We report a case of a 57-year-old woman with thymoma-associated generalized myasthenia gravis (MG) showing severe bulbar and respiratory symptoms, moderate weakness of the neck muscles, and mild weakness of extremity muscles. Corticosteroid treatment with various types of immunosuppressive agents, such as cyclosporine, tacrolimus, and azathioprine, did not improve her symptoms. Plasma exchange transiently improved her symptoms, and she was required to undergo plasmapheresis every 4 weeks. At first, cyclophosphamide pulse therapy was administered, which improved her symptoms transiently. Thereafter, rituximab (RTX) was administered. Six months after RTX administration, respiratory distress and dysphagia improved gradually, and reduction in the dosage of corticosteroids from 30 mg/day to 10 mg/day did not result in symptom deterioration. Therefore, the interval between successive plasmapheresis treatments was increased from 4 to 9 weeks 19 months after the first RTX administration. During a 26-month period from the first administration of RTX, the number of CD20+ B cells in peripheral blood decreased and remained at 0% to 26% of that before RTX treatment. The titer of anti-acetylcholine receptor antibodies did not change during the first course of treatment (0.6–0.9 nmol/l). The clinical symptom worsened with the increase of the number of CD20+ B cells in peripheral blood in the 27 month after 1st RTX administration. Therefore, RTX was administered a second time, after which the patient’s clinical symptoms again improved gradually. The titer of anti-acetylcholine receptor antibodies came to be stable with 0.5–0.7 nmol and low level during the 2nd course. Corticosteroids could be discontinued in the 16th month. The findings suggest that RTX can be one of the choices for pharmacological therapy in patients with intractable MG accompanied by the presence of anti-acetylcholine receptor antibodies.

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An 18-year-old man with congenital weakness in the facial and mastication muscles was referred to us. His facial senses were intact; however, the bilateral massetter and facial muscles were extremely weak and atrophic. He presented lagophthalmos and had difficulty in closing his mouth. The voluntary movements of his left eye, such as abduction, adduction, and elevation, were partially impaired, without the impairment of the Bell phenomenon. Nerve conduction studies of the facial nerves revealed normal distal latencies for bilateral orbicularis oculi. Blink reflexes were not evoked on both sides. Needle electromyography showed a chronic neurogenic change in the tongue. A biopsy of the biceps brachii and skin did not show abnormality. We diagnosed his condition as Möbius syndrome with congenital facial palsy and supranuclear oculomotor palsy. Möbius syndrome, which manifests itself as congenital and non-progressing facial and abducens palsy, is associated with many clinical symptoms and is probably heterogenous nosological entity. Although several cases of Möbius syndrome with supranuclear binocular elevation palsy were previously known, this is the first case of Möbius syndrome presenting supranuclear monocular elevation palsy.

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A 60-year-old man presented with progressive dementia and generalized convulsions. An initial MRI revealed a widespread high-intensity area with a mass effect in the right frontal and temporal lobes on T₂-weighted images. Findings on digital subtraction angiography were normal. Serum and CSF tests showed high titers of antibodies to Treponema pallidum, which helped to distinguish neurosyphilis from glioma. He was initially treated with penicillin injection; however, it caused liver dysfunction and penicillin was switched to erythromycin. Even after antibiotic therapy for 2 months, his dementia did not improve. He underwent brain MRI four times during the treatment course, and they showed steady progression of brain atrophy in the right hemisphere. Taking these findings together, we diagnosed Lissauer form of general paresis. To the best of our knowledge, this is the first case of Lissauer form of paretic neurosyphilis, in which the progression of brain atrophy was clearly demonstrated on MRI.

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A 57-year-old man was admitted to our hospital because of bradykinesia. He was diagnosed with Parkinson disease (Hoehn and Yahr grade 2) and administered levodopa at the maximum dose of 800 mg. However, his condition did not improve. While his symptoms were responsive to levodopa therapy, the sensitivity to the drug was poor. Brain MRI revealed atrophy of the upper vermis and cerebral hemispheres, and brain SPECT revealed low perfusion in both parietal lobes. I¹²³-metaiodobenzylguanidine scintigraphy showed a decrease in the heart/mediastinum ratio. Striatal dopamine transporter (DAT) density was evaluated using I¹²³-FP-CIT. The patient showed moderately reduced DAT density, which suggested nigrostriatal dopaminergic damage. His mother was found to have pure cerebellar ataxia without parkinsonism, and her two siblings also had celebellar type of multiple system atrophy (MSA-C) and progressive supranuclear palsy, respectively. Genetic testing revealed that the patient, his mother and the uncle with MSA-C had spinocerebellar ataxia type 6 (SCA6). SCA6 presenting parkinsonism without ataxia is very rare and important for the pathomechanism of disease.

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A 53-year-old Japanese female developed a fever about two months after a tick bite. She also exhibited blurred vision, central scotoma in the left eye, left facial paresis and mild ataxia. A fundus examination revealed left disc swelling in the left eye. An ophthalmological examination showed decreased visual acuity with central scotoma in the left eye. We suspected neuroborreliosis because of the presence of pleocytosis and an elevated level of IL-6 in the cerebrospinal fluid (CSF), in addition to the characteristic neurological findings. She was positive for serum IgG antibodies against Borrelia by a Western blot of her serum. Therefore, we diagnosed her to have neuroborreliosis with papillitis. After the combined administration of antibiotics and steroids, her symptoms gradually improved, but not all of her eye manifestations resolved. Although ocular involvement is rare in neuroborreliosis, this case highlights the fact that neuroborreliosis shoud be considered as a differential diagnosis for patients presenting with papillitis. The diagnosis of neuroborreliosis is important since improvement of the visual acuity is possible with specific antibiotheraphy. In cases with papillitis of unknown etiology, it might be better to consider the possibility of neuroborreliosis should be considered when there are signs of Lyme borreliosis, such as facial nerve palsy, arthritis or radiculoneuritis.

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A 65-year-old man first visited our hospital due to hypercreatinekinasemia (hyperCKemia) (669 IU/l) 12 years ago at age 53. At that time, he had normal muscle strength without other neurological deficits, electromyography (EMG) was normal, and a muscle biopsy obtained from the biceps brachii was intact in routine histochemical studies. These findings led to a diagnosis of idiopathic hyperCKemia that lasted for over a decade. At age 65, the patient became aware of muscle weakness and serum CK was elevated to 4,846 IU/l. Neurological examination revealed very mild atrophy in both thighs, proximal muscle weakness in the left upper and right lower limbs without myalgia, grasping pain, joint pain, and skin lesions. A typical myogenic pattern was detected on EMG exclusively in proximal limb muscles, and fat-suppressed MRI showed high intensity signal areas in adductor magnus muscles. The clinical diagnosis was limb-girdle muscular dystrophy, but MRI findings suggestive of an inflammatory process prompted us to perform muscle biopsy at the rectus femoris. The pathology had characteristic features of necrotizing myopathy containing necrotic and regenerating fibers without prominent inflammatory cell infiltration. Serum anti-signal recognition particle (SRP) antibodies were found to be positive and the final diagnosis was anti-SRP antibody myopathy. Muscle weakness progressed slowly despite therapy with oral corticosteroids. Addition of intravenous high-dose immunoglobulin therapy led to an apparent improvement of muscle weakness in parallel with lowering of the serum CK level. In those who were thought to be idiopathic hyperCKemia or hereditary muscle disorders, potential immunotherapy-effective group does exist. We suggest considering such cases including anti-SRP antibody myopathy during diagnosis, and non-invasive MRI study may be useful to differentiate immunotherapy-effective group from hereditary muscle disorders.

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Posture abnormality and gait impairments characterize of Parkinson’s disease (PD), predict the risk of falling, and are important contributors to reduced quality of life. The quantitative measures of posture and gait may eventually provide usefulness as a biomarker in PD. This study included that 40 patients with PD (male 26, female 14, average age 70.4 ± 7.6 years old) and 17 normal healthy controls. We selected the quantified measures of the gait function, such as MDS-UPDRS, Timed up & go test, 5 feet walk test, 6 minutes-walk test. The posture angle of both forward flexion and lateral flexion were measured using the application of smartphone, which is capable even in a consulting room. The new posture quantitative measurement is stabile between examiners. The gait functions and the posture angles were significantly abnormal in the PD patients, compared to healthy controls (P < 0.001). The forward flexion angles were well correlated with the ages, on the other hand the lateral flexion angles were well correlated with the duration of the disease. The posture angles do not positively correlate with freezing gait but do correlate in limited univariate analyses with measures of gait function.

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Musician’s dystonia is known as a task specific dystonia. Though it is thought to occur during a long course of repetitive performance, the actual circumstances that precipitate this condition are not clear. According to factual reports this disease is not commonly known, probably because many of these patients may not have been visiting a hospital. We prepared a questionnaire and did a survey among the students of a music college. This is the first questionnaire survey aimed at finding out the prevalence of musician’s dystonia among the students of music. Among the 480 participants of this survey, 29% of the students had knowledge of this disorder and 1.25% of the students had dystonia while performing music.

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A 62-year-old woman experienced uncomfortable genial sensation in 2010. Her uncomfortable sensation was exacerbated during rest at night and improved by walking. She exhibited short-stepped gait with postural disturbance and was diagnosed as suffering from Parkinson’s disease (PD) in 2013. Administration of clonazepam and pramipexisole improved her uncomfortable genial sensation. In persistent genital arousal disorder (PGAD)/restless genial syndrome (RGS), abnormal genital sensation occurred without sexual desire, which was relieved by clonazepam administration. PGAD/RGS often coexists with restless legs syndrome (RLS). PGAD/RGS and RLS share common characteristics. This is the first case report of PD following PGAD/RGS, suggesting similar underlying mechanisms between PGAD/RGS and RLS associated with PD.

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[in Japanese]

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[in Japanese]

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