotropism, granulomas, abscesses causing structural damage, and inflammatory and autoimmune responses triggered by infections. Understanding the prevalence, spectrum, and pattern of these IRMD and common infections that are responsible helps in early diagnosis, and instituting appropriate, timely treatment, thereby improving the overall prognosis and avoiding unnecessary investigations. In this review, we aim to provide a brief overview of common infections associated with MD, common clinical presentations of IRMD, their underlying pathophysiology, and overall approach to their treatment, with a focus on specific treatments of prevalent and treatable IRMD.
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Affiliation(s)
- Vikram V Holla
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, 560029, Karnataka, India
| | - Pramod Kumar Pal
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, 560029, Karnataka, India
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16
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Vozar A, Dugas J, Mains N. Opsoclonus in a Pediatric Patient With COVID-19 Infection. Clin Pediatr (Phila) 2024; 63:119-121. [PMID: 37991173 DOI: 10.1177/00099228231212770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Affiliation(s)
- Amber Vozar
- Department of Pediatrics, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - John Dugas
- Department of Pediatrics, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Nicholas Mains
- Department of Pediatrics, School of Medicine, West Virginia University, Morgantown, WV, USA
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17
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Kadish R, Clardy SL. Epidemiology of paraneoplastic neurologic syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:57-77. [PMID: 38494297 DOI: 10.1016/b978-0-12-823912-4.00011-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes (PNS), initially depicted as seemingly cryptic remote manifestations of malignancy, were first described clinically in the early 20th century, with pathophysiologic correlates becoming better elucidated in the latter half of the century. There remain many questions not only about the pathophysiology but also regarding the epidemiology of these conditions. The continuous discovery of novel autoantigens and related neurologic disease has broadened the association in classical PNS to include conditions such as paraneoplastic cerebellar degeneration. It has also brought into focus several other neurologic syndromes with a putative neoplastic association. These conditions are overall rare, making it difficult to capture large numbers of patients to study, and raising the question of whether incidence is increasing over time or improved identification is driving the increased numbers of cases. With the rise and increasing use of immunotherapy for cancer treatment, the incidence of these conditions is additionally expected to rise and may present with various clinical symptoms. As we enter an era of clinical trial intervention in these conditions, much work is needed to capture more granular data on population groups defined by socioeconomic characteristics such as age, ethnicity, economic resources, and gender to optimize care and clinical trial planning.
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Affiliation(s)
- Robert Kadish
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Stacey L Clardy
- Department of Neurology, University of Utah, Salt Lake City, UT, United States; George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States.
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18
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Abbatemarco JR, Vedeler CA, Greenlee JE. Paraneoplastic cerebellar and brainstem disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:173-191. [PMID: 38494276 DOI: 10.1016/b978-0-12-823912-4.00030-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic cerebellar and brainstem disorders are a heterogeneous group that requires prompt recognition and treatment to help prevent irreversible neurologic injury. Paraneoplastic cerebellar degeneration is best characterized by Yo antibodies in patients with breast or ovarian cancer. Tr (DNER) antibodies in patients with Hodgkin lymphoma can also present with a pure cerebellar syndrome and is one of the few paraneoplastic syndromes found with hematological malignancy. Opsoclonus-myoclonus-ataxia syndrome presents in both pediatric and adult patients with characteristic clinical findings. Other paraneoplastic brainstem syndromes are associated with Ma2 and Hu antibodies, which can cause widespread neurologic dysfunction. The differential for these disorders is broad and also includes pharmacological side effects, infection or postinfectious processes, and neurodegenerative diseases. Although these immune-mediated disorders have been known for many years, mechanisms of pathogenesis are still unclear, and optimal treatment has not been established.
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Affiliation(s)
- Justin R Abbatemarco
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, United States.
| | - Christian A Vedeler
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, University of Bergen, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - John E Greenlee
- Neurology Service, George E. Wahlen Veterans Affairs Health Care System, Salt Lake City, UT, United States; Department of Neurology, University of Utah, Salt Lake City, UT, United States
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19
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Al-Muqbel K, Alardah H, Al-Smadi R, Al-Khatib S, Abughanmi R. Cervical Ganglioneuroblastoma Diagnosed by 68Ga-DOTATOC PET/CT in a Child with Opsoclonus Myoclonus Syndrome. J Nucl Med Technol 2023; 51:337-338. [PMID: 37586852 DOI: 10.2967/jnmt.123.265776] [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] [Received: 04/05/2023] [Revised: 07/06/2023] [Indexed: 08/18/2023] Open
Abstract
We performed a 68Ga-DOTATOC PET/CT scan on a 25-mo-old female patient who presented with opsoclonus myoclonus ataxia syndrome and had negative initial anatomic imaging. The scan showed a somatostatin receptor-overexpressing cervical tumor in favor of a cervical neuroendocrine tumor, with subsequent histopathologic findings of ganglioneuroblastoma.
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Affiliation(s)
- Kusai Al-Muqbel
- Department of Radiology and Nuclear Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Hamza Alardah
- Department of Radiology and Nuclear Medicine, Jordan University of Science and Technology, Irbid, Jordan;
| | - Ruba Al-Smadi
- Department of Radiology and Nuclear Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Sohaib Al-Khatib
- Department of Pathology, Jordan University of Science and Technology, Irbid, Jordan; and
| | - Raya Abughanmi
- Department of Neurosurgery, Jordan University of Science and Technology, Irbid, Jordan
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20
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Anuar MA, Lee JX, Musa H, Abd Hadi D, Majawit E, Anandakrishnan P, Murugesu S, Mohamed AR, Khoo TB. Severe and rare neurological manifestations following COVID-19 infection in children: A Malaysian tertiary centre experience. Brain Dev 2023; 45:547-553. [PMID: 37661525 DOI: 10.1016/j.braindev.2023.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 09/05/2023]
Abstract
INTRODUCTION Since the emergence of COVID-19, we have experienced potent variants and sub-variants of the virus with non-specific neurological manifestations. We observed a surge of the Omicron variant of COVID-19 patients with neurological manifestations where less cases of multisystem inflammatory syndrome in children (MIS-C) were reported. This article describes our experience of children with severe and rare neurological manifestations following COVID-19 infection. METHODS This is a retrospective observational case series of patients under 18 years old who fulfilled the WHO COVID-19 case definition and were referred to our paediatric neurology unit at Hospital Tunku Azizah Kuala Lumpur. Their demographic data, neurological symptoms, laboratory and supporting investigations, neuroimaging, treatment and outcomes were collected and analysed. RESULTS There were eleven patients with neurological manifestations who fulfilled the WHO COVID-19 case definition. Nine patients presented with seizures and/or encephalopathy, one patient with eye opsoclonus and another patient with persistent limbs myokymia. Based on the history, clinical, electrophysiological and radiological findings, two of them had febrile infection-related epilepsy syndrome, two had acute disseminated encephalomyelitis, two had acute necrotising encephalopathy of childhood, one each had hemiconvulsion-hemiplegia-epilepsy syndrome, acute encephalopathy with bilateral striatal necrosis, hemi-acute encephalopathy with biphasic seizures and reduced diffusion, infection-associated opsoclonus and myokymia. CONCLUSIONS This case series highlighted a wide spectrum of neurological manifestations of COVID-19 infection. Early recognition and prompt investigations are important to provide appropriate interventions. It is essential that these investigations should take place in a timely fashion and COVID-19 quarantine period should not hinder the confirmation of various presenting clinical syndromes.
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Affiliation(s)
- Muhamad Azamin Anuar
- Paediatric Neurology Unit, Hospital Tunku Azizah Kuala Lumpur, Malaysia; Department of Paediatrics, Kulliyyah of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia.
| | - Jun Xiong Lee
- Paediatric Neurology Unit, Hospital Tunku Azizah Kuala Lumpur, Malaysia
| | - Husna Musa
- Paediatric Neurology Unit, Hospital Tunku Azizah Kuala Lumpur, Malaysia; Department of Paediatrics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia
| | - Dianah Abd Hadi
- Paediatric Neurology Unit, Hospital Tunku Azizah Kuala Lumpur, Malaysia
| | - Elyssa Majawit
- Paediatric Neurology Unit, Hospital Tunku Azizah Kuala Lumpur, Malaysia
| | | | - Sumitha Murugesu
- Paediatric Neurology Unit, Hospital Tunku Azizah Kuala Lumpur, Malaysia
| | | | - Teik Beng Khoo
- Paediatric Neurology Unit, Hospital Tunku Azizah Kuala Lumpur, Malaysia
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21
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Conti F, Moratti M, Leonardi L, Catelli A, Bortolamedi E, Filice E, Fetta A, Fabi M, Facchini E, Cantarini ME, Miniaci A, Cordelli DM, Lanari M, Pession A, Zama D. Anti-Inflammatory and Immunomodulatory Effect of High-Dose Immunoglobulins in Children: From Approved Indications to Off-Label Use. Cells 2023; 12:2417. [PMID: 37830631 PMCID: PMC10572613 DOI: 10.3390/cells12192417] [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] [Received: 08/07/2023] [Revised: 09/23/2023] [Accepted: 10/05/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND The large-scale utilization of immunoglobulins in patients with inborn errors of immunity (IEIs) since 1952 prompted the discovery of their key role at high doses as immunomodulatory and anti-inflammatory therapy, in the treatment of IEI-related immune dysregulation disorders, according to labelled and off-label indications. Recent years have been dominated by a progressive imbalance between the gradual but constant increase in the use of immunoglobulins and their availability, exacerbated by the SARS-CoV-2 pandemic. OBJECTIVES To provide pragmatic indications for a need-based application of high-dose immunoglobulins in the pediatric context. SOURCES A literature search was performed using PubMed, from inception until 1st August 2023, including the following keywords: anti-inflammatory; children; high dose gammaglobulin; high dose immunoglobulin; immune dysregulation; immunomodulation; immunomodulatory; inflammation; intravenous gammaglobulin; intravenous immunoglobulin; off-label; pediatric; subcutaneous gammaglobulin; subcutaneous immunoglobulin. All article types were considered. IMPLICATIONS In the light of the current imbalance between gammaglobulins' demand and availability, this review advocates the urgency of a more conscious utilization of this medical product, giving indications about benefits, risks, cost-effectiveness, and administration routes of high-dose immunoglobulins in children with hematologic, neurologic, and inflammatory immune dysregulation disorders, prompting further research towards a responsible employment of gammaglobulins and improving the therapeutical decisional process.
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Affiliation(s)
- Francesca Conti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
| | - Mattia Moratti
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Lucia Leonardi
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00185 Rome, Italy;
| | - Arianna Catelli
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Elisa Bortolamedi
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Emanuele Filice
- Department of Pediatrics, Maggiore Hospital, 40133 Bologna, Italy;
| | - Anna Fetta
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell’Età Pediatrica, 40139 Bologna, Italy
| | - Marianna Fabi
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Elena Facchini
- Pediatric Oncology and Hematology Unit “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.F.); (M.E.C.)
| | - Maria Elena Cantarini
- Pediatric Oncology and Hematology Unit “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.F.); (M.E.C.)
| | - Angela Miniaci
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
| | - Duccio Maria Cordelli
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell’Età Pediatrica, 40139 Bologna, Italy
| | - Marcello Lanari
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Andrea Pession
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
| | - Daniele Zama
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
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22
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Marion P, Chalus AD, Giorgi L, Bellesme C, Crétien P, Maurey H, Deiva K. Early and Aggressive Treatment May Modify Anti-Hu Associated Encephalitis Prognosis. Neuropediatrics 2023; 54:64-67. [PMID: 35817357 DOI: 10.1055/a-1896-6687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Anti-Hu encephalitis is a paraneoplastic syndrome in adults. In children, rare cases of anti-Hu encephalitis were reported mostly without underlying tumors and clinical outcome are usually severe. Here, we describe a 4-year-old girl who developed cerebellar syndrome with abnormal behavior. The brain magnetic resonance imaging showed several T2/fluid-attenuated inversion recovery bilateral brain lesions and autoimmune assessment showed positive anti-Hu antibodies. Computed tomography scan revealed ganglioneuroblastoma which was surgically removed 3 months after onset. Aggressive immunotherapy including dexamethasone, rituximab, and intravenous immunoglobulins were used and a marked neurological improvement soon after 9 months of onset was observed with the child being able to go back to school. The short delay between diagnosis and start of aggressive immunotherapy demonstrate the paramount importance of early diagnosis and early specific therapy after onset of symptoms.
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Affiliation(s)
- Perrine Marion
- Pediatric Neurology Department, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Saclay, Le Kremlin Bicêtre, France
| | - Aliénor De Chalus
- Pediatric Neurology Department, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Saclay, Le Kremlin Bicêtre, France
| | - Laetitia Giorgi
- Pediatric Neurology Department, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Saclay, Le Kremlin Bicêtre, France
| | - Céline Bellesme
- Pediatric Neurology Department, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Saclay, Le Kremlin Bicêtre, France
| | - Pascale Crétien
- Pediatric Neurology Department, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Saclay, Le Kremlin Bicêtre, France
| | - Hélène Maurey
- Pediatric Neurology Department, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Saclay, Le Kremlin Bicêtre, France.,Pediatric Neurologic Department, National Referral Center for Rare Brain and Spinal Diseases, Le Kremlin-Bicêtre, France
| | - Kumaran Deiva
- Pediatric Neurology Department, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Saclay, Le Kremlin Bicêtre, France.,Pediatric Neurologic Department, National Referral Center for Rare Brain and Spinal Diseases, Le Kremlin-Bicêtre, France.,Inserm UMR 1184, Immunology of Viral Infections and Autoimmune Diseases, CEA, IDMIT, Le Kremlin Bicêtre, France
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23
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Dalmau J, Dalakas MC, Kolson DL, Paul F, Sánchez-Valle R, Zamvil SS. N2 Year in Review. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:10/1/e200076. [PMID: 36596717 PMCID: PMC9827124 DOI: 10.1212/nxi.0000000000200076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Josep Dalmau
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (J.D., R.S.-V.), Hospital Clínic, Universitat de Barcelona, Spain; Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain; Department of Neurology (J.D., D.L.K.), University of Pennsylvania, Philadelphia; Neuroimmunology Unit (M.C.D.), National and Kapodistrian University of Athens Medical School, Greece; Thomas Jefferson University (M.C.D.), Philadelphia, PA; Charité-Universitätsmedizin Berlin und Max Delbrueck Center for Molecular Medicine (F.P.), Germany; and Department of Neurology (S.S.Z.), Weill Institute for Neurosciences and Program in Immunology, University of California, San Francisco.
| | - Marinos C Dalakas
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (J.D., R.S.-V.), Hospital Clínic, Universitat de Barcelona, Spain; Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain; Department of Neurology (J.D., D.L.K.), University of Pennsylvania, Philadelphia; Neuroimmunology Unit (M.C.D.), National and Kapodistrian University of Athens Medical School, Greece; Thomas Jefferson University (M.C.D.), Philadelphia, PA; Charité-Universitätsmedizin Berlin und Max Delbrueck Center for Molecular Medicine (F.P.), Germany; and Department of Neurology (S.S.Z.), Weill Institute for Neurosciences and Program in Immunology, University of California, San Francisco
| | - Dennis L Kolson
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (J.D., R.S.-V.), Hospital Clínic, Universitat de Barcelona, Spain; Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain; Department of Neurology (J.D., D.L.K.), University of Pennsylvania, Philadelphia; Neuroimmunology Unit (M.C.D.), National and Kapodistrian University of Athens Medical School, Greece; Thomas Jefferson University (M.C.D.), Philadelphia, PA; Charité-Universitätsmedizin Berlin und Max Delbrueck Center for Molecular Medicine (F.P.), Germany; and Department of Neurology (S.S.Z.), Weill Institute for Neurosciences and Program in Immunology, University of California, San Francisco
| | - Friedemann Paul
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (J.D., R.S.-V.), Hospital Clínic, Universitat de Barcelona, Spain; Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain; Department of Neurology (J.D., D.L.K.), University of Pennsylvania, Philadelphia; Neuroimmunology Unit (M.C.D.), National and Kapodistrian University of Athens Medical School, Greece; Thomas Jefferson University (M.C.D.), Philadelphia, PA; Charité-Universitätsmedizin Berlin und Max Delbrueck Center for Molecular Medicine (F.P.), Germany; and Department of Neurology (S.S.Z.), Weill Institute for Neurosciences and Program in Immunology, University of California, San Francisco
| | - Raquel Sánchez-Valle
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (J.D., R.S.-V.), Hospital Clínic, Universitat de Barcelona, Spain; Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain; Department of Neurology (J.D., D.L.K.), University of Pennsylvania, Philadelphia; Neuroimmunology Unit (M.C.D.), National and Kapodistrian University of Athens Medical School, Greece; Thomas Jefferson University (M.C.D.), Philadelphia, PA; Charité-Universitätsmedizin Berlin und Max Delbrueck Center for Molecular Medicine (F.P.), Germany; and Department of Neurology (S.S.Z.), Weill Institute for Neurosciences and Program in Immunology, University of California, San Francisco
| | - Scott S Zamvil
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (J.D., R.S.-V.), Hospital Clínic, Universitat de Barcelona, Spain; Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain; Department of Neurology (J.D., D.L.K.), University of Pennsylvania, Philadelphia; Neuroimmunology Unit (M.C.D.), National and Kapodistrian University of Athens Medical School, Greece; Thomas Jefferson University (M.C.D.), Philadelphia, PA; Charité-Universitätsmedizin Berlin und Max Delbrueck Center for Molecular Medicine (F.P.), Germany; and Department of Neurology (S.S.Z.), Weill Institute for Neurosciences and Program in Immunology, University of California, San Francisco
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24
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Reinecke R, Reiländer A, Seiler A, Koch C, Voss M. Opsoclonus-myoclonus syndrome associated with pancreatic neuroendocrine tumor: a case report. BMC Neurol 2022; 22:507. [PMID: 36581905 PMCID: PMC9801616 DOI: 10.1186/s12883-022-03012-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 12/06/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Opsoclonus-myoclonus syndrome (OMS) is a rare, immune-mediated neurological disorder. In adults, the pathogenesis can be idiopathic, post-infectious or paraneoplastic, the latter etiology belonging to the ever-expanding group of defined paraneoplastic neurological syndromes (PNS). In contrast to other phenotypes of PNS, OMS cannot be ascribed to a single pathogenic autoantibody. Here, we report the first detailed case of paraneoplastic, antibody-negative OMS occurring in association with a pancreatic neuroendocrine tumor (pNET). CASE PRESENTATION A 33-year-old female presented with a two-week history of severe ataxia of stance and gait, dysarthria, head tremor, myoclonus of the extremities and opsoclonus. Her past medical history was notable for a metastatic pancreatic neuroendocrine tumor, and she was subsequently diagnosed with paraneoplastic opsoclonus-myoclonus syndrome. Further workup did not reveal a paraneoplastic autoantibody. She responded well to plasmapheresis, as she was refractory to the first-line therapy with corticosteroids. CONCLUSIONS This case expands current knowledge on tumors associated with paraneoplastic opsoclonus-myoclonus syndrome and the age group in which it can occur. It further adds evidence to the effectiveness of plasmapheresis in severe cases of opsoclonus-myoclonus syndrome with a lack of response to first-line therapy.
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Affiliation(s)
- Raphael Reinecke
- grid.7839.50000 0004 1936 9721Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721Dr. Senckenberg Institute of Neurooncology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Annemarie Reiländer
- grid.7839.50000 0004 1936 9721Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Alexander Seiler
- grid.7839.50000 0004 1936 9721Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Christine Koch
- grid.7839.50000 0004 1936 9721Department of Gastroenterology, Hepatology and Endocrinology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Martin Voss
- grid.7839.50000 0004 1936 9721Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721Dr. Senckenberg Institute of Neurooncology, Goethe University Frankfurt, Frankfurt am Main, Germany
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25
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Clinical features and outcomes of opsoclonus myoclonus ataxia syndrome. Eur J Paediatr Neurol 2022; 41:19-26. [PMID: 36155293 DOI: 10.1016/j.ejpn.2022.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 08/14/2022] [Accepted: 09/14/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES AND METHODS Opsoclonus myoclonus ataxia syndrome (OMAS) is a rare neuroinflammatory disorder. We aimed to retrospectively evaluate clinical and laboratory data and outcomes of 23 children diagnosed with OMAS in two children's hospitals between 2010 and 2021. RESULTS There were 14 boys and 9 girls aged 4-113 months, median 24 months. Ten (43.5%) children had paraneoplastic causes: neuroblastoma/ganglioneuroblastoma (n = 9), acute lymphoblastic leukemia (n = 1). Three children had a postinfectious cause (upper respiratory tract infection in 2, EBV infection in 1) and two had a history of vaccination (varicella in 1, hepatitis A and meningococcal in 1). No underlying factor was identified in 8 (34.8%) children. Speech disorders were more frequent in patients with neural tumors than in those without (p = 0.017). Intravenous immunoglobulin and steroids were effective as initial treatment in most children. Rituximab resulted in at least mild improvement in all 6 children with persistent or recurrent symptoms. Nine (39%) children experienced at least one relapse. Neurological sequelae were detected in 13 (57%) children. There was no significant correlation between clinical characteristics and outcome, except for higher risk of relapse in case of incomplete recovery after first attack (p = 0.001). CONCLUSIONS Acute lymphoblastic leukemia, vaccines against hepatitis A and meningococci can be included among antecedent factors in OMAS. Among clinical symptoms, speech problems might point to the likelihood of an underlying neoplasm in OMAS. Intravenous immunoglobulin and steroids may be chosen for initial treatment while rituximab can increase the chance of recovery in case of persistent or recurrent symptoms. The presence of relapse was associated with poor outcome.
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26
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Rossor T, Lim M. OMAS editorial. Eur J Paediatr Neurol 2022; 41:A3. [PMID: 36400623 DOI: 10.1016/j.ejpn.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Thomas Rossor
- Children's Neurosciences, Evelina London Hospital, London SE17EH, UK.
| | - Ming Lim
- Children's Neurosciences, Evelina London Hospital, London SE17EH, UK
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27
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Abreu JB, Cordeiro CR, Amorim AI, Catanho TG, Gama KD. Combined neuraxial-general anesthesia in opsoclonus-myoclonus syndrome: A case report. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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28
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Banerjee B, Thanvi A, Prabhu SM. Profile and Outcome of Children with Opsoclonus Myoclonus Ataxia: A Tertiary Care Hospital Experience from India. JOURNAL OF PEDIATRIC NEUROLOGY 2022. [DOI: 10.1055/s-0042-1750762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
AbstractOpsoclonus myoclonus ataxia syndrome (OMAS) is a rare but treatable, often paraneoplastic neuroimmunologic condition. This is a retrospective chart review of 8 patients diagnosed in the past 11 years at a tertiary care hospital. The mean age of children with OMAS was 21.2 ± 8 months. There was a female preponderance (62.5%). Median symptom duration was 24.5 days (interquartile range [IQR] 12.7; 97.5). All patients had ataxia and irritability; 6 had opsoclonus.An underlying neurogenic tumor was identified in 87.5% (⅞) of the patients by computed tomography (CT)/magnetic resonance imaging. Neuroblastoma was detected in ⅘ with normal 24-hour urinary vanillylmandelic acid and 2 had negative metaiodobenzylguanidine scan.All patients received adrenocorticotropic hormone/steroids for a median of 9.5 months (IQR 5.3; 13.5) with clonazepam. Five received intravenous immunoglobulin (IVIG), including repeated cycles in ⅘. Two received rituximab. One child with relapsing-remitting course received pulse dexamethasone and cyclophosphamide, resulting in improvement. Clonazepam restored ambulation in one with delayed diagnosis and failure of response to steroids. Six patients underwent tumor resection and four needed chemotherapies.Median follow-up was 15 months (IQR 10.7; 23.2). Mean OMAS-severity scale reduced from 10 to 1.4 in the IVIG group and 10.6 to 5.3 in those who did not receive IVIG. Cognitive delay and behavioral issues were seen in 100% treated with steroids only; 50 and 25%, respectively, treated with multimodal immunotherapy. Five had relapses, one with tumor recurrence.Thorax and abdomen CT scan was found to be a sensitive tool for tumor detection. Better motor and cognitive behavioral outcome were noted in patients who received adjunctive IVIG.Future studies on optimum investigation and treatment protocol in various resource settings are needed.
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Affiliation(s)
- Bidisha Banerjee
- Department of Pediatrics, Manipal Hospital, Bengaluru, Karnataka, India
| | - Ayesha Thanvi
- Department of Pediatrics, Manipal Hospital, Bengaluru, Karnataka, India
| | - Sameeta M. Prabhu
- Department of Pediatrics, Manipal Hospital, Bengaluru, Karnataka, India
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