Opsoclonus-Myoclonus Syndrome

Opsoclonus Myoclonus Syndrome

1. Opsoclonus-myoclonus syndrome Ade Wijaya, MD July 2018

2. Outline: Introduction Pathophysiology Epidemiology Clinical presentation Diagnostic criteria Differential diagnosis Etiology / risk factors Clinical work-up / diagnostic Management Prognosis Summary

3. Introduction Marcel Kinsbourne, 1962 Opsoclonus + myoclonus (dancing eyes, dancing feet) Both children and adults; in children related to neuroblastoma Opsoclonus is a form of saccadic intrusion characterized by multidirectional conjugate eye movements with horizontal, vertical, and torsional directions. The saccades are rapid, involuntary, lack an intersaccadic interval, and do not follow a rhythmic pattern. Because of these characteristics, opsoclonus is also often referred to as saccadomania . Myoclonus is a rapid, abnormal movement featuring brief, shock-like muscle contractions (“positive myoclonus”) or muscle tone inhibitions (“negative myoclonus”) Kinsbourne M. Myoclonic encephalopathy of infants.  J Neurol Neurosurg Psychiatry . 1962; 25:271-276. Espay AJ, Chen R.  Myoclonus . Continuum (Minneap Minn). 2013; 19:1264-1286.

4. introduction Wong AM, Musallam S, Tomlinson RD, Shannon P, Sharpe JA. Opsoclonus in three dimensions: oculographic, neuropathologic and modelling correlates.  J Neurol Sci . 2001; 189:71-81.

5. Pathophysiology Autoimmune, inflammatory triggered by paraneoplastic or infection Anti-neuronal and anti-Purkinje cell antibodies have been associated with OMS and neuroblastoma in some patients Proposed mechanisms: The first is that oculomotor neurons of the caudal fastigial nucleus of the cerebellum become disinhibited secondary to Purkinje cell dysfunction in the cerebellar vermis A second potential mechanism is disinhibition of burst neurons, which are cells that normally generate saccadic eye movements Wong AM, Musallam S, Tomlinson RD, Shannon P, Sharpe JA. Opsoclonus in three dimensions: oculographic, neuropathologic and modelling correlates.  J Neurol Sci . 2001; 189:71-81. Rucker JC, Ying SH, Moore W, et al. Do brainstem omnipause neurons terminate saccades? Ann N Y Acad Sci . 2011; 1233:48-57.

6. Epidemiology Rare 1/1,000,000 population Incidence 1/5,000,000 per year No gender / ethnic predilection No genetic cause identifiable Children 1 & 3 years old of age Adults: any age Pang KK, de Sousa C, Lang B, Pike MG. A prospective study of the presentation and management of dancing eye syndrome/opsoclonus-myoclonus syndrome in the United Kingdom. Eur J Paediatr Neurol . 2010; 14:156-161. Tate ED, Allison TJ, Pranzatelli MR, Verhulst SJ. Neuroepidemiologic trends in 105 US cases of pediatric opsoclonus-myoclonus syndrome.  J Pediatr Oncol Nurs . 2005; 22:8-19. Klaas JP, Ahlskog JE, Pittock SJ, et al. Adult-onset opsoclonus-myoclonus syndrome.  Arch Neurol . 2012; 69:1598-1607.

7. Clinical presentation Acute or subacute onset of ataxia over a period of days to weeks, resulting in an inability to walk or sit normally Attempts to move or maintain certain postures are often disrupted by myoclonic jerking movements that may include the head, trunk, or extremities Behavioral and sleep disturbances as well as profound irritability, sometimes being inconsolable Sometimes apathy or social withdrawal Opsoclonus is generally observed within days after the onset of ataxia, but has been reported to occur weeks to months later in some cases Klaas JP, Ahlskog JE, Pittock SJ, et al. Adult-onset opsoclonus-myoclonus syndrome.  Arch Neurol . 2012; 69:1598-1607.

8. Diagnostic criteria 3 of 4 : ( 1) opsoclonus , ( 2) ataxia and/or myoclonus , ( 3) behavioral changes or sleep disturbances, and ( 4) diagnosis of neuroblastoma Additional signs on examination that may be suggestive of neuroblastoma include periorbital ecchymoses (“raccoon eyes ”) In adults: dizziness, imbalance, nausea, and vomiting Klaas JP, Ahlskog JE, Pittock SJ, et al. Adult-onset opsoclonus-myoclonus syndrome.  Arch Neurol . 2012 ; 69:1598-1607. Matthay KK, Blaes F, Hero B, et al. Opsoclonus myoclonus syndrome in neuroblastoma: a report from a workshop on the dancing eyes syndrome at the advances in neuroblastoma meeting in Genoa, Italy, 2004.  Cancer Letters . 2005; 228:275-282.

9. Differential diagnosis S quare wave jerks, ocular flutter , nystagmus Acute cerebellar ataxia/acute cerebellitis spectrum Labyrinthitis GBS Epileptic seizures Desai J, Mitchell WG. Acute cerebellar ataxia acute cerebellitis and opsoclonus-myoclonus syndrome.  J Child Neurol . 2012; 27:1482-1488. Sivaswamy L. Approach to acute ataxia in childhood: diagnosis and evaluation.  Pediatr Ann . 2014; 43:153-159. Haden SV, McShane MA, Holt CM. Opsoclonus myoclonus: a non-epileptic movement disorder that may present as status epilepticus.  Arch Dis Child . 2009; 94:897-899.

10. Association with neuroblastoma 48 % children with OMS  have occult neuroblastoma 2 % of neuroblastoma patients have OMS Paraneoplastic W arrant a thorough evaluation to detect an occult neuroblastic tumor Gorman MP. Update on diagnosis, treatment, and prognosis in opsoclonus-myoclonus-ataxia syndrome.  Curr Opin Pediatr . 2010; 22:745-750. Aydin GB, Kutluk MT, Buyukpamukcu M, Akyuz C, Yalcin B, Varan A. Neurological complications of neuroblastic tumors: experience of a single center.  Childs Nerv Syst . 2010; 26:359-365.

11. Other etiologies / risk factors Idiopathic Post- or parainfectious: influenza, West Nile virus, varicella, cytomegalovirus, human herpes virus 6, human immunodeficiency virus, and hepatitis C A ntecedent bacterial infections including  Mycoplasma pneumoniae  and salmonella . Post-immunization Toxic-metabolic: phenytoin overdose, hyperosmolar non-ketotic diabetic coma, and cocaine intoxication Post traumatic: severe brain injury O ther paraneoplastic syndromes, particularly in the setting of small-cell lung carcinoma and breast adenocarcinoma in adults Klaas JP, Ahlskog JE, Pittock SJ, et al. Adult-onset opsoclonus-myoclonus syndrome.  Arch Neurol . 2012; 69:1598-1607. Gorman MP. Update on diagnosis, treatment, and prognosis in opsoclonus-myoclonus-ataxia syndrome.  Curr Opin Pediatr . 2010; 22:745-750. Morita A, Ishihara M, Kamei S, Ishikawa H. Opsoclonus-myoclonus syndrome following influenza A infection.  Intern Med . 2012; 51:2429-2431. Hasegawa S, Matsushige T, Kajimoto M, et al. A nationwide survey of opsoclonus-myoclonus syndrome in Japanese children.  Brain Dev . 2015; 37:656-660. Turazzi S, Alexandre A, Bricolo A, Rizzuto N. Opsoclonus and palatal myoclonus during prolonged post-traumatic coma. A clinico-pathologic study.  Eur Neurol . 1977; 15:257-263.

12. Clinical work-up/diagnostics Urine/serum analysis Cerebrospinal fluid analysis Radiological studies

13. Urine/serum analysis Urinary levels of the catecholamine metabolites homovanillic acid (HVA) and vanillylmandelic acid (VMA) are useful tumor markers for neuroblastoma. These assays are reportedly elevated in 95% of cases of neuroblastoma and are useful for confirmatory purposes Autoantibodies (?) Ater JL, Worth LL. Neuroblastoma. In: Chan KW, Raney RB, editors.  Pediatric Oncology . New York (NY): Springer. :82-95. Connolly AM, Pestronk A, Mehta S, Pranzatelli MR 3rd, Noetzel MJ. Serum autoantibodies in childhood opsoclonus-myoclonus syndrome: targets in neural tissues.  J Pediatr . 1997; 130:878-884. Antunes NL, Khakoo Y, Matthay KK, et al. Antineuronal antibodies in patients with neuroblastoma and paraneoplastic opsoclonus-myoclonus.  J Pediatr Hematol Oncol . 2000; 22:315-320.

14. Cerebrospinal fluid analysis Higher amounts of B cells in their CSF Unspecified pleocytosis CSF lymphocytosis Pang KK, de Sousa C, Lang B, Pike MG. A prospective study of the presentation and management of dancing eye syndrome/opsoclonus-myoclonus syndrome in the United Kingdom. Eur J Paediatr Neurol . 2010; 14:156-161. Pranzatelli MR, Travelstead AL, Tate ED, Allison TJ, Verhulst SJ. CSF B-cell expansion in opsoclonus-myoclonus syndrome: a biomarker of disease activity.  Mov Disord . 2004; 19:770-777.

15. Radiological studies MRI / CT scan 123 I-metaiodobenzylguanidine (MIBG ) scintigraphy  monitor disease course Matthay KK, Blaes F, Hero B, et al. Opsoclonus myoclonus syndrome in neuroblastoma: a report from a workshop on the dancing eyes syndrome at the advances in neuroblastoma meeting in Genoa, Italy, 2004.  Cancer Letters . 2005; 228:275-282. Ater JL, Worth LL. Neuroblastoma. In: Chan KW, Raney RB, editors.  Pediatric Oncology . New York (NY): Springer. :82-95.

16. Management medical treatment Corticosteroids / ACTH combined with immunotherapy Immunotherapy:  intravenous immunoglobulin (IVIG), rituximab, cyclophosphamide, azathioprine, or plasmapheresis Rituximab De Grandis E, Parodi S, Conte M, et al. Long-term follow-up of neuroblastoma-associated opsoclonus-myoclonus-ataxia syndrome.  Neuropediatrics . 2009; 40:103-111 Tate ED, Pranzatelli MR, Verhulst SJ, et al. Active comparator-controlled rater-blinded study of corticotropin-based immunotherapies for opsoclonus-myoclonus syndrome.  J Child Neurol . 2012; 27:875-884. Pranzatelli MR, Tate ED, Travelstead AL, et al. Rituximab (anti-CD20) adjunctive therapy for opsoclonus-myoclonus syndrome.  J Pediatr Hematol Oncol . 2006; 28:585-593.

17. Management Addressing underlying neuroblastoma  surgical Rehabilitation Rudnick E, Khakoo Y, Antunes NL, et al. Opsoclonus-myoclonus-ataxia syndrome in neuroblastoma: clinical outcome and antineuronal antibodies – a report from the Children’s Cancer Group Study.  Med Pediatr Oncol . 2001; 36:612-622. Cooper R, Khakoo Y, Matthay KK, et al. Opsoclonus-myoclonus-ataxia syndrome in neuroblastoma: histopathologic features – a report from the Children’s Cancer Group.  Med Pediatr Oncol . 2001; 36:623-629. Pranzatelli MR, Tate ED, Dukart WS, Flint MJ,video 2 Hoffman MT, Oksa AE. Sleep disturbance and rage attacks in opsoclonus-myoclonus syndrome: response to trazodone.  J Pediatr . 2005; 147:372-378.

18. Prognosis T he survival prognosis of children with OMS secondary to neuroblastoma is very favorable better than neuroblastoma without OMS A monophasic course and that those patients generally had a more favorable neurologic prognosis than patients who followed a more chronic, relapsing course Approximately 70% of patients are estimated to have some form of motor, speech, cognitive, or behavioral disturbance E arly-stage neuroblastoma may correlate with a higher rate of neurological sequelae, suggesting that more differentiated tumors may elicit a stronger inflammatory reaction to CNS tissues More intense immunosuppression with chemotherapy may help improve neurological outcomes in OMS patients Rudnick E, Khakoo Y, Antunes NL, et al. Opsoclonus-myoclonus-ataxia syndrome in neuroblastoma: clinical outcome and antineuronal antibodies – a report from the Children’s Cancer Group Study.  Med Pediatr Oncol . 2001; 36:612-622. Cooper R, Khakoo Y, Matthay KK, et al. Opsoclonus-myoclonus-ataxia syndrome in neuroblastoma: histopathologic features – a report from the Children’s Cancer Group.  Med Pediatr Oncol . 2001; 36:623-629. Mitchell WG, Brumm VL, Azen CG, Patterson KE, Aller SK, Rodriguez J. Longitudinal neurodevelopmental evaluation of children with opsoclonus-ataxia.  Pediatrics . 2005; 116:901-917.

19. SUMMARY Rare autoimmune, inflammatory Paraneoplastic / parainfectious Clinical presentation ( 1) opsoclonus, (2) ataxia and/or myoclonus, (3) behavioral changes or sleep disturbances, and (4) diagnosis of neuroblastoma Corticosteroids/ACTH + immunomodulatory agents + (rituximab) Favorable prognosis with neurological sequele

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