Development of progressive multifocal leukoencephalopathy after cord blood transplantation in a patient with refractory angioimmunoblastic T-cell lymphoma.

A patient undergoing cord blood transplantation for refractory angioimmunoblastic T-cell lymphoma was subsequently managed with long-term immunosuppressants for chronic graft-versus-host disease (GVHD). On day 591 post-transplant, she exhibited disorientation and cognitive dysfunction. Magnetic resonance imaging (MRI) of the brain revealed two hyperintense foci in the white matter, suggestive of progressive multifocal leukoencephalopathy (PML). However, we did not include PML in the differential diagnosis at that time. Unfortunately, she developed progressive cognitive impairment, and repeated brain MRIs showed a progression in lesion size. She was still taking immunosuppressants to control her GVHD, therefore we suspected PML. The diagnosis of PML was confirmed through the detection of a John Cunningham (JC) virus in the cerebrospinal fluid on day 640 post-transplant. This report highlights the critical need to consider PML in differential diagnoses for post-allogeneic transplant patients, especially those who exhibit progressive neurological symptoms while on prolonged immunosuppressant therapy.

Anti-signal Recognition Particle Antibody-positive Immune-mediated Myopathy after mRNA-1273 SARS-CoV-2 Vaccination.

A 26-year-old Japanese woman developed a fever, myalgia and gait disturbance one day after receiving the second dose of the mRNA-1273 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. A neurological examination revealed symmetrical weakness and myalgia in proximal lower limbs, and a blood examination showed prominent elevation of creatinine kinase. Magnetic resonance imaging (MRI) revealed a high signal intensity in the thigh muscles on short-tau inversion recovery images, and antibody testing revealed positive findings for anti-signal recognition particle (SRP) antibody. Thus, anti-SRP antibody-positive immune-mediated myopathy was diagnosed. We initiated immunotherapy, and she was ultimately able to walk stably.

[Morvan syndrome associated with unresectable thymoma responsive to chemotherapy: a case report].

A 51-year-old Japanese man presenting with a several-month history of parasomnia, orthostatic hypotension and generalized myokymia was admitted to our hospital. He had a past medical history of unresectable recurrent thymoma, but chemotherapy for thymoma was discontinued according to the patient's decision four years before this hospitalization, and the thymoma had enlarged. He exhibited symptoms of the peripheral nervous system (myokymia), central nervous system (parasomnia, short-term memory impairment), and autonomic nervous system (orthostatic hypotension), and his serum was positive for voltage-gated potassium channel (VGKC)-complex antibodies. Based on the above findings, Morvan syndrome was diagnosed. Resumption of chemotherapy for thymoma resulted in shrinkage of the thymoma accompanied by remission of Morvan syndrome. Subsequently, discontinuation of chemotherapy led to aggravation of thymoma with recurrence of Morvan syndrome. This clinical course suggests a strong correlation between the disease activity of thymoma and Morvan syndrome. In the present case of Morvan syndrome associated with unresectable thymoma, chemotherapy contributed to the remission of Morvan syndrome. Our patient suggests a possibility that chemotherapy for thymoma is a useful treatment for Morvan syndrome.

[A case of mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) complicated by chronic intestinal pseudo-obstruction].

A 42-year-old woman presented at our hospital with acute paraphasia and word finding difficulty. She was not paralyzed or ataxic. Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) was diagnosed based on brain MRI finding of edematous lesions in bilateral temporal lobe cortexes that did not match the vascular territory, elevated lactate and pyruvate levels in blood and cerebrospinal fluid, and the presence of a mtDNA 3243A>G mutation. From six months before her visit, she had persistent anorexia, bloating, nausea and vomiting, and weight loss to 25 kg. We diagnosed her condition as chronic intestinal pseudo-obstruction (CIPO) associated with MELAS, because a gastroenterologist had previously diagnosed her with megacolon associated with colonic dysfunction. Usually, CIPO is often associated with the chronic phase of MELAS. However, since CIPO complication from the early stage of the disease is occasionally encountered, it is necessary to include mitochondrial disease in differential diagnosis of CIPO of unknown cause.

An Anti-PM/Scl-75 Antibody-positive Japanese Woman Who Developed Inflammatory Myopathy.

A 69-year-old Japanese woman presented with mild muscle weakness of the neck and symmetrical proximal parts of the upper and lower limbs. Laboratory tests, needle electromyography, and a muscle biopsy revealed inflammatory myopathy with an apparent clinical classification of polymyositis and positive findings for anti-PM/Scl-75 antibody. This antibody is rare among Japanese populations, and most Japanese patients with the antibody are not classified with the inflammatory myopathy seen in polymyositis. The muscle biopsy also showed marked necrotic and regenerative fibers. We need to collectively investigate patients with the potential to develop this disease, and to identify any unique characteristics for Asian populations, including Japanese.

Myopericarditis in a case of anti-signal recognition particle (anti-SRP) antibody-positive myopathy.

A 79 year-old female was admitted to our hospital because of high serum creatine kinase level together with proximal muscle weakness and pain on grasping. MRI revealed inflammatory changes in femoral muscles on both sides. Muscle biopsy showed size irregularity of muscle cells, and necrosis and regeneration of fibers. Study of antibodies was also consistent with the diagnostic criteria of anti-signal recognition particle (anti-SRP) antibody-positive myopathy. On admission, the patient required pericardiocentesis for the management of exudative pericarditis. Accompanying the aggravation of myositis, negative T wave in precordial leads on ECG, ventricular extrasystoles and non-sustained ventricular tachycardia were observed. These abnormalities were resolved with the improvement of myositis by immunosuppressive treatment. These observations suggest that the myopericarditis was associated with anti-SRP antibody-positive myopathy.

A case of neuromyelitis optica presenting marked pleocytosis and hypoglycorrhachia.

A 57-year-old man initially developed chest discomfort, nausea, vomiting, headache and low-grade fever, followed by paraplegia, sensory disturbance below level Th5 and bilateral visual loss. He was admitted to our hospital on the 15th day of illness. MRI short T1 inversion recovery image showed multiple longitudinal lesions in the spinal cord below C3, and T2-weighted image showed abnormal hyperintensity within the left optic nerve. Cerebrospinal fluid (CSF) analysis revealed marked pleocytosis (1,719/µl) and hypoglycorrhachia (CSF glucose; 20 mg/dl). Intensive immunosuppressive therapy combined with antibiotics and antiviral agent were started immediately, resulting in relatively good visual outcome but no improvement of paraplegia and sensory disturbance. The patient's serum sample on admission was subsequently reported to be positive for anti-aquaporin-4 antibody. With no evidence of infectious diseases, neuromyelitis optica (NMO) was diagnosed. It should be borne in mind that marked hypogylcorrhachia may also be seen in NMO.

[A case of dural arteriovenous fistula of right cavernous sinus presenting bilateral eye symptoms].

An 85-year-old woman was first admitted to our hospital because of right ptosis and diplopia. Examinations showed right oculomotor paralysis and reduced vision in the right eye. Serological and neuroradiological examinations failed to reveal the etiology. Oral prednisolone was started for a presumptive diagnosis of idiopathic oculomotor nerve palsy, which resulted in little improvement. Approximately ten months after the first admission, left ptosis appeared and she was re-admitted to our hospital. One day after admission, external ophthalmoplegia and conjunctival injection on the left side appeared. MRI revealed abnormal flow void in the right cavernous sinus. Based on cerebral angiographic findings, dural arteriovenous fistula of the right cavernous sinus was diagnosed. Symptoms on the left side were considered to result from increased perfusion pressure due to venous drainage via the intercavernous sinus to the contralateral cavernous sinus. After transvenous embolization, symptoms and signs improved gradually. In a case of external ophthalmoplegia with unknown etiology, detailed neuroradiologyical examinations such as cerebral angiogram are advisable.

Transient phrenic nerve palsy after cardiac operation in infants.

OBJECTIVE: The aims of this study were to prove the presence of transient phrenic nerve palsy in children after cardiac surgery by successive recordings of diaphragmatic action potentials (DAPs), and to decide the indication of diaphragmatic plication in infants with postoperative phrenic nerve palsy. METHODS: The DAPs were recorded from 11 infants (age 0-54 months) under artificial ventilation after cardiac surgery. The successive DAP recordings were performed within 3-4 days (0W), 1 week (1W) and 2 weeks (2W) after operation to make a final decision for diaphragmatic plication to wean artificial ventilation. RESULTS: The patients were divided into 3 groups according to the DAP changes in successive recordings, namely, patients with normal DAPs at 0W, patients with transient depression of DAPs at 0W followed by recovery to normal DAPs by 1W and/or 2W, and patients with persistent depression of DAPs of the affected side necessitating plication of hemidiaphragm. CONCLUSIONS: In infants with phrenic nerve palsy after cardiothoracic surgery, persistently abnormal DAPs in repeated electrophysiologic examinations for at least 2 weeks after surgery are a useful guidance to support clinical and radiological evidence for an indication of diaphragmatic plication.