Paraneoplastic Neurological Syndromes of the Central Nervous System: Pathophysiology, Diagnosis, and Treatment

Hodgkin lymphoma presenting as paraneoplastic cerebellar degeneration: A case report

A 49-year-old male presented with subacute onset of ataxia, dizziness, and dysarthria over a 4-week period. Laboratory workup and magnetic resonance imaging brain imaging were unremarkable, and no neurological etiology was identified. Anti-Tr antibodies were detected in serum and cerebrospinal fluid. A positron-emission tomography scan showed small nonspecific periaortic and aortocaval lymph nodes, which were not amenable for biopsy. He was treated with immunosuppressive treatment, and a CT scan showed resolution of the previous activity. A repeat positron-emission tomography scan 6 months after the original presentation showed reappearance with increased size and activity of the lymph nodes. An abdominal lymph node biopsy showed classical Hodgkin's lymphoma. The bone marrow biopsy was negative, placing him at Ann Arbor stage IIA. He was treated with two cycles of Adriamycin, Bleomycin, Vinblastine, and Dacarbazine followed by two cycles of Adriamycin, Brentuximab Vedotin, Vinblastine, and Dacarbazine due to a drop in diffusion capacity of the lungs for carbon monoxide from Bleomycin. He remains in remission from the lymphoma but with residual neurological symptoms. This case report suggests that patients with Hodgkin's and paraneoplastic neurological syndrome may demonstrate radiological improvement related to immunosuppressive treatment which can delay diagnosis and accurate treatment in patients with paraneoplastic cerebellar degeneration and underlying malignancy. The presence of anti-Tr antibody supports the diagnosis of Hodgkin lymphoma in the setting of paraneoplastic cerebellar symptoms.

A 7-year-old with new-onset seizures, behavior disturbance, and encephalitis

Refractory seizures are common in pediatric neurology; consideration of whether seizures are acutely symptomatic of an underlying disease process is critical. In this case, a previously healthy 7-year-old patient presented with intractable focal seizures in the setting of a viral prodrome and headache. This case highlights a comprehensive work up of new-onset refractory seizures in a patient with features of encephalitis and describes a diagnostic quandary that ultimately led to a rare unifying diagnosis.

Clinical characteristics and immunotherapy response in paraneoplastic neurologic syndrome patients with increased number of high-risk antibodies

Objective

To investigate the differences of clinical characteristics and treatment outcomes between paraneoplastic neurologic syndrome (PNS) patients with one high-risk antibody and patients with two high-risk antibodies.

Methods

We retrospectively analyzed the data of 51 PNS patients with high-risk antibody. Clinical data were extracted from the patients' electronic medical records. Clinical presentations, cerebrospinal fluid (CSF) parameters, radiological characteristics and treatment outcomes between patients with one high-risk antibody and patients with two high-risk antibodies were analyzed.

Results

41 patients with 1 high-risk antibody and 10 patients with 2 high-risk antibodies were enrolled in this study. It was found that psychobehavioral abnormality (OR = 11.327, 95% CI: 1.371 to 93.602, P = 0.024), bowel and bladder dysfunction (OR = 23.537, 95% CI: 1.753 to 316.005, P = 0.017), and total protein of CSF (OR = 61.556, 95% CI: 2.926 to 1294.974, P = 0.008) were risk factors for increased number of high-risk antibodies in PNS. After immunotherapy treatment, Expanded Disability Status Scale (EDSS) scores in PNS patients with 2 high-risk antibodies were higher than that in PNS patients with 1 high-risk antibody (4.8 ± 2.4 vs. 3.0 ± 2.4, p = 0.043). EDSS change analysis also revealed that average EDSS score decreased after treatment in PNS with 1 Ab group while increased in PNS with 2 Abs group (p = 0.032).

Conclusions

Psychobehavioral abnormality, bowel and bladder dysfunction, and total protein of CSF were three variables associated with increased number of high-risk antibodies in PNS patients, while increased number of high-risk antibodies might indicate a poor immunotherapy response. Our findings might help to understand the association of PNS patients' clinical features and high-risk antibodies, as well as to guide clinical practice.

Case report: Immune checkpoint inhibitor-induced paraneoplastic neurological syndrome in two patients: a case series

Immune checkpoint inhibitors (ICIs) combined with chemotherapy have improved overall survival in patients with small-cell lung cancer, but have also led to an increase in adverse effects. The incidence of ICI-induced paraneoplastic neurological syndrome (PNS) is relatively low when the primary lung lesion is well controlled. However, it is associated with high mortality and disability rates. In this report, we present two cases of extensive-stage small-cell lung cancer with neurological symptoms and positive paraneoplastic antibodies in the serum and cerebrospinal fluid (CSF) following ICI therapy. Although the symptoms improved after treatment with systemic high-dose immunoglobulin and glucocorticoids, one patient, unfortunately, succumbed to tumor progression four months later, whereas the other patient experienced persistent difficulty in standing and walking despite improved muscle strength. In cases where neurological symptoms that cannot be explained by tumor metastases arise during ICI treatment, paraneoplastic syndromes should be considered and testing for antineuronal antibodies is crucial, as early detection and intervention can help mitigate their impact. Further research is needed to develop better predictive strategies and treatment protocols for these adverse reactions.

A case of corticobasal syndrome possibly associated with anti-Yo antibodies

INTRODUCTION

Corticobasal syndrome (CBS) is a rare form of atypical parkinsonism, most commonly caused by neurodegenerative disorders. Autoimmune underlying conditions are extremely rare, and anti-Yo antibody-associated CBS has not been reported yet.

CASE REPORT

Herein, we describe a case of a 68-year-old woman presenting with progressive dysarthria, gait instability and difficulty using her left hand with subacute deterioration during the last 3 months. Neurological examination revealed asymmetrical parkinsonism and pyramidal syndrome, reflex myoclonus and dystonia of her left upper limb, accompanied by apraxia of her left lower limb, fulfilling the criteria for possible CBS. Neuroimaging showed asymmetric frontoparietal atrophy, while cerebrospinal fluid and dopamine transporter imaging were normal. Prior to our evaluation, antineuronal autoantibody testing indicated positive anti-Yo antibodies. There was mild improvement after second IVIG cycle, and further investigation revealed no tumor.

CONCLUSION

Although autoimmune etiology of this case cannot be certain, it highlights the potential expansion of the clinical spectrum of anti-Yo-associated paraneoplastic syndrome.

Testicular Cancer and Paraneoplastic Encephalitis: A Review of the Current Literature

INTRODUCTION

Paraneoplastic encephalitis (PE) represents a rare but significant complication in patients with testicular cancer (TC). Given the paucity of comprehensive literature on this topic, our review seeks to consolidate current knowledge and provide evidence-based recommendations for the diagnosis, prognosis, and management of PE in the context of TC.

MATERIALS AND METHODS

In adherence to PRISMA guidelines, a systematic literature review was conducted from 1950 to April 2024 using PubMed. The search focused on articles where TC was identified as the primary etiology of PE. The Mixed Methods Appraisal Tool and the Oxford Centre for Evidence-Based Medicine's levels of evidence tool were employed for assessing study quality, and a thematic analysis was conducted to identify trends and patterns.

RESULTS

Out of 91 articles identified, 29 met the inclusion criteria, encompassing 5 retrospective chart reviews, 3 case series, and 22 case reports. Findings indicate that PE symptoms can manifest at any stage of TC-before tumor detection, during treatment, or even years posttreatment. A notable observation was the frequent oversight of microscopic testicular tumors in ultrasound imaging, leading to diagnostic delays. The outcomes of PE in the context of TC were diverse, reflecting the heterogeneity of the studies included.

CONCLUSION

PE, although rare, is a critical consideration in patients with TC presenting with neuropsychiatric symptoms. Early recognition and appropriate diagnostic workup, including consideration for microscopic neoplasms, are essential for timely intervention and improved patient outcomes.

Expression of mGluR5 in Pediatric Hodgkin and Non-Hodgkin lymphoma-A Comparative Analysis of Immunohistochemical and Clinical Findings Regarding the Association between Tumor and Paraneoplastic Neurological Disease

Autoantibodies targeting the neuronal antigen metabotropic glutamate receptor 5 (mGluR5) have been identified in patients with Ophelia syndrome, which describes a co-occurrence of paraneoplastic limbic encephalitis and Hodgkin lymphoma (HL). Little data exist regarding frequency and function of mGluR5 in HL and its potential role in causing seropositive paraneoplastic disease. We studied a representative cohort of pediatric HL and NHL patients (n = 57) using immunohistochemistry and fluorescence staining to investigate mGluR5 expression. All lymphoma tissues displayed positive mGluR5 staining, with focus on Hodgkin-Reed-Sternberg (H-RS) cells. We did not detect any mGluR5 staining in tumor-free lymph nodes, which is consistent with the absence of GRM5 transcripts in RNA-sequencing data from non-malignant B and T cells. The frequent presence in pediatric lymphoma falls in line with reports of mGluR5 expression and associated tumor progression in other malignancies. We tested for correlation with clinical features, focusing on disease progression and neurological symptoms. Low mGluR5 expression in H-RS cells correlated with young patient age (<15 years) and positive histology for EBV infection. Paraneoplastic or neurological symptoms were found exclusively in HL patients. While an impact of mGluR5 on HL severity remains possible, a prognostic value of mGluR5 expression levels requires further investigation.

Polyphenols Targeting MAP Kinase Signaling Pathway in Neurological Diseases: Understanding Molecular Mechanisms and Therapeutic Targets

Polyphenols are a class of secondary metabolic products found in plants that have been extensively studied for how well they regulate biological processes, such as the proliferation of cells, autophagy, and apoptosis. The mitogen-activated protein kinase (MAPK)-mediated signaling cascade is currently identified as a crucial pro-inflammatory pathway that plays a significant role in the development of neuroinflammation. This process has been shown to contribute to the pathogenesis of several neurological conditions, such as Alzheimer's disease (AD), Parkinson's disease (PD), CNS damage, and cerebral ischemia. Getting enough polyphenols through eating habits has resulted in mitigating the effects of oxidative stress (OS) and lowering the susceptibility to associated neurodegenerative disorders, including but not limited to multiple sclerosis (MS), AD, stroke, and PD. Polyphenols possess significant promise in dealing with the root cause of neurological conditions by modulating multiple therapeutic targets simultaneously, thereby attenuating their complicated physiology. Several polyphenolic substances have demonstrated beneficial results in various studies and are presently undergoing clinical investigation to treat neurological diseases (NDs). The objective of this review is to provide a comprehensive summary of the different aspects of the MAPK pathway involved in neurological conditions, along with an appraisal of the progress made in using polyphenols to regulate the MAPK signaling system to facilitate the management of NDs.

Paraneoplastic movement disorder due to suspected metastatic Leiomyosarcoma of tongue: A case report

Paraneoplastic movement disorders, though rare, can be the initial symptoms of malignancies like leiomyosarcoma, as in our case. Clinicians should keep malignancies in their differential diagnosis in cases of unexplained movement abnormalities.

Canadian Consensus Guidelines for the Diagnosis and Treatment of Autoimmune Encephalitis in Adults

Autoimmune encephalitis is increasingly recognized as a neurologic cause of acute mental status changes with similar prevalence to infectious encephalitis. Despite rising awareness, approaches to diagnosis remain inconsistent and evidence for optimal treatment is limited. The following Canadian guidelines represent a consensus and evidence (where available) based approach to both the diagnosis and treatment of adult patients with autoimmune encephalitis. The guidelines were developed using a modified RAND process and included input from specialists in autoimmune neurology, neuropsychiatry and infectious diseases. These guidelines are targeted at front line clinicians and were created to provide a pragmatic and practical approach to managing such patients in the acute setting.

Paraneoplastic Neurological Syndromes as Initial Presentation of Tumors: An Eight-Year Single-Center Experience

BACKGROUND

Paraneoplastic Neurological Syndromes (PNS) comprise a diverse group of disorders propagated by immune-mediated effects of malignant tumors on neural tissue.

METHODS

A single-center longitudinal study was performed including consecutive adult patients treated at a tertiary academic hospital between 2015 and 2023 and diagnosed with PNS. PNS were ascertained using the 2004 and the revised 2021 PNS-Care diagnostic criteria.

RESULTS

Thirteen patients who fulfilled the 2004 definite PNS criteria were included. PNS comprise diverse neurological syndromes, with neuromuscular junction disorders (54%) and limbic encephalitis (31%) being predominant. PNS-related antibodies were detected in 85% of cases, including anti-AChR (n = 4), anti-P/Q-VGCC (n = 3), anti-Hu (n = 3), anti-Yo (n = 1), anti-Ma (n = 1), anti-titin (n = 1), anti-IgLON5 (n = 1), and anti-GAD65 (n = 1). Thymoma (31%), small-cell lung cancer (23%), and papillary thyroid carcinoma (18%) were the most frequent tumors. Imaging abnormalities were evident in 33% of cases. Early immunotherapy within 4-weeks from symptom onset was associated with favorable outcomes. At a mean follow-up of 2 ± 1 years, two patients with anti-Hu and anti-Yo antibodies died (18%). Four and three patients fulfilled the 2021 PNS-Care diagnostic criteria for definite and probable PNS, respectively.

CONCLUSIONS

This study highlights the clinical heterogeneity of PNS, emphasizing the need for early suspicion and prompt treatment initiation for optimal outcomes.

Management of Paraneoplastic Syndromes in the Era of Immune Checkpoint Inhibitors

OPINION STATEMENT

Our understanding of paraneoplastic neurologic syndromes (PNS) has blossomed over the past few decades. Clinicians have access to more robust diagnostic criteria and have a heightened index of suspicion for these disorders. Nonetheless, treatment, which typically includes immunosuppression, and response to treatment, varies. Due to persistent difficulty in making a definitive diagnosis, we favor empiric treatment when a possible diagnosis of PNS is suspected, and other alternative causes have substantially been excluded (e.g., infections, toxic-metabolic derangements, metastasis, or leptomeningeal disease). Treatment of the underlying cancer, if identified, is the first therapeutic step and can prevent disease worsening and in rare cases, can reverse neurologic symptoms. In addition to anti-cancer treatment, first line immunotherapies, which include corticosteroids, intravenous immunoglobulins (IVIG), or plasma exchange (PLEX) are typically used. If partial or no benefit is seen, second line immunotherapeutic agents such as rituximab are considered. Additionally, the severity of the initial presentation and possible risk for relapse influences the use of the latter agents. Symptomatic management is also an important component in our practice and will depend on the syndrome being treated. One of the more novel entities we are facing currently is the management of immune checkpoint (ICI)-induced PNS. In those cases, current American Society of Clinical Oncology (ASCO) guidelines are followed.

Opsoclonus and ocular flutter: evaluation and management

PURPOSE OF REVIEW

Opsoclonus and ocular flutter are saccadic intrusions characterized by spontaneous, back-to-back, fast eye movements (saccades) that oscillate about the midline of central visual fixation without intervening inter-saccadic intervals. When this type of movement occurs exclusively in the horizontal plane, it is called ocular flutter. When it occurs in multiple planes (i.e. horizontal, vertical, and torsional) it is called opsoclonus. The most common etiologic categories are parainfectious and paraneoplastic diseases. Less common are toxic-metabolic, traumatic, or idiopathic origins. The mechanism of these movements relates to dysfunction of brainstem and cerebellar machinery involved in the generation of saccades. In this review, we discuss the characteristics of opsoclonus and ocular flutter, describe approaches to clinical evaluation and management of the patient with opsoclonus and ocular flutter, and review approaches to therapeutic intervention.

RECENT FINDINGS

Recent publications demonstrated eye position-dependent opsoclonus present only in left gaze, which may be related to dysfunction of frontal eye fields or structures in the cerebellar vermis.

SUMMARY

Opsoclonus and ocular flutter originate from a broad array of neuropathologies and have value from both a neuroanatomic and etiologic perspective.

Case report: Atypical Parkinsonism following SARS-CoV-2 infection

A wide range of neurological manifestations have been reported during the COVID-19 pandemic, including a variety of Parkinsonian cases. The association of numerous viruses with the development of persistent or transient Parkinsonism has been well-documented. We observed a patient who developed a levodopa non-responsive Parkinsonian syndrome with dysautonomia during a prolonged stay at home for COVID-19. Although the temporal proximity of the emerging Parkinsonian features with a COVID-19 diagnosis suggested a causal relationship, we considered the possibility of a coincidental occurrence of multiple system atrophy. We discuss the patient's clinical features in relation to the established clinical diagnostic criteria and review differential diagnoses as well as the role of SARS-CoV-2 infection.

Secondary Central Nervous System Demyelinating Disorders in the Elderly: A Narrative Review

Secondary demyelinating diseases comprise a wide spectrum group of pathological conditions and may either be attributed to a disorder primarily affecting the neurons or axons, followed by demyelination, or to an underlying condition leading to secondary damage of the myelin sheath. In the elderly, primary demyelinating diseases of the central nervous system (CNS), such as multiple sclerosis, are relatively uncommon. However, secondary causes of CNS demyelination may often occur and in this case, extensive diagnostic workup is usually needed. Infectious, postinfectious, or postvaccinal demyelination may be observed, attributed to age-related alterations of the immune system in this population. Osmotic disturbances and nutritional deficiencies, more commonly observed in the elderly, may lead to conditions such as pontine/extrapontine myelinolysis, Wernicke encephalopathy, and demyelination of the posterior columns of the spinal cord. The prevalence of malignancies is higher in the elderly, sometimes leading to radiation-induced, immunotherapy-related, or paraneoplastic CNS demyelination. This review intends to aid clinical neurologists in broadening their diagnostic approach to secondary CNS demyelinating diseases in the elderly. Common clinical conditions leading to secondary demyelination and their clinical manifestations are summarized here, while the current knowledge of the underlying pathophysiological mechanisms is additionally presented.