Patient 1 was a 40-year-old man, who suffered from right leg myoclonus 1 week after an episode of fever and headache. Myoclonus disappeared 4 months after administration of clonazepam. Patient 2 was a 42-year-old man, who suffered from right leg myoclonus, attacks of speech arrest and a generalized tonic-clonic seizure. His symptoms disappeared after steroid-pulse therapy, but right leg myoclonus and episodic impairment of consciousness recurred within a month. He underwent another steroid-pulse therapy and his symptoms disappeared. In both patients, cerebrospinal fluid (CSF) study showed pleocytosis and elevated protein level, electrophysiological study showed cortical reflex by stimulation of the right tibial nerve, and brain MRI showed the high intensity area in the left parietal lobe. In addition, on electroencephalogram (EEG) spikes at vertex preceded myoclonic jerk of the right tibialis anterior muscle in both patients. These findings indicate that focal cortical reflex myoclonus was accompanied by acute central nervous system (CNS) infection. Furthermore, in both patients, autoantibody against glutamate receptor subunits ε2 was detected both in serum and CSF, which also suggest that autoimmune mechanism contributed in the pathophysiology of acute development of focal cortical reflex myoclonus.
A 39 years old woman was admitted to our hospital with a status epilepticus, with high fever of 41°C. Magnetic resonance Imaging (MRI) revealed high signal intensities of both sides of thalami and hypothalami in T2 weighted and fluid attenuated inversion recovery (FLAIR) images. A needle biopsy of the thalamic lesion was consistent with neuromyelitis optica spectrum disorder although her serum antibody to aquaporin-4 was negative. The level of orexin in celebrospinal fluid (CSF) was reduced. She presented hypersomnia, which didn’t improve even after intravenous methylprednisolone 1 g daily for 3 days. Administration of oral modafinil extended her waking time. There is a number of reports about neuromyelitis optica (NMO) with hypothalamic lesions. We report this case as important suggestion of treatment of thse cases.
A 36-year-old woman complained of general malaise. She presented with hyponatremia and plasma osmotic pressure was lower than urinary osmotic pressure. In addition, serum antidiuretic hormone level was higher than the measurement sensitivity. She was diagnosed with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). She fell into a coma despite correction of serum sodium level. Brain magnetic resonance imaging (MRI) revealed high signal intensities in the cerebral cortex, striatum, thalamus, hypothalamus, midbrain, and pons in fluid-attenuated inversion recovery images. Spinal MRI revealed a longitudinally extending lesion in the cervical cord. Serum sample was positive for anti-aquaporin-4 antibody, supporting the diagnosis of neuromyelitis optica spectrum disorder (NMOSD) combined with central pontine and extrapontine myelinolysis. In patients with NMOSD, the immune reaction can gradually cause destructive changes of the hypothalamus and lead to unstable ADH secretion in the absence of immunomodulatory treatment.
We report a 26-year-old woman who had respiratory dysfunction and muscle weakness at birth and was diagnosed with facioscapulohumeral dystrophy at the age of 5. The extent of muscle weakness fluctuated daily or weekly and deteriorated in menstrual periods. At the age of 12, she noted improvements in symptoms when taking procaterol hydrochloride and began to take it regularly. After that, her condition stabilized. At the age of 26, she visited our hospital presenting with ptosis, muscle weakness in the face, trunk, and proximal limbs, and easy fatigability. Serum CK was normal; anti-acetylcholine receptor and anti-muscle specific tyrosine kinase antibodies were negative. A repetitive stimulation test in the trapezius muscle showed a waning phenomenon. Gene analysis for congenital myasthenic syndrome (CMS) revealed a new mutation in the DOK7 gene; the diagnosis of CMS was confirmed. Her symptoms worsened with ambenonium chloride but improved with 3,4-diaminopyridine. Our findings suggest that daily or weekly fluctuation and worsening with a menses in muscle weakness is an important diagnostic feature of CMS.
A 35-year-old man came to the hospital showing signs of worsening dysesthesia on his right hand. The dysesthesia started on his right hand and then spread to his forearm in two months. It also appeared on his left hand transiently. Initial MR imaging revealed a high signal intensity lesion at Th1-Th10 with an irregular margin (presyrinx state) below C3 on T2WI. The legion extended up to the medulla oblongata rapidly. Corticosteroid therapy lead to a slight improvement in dysesthesia symptoms but did not last. Immunosuppressant was also ineffective. Further examination using Gd enhanced MR imaging in a neurosurgery clinic in a university hospital revealed a spinal tumor at the Th10 level. A tumor resection was performed and dysesthesia improved. Pathological analysis showed hemangioblastoma. Presyrinx and syrinx above Th1 disappeared after the operation. It is necessary to search the whole spine carefully for the possibility of a tumor in the case of steroid resistant progressive spinal lesions with an unknown origin. And we stress the importance of timely surgical intervention regardless of idiopathic or secondary syringomyelia. We would like to report this clinical course presenting MR imaging and discuss the mechanism of forming syringomyelia based on the hypothesis of the alteration of CSF flow.
A 53-year-old woman was admitted to our hospital because of gait disturbance and paresthesia of the lower extremities. She also had marked deep sense impairment in her lower limbs. Cervical MRI showed a longitudinally extensive spinal cord lesion of the dorsal column at levels C1–T11. The findings of cerebrospinal fluid examination, including the IgG index (0.65), were normal. Serum anti-AQP4 antibody was negative, but anti-amphiphysin antibody was positive. Electrophysiological examinations suggested the presence of lesions in the dorsal column of the spinal cord and dorsal root ganglion (DRG). Enlargement of and fluorodeoxyglucose accumulation in her left parasternal lymph node was observed on contrast-enhanced CT and PET-CT, respectively. The lymph node biopsy was underwent by using thoracoscopy. The metastasis of carcinoma was pathologically confirmed. Although the primary tumor was not detected on PET-CT re-examination, immunostaining of the biopsied lymph node specimen was positive for both the progesterone receptor and estrogen receptor. On the basis of these findings, the patient was diagnosed with paraneoplastic neurological syndrome due to potential breast cancer. The disorder is an immunological subacute sensory neuropathy with a longitudinally extensive spinal cord lesion of the dorsal column and a DRG lesion.
Recurrence of Guillain-Barré syndrome (GBS) and Fisher syndrome (FS) is uncommon. We retrospectively studied the cases of 93 consecutive patients with GBS and FS who were admitted to our hospital between January 2000 and March 2013. We analyzed the clinical features of and anti- glycolipid antibodies in patients who experienced recurrence. Of the 93 patients, 53, 37, and 3 had GBS, FS, and overlapping GBS and FS, respectively. There were 6 recurrences in 4 patients, all of whom were women; their onset age ranged from 26 to 51 years, and the average time to recurrence ranged from 9 months to 25 years. The recurrence rate of FS was 10.8%. On the recurrence, 2 patients showed FS (5.4%) and 2 patients showed overlap of GBS and FS (5.4%). All patients with recurrence showed good prognosis and increased anti-GQ1b glycolipid antibody levels both at the initial episode and at recurrence. Immunological examinations, including those for detecting changes in anti-glycolipid antibodies, are important for clarifying the pathomechanism of recurrence in GBS and FS.
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a rare central nervous system inflammatory disease characterized by the punctate gadolinium enhancement peppering the pons and the cerebellar peduncles as neuroimaging. We report the case of a 66-year-old woman who presented with CLIPPERS associated with swelling in the brainstem. She was hospitalized because of gait ataxia and consciousness disturbance. MRI of the brain showed FLAIR hyperintense lesions in the pons, cerebellar peduncles, cerebellum and the subcortical white matter lesion in the right occipital lobe with significant swelling in the brainstem. Diffusion-weighted MRI did not show an abnormal signal, indicating vasogenic edema. Post-contrast T1-weighted MRI showed enhanced area in the right occipital lobe and panctate gadolinium enhancement peppering brainstem. Treatment with steroids led to rapid improvement. However, she showed exacerbation of clinical and radiological findings during the tapering schedule of steroid. The biopsy from the occipital lobe revealed intense perivascular and parenchymal lymphocytic infiltrates composed of primarily T cells, B cells and macrophages. The patient was diagnosed with CLIPPERS, and treatment with increased dose of corticosteroid induced a clinical improvement. Previous reports well described a characteristic MRI finding of punctate enhancement peppering the pons. In addition, the pons and cerebellar peduncles swelling can occur in this disorder.
We report a case of complete Heerfordt syndrome accompanied by the involvement of small fiber neuropathy (SFN) manifesting as refracory facial pain. A 30-year-old man presented with pyrexia, a 2-week history of facial burning pain, and difficulty of mastication. After admission to our hospital, neurological examinations showed bilateral facial pain, trigeminal motor palsy, left facial nerve palsy, bilateral sensory neural deafness, uveitis and swelling of the parotid gland. Other examinations revealed bilateral hilar lymphadenopathy, high serum titer of angiotensin coenzyme, and no response in a tuberculin-tested, non-caseating epithelioid granuloma from lip biopsy, leading to the diagnosis of complete Heerfordt syndrome. Mandibular skin biopsy with immunostaining for PGP 9.5 showed SFN. High-dose corticosteroids proved somewhat effective against SFN as facial pain, but reducing the corticosteroid dose proved difficult, as symptoms were refractory to other immunosuppressants and pain-control drugs such as anti-epileptics and anti-depressants. The patient died of acute pancreatitis 3 years after disease onset. Autopsy showed no granuloma in hilar lymph node, trigeminal nerve, cranial base, nerve root, and muscle. SFN in this case probably represent a cause of refractory facial pain.
A 52-year-old woman complained of the sudden onset of a left temporal headache, left neck stiffness and dizziness. Brain magnetic resonance imaging showed a high-intensity lesion in the right medial medulla. Dynamic cerebral angiography revealed vertebral artery dissection and compression at the C6 level due to a transverse process at the C6 level associated with rightward head rotation. Removal of bone and decompression of the vertebral artery were performed from the C5 to C6 levels. Intraoperasively, obstruction of blood flow due to a laryngeal cartilage that rotated with the passive rotation of the patient’s head to the right was found. To the best of our knowledge this is the first reported case of vertebral artery occlusion due to a laryngeal cartilage associated with head rotation.