Sclerosis, Volume 1, Issue 1 (June 2023) – 8 articles

Isolated paraneoplastic myelopathy (IPM) is a rare neurological manifestation of systemic cancer and represents an intermediate-risk phenotype of disease according to the diagnostic criteria for Paraneoplastic Neurologic Syndromes (PNS). Here, we present the case of a 47-year-old woman who developed subacute cervical myelopathy and was then diagnosed with breast cancer. Through this lens, we provide a discussion of current literature on IPM. Over four months, our patient developed progressive tetraparesis, hypoesthesia with C3 level, and urinary retention. The first MRI was negative, but a four-month-control MRI showed a T2-hyperintense spinal lesion (C2–C7 and T2–T4). Cerebrospinal fluid (CSF) analysis was normal. Infective and autoimmune screening, including onconeural, anti-MOG, and aquaporin-4 antibodies, was unremarkable. The total-body CT scan was negative, but total-body PET-CT scan evidenced an enlarged axillary lymph node, with the detection of breast cancer cells at fine-needle aspiration. Despite negative mammography, a breast MRI confirmed a mammary nodule, which was removed, and a ductal infiltrating breast carcinoma diagnosis was made. Her neurological condition partially improved after steroid therapy. Our final diagnosis was probable IPM, according to PNS criteria. This rare condition affects most frequently middle-aged women and is often associated with breast and lung cancer, even if two-thirds of patients’ cancer diagnosis is subsequent to the onset of neurological deficits. Clinical presentation is often subtle, and CSF analysis, neuroimaging, and onconeural autoantibodies could be negative or non-specific. However, if the suspect of paraneoplastic disease is strong, cancer should be searched thoroughly since early diagnosis and treatment are associated with a better outcome. Full article

Multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD) are among the commonly considered differential diagnoses in patients with inflammatory central nervous system (CNS)-diseases. Formerly diagnosed competing autoimmune diseases might impair diagnostics and treatment. Here, we report on a 41-year-old woman admitted to our hospital with primary manifestation of NMOSD (paresthesia, paralysis of the lower extremities, and urinary incontinence) while undergoing treatment for a diagnosed systemic lupus erythematosus (SLE) with hydroxychloroquine. CNS manifestation of the disease was considered. Magnetic resonance imaging (MRI) of the cranium and spinal cord showed multiple supratentorial lesions of the white matter and massive intramedullary lesions with contrast enhancement. Cerebrospinal fluid (CSF) showed pleocytosis (20/µL), positive antinuclear antibodies (ANA), antiphospholipid antibodies, and SSA/Ro antibodies, while formerly positive dsDNA antibodies were negative. Further diagnostics revealed a 1:10,240 serum titer of Aquaporine-4 antibodies. The patient received intravenous methylprednisolone for three days (2 g per day), which led to an escalation to plasmapheresis and to an improved EDSS from 8.0 to 4.0. Because of the comorbidity, a combined relapse prophylaxis with satralizumab and mycophenolate mofetil was established. Rehabilitation and continued treatment improved EDSS to 1.0 with no impairment of mobilization. Although formerly diagnosed SLE could have explained the symptoms, it is important to reconsider competitive diseases in order to establish adequate immunotherapy. Full article

Background: This pilot study explored the effectiveness and feasibility of an online version of a group acceptance and commitment therapy (ACT) resilience training intervention for people with multiple sclerosis (PwMS), called e-READY for Multiple Sclerosis (MS). Methods: Fifty-six PwMS were randomized to intervention (n = 31) or waitlist control (WLC) (n = 25). The primary outcome, resilience, and secondary outcomes (quality of life (QoL), distress, psychological flexibility) were assessed at pre- and post-intervention and 12-week follow-up. Results: Intervention participants reported greater pre- to post-intervention improvements in anxiety (d = 0.56) and stress (d = 0.62) than WLC. Gains were maintained at follow-up. Confidence intervals revealed a trend for the intervention group to report greater improvements than WLC across all outcomes. Reliable Change Index data showed that, compared to WLC, there were trends for more intervention participants to evidence clinically significant improvements in physical health QoL. Recruitment response was weak, intervention retention was good, adherence to program progression guidelines was satisfactory, program usability satisfaction was high, and study protocol attrition at post-intervention and follow-up was low and high, respectively. Most participants viewed the intervention as enjoyable, helpful, and resilience-building, and would recommend it to other PwMS. Qualitative feedback validated the usefulness of intervention tools and digital delivery mode and bolstered resilience through improved ACT-related skills. Conclusions: Effectiveness and feasibility results from this proof-of-concept study provide preliminary support for the e-READY for MS program. Full article

A 38-year-old Brazilian man presented with slowly progressive quadriparesis since age 11 years. He progressed over 15 years with symptoms restricted to the lower limbs, and since then, with a progressive compromise of the upper limbs. His deceased brother had a similar clinical presentation. Examination showed spastic dysarthria, global amyotrophy, brisk tendon reflexes in the lower limbs, symmetrical quadriparesis, and fasciculations in the four limbs. Neurophysiological studies disclosed acute and chronic signs of denervation and chronic reinnervation involving the cervical, thoracic, and lumbosacral myotomes, with normal sensory conduction study. Fibrillation potentials, fasciculations, and positive sharp waves involved mainly the upper limbs. A diagnosis of long-standing juvenile-onset motor neuronopathy was established. Genetic testing identified the possibly pathogenic variant c.3G>T (p.Met1?) in homozygosity in the COQ7 gene. This report highlights the importance of considering a potentially treatable metabolic dysfunction as the primary mechanism in cases of juvenile motor neuron disease. Full article

Salt intake is associated with multiple sclerosis; however, controversial findings that challenge this association rely primarily on methods that do not measure total sodium storage within the body, such as food surveys and urinary sodium excretion. In contrast, tissue sodium concentrations measured with sodium MRI confirm high sodium levels in multiple sclerosis, suggesting a role for sodium toxicity as a risk factor for the disease. Research on demyelination in the central nervous system has identified myelin phase transitions associated with increased salinity, which cause structural instabilities of myelin sheaths and add further evidence implicating sodium toxicity as a causative factor in multiple sclerosis. Inflammatory and immune responses in multiple sclerosis are also related to high sodium intake. In addition, salt is a potential mediating factor associating multiple sclerosis with comorbidities, including systemic lupus erythematosus, rheumatic arthritis, inflammatory bowel disease, and cardiovascular disease. Current confusion exists over classifying dietary sodium intake levels as low, normal, and high, and questions remain over levels of sodium restriction necessary for disease prevention. To reduce multiple sclerosis symptoms and prevent disease progression in patients, future research should investigate low-salt interventions with levels of sodium intake associated with ancestral hunter-gatherer tribes. Full article

Paraneoplastic neurological syndromes (PNS) occur in 1–3% of all cancer patients with several cancer-related neurologic diseases involving any part of the nervous system. Paraneoplastic cerebellar degeneration (PCD) is a specific type of PNS characterized by sub-acute cerebellar syndrome with trunk and limb ataxia, dysarthria, diplopia, and vertigo. We report herein the case of a 70-year-old female patient with cerebellar symptoms and transient anti-Yo antibody PCD positivity manifested three years after a breast cancer diagnosis who is currently neurologically stable after an extended follow-up. Full article

Aggressive neuromyelitis optica spectrum disorders (NMOSDs) with antibodies (Abs) against aquaporin-4 (AQP4) can be treated by blocking the interleukin 6 (IL6) pathways with tocilizumab. This IL6-inhibitor was employed to treat coronavirus disease 2019 (COVID-19) pneumonia with unconclusive results. We present a 52-year-old woman with AQP4 NMOSD, unresponsive to rituximab, that stabilized on tocilizumab one year after the disease onset. She was bed-bound and progressively recovered her mobility. During intensive rehabilitation, she presented fever and cough for one week with nasopharyngeal swabs positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This mild COVID-19 recovered spontaneously without sequelae, and the monthly tocilizumab infusions were continued for another 10 months. Subsequently, serious and prolonged respiratory and urinary infections caused treatment interruption, and then her disease re-activated. In our case, tocilizumab was effective in preventing NMOSD relapse and was safe to use during SARS-CoV-2 infection. Full article