Endgames Case report

A woman with ataxia

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b180 (Published 29 January 2009) Cite this as: BMJ 2009;338:b180
  1. Phillip Fletcher, Specialist registrar in neurology
  1. 1St George’s Hospital, London
  1. fletcherphillip{at}hotmail.com

    A 41 year old woman was admitted to hospital with a one week history of transient episodes of blurred vision and progressive dysarthria, incoordination and ataxia, such that she could no longer stand.

    Three months earlier she had experienced the gradual onset of a mild occipital headache and episodes of transient blurred vision. Her speech had felt slower and slurred and her left hand was clumsy. These symptoms had been preceded by a severe outbreak of cold sores, which had been treated with oral acyclovir. On this occasion, her neurological symptoms gradually resolved over a month. She had no family history or other history of note, and she was not taking any drugs except the oral contraceptive pill.

    On examination there were cold sores around her mouth and she had bilateral cerebellar signs, more prominent on the left. She had negative viral serology and a normal magnetic resonance imaging of her head and venous sinuses, and electroencephalogram. Lumbar puncture showed an acellular cerebrospinal fluid with mildly raised protein (0.52 g/l) and unmatched oligoclonal banding. Results of viral polymerase chain reaction testing were negative. Antineuronal antibodies were sent and returned a positive anti-Yo antibody.

    Questions

    (1) What is the significance of this result?

    (2) What is your management plan?

    (3) What is the likely prognosis?

    Answers

    Short answers

    • 1 The presence of antineuronal antibodies indicates that the woman has a paraneoplastic cerebellar syndrome.

    • 2 Any patient with positive antineuronal antibodies on testing needs full investigation to exclude an underlying malignancy. Although the paraneoplastic phenomenon is thought to occur only once metastasis or micrometastases have occurred, the underlying malignancy can be difficult to find. Investigations may include ultrasonography, computed tomography, and positron emission tomography scanning.

    • 3 The prognosis depends on the underlying malignancy. The neurological improvement once the underlying cancer has been treated depends upon the …

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