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212-3 Paraneoplastic Upbeat Nystagmus

212-3 Paraneoplastic Upbeat Nystagmus. The patient is a 65 year old woman who was in good health until seven weeks prior to admission.

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212-3 Paraneoplastic Upbeat Nystagmus

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  1. 212-3 Paraneoplastic Upbeat Nystagmus

  2. The patient is a 65 year old woman who was in good health until seven weeks prior to admission. On June 22/09 on the return flight from her daughter’s wedding in Oregon she began to feel “dizziness”, characterized as “inability to sense herself in space .”

  3. Dizziness progressed insidiously over several hours and caused difficulty in standing and inability to walk off the plane unassisted. Fully upright she felt as though “there is a sensation of backwards motion with someone trying to push me off my heels.”

  4. The next day she had intermittent blurring of vision and “eyes bobbing up and down“, a prominent feature that “caused quite a stir among physicians.” An ENT specialist on Cape Cod diagnosed inner ear disease and prescribed meclizine.

  5. Opinions The PCP diagnosed vestibular neuritis and prescribed a short course of prednisone. The symptoms progressed and she was referred to the Massachusetts Eye and Ear Infirmary and admitted to the Massachusetts General Hospital on August 14/09

  6. Additional History Impaired short term memory for 3 months Ten pound weight loss without GI symptoms Past Hx Negative for head trauma, migraine, syncope seizures , vertigo, deafness, tinnitus , impaired balance and visual symptoms

  7. Social History Retired bookkeeper now helping in family business Smoked 2 packs/day for 25 years, quit 4 years ago Alcohol at least 2 glasses of wine/night for many years, occasionally “the better part of a bottle of wine on weekends”

  8. Family History Negative for neurological disease Both parents were alcoholics and had hypertension They died of cardiovascular disease

  9. Ocular Motility Upbeat Nystagmus Lid Nystagmus Full horizontal and vertical eye movements Saccadic hypermetria in all directions Saccadic pursuit Square wave jerks Suppression of nystagmus on convergence Absent vertical OKN No skew

  10. Neurological Findings Oriented to person and 2009. States MEEI for place. Cambridge for City, June for August. Spells WORLD backwards without error Memory 3/3 at registration and 0/3 at 5 mins. Impaired vibration sense, intact joint position Normal reflexes Limb & gait ataxia, tending to sway backwards

  11. Lumbar Puncture Protein 69 mg/dl Sugar 60 mg/dl WBC 7 97% lymphs 3% monos Elevated IgG 22.5 mg/dl (0-8.0) CSF albumin 33.2 mg/dl (normal)

  12. Neuroimaging Brain MRI: Non-specific white matter foci consistent with small vessel ischemic change.

  13. Neuroimaging MRI: Sagittal view showing mild cortical atrophy

  14. CT of abdomen / pelvis with contrast showing a solid 3.8 x 2.9 x 3.5 cm well defined heterogenous mass arising from the tail of the pancreas

  15. CT guided core biopsy • Normal pancreatic acinar and endocrine cells contrasted with small, monomorphic, polygonal tumor cell population (H.E.x200) • Immunohistochemical stains for chromogranin, synaptophysin, endocrine markers, highlight tumor cell population • Dx Pancreatic endocrine carcinoma

  16. Normal pancreatic acinar epithelium Endocrine Neoplasm A

  17. Benign islet and tumor cells are positive Benign acinar cells are negative B Chromogranin Immunohistochemical Stain

  18. Synaptophysin Immunohistochemical Stain: This marker and chromogranin stain the cytoplasm of endocrine cells. C

  19. Trypsin Immunohistochemical Stain Benign islet is negative Tumor is negative D Benign acinar cells are positive

  20. Normal pancreas Tumor

  21. Eye Movement Records A-C show a 5 second epoch of nystagmus A. Divergent quick phases B. A large vertical component C. Smaller clockwise quick phases D. UBN decreased during convergence Courstesy R John Leigh MD

  22. Paraneoplastic Upbeat Nystagmus

  23. Therapy Appropriate therapy for Cancer Distal pancreatectomy Chemotherapy with cyclophosphamide Immune modulation Intravenous methylprednisolone Intravenous immunoglobulin Symptomatic treatment for nystagmus Memantine

  24. References Dalmau J, Graus F, Villarejo A, Posner JB, Blumenthal D, Thiessen B, Saiz A, Meneses P, Rosenfeld MR. Clinical analysis of anti-Ma2-associated encephalitis. Brain 2004;127:1831-1844. Graus F, Keime-Guibert F, Rene R, Benyahia B, Fibalta T, Ascaso C, Escaramis G, Delattre JY. Anti-Hu-associated paraneoplastic encephalomyelitis: analysis of 200 patients. Brain 2001;124:1138-1148.

  25. References Wray S.H, Maheshwari A, Chen A, King S, Bishop-Pitman M, Leigh R.J. Paraneoplastic Upbeat Nystagmus: Evidence for underlying mechanisms Submitted to Annals of Neurology, March 2010

  26. http://www.library.med.utah.edu/NOVEL

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