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Letter to the Editor
“Flail arm syndrome” with anti-Hu antibodies
Síndrome del “hombre en barril” con anticuerpos anti-Hu
Maria Magdalena Rosselló Vadell
Corresponding author
, Francesc Miralles
Neurology Department, Hospital Universitari Son Espases, Carretera de Valldemossa 79, 07120, Palma de Mallorca, Illes Balears, Spain
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In addition&#44; she reported having lost 10&#8239;kg in the last 6 months&#46; Neurological examination revealed weakness in the neck extensor muscles and a severe weakness of the upper limbs&#44; both proximal and distal&#44; with inability to raise both arms&#46; Atrophy of the shoulder girdle and intrinsic muscles of both hands was observed without visible fasciculations&#46; She also had generalized arreflexia with normal superficial sensitivity and no upper motor neuron signs&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Cervical MRI revealed no significant foraminal or canal stenosis&#46; Blood tests were normal including serologies and serum immunofixation&#46; High titers of ANA and high titers of anti-Hu antibodies were detected &#40;Western Blot technique&#41;&#46; The biochemical analysis of the cerebrospinal fluid was normal&#46; Electrodiagnostic findings show extensive neurogenic involvement predominantly in the cervical and thoracic region&#44; with signs of ongoing denervation&#47;reinnervation and massive loss of motor units&#44; without signs of segmental demyelination or sensory neurographic involvement&#46; Whole-body PET-CT scan detected a 10&#8239;mm diameter hypermetabolic pulmonary nodule in right upper lobe&#44; suggestive of malignancy&#46; See <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A course of intravenous immunoglobulin 0&#46;4&#8239;g&#47;kg&#47;day was administered for 5 days&#44; with no effect on the neurological condition&#46; The case was presented to a multidisciplinary committee&#44; deciding on radiotherapy treatment given the high surgical risk and the impossibility to perform needle biopsy given the deep location of the lesion and the anatomical characteristics&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">After 8 months we observed a progression of the neuromuscular disease&#44; with functionality loss of the upper limbs and development of weakness of the lower limbs&#44; making her unable to stand and walk&#44; with no other signs of the first motor neuron&#46; However&#44; in the control CT scan&#44; the nodule had decreased in size &#40;3&#8239;mm&#8239;&#215;&#8239;4&#8239;mm&#41;&#46; The patient was admitted 4 months later due to a 2-week history of constipation&#44; with a large dilated loop observed on the abdominal CT scan&#44; diagnosing paralytic ileus&#46; During this admission&#44; the patient presented deterioration in her general condition&#44; with bronchial aspiration&#44; so it was decided together with the relatives to limit the therapeutic effort&#44; and she finally died during admission&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Various studies have argued that routinely screening MND cases for anti-neuronal antibodies is of no value&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> Nevertheless&#44; few case series have reported well-characterized onconeuronal antibodies in patients with MND&#44; and the pathophysiology of these onconeuronal antibodies is disputed&#46; A recent review by Tolkovsky et al&#46; has analyzed the 17 cases described in the literature about MND and anti-Hu&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The most common phenotype was women with pattern of &#96;&#96;flail arm syndrome&#39;&#39; with anti-Hu antibodies and SCLC&#44; as in our case&#46; In most of these patients&#44; lung cancer was diagnosed within a year of the onset of neurological signs&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;7</span></a> However&#44; most patients responded little or not at all to immunotherapy and tumor treatment&#44; except in 2 cases that improved after chemoradiotherapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In our case&#44; we do not have a pathological diagnosis&#44; but due to the PET characteristics uptake and association with Hu antibodies&#44; the most probable diagnosis was SCLC&#46; Some authors consider that the presence of anti-Hu antibodies in serum could be a marker of SCLC&#46; In this study by List M et al&#46;&#44; all patients evaluated with positive anti-Hu antibodies had SCLC&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> On the other hand&#44; Dalmau J et al&#46; evaluated the presence of anti-Hu antibodies in patients with SCLC and healthy subjects&#46; It was found that all those who presented paraneoplastic syndrome had positive anti-Hu and those who did not present paraneoplastic syndrome had positive anti-Hu 7&#47;44 patients&#46; No healthy subject presented anti-Hu antibodies&#46; The anti-Hu antibodies appears&#44; when present&#44; to be a good marker for SCLC&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In addition&#44; we must consider the autonomic involvement that our patient had&#44; with the development of a paralytic ileus&#46; This could be related to enteric neuropathy in the context of anti-Hu antibodies&#44; although its appearance is not rare as a complication of seriously ill and bedridden patients&#46; Dysautonomia is described in PNS associated with anti-Hu antibodies<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and has also been described only in one case of 32-year-old woman with brachial amyotrophic dyparesis with anti-Hu antibodies&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> with no other cases described in the literature&#44; apart from our case&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Although PMND is considered a non-classical syndrome&#44; the PNS diagnostic criteria proposed by Graus et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> allow us to diagnose a &#8220;definitive PNS&#8221; in the presence of a well-characterized onconeuronal antibody&#44; even in the absence of a classical clinical syndrome&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion&#44; our case indicated a possible link between antineuronal antibodies and MND&#44; but further investigations are required to evaluate their pathophysiological significance&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethics</span><p id="par0055" class="elsevierStylePara elsevierViewall">This article has been reviewed by the Ethical Review board of the Balearic Islands &#40;CEI-IB&#41;&#46; The confidentiality of the patient has been preserved &#40;neither text nor images contain identification data nor dates&#41; and the patient&#39;s husband has granted his consent for publication&#46; Therefore&#44; this CEI-IB authorizes its publication &#40;IB 4898&#47;22&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0060" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">On behalf of all authors&#44; the corresponding author states that there is no conflict of interest&#46;</p></span></span>"
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ISSN: 21735808
Original language: English
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