Subacute cerebellar ataxia following respiratory symptoms of COVID-19: a case report

Abstract Background Severe acute respiratory syndrome virus 2 (SARS-CoV-2) is spreading globally and causes most frequently fever and respiratory symptoms, i.e. Coronavirus disease 2019 (COVID-19), however, distinct neurological syndromes associated with SARS-CoV-2 infection have been described. Among SARS-CoV-2-infections-associated neurological symptoms fatigue, headache, dizziness, impaired consciousness and anosmia/ageusia are most frequent, but less frequent neurological deficits such as seizures, Guillain-Barré syndrome or ataxia may also occur. Case presentation Herein we present a case of a 62-year-old man who developed a subacute cerebellar syndrome with limb-, truncal- and gait ataxia and scanning speech 1 day after clinical resolution of symptomatic SARS-CoV-2 infection of the upper airways. Apart from ataxia, there were no signs indicative of opsoclonus myoclonus ataxia syndrome or Miller Fisher syndrome. Cerebral magnetic resonance imaging showed mild cerebellar atrophy. SARS-CoV-2 infection of the cerebellum was excluded by normal cerebrospinal fluid cell counts and, most importantly, absence of SARS-CoV-2 RNA or intrathecal SARS-CoV-2-specific antibody production. Other causes of ataxia such as other viral infections, other autoimmune and/or paraneoplastic diseases or intoxication were ruled out. The neurological deficits improved rapidly after high-dose methylprednisolone therapy. Conclusions The laboratory and clinical findings as well as the marked improvement after high-dose methylprednisolone therapy suggest a post-infectious, immune-mediated cause of ataxia. This report should make clinicians aware to consider SARS-CoV-2 infection as a potential cause of post-infectious neurological deficits with an atypical clinical presentation and to consider high-dose corticosteroid treatment in case that a post-infectious immune-mediated mechanism is assumed.

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Nonepileptic Myoclonus in COVID-19: Case Report

The Neurohospitalist ◽

10.1177/19418744211004315 ◽

2021 ◽

pp. 194187442110043

Author(s):

Henly Hewan ◽

Annie Yang ◽

Aparna Vaddiparti ◽

Benison Keung

Keyword(s):

Case Report ◽

Critically Ill ◽

Recovery Phase ◽

Critically Ill Patient ◽

High Dose ◽

The Novel ◽

Neurological Manifestations ◽

Immune Mediated ◽

Novel Coronavirus ◽

Post Infectious

In late 2019, the novel coronavirus, SARS-CoV-2, and the disease it causes, COVID-19, was identified. Since then many different neurological manifestations of COVID-19 have been well reported. Movement abnormalities have been rarely described. We report here a critically ill patient with COVID-19 who developed generalized myoclonus during the recovery phase of the infection. Myoclonus was associated with cyclical fevers and decreased alertness. Movements were refractory to conventional anti-epileptic therapies. There was concern that myoclonus could be part of a post-infectious immune-mediated syndrome. The patient improved fully with a 4-day course of high-dose steroids. Our experience highlights a rare, generalized myoclonus syndrome associated with COVID-19 that may be immune-mediated and is responsive to treatment.

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Anti-NMDAR encephalitis in 10-year-old girl

International Journal of Health Sciences ◽

10.29332/ijhs.v5n1.600 ◽

2021 ◽

Vol 5 (1) ◽

pp. 1-8

Author(s):

I Gusti Ngurah Made Suwarba

Keyword(s):

Right Hemisphere ◽

Definitive Diagnosis ◽

High Dose ◽

History Taking ◽

Head Turning ◽

Head Ct ◽

Nmdar Encephalitis ◽

Immune Mediated ◽

High Dose Methylprednisolone ◽

Space Occupying Lesion

Anti-NMDAR encephalitis is a central nervous system (CNS) disease involving dysfunction of the autoimmune system. Anti-NMDAR encephalitis is an immune-mediated disease characterized by a complex neuropsychiatric syndrome and the presence of CSF antibodies against the GluN1 subunit of the NMDAR. The diagnosis was by history taking, physical examination, and antibody NMDAR for definitive diagnosis. Principal management is starting therapy earlier may lead to better outcomes. A 10-year-old girl was admitted to Sanglah Hospital, with a complaint of seizure with the characteristic of the seizure was head-turning to the left side then continue to stiff extremities and body, involved stiffening and jerking, both eyes glared up, and unconscious. A Head CT scan showed no signs of hemorrhage, intracerebral or intracerebellar space-occupying lesion, hypertrophy chance nasal inferior bilateral, blurring in grey-white matter junction regio right parietal lobus with narrowing of right lateral ventricle, suspected right hemisphere edema. MRA showed no signs of the infarct, hemorrhage, or space-occupying lesion, with normal anterior and posterior arterial cerebri system. Anti-NMDAR serum was positive. The patient was treated with high-dose methylprednisolone and planned to get cyclophosphamide. Anti-NMDAR encephalitis is a disease with the challenging diagnosis of neuropsychiatric syndrome in children.

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A Patient with Post Infectious Immune Mediated Neuropathy (Miller Fisher Syndrome)

International Journal of Clinical Medicine ◽

10.4236/ijcm.2017.83011 ◽

2017 ◽

Vol 08 (03) ◽

pp. 123-127

Author(s):

Sharlene Sanchez ◽

Azad Esack

Keyword(s):

Miller Fisher Syndrome ◽

Fisher Syndrome ◽

Immune Mediated ◽

Post Infectious

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Ofatumumab and High-Dose Methylprednisolone Is An Effective Salvage Treatment for Heavily Pretreated, Unfit or Refractory Patients with Chronic Lymphocytic Leukemia: Single Institution Experience

Blood ◽

10.1182/blood.v116.21.4638.4638 ◽

2010 ◽

Vol 116 (21) ◽

pp. 4638-4638 ◽

Cited By ~ 2

Author(s):

Januario E Castro ◽

Juan Sebastian Barajas-Gamboa ◽

Johanna Melo-Cardenas ◽

Rosa N Paz ◽

Cesar Bernal-Corzo ◽

...

Keyword(s):

High Risk ◽

Response To Therapy ◽

High Dose ◽

Costal Margin ◽

Cell Transplant ◽

Single Institution ◽

Salvage Regimen ◽

Bulky Disease ◽

Cell Counts ◽

High Dose Methylprednisolone

Abstract Abstract 4638 High-dose methylprednisolone (HDMP) and the fully human monoclonal anti-CD 20 Ofatumumab each can produce partial responses in CLL, even though complete remissions are not often observed following treatment with either agent alone. Previously we have reported that the combination of Rituximab and HDMP is an effective non-myelosuppressive treatment combination for previously untreated CLL patients as well as in patients that are fludarabine refractory. We report here our single institution experience of treatment using the combination of HDMP and Ofatumumab in CLL patients that were not considered to be good candidates for chemotherapy treatment due to comorbidities, poor performance status, profound cytopenias or because refractory status to fludarabine and/or alemtuzumab. Eight patients with progressive, symptomatic CLL were treated with HDMP 1 g/m2 IV daily × 3 every 28 days for three consecutive cycles, and ofatumumab administered based on package insert instructions (300 mg dose # 1 followed by 11 doses of 2,000 mg over a 6 month period) along with prophylactic antimicrobial therapy. The main objectives were to determine the safety, toxicity and clinical efficacy of this regimen. All of the patients were males with a median age of 69 years (range 49–78). The median of prior treatments was 4.5 including 4 patients that have received previously HDMP and rituximab and two patients that underwent matched unrelated donor stem cell transplant. All patients have been previously treated with rituximab, 75% of the patients failed or were intolerant to fludarabine and/or aletuzumab and 88% had high-risk disease by the modified Rai classification. Most of the patients had bulky disease with median lymph node product of 42 cms2 and median splenomegaly of 6. 5 cm (range 0–17) below the left costal margin. The median lymphocyte count was 28,000 cells/mm3. 75% of the patients had high-risk prognostic markers including unfavorable cytogenetics, unmutated IgVH region genes or high expression levels of ZAP-70. All patients completed the planned therapy with no major side effects or toxicities. There was no evidence of marrow suppression and even patients with pancytopenia improved their peripheral blood counts with this salvage regimen. During treatment patients experience significant decrease in peripheral white blood cell counts, increase in hemoglobin, elevation of platelets and a dramatic reduction in lymphadenopathy and splenomegaly. Response assessment based on the IW-CLL 2008 criteria showed that the overall response rate was 50% (4 partial remissions), 25% of patients had stable disease and the remainder showed progressive disease. Overall, these data suggest that the combination of HDMP and Ofatumumab is a safe and effective salvage regimen for high-risk CLL patients that otherwise were not candidates for additional treatment. The response rates observed for the combination of HDMP and Ofatumumab in this group of patients appear to be favorable with the majority of patients achieving a response to therapy or experiencing disease stabilization. Moreover, HDMP and Ofatumumab treatment was not associated with bone marrow suppression, which is a major limiting factor for treatment administration, making this regimen a potential valid alternative for high-risk CLL patients. Additional clinical studies of this combination are warranted. Disclosures: No relevant conflicts of interest to declare.

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Case Report: Delayed Alemtuzumab-Induced Concurrent Neutropenia and Thrombocytopenia in Relapsing-Remitting Multiple Sclerosis

Journal of Pharmacy Practice ◽

10.1177/08971900211021235 ◽

2021 ◽

pp. 089719002110212

Author(s):

Akaansha Ganju ◽

James C. Stock ◽

Kim Jordan

Keyword(s):

Multiple Sclerosis ◽

Case Reports ◽

Severe Neutropenia ◽

Cell Counts ◽

Immune Mediated ◽

Relapsing Remitting ◽

Remitting Multiple Sclerosis ◽

Study Participants ◽

Relapsing Remitting Multiple Sclerosis

Alemtuzumab is an anti-CD52 monoclonal antibody used to treat relapsing-remitting multiple sclerosis following failure of second-line medications. It is administered intravenously in 2 treatment sequences 1 year apart. This drug is frequently associated with mild infusion reactions within days of administration, increased infection risk, and long term adverse events from secondary autoimmunity. Alemtuzumab-induced serious immune-mediated thrombocytopenia (ITP) is well-reported and occurred in 1.0-2.2% of participants in initial phase 2 and 3 trials for multiple sclerosis. Significant neutropenia, however, is rare and was only observed in 0.1% of study participants. Delayed neutropenia and/or ITP is thought to occur from secondary autoimmunity. Few case reports have described severe neutropenia occurring beyond 2 months of last alemtuzumab dose. We present an unusual case of delayed combined neutropenia and thrombocytopenia that occurred 15 months after the second infusion of alemtuzumab. The patient was asymptomatic and presented following discovery of neutropenia and thrombocytopenia during routine laboratory studies. The patient responded to steroids initially and was discharged, although outpatient cell counts subsequently revealed recurrent neutropenia and ITP. The adverse drug reaction probability (Naranjo) scale was completed and showed probable likelihood that the adverse event was alemtuzumab-related. Long term screening for delayed hematologic abnormalities, at least 4 years after initial dose, is necessary when using alemtuzumab. Greater research is needed to understand the mechanism of drug-associated neutropenia.

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Bilateral dysthyroid compressive optic neuropathy responsive to teprotumumab

European Journal of Ophthalmology ◽

10.1177/1120672121991042 ◽

2021 ◽

pp. 112067212199104

Author(s):

Catherine J Hwang ◽

Erin E Nichols ◽

Brian H Chon ◽

Julian D Perry

Keyword(s):

Side Effects ◽

Optic Neuropathy ◽

Surgical Decompression ◽

Thyroid Eye Disease ◽

Eye Disease ◽

High Dose ◽

Compressive Optic Neuropathy ◽

Traditional Management ◽

Immune Mediated ◽

Orbital Radiation

Thyroid eye disease is an auto-immune mediated orbitopathy which can cause dysthyroid compressive optic neuropathy. Traditional management of active thyroid eye disease includes temporizing high-dose steroids, orbital radiation and surgical decompression, which each possess significant limitations and/or side effects. Teprotumumab is an IGF-IR inhibitor recently FDA-approved for active thyroid eye disease. The authors report reversal of bilateral dysthyroid compressive optic neuropathy managed medically utilizing teprotumumab.

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Inflammatory Skin Lesions in Three SARS-CoV-2 Swab-Negative Adolescents: A Possible COVID-19 Sneaky Manifestation?

Pediatric Reports ◽

10.3390/pediatric13020025 ◽

2021 ◽

Vol 13 (2) ◽

pp. 181-188

Author(s):

Giuseppe Ingravallo ◽

Francesco Mazzotta ◽

Leonardo Resta ◽

Sara Sablone ◽

Gerardo Cazzato ◽

...

Keyword(s):

Electron Microscopy ◽

Respiratory Symptoms ◽

Clinical Manifestations ◽

Skin Lesions ◽

Sweat Glands ◽

Histological Findings ◽

Immune Mediated ◽

Nodular Lesions ◽

Immunohistochemical Evidence ◽

Eccrine Sweat Glands

Coronavirus disease 19 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is associated with various clinical manifestations, including skin lesions. In particular, during the COVID-19 pandemic lock-down period numerous chilblain-like lesions, mainly located on the feet, were observed in adolescents. The latter were often asymptomatic or associated with very mild respiratory symptoms. Here, we report three cases of acral nodular lesions in SARS-CoV-2 swab-negative adolescents with histological findings of chronic immune-mediated inflammation and immunohistochemical evidence of SARS-CoV-2 spike glycoproteins in endothelial cells and eccrine sweat glands. In one of these cases, the virus presence was confirmed by electron microscopy.

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Incomplete septal cirrhosis after high-dose methylprednisolone therapy and regression of liver injury

Liver International ◽

10.1111/liv.12607 ◽

2014 ◽

Vol 35 (2) ◽

pp. 674-676 ◽

Cited By ~ 12

Author(s):

Elisabetta Grilli ◽

Vincenzo Galati ◽

Nicola Petrosillo ◽

Franca Del Nonno ◽

Andrea Baiocchini

Keyword(s):

Liver Injury ◽

High Dose ◽

High Dose Methylprednisolone ◽

Incomplete Septal Cirrhosis

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Immunomodulating functions of recombinant ovine interferon tau: potential for therapy in mulitple sclerosis and autoimmune disorders

Multiple Sclerosis Journal ◽

10.1177/135245859800400204 ◽

1998 ◽

Vol 4 (2) ◽

pp. 63-69 ◽

Cited By ~ 10

Author(s):

O A Khan ◽

H Jiang ◽

P S Subramaniam ◽

H M Johnson ◽

S S Dhib-Jalbut

Keyword(s):

Therapeutic Option ◽

High Dose ◽

Interferon Tau ◽

Unique Type ◽

Immune Mediated ◽

High Concentrations ◽

Ifn Treatment ◽

High Doses ◽

Mulitple Sclerosis

The interferons (IFN) are a family of complex proteins possessing antiviral, antiproliferative, and immunomodulatory activities. Two type 1 recombinant human IFN have been recently approved for the treatment of multiple sclerosis (MS). However, use of high dose type 1 IFN treatment in MS patients has been limited by dose-related toxicity. Ovine IFNt is a unique type 1 interferon discovered for its role in the animal reproductive cycle. It differs from other type 1 IFNs in that it is remarkably less toxic even at high concentrations, is able to cross species barriers, and is not inducible by viral infection. Ovine IFNt has been shown to be very effective in the treatment of animal models of MS. In this study, we examined the toxicity of OvIFNt on human T-cells at high doses and its immunregulatory properties at equivalent doses. Our experiments confirmed the remarkably non-toxic nature of OvIFNt on human cells at high concentrations as well as immunomodulating properties consistent with other type 1 IFNs including an antilymphoproliferative effect and inhibition of IFNg-induced HLA class II expression. These results suggest that OvIFNt could be developed into a potentially less toxic therapeutic option for immune-mediated disorders including MS.

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