[A 60-year-old man with intention tremor as an initial symptom followed by cerebellar ataxia, peripheral neuropathy and dementia].
We report a 60-year-old man with a 6-year history of tremor in his hands. He noted the onset of short of breath and gait disturbance in 1994; both of these symptoms were slowly progressive. Then recently he developed fever two months prior to the present admission. He was admitted to the rheumatology department of our hospital and neurological consultation was asked on December 13, 2000. On neurologic examination, he showed Gottron sign and fine crackle in both lungs. Pertinent neurological findings were bilateral dysmetria in finger-to-nose and heel-to-knee tests and a broad-based gait. In addition, he showed intention tremor in upper extremities more on the left. Romberg sign was positive. Deep tendon reflexes were decreased. Vibratory sensation was reduced at the wrists. The patient's hemoglobin was 11.1 g/dl, with a mean corpuscular volume of 92.0 fl. Vitamin B12 level was 190 (reference range, >230 pg/ml). Serum lactic acid, pyruvic acid and ceruloplasmin were slightly elevated. Chest X-ray showed interstitial pneumonia. Muscle biopsy showed grouping of small angular fiber. Brain MRI showed diffuse atrophy of the cerebral cortex and the cerebellum hemisphere. Thalamotomy did not improve his tremor. He was admitted again in November 2001. General worsening of his neurological findings was observed. IL2-receptor was markedly elevated. Serum anti-Hu, Yo and Ri antibodies were negative. An anaplastic carcinoma was found in his jejunum. He died from respiratory failure in February 2002. He was discussed in a neurological CPC and the chief discussant arrived at a conclusion that the patient had paraneoplastic syndrome. Other diagnosis entertained included MERRF, GSS, Ramsay Hunt syndrome, subacute combined degeneration, spinocerebellar degeneration. Majority of the participants thought that paraneoplastic syndrome was most likely. Post-mortem examination revealed poorly differentiated carcinoma in the small intestine. Myeline pallor was noted in the posterior and the lateral columns in the thoracic spine. Neuronal cell loss was observed in the Purkinje cell and granular cell layer in the cerebellum. Sural nerve demonstrated loss of myelinated fibers and grouping of small fibers. Neuropathological findings were consistent with Friedreich ataxia; nevertheless, no mutation was reported in frataxin in Japan. The neuropathologist concluded that neuropathological diagnosis was a spinocerebellar ataxia with neuropathological similarities to Friedreich ataxia.
Machida
Yuh
Y
Department of Neurology, University School of Medicine, Tokyo, Japan
Lijima
Makiko
M
Nakamura
Kazuhiro
K
Ota
Satoshi
S
Hattori
Nobutaka
N
Mizuno
Yoshikuni
Y
D000368:Aged; D015415:Biomarkers / Q000032:analysis; D001921:Brain / Q000473:pathology; D002277:Carcinoma / Q000150:complications / Q000175:diagnosis; D003704:Dementia / Q000150:complications* / Q000175:diagnosis* / Q000473:pathology; D003937:Diagnosis, Differential; D017809:Fatal Outcome; D006801:Humans; D007414:Intestinal Neoplasms / Q000150:complications / Q000175:diagnosis; D007421:Intestine, Small; D017563:Lung Diseases, Interstitial / Q000150:complications / Q000175:diagnosis; D008279:Magnetic Resonance Imaging; D008297:Male; D018482:Muscle, Skeletal / Q000473:pathology; D010257:Paraneoplastic Syndromes / Q000150:complications* / Q000175:diagnosis* / Q000473:pathology; D015375:Receptors, Interleukin-2 / Q000032:analysis; D020754:Spinocerebellar Ataxias / Q000150:complications* / Q000175:diagnosis* / Q000473:pathology; D014057:Tomography, X-Ray Computed; D014202:Tremor / Q000209:etiology*
D015415:Biomarkers; D015375:Receptors, Interleukin-2