Refractory epilepsia partialis continua during SARS-CoV-2 infection

We report about an 87-year-old female patient who had an ovarian tumor 2 years ago. Further on she developed an epilepsia partialis continua (Kojewnikoff epilepsy) concomitant with a paraneoplastic syndrome with positive anti-Yo detection in the CSF during a SARS-CoV-2 infection.Copyright © 2023 Georg Thieme Verlag. All rights reserved.

Thymoma and Myasthenia Gravis: An Examination of a Paraneoplastic Manifestation.

Thymoma is a rare type of malignancy but is considered one of the most common neoplasms that occur in the anterior mediastinum. A large proportion of thymomas are associated with paraneoplastic syndromes, such as myasthenia gravis. Whenever feasible, the standard of care for the treatment of thymoma should focus on the control of paraneoplastic syndromes, surgical resection, and adjuvant therapy if appropriate. A 36-year-old female patient with a significant past medical history of obesity and iron deficiency anemia who underwenten bloc resection of thymoma three months prior now presented to the benign hematology clinic to establish care for the management of anemia. Upon review of systems, the patient incidentally reported fatigue, weakness with repetitive motion, occasional blurred vision, headaches, and exertional dyspnea. Physical examination was positive for horizontal nystagmus. Given the patient's history and clinical findings, suspicion of myasthenia gravis was high. Further work-up demonstrated anti-acetylcholine receptor titers of 5.70 nmol/L (normal < 0.21 nmol/L), supporting a diagnosis of myasthenia gravis in this patient. She was subsequently started on pyridostigmine. Often, patients with thymoma experience paraneoplastic syndrome-related symptoms prior to thymectomy, and in many cases thymectomy is curative. However, in the case presented, we examine a patient that was asymptomatic prior to surgery and subsequently reported the onset of symptoms following what we suspect was an exacerbation due to general anesthesia and pain control medications. We argue that all patients with thymoma should undergo systematic evaluation and treatment of paraneoplastic syndromes, regardless of clinical symptoms and prior to surgery, in order to improve patient quality of life and hospital outcomes.

Optic neuritis in lung adenocarcinoma: A challenging diagnosis.

Optic neuritis with CRMP-5 IgG is a paraneoplastic inflammation of the optic nerve associated with lung cancer, mostly small-cell lung cancer. We present the case of a patient with lung adenocarcinoma who developed progressive bilateral visual loss a few months after immune-chemotherapy with pembrolizumab and after Covid-19 vaccination. Positive CRMP-5 IgG were detected in blood sample and complete work-up - including brain MRI - did not show any progression. High dose systemic corticoids were administered with transient improving, followed by intravenous immunoglobulins, methotrexate and rituximab but despite negativization of CRMP-5 IgG, the patient had a progressive visual loss.

CASE REPORT of A HARD to TREAT DERMATOMYOSITIS after A COVID-19 INFECTION and SUBSEQUENT VACCINATION

Background: A 50 years old woman, a medical doctor, came to our department with symmetrical proximal muscular weakness, several months after Covid-19 infection and three weeks after a second dose of Covid-19 mRNA vaccine. The patient had no prior or family history of autoimmune diseases and take no medicines. In the past she undergone an operation for double-kidney with frequent urinary infections. Objective fndings have shown symmetrical proximal muscular weakness and classic sings of dermatomyositis-Gottron's papules, shawl and holster signs, periungual vasculitis. Objectives: We present a case of a 50 old woman with clinical and laboratory proven dermatomyositis, starting three weeks after a second dose of a Covid1-19 mRNA vaccine without other reasons. Methods: The laboratory tests showed elevated CPK, lactate dehydroge-nase, aspartate aminotransferase and alanine aminotransferase, high ANA-1:1280 and myositis specifc autoantibodies-anti-NXP2 and anti-Mi-2-beta. The electromyography showed myopathic changes and the muscle MRI-symmetrical edema of mm.obturator and mm.adductor brevis. We exclude diseases that may mimic infammatory myopathies. We made a cancer screening-whole body MRI, colonoscopy, gastroscopy, mammography and gynecological exam, immunoblot for detection of paraneoplastic syndrome-associated neuronal antibodies, with no detection of cancer. Muscle biopsy of m.vastus lateralis showed attenuating muscle infammation with advancing muscle atrophy and fbrosis. Results: The diagnose dermatomyositis was made according Bohan and Peter criteria and we start a high dose (1mg/kg/day) glucocorticoid therapy with good initial clinical and laboratory effect. Two months after starting a therapy muscle weakness worsened together with difficulty of swallowing. We excluded steroid myopathy after second EMG and lack of improvement when tapering the GS dose. Methotrexate 20 mg/weekly was added as a steroid sparing drug with good response, but was stopped because fare of pyelonephritis. Accordning to the opinion of dermatologist hydroxychloroquine was started for a couple of weeks, because of active skin manifestations. Muscle weakness worsened on the background of treatment, which was stopped. We started a therapy with intravenous immunoglobulins and considered therapy with cyclophosphamide or azathio-prine after urinary infection. Because the patient was infected for a second time with covid-19, although vaccine, we continued only with glucocorticoids and anti-osteoporotic therapy. Conclusion: The etiology and pathogenesis of infammatory myopathies are not fully clarifed so far. We speculate that the infection with Covid-19 as well as mRNA vaccine trigger infammatory myopathy and compromise the patient's immunity for poor treatment response with glucocorticoids and immunosuppres-sives. On the other hand advanced muscle atrophy and fbrosis within a short period show that suspected triggering factors could be a reason for difficult to treat such type of dermatomyiositis.

MUSCULOSKELETAL MANIFESTATIONS and POSTCOVID SYNDROME in HOSPITALIZED PATIENTS INFECTED with COVID-19

Background: Covid-19 may cause musculoskeletal manifestations or postcovid syndrome (1-3). Molecular mimicry, precursor activation, continue immune activation are held responsible for the development of autoimmunity (4). It has been suggested that SARSCoV-2 infection can cause blockage of lymph vessels since the virüs can infect lymph endothelial cells branching tot he nasal cavity and may cause postcovid syndrome (5). Objectives: The aim of this study was to characterise the prevalence of mus-culoskeletal complaints, postcovid syndrome in hospitalized COVID-19 patients and relationship between clinical features and labaratory parameters. Methods: A single-centre retrospective cohort study was conducted of patients at Baskent University between March 1 and December 31, 2020. The study protocol was approved by the Ethics Committee. Hospitalized patients aged above 18 years, diagnosed with COVID-19 via RT-PCR are included the study. Pregnant patients, those with severe end-stage disease or with missing documentation were excluded. Data were obtained from electronic health records. Information was collected about patient demographics, history and duration of complaints, history of postcovid syndrome, fever or anosmia, respiratory problems, length of stay, history of intensive care and COVID-19-related biochemical parameters and rheumato-logic tests. The corelation between musculoskeletal manifestations, postcovid syndrome and clinical and labaratory parameters were observed. P value<0,05 was considered statistically signifciant. Results: Totaly 109 patiensts included to the study. %39,45 of patients were female (n=66), %60,55 of patients were male (n=43). %34,86 (n=38)of patiens complained about athralgia, %1.83 (n=2) had arthritis and %41,28 (n=45) described fatigue. Postcovid syndrome was determined in %32.11 (n=35) of patients. Positive otoantibody was determined in one patient and arthritis due to paraneoplastic syndrome was detected in a case. There was signifciant corelation between fever, length of stay and control CRP (p<0,05). There was signifciant corelation between basal CRP and control CRP, length of stay, history of intensive care, oxygen support (p<0,05). There was signifciant corelation between postcovid syndrome and arthritis, arthralgia, fatigue (p<0.05) but there was no corelation between postcovid syndrome and basal or control CRP, fever, anosmia, length of stay, intenssive care or oxygen support (p>0.05). Conclusion: As there was no corelation between musculoskeletal manifestations, postcovid syndrome and labaratory and clinical fndings. There should be further studies for understanding mechanisms of musculoskeletal manifestations and postcovid syndrome in SARSCoV-2 infection.

Case Report: Paraneoplastic Tumefactive Demyelination Associated With Seminoma.

Paraneoplastic tumefactive demyelination (TD) is a rare disorder of the central nervous system that can be challenging to diagnose. Here, we describe a 32-year-old Japanese man with a TD associated with testicular seminoma. He presented with symptoms of right-sided motor and sensory impairment 2 days after vaccination for coronavirus disease 2019 (COVID-19). Brain magnetic resonance imaging (MRI) showed a high-intensity lesion in the left internal capsule. He had a 3-year history of enlargement of the left testicle. Blood examination showed tumor marker elevation and the presence of anti-amphiphysin antibodies. Whole-body computed tomography (CT) revealed mass lesions in the left testicle and enlargement of the retroperitoneal lymph nodes. Radical orchiectomy was performed. As the pathology showed testicular seminoma, chemotherapy was administered. After surgery, his neurological symptoms deteriorated. MRI revealed that the brain lesion had enlarged and progressed to a tumefactive lesion without gadolinium enhancement. The cerebrospinal fluid (CSF) examination was normal without pleocytosis or protein elevation. Steroid pulse therapy was added; however, his symptoms did not improve. A brain stereotactic biopsy was performed and the sample showed demyelinating lesions without malignant cells. As the initial corticosteroid therapy was ineffective, gamma globulin therapy was administered in parallel with chemotherapy, and the clinical symptoms and imaging findings were partially ameliorated. TD seldom appears as a paraneoplastic neurological syndrome. In addition, there are few reports of COVID-19 vaccination-associated demyelinating disease. Clinicians should recognize paraneoplastic TD, and the further accumulation of similar cases is needed.