Studies of the Immune System

• Spinal Fluid Markers
• B and T Cell Spinal Fluid Markers for OMS
• B-Cell Abnormalities in OMS
• Blood Lymphocytes in OMS
• Screening for autoantibodies
• Elevated spinal fluid neopterin

Brain Neurotransmitter Abnormalities

• Reduced serotonin and dopamine
• Normal choline

Conceptional Framework/Hypothesis Building

• Neurobiology
• Immunopharmacology
• Paraneoplastic syndrome
• Myoclonus in childhood

Epidemiology and outcome

• Questionnaire study of 105 cases of OMS
• Forty-one-year follow-up

Neurobehavioral and Psychosocial Functioning

• Neuropsychological testing
• Sleep disturbance and rage: response to Trazodone

Neuroblastoma Tumor Markers

• Serotonin receptors on tumors
• Characterization sites on tumors

Pilot Clinical Trials

• High-dose ACTH protocol
• Piracetam
• 5-Hydroxy-L-tryptophan
• Effect of rituximab
• Responses to rituximab
• Rituximab Adjunctive Therapy for OMS
• Cyclophosphamide (cytoxan)

Sedation/Anesthesia

• IV propofol

Cerebrospinal Fluid 5-Hydroxyindoleacetic Acid and Homeovanillic Acid in the Pediatric Opsoclonus-Myoclonus Syndrome

To study the purported role of central monoamine disturbances in the pathophysiology of the opsoclonus-myoclonus syndrome, the serotonin metabolite 5-hydroxyindoleacetic acid and the dopamine metabolite homovanillic acid were measured in cerebrospinal fluid samples from 27 affected children and 47 age- and gender-matched control subjects by high-pressure liquid chromatography with electrochemical detection. 5-Hydroxyindoleacetic acid and homovanillic acid concentrations in the cerebrospinal fluid were approximately 30 to 40% lower in opsoclonus-myoclonus patients compared to control subjects, and the normal inverse correlation between age and monoamine metabolite concentrations in the cerebrospinal fluid of control subjects was not found in opsoclonus-myoclonus patients. Patients with the lowest values were less than 4 years old, and a subgroup had extremely low levels, but differences in older children were not significant. Cerebrospinal fluid levels of 5-hydroxyindoleacetic acid and homovanillic acid were more positively correlated in control subjects than in opsoclonus-myoclonus patients. None of the patients exhibited high levels of monoamine metabolites. Homovanillic acid levels were slightly lower in the cerebrospinal fluid of patients receiving corticotropin or steroids at the time of lumbar puncture. Clinical variables that could be excluded were paraneoplastic etiology, anesthetic for lumbar puncture, syndrome duration, age at onset, gender, response to steroids, length of time until initiation of corticotropin or steroids, presence of seizures, opsoclonus, and functional impairment. These data suggest a disturbance and possible altered ontogeny of serotonin or dopamine neurotransmission in a subpopulation of children with opsoclonus-myoclonus with low cerebrospinal fluid levels of 5-hydroxyindoleacetic acid and homovanillic acid. Biochemical heterogeneity for this clinical phenotype may have implications for responsiveness to treatment with serotonergic and other drugs.

Annals of Neurology. 1995;37:189-197.

Clinical Response to 5-Hydroxy-L-tryptophan in Chronic Pediatric Opsoclonus-Myoclonus: A Double-Blind Placebo Crossover Pilot Study

We found low levels of cerebrospinal fluid (CSF) 5-hydroxyindoleacetic acid (5-HIAA) in a subgroup of children with opsoclonus-myoclonus, a pervasive neurological disorder that disables previously normal infants and children. As part of a systematic study to define the neuropharmacologic basis of opsoclonus-myoclonus, five chronically affected children were enrolled in an open, randomized, two-period, dose-ranging, double-blind, cross-over pilot clinical trial designed to compare the antimyoclonic properties of oral 5-hydroxy-L-tryptophan (L-5-HTP) with placebo. Subjects received an increasing L-5-HTP dose from 2 to 15 mg/kg/day as well as oral carbidopa throughout the study but were on no other drugs. Subjective improvement was reported in two subjects, but none showed significantly improved scores on rating scales for myoclonus, opsoclonus, and ataxia, even after further treatment with L-5-HTP for 1-3 months. After treatment, three patients had worse emotional and behavioral problems, and the electroencephalograms of two showed mild slowing but normalized during washout. Blood tests to evaluate hematologic, renal, and hepatic systems showed no changes and no evidence of the eosinophilia-myalgia syndrome. None of the subjects exhibited seizures or worsening of myoclonus. Two patients had vary low predrug CSF 5-HIAA levels, but CSF 5-HIAA did not appear to correlate with response to L-5-HTP. The data suggest that L-5-HTP with carbidopa can be used safely in children using our dosing schedule. However, behavioral side effects, which tended to be exacerbations of severe baseline difficulties, though reversible, were prohibitive. Serotonin may play a role in the chronic neurobehavioral problems of opsoclonus-myoclonus. The data support our hypothesis of biochemical subgroups of opsoclonus-myoclonus based on CSF neurochemical studies. Key Words: Opsolclonus-myoclonus--Paraneoplastic syndromes--L-5-HTP--Cerebrospinal fluid 5-HIAA--Eosinophilia-myalgia--Myoclonus scale--Aggression. Clinical Neuropharmacology. 1994;17(2):103-116.

Serotonin Receptors in Human Neuroblastoma: A Possible Biologic Tumor Marker

We used saturation radioligand binding to measure nine types of serotonin receptors in 13 neuroblastomas from children. 5-HT1E and 5-HT3 sites were found in neuroblastomas with receptor density and affinity similar to human or rat brain. No 5-HT1A, 5-HT1B, 5-HT1C, 5-HT1D, 5-HT2, or 5-HT uptake sites were found in any of the tumors, although all were detected in human or rat brain. These data demonstrate that human neuroblastomas psssess 5-HT receptors found in human brain and relevant to human myoclonus. We speculate that 5-HT receptors in human neural crest-derived tumors may have clinical and neurobiological significance. Experimental Neurology. 1992;115:423-427.

On the Molecular Mechanism of Adrenocorticotrophic Hormone in the CNS: Neurotransmitters and Receptors

A neural mechanism for the clinical efficacy of adrenocorticotrophic hormone (ACTH) independent of steroid effects in neurological disorders such as infantile spasms, myoclonic seizures in infants, and the opsoclonus-myoclonic syndrome remains controversial. This article reviews evidence that ACTH is a neurotransmitter, neuromodulator, and growth factor. It summarizes studies of anticonvulsant, antimyoclonic, and neurophysiologic effects of ACTH and ACTH gragments, the binding of ACTH in vitro to neurotransmitter receptors in brain, the chronic effects of ACTH on central neurotransmitter receptors and metabolism, effects of neurotransmitters on ACTH secretion, effects of ACTH on growth of cultured neurons, anatomic evidence for interactions of ACTH with neurotransmitters, behavioral effects and interactions of ACTH with neurotransmitter systems in vivo, and other neurochemical properties which my alter neurotransmission. Experimental Neurology. 1994;125:142-161.

Characterization of 5-hydroxytryptamine 1A-like binding sites in human ganglioneuroblastoma

Tumors derived from primitive neural crest cells are the most common malignant neoplasms of infancy and early childhood. We recently reported [3H]8-hydroxy-2-(di-n-propylamino)tetralin specific binding in one suchb tumor, the ganglioneuroblastoma. We now characterize this binding and compare it with 5-hydroxytryptamine 1A (5-HT1A binding site: 5-HT>8-OH-DPAT, RU24967>methysergide, methiothepin, 1-2,5-dimethoxy-4-iodophenyl aminopropane (DOI), ketanserin>mianserin. Regression analysis showed a correlation with drug affinitics in human cortex. [3H]8-OH-DPAT binding was saturable and linear with absence of cooperativity, indicative of a single population of sites. The density of sites in ganglioneuroblastoma was two to four-fold less than in human or rat cortex. [3H]5-HT binding also identified 5-HT1 binding sites in ganglioneuroblastoma, comparable in density to [3H]8-OH-DPAT labeled sites. No specific binding was found using [3H]paroxetine, [3H]DOB, [3H]mesulergine to label other types of 5-HT recognition sites. These data confirm the present of a 5-HT1A-like binding site in human ganglioneuroblastoma. Neuroscience Letters. 1991;132:117-120.

The Neurobiology of the Opsoclonus-Myoclonus Syndrome

Opsoclonus-myoclonus is a pervasive neurological syndrome of children and adults. Although rare, it raises important clinical and neurobiological issues. This article provides an overview of the clinical and laboratory features, differential diagnosis, treatment, and outcome of opsoclonus-myoclonus. It pursues immunologic, genetic, electrophysiologic, neurochemical, and other clues to a pharmacologic model. Key questions include how and where the brain is injured, reversibility of the injury, possible targets for pharmacologic intervention, and which new studies are needed. Key Words: Myoclonus--Opsoclonus--Paraneoplastic--Neuroblastoma--ACTH. Clinical Neuropharmacology. 1992;15(3):186-228.

The Immunopharmacology of the Opsoclonus-Myoclonus Syndrome

The opsoclonus-myoclonus syndrome (OMS) is a potentially devastating paraneoplastic or paraviral syndrome. Although it is a rare disorder, it has major implications for cancer, virology, immunology, developmental neurobiology, and molecular pharmacology. The mechanism of brain injury in OMS is unknown, but evidence suggests immune system dysregulation. This article surveys recent clinical and laboratory evidence for the autoimmune theory and discusses how some current therapies for OMS may exert their effects through immunomodulation. Specific testable hypotheses on the immunologic defect in OMS involving both B cells and T cells, the nature and mechanisms of brain injury, and their clinical correlations are proffered. The current therapeutic armamentarium provides a broad spectrum of nonselective immunotherapies, including noncytotoxic and cytotoxic drugs, intravenous immunoglobulins, and plasma exhcnage, some selected for induction and others for maintenance. The use of combination immunotherapies may allow steroid sparing, targeting of more than one immunologic effector pathway, and a mixture of early- and late-acting drugs. More selective immunotherapies, now available or in preclinical and clinical trials, have great potential for the treatment of OMS but require precise information on the underlying immunological problem. These data provide possible new directions for immunologic research and therapy in OMS. Key Words: Myoclonus--Opsoclonus--Intravenous immunoglobulins--ACTH--Neuroblastoma--Plasmapheresis--Paraneoplastic syndromes--Immunomodulation--Autoimmunity. Clinical Neuropharmacology. 1996;19(1):1-47.

Monoaminergic Effects of High-Dose Corticotropin in Corticotropin-Responsive Pediatric Opsoclonus-Myoclonus

Children with the opsoclonus-myoclonus syndrome (OMS) usually respond to corticotropin (adrenocorticotropic hormone, ACTH) treatment but the mechanism of benefit is unknown. We previously showed that both cerebrospinal fluid (CSF) homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5-HIAA) concentrations are low in pediatric OMS. In this study, we measured levels of CSF Dopa, catecholamines, deaminated metabolites of catecholamines, as well as HVA and 5-HIAA in eight patients before and during treatment with ACTH. All the children were ACTH-responsive with 50-70% improvement in multiple clinical features of OMS. ACTH treatment reduced the HVA concentration in every child by a mean of 21% (p <0.001). Treatment with ACTH was associated with significant correlations between dopaminergic markers such as HVA, dihydroxyphenylacetic acid (DOPAC), and Dopa. There were no significant changes in the CSF concentrations of the noradrenergic markers norepinephrine (NE) and dihydroxyphenylglycol (DHPG), or the serotonergic marker 5-HIAA. The only child with a marked inflammatory pattern in CSF, which was reversed by ACTH, was atypical for a large increase in NE and decrease in 5-HIAA during ACTH treatment. Beneficial effects of ACTH in OMS are not associated with normalization of HVA or 5-HIAA levels. The pattern of decreased HVA and unchanged DOPAC levels could reflect decreased extraneuronal uptake of catecholamines (which steroids inhibit) or decreased 0-methylation of catecholamines in nonneuronal cells. Key Words: ACTH--CSF 5-HIAA--HVA--Myoclonus--Opsoclonus--OMS--Paraneoplastic. Movement Disorders. 1998;13(3):522-528.

Paraneoplastic Syndromes: An Unsolved Murder

With neuroimmunology playing an ever greater role in child neurology, paraneoplastic syndromes--uncommon but often devastating complications of cancer--are in the forefront. Abnormalities of both humoral and cellular immunity support the immunological theory of causation. Through co-complicity of host and tumor factors, targets of immunologically mediated injury remote from the tumor may be damaged or destroyed, giving rise to discrete neurological deficits. In the nervous system, the main targets are neuronal nuclei or cell bodies, structural constituents, surface receptors, synapses, and ion channels. The clinical syndromes and response to treatment differ substantially between children and adults. Current pharmacological and biological therapies, which are nonselective, include noncytotoxic and cytotoxic drugs, intravenous immunoglobulins, plasma exchange, and immunoadsorption, some chosen for induction and others for maintenance. Tumor resection and thymectomy are surgical treatments. Combination immunotherapies allow steriod sparing, targeting of more than one immunologic effector pathway, and deploy an advantageous mixture of early- and late-acting drugs. More selective and efficacious immunotherapies are needed. Seminars in Pediatric Neurology. 2000;7(2):118-130.

Cerebrospinal fluid free choline in movement disorders of paediatric onset

We measured free choline in cerebrospinal fluid (CSF) of 78 patients with movement disorders of paediatric onset and various controls as a putative index of central phospholipid metabolism. Most of the disorders studied were myoclonic disorders, such as progressive myoclonus epilepsy, the opsoclonus-myoclonus syndrome, and essential myoclonus, but other movement disorders, interictal seizure disorders, and different neurological and non-neurological disorders were also included. There were no significant differences in CSF choline concentrations in myoclonic disorders or other movement disorders compared with controls. The CSF choline levels were lowest in children with seizure disorders including progressive myoclonus epilepsy. In progressive myoclonus epilepsy, the CSF choline values resembled other epileptic disorders rather than other myoclonic disorders. When all the data were analysed collectively, no significant relation of CSF choline was found to patient age, gender, aliquot of CSF measured, or the lenth of time the sample was stored at -70°C. Separate analyses of data from children and adults showed a trend toward a biphasic relation between patient age and CSF choline which could be pursued in developmental studies of normal subjects. Reduced CSF choline may indicate increased choline incorporation into brain phospholipids, disturbances of choline metabolism, decreased choline release, or non-neural factors. European Journal of Paediatric Neurology. 1998;1:33-39.

An Innovative Approach to the Problem of Sedating Children with Opsoclonus-Myoclonus Syndrome: Effects on Myoclonus and CSF Monoamine Metabolites

The opsoclonus-myoclonus syndrome (OMS) is a neurological syndrome with involuntary myoclonic jerks of the head, trunk, and limbs; ataxia; opsoclonus; developmental delay; and behavioral problems. Children with OMS are difficult to sedate for procedures necessary to rule out a neuroblastoma (CT scan, MRI, lumbar puncture, MIBG). Conventional drugs used for sedation have been associated with lack of efficacy, despite high doses, increased myoclonus, paradoxical responses, and cancellations of the needed procedures. Propofol, an intravenous anesthetic that does not require intubation, is an ideal drug for short diagnostic procedures because of its short mechanism of action and rapid return to wakefulness. Our study compared the effectiveness of propofol with other sedatives 1. to sedate patients with OMS and abate myoclonus; and 2. to determine if metabolites of serotonin or dopamine in the CSF were changed. Following IRB approval, a total of 22 patients were given midazolam (0.5 mg/kg), fentanyl (1 microgram/kg), chloral hydrate (100 mg/kg), and/or pentobarbital (5 mg/kg) (n = 14); or propofol was administered 2 mg/kg with additional boluses of 1 mg/kg (n = 2), or infusion 100 to 500 microgram/kg/min (n= 6). Neurotransmitter metabolites 5-hyrdroxyindoleacetic acid (5-HIAA) and homovanillic acid (HVA) were analyzed by high-pressure liquid chromatography. All 8 patients were effectively sedated using propofol, with cessation of myoclonus except in 1 who had transiently increased myoclonus. No patient developed postsedation increased myoclonus. Other standard sedative agents were associated with a high rate (9 out of 14) of complications: inadequate sedation (7 out of 14) and/or paradoxical agitation (2 out of 14) (p = 0.08X2). Propofol or midazolam alone did not significantly change CSF 5-HIAA (p = 0.20) or HVA (p = 0.66), compared to patients who were not sedated (ANOVA). Propofol is an effective sedative in children with OMS because of its quick onset of action, decreased adverse effects, and rapid return to wakefulness. Annals of Neurology. 1994;36(3):543-544.

Antibodies to ACTH in opsoclonus-myoclonus

Antibodies to ACTH1-24 detected by radioimmunoassay were present in the serum of a child with opsoclonus-myoclonus for at least 24 weeks after discontinuation of chronic ACTH treatment. The antibody-bound ACTH did not interfere with cortisol secretion. Six other children with opsoclonus-myoclonus and 16 control sera, including patients with chronically elevated endogenous ACTH, did not exhibit autoantibodies to ACTH. Antibodies to ACTH should be sought in patients who develop tolerance to ACTH treatment. The indirect but not direct ACTH assay method is sensitive to the presence of ACTH antibodies. Neuropediatrics. 1993 Jun;24(3):131-3.

Neurobehavioral and Psychosocial Functioning of Children with Opsoclonus-Myoclonus Syndrome

Childhood opsoclonus-myoclonus syndrome (OMS) is a movement disorder which typically strikes children in the early preschool years, seriously affecting intellectual, social-emotional and general adaptive development. This series of 13 cases with well-documented neurological histories, aged 1.7 to 16.3 years, provides an initial systematic evaluation of these children's neuropsychological, psychosocial and adaptive status. As expected, children with OMS had significantly reduced intelligence and severe speech and motor output problems; however, most of them also demonstrated a range of preserved neurocognitive abilities and impressive goal-directedness and communicative effort. Psychosocial problems included mild behavioral impairment on the Achenbach Child Behavior Checklist, and severe adaptive limitations on the Vineland Adaptive Behavior Scales despite relatively strong social skills. Developmental factors and likelihood of subcortical localization are discussed, and practical guidelines are provided for behavioral and educational management of these children. Developmental Medicine and Child Neurology. 1995;37:915-932.

Piracetam is an effective symptomatic treatment for some types of myoclonus in adults. To survey the efficacy and safety of piracetam in pediatric opsoclonus-myoclonus, we conducted an open, randomized, two-period, dose-ranging, double blind, crossover, clinical trial of five children comparing the antimyoclonic properties of oral piracetam to placebo. We devised and validated a new rating scale, specifically for pediatric opsoclonus-myoclonus. Two parents while blinded were able to identify the active phase by improvement in behavior, but another thought the behavior was worse. None of the patients showed improvement in myoclonus. The adult-equivalent dose of piracetam used in this study, which is threefold higher than that used in previous pediatric studies, was well tolerated and safe. We found our rating scale to be a reliable and useful tool for future studies of opsoclonus-myoclonus in children. Key Words: Dancing eyes syndrome-Kinsbourne syndrome-Opsoclonus-myoclonus-Subcortical myoclonus-Myoclonus rating scale.
Clinical Neuropharmacology. 2001;24(6):352-357.

Opsoclonus-myoclonus-ataxia (OMA) is a paraneoplastic syndrome associated with neuroblastoma. To elucidate immunopathophysiology, we investigated expression of lymphocyte surface antigens and intracellular cytokines in cerebrospinal fluid (CSF) and peripheral blood of 26 symptomatic children, 13 of whom had tumor resection, and in 8 neurological controls. A comprehensive panel of monoclonal antibodies to adhesion and activation proteins was used in combination with anti-CD3 and anti-CD45 antibodies in four-color flow cytometry. Most children with OMA had normal CSF mononuclear cell counts but exhibited 22% lower CD4+ T cells and an overexpanded subset of CD19+ (activated) B cells, as high as 29% of total cells. CSF TCR-y8+ T cells were significantly overexpanded (up to 26%) in children who had not received chemotherapy compared with those who had and with controls. Abnormalities were found years after the onset of neurological symptoms. Neurological severity, on a 12-item motor scale scored blinded from videotapes, was negatively correlated with the percentage of CSF CD4+ cells (p - 0.01) and positively correlated with the percentage of CSF CD5+CD19+ cells (p = 0.04) and with the CSF/blood ratio of y8 T cells (p = 0.01). There were no significant differences between the tumor and no-tumor groups in the distribution of CSF lymphocyte populations, T-cell activation markers (HLA-DR and CD25), or intracellular cyrokines (IL-4 and IFN-y). Demonstrating a direct relation between central nervous system inflammation and neurological signs in OMA, these data support the hypothesis that failure to eliminate inflammatory cells induces chronic neurological dysfunction and relapses. CSF immunophenotyping provides a powerful new tool in OMA, allowing evidence-based treatment.
Annals of Neurology, 2002; 52(3); Suppl 1, S123, abstract #40, B.

OBJECTIVE: To determine if CSF B-cells are over-expanded in opsoclonus-myoclonus and if rituximab, a monoclonal antibody against CD20+ B-cells, eliminates them.
BACKGROUND: Opsoclonus-myoclonus is a pervasive, paraneoplastic, neurological disorder purported to be autoantibody-mediated. Because commercial autoantibody testing is typically negative in children with the disorder and research Ig testing does not allow crucial treatment decisions to be made rapidly, we decided to focus on the B lymphocyte, which may traffic into the CNS to produce Ig locally, as a potential marker.
DESIGN/METHODS: B lymphocytes were immunophenotyped in the CSF and blood of 39 children with opsoclonus-myoclonus and 15 pediatric controls by dual-laser flow cytometry. Six children with high values were then treated with rituximab 375 mg/m2 once weekly for four consecutive weeks as adjunctive immunotherapy and testing was repeated 6 months later. Clinical outcome was rated blindly from videotapes using a validated 12-item motor evaluation scale, each item scored from 0 to 3.
RESULTS: The percentage of both CD19+ (activated) B-cells (p=0.0001, t test) and CD5+ B-cells (p=0.02) was 6-fold higher in opsoclonus-myoclonus CSF than in controls. The most acute (p=0.0001, ANOVA) and severe (p=0.007) subgroups had the highest values. Prior neuroblastoma or treatment with chemotherapy, IVIG, ACTH, or steroids had no significant effect. In most patients, B-cells were CD20+ (mature), but CD5+ cells (fetal-type) predominated in a few. In blood, the percentage of CD19+, CD20+, and CD5+ B-cells did not differ significantly between groups. By one month after treatment with rituximab, B-cells in peripheral blood were 0%. At six months, the percentage of CSF B-cells was reduced to zero in 4 children, with an 82% reduction in the group mean (p= 0.03, Wilcoxin test) and a 66% improvement in total neurological score (p=0.004).
CONCLUSIONS: These data support B-cell trafficking as a pathophysiologic mechanism in opsoclonus-myoclonus. The statistical association of CSF B-cells with neurological severity provides direct evidence of an autoimmune etiology. Rituximab is an efficacious and safe method of treating CSF B-cell over-expansion. Targeting of CSF B lymphocytes represents a novel and valuable paradigm shift in the therapy of centrally-mediated paraneoplastic disorders.

ABSTACT: Opsoclonus-myoclonus syndrome (OMS) is a rare, autoimmune neurological disorder that is poorly recognized and undertreated. Neuroblastoma is found in one half of the cases. Because of the high incidence of spontaneous regression of neuroblastoma, it is unknown whether not finding a tumor means there was none. To define demographic trends and the standard of care in the first large series of OMS, 105 children were recruited over a 13-year period in a retrospective questionnaire survey. Children with and without a tumor differed little in viral-like prodrome and neurological symptoms. Earliest neurological symptoms were staggering and falling, leading to a misdiagnosis of acute cerebellitis. Later symptoms included body jerks, drooling, refusal to walk or sit, speech problems, decreased muscle tone, opsoclonus, and inability to sleep. Tumor resection alone did not provide adequate therapy for most. Adrenocorticotropic hormone (ACTH), prednisone, and intravenous immunoglobulin were used with equal frequency, but ACTH was associated with the best early response. More than one half of the children had relapses. Residual behavioral, language, and cognitive problems occurred in the majority. The delay in diagnosis (11 weeks) and initiation of treatment (17 weeks) is unacceptably long.

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B- and T-cell markers in opsoclonus–myoclonus syndrome:
Immunophenotyping of CSF lymphocytes
M. R. Pranzatelli, A. L. Travelstead, E. D. Tate, T. J. Allison, E. J.
Moticka, D. N. Franz, M. A. Nigro, J. T. Parke, D. A. Stumpf, and S. J.
Verhulst

OBJECTIVE: To test the cellular immune hypothesis of OMS in a
cross-sectional study and determine if CSF lymphocyte subset analysis
provides biomarkers of disease activity
BACKGROUND: Although many lines of evidence suggest an autoimmune
etiology, the pathophysiology of opsoclonus–myoclonus syndrome (OMS)
remains poorly understood and no immunologic abnormalities have
correlated with neurologic severity. Conventional immunotherapies often
do not prevent relapse or permanent sequelae.
METHODS: The expression of lymphocyte surface antigens was investigated
in CSF and blood of 36 children with OMS and 18 control subjects, using
a comprehensive panel of monoclonal antibodies to adhesion and
activation proteins in combination with anti-CD3 and anti-CD45
antibodies in four-color fluorescence-activated cell sorting.
RESULTS: Although most children with OMS had normal CSF cell counts,
they exhibited expansion of CD19+ B-cell (up to 29%) and T-cell (up to
26%) subsets and a lower percentage of CD4+ T-cells and CD4/CD8 ratio,
which persisted even years after disease onset and conventional
treatments. The percentage of activated CSF T-cells was also higher.
Abnormalities correlated with neurologic severity, as scored blinded
from videotapes using a 12-item motor scale, and disease duration. No
significant differences were found between tumor and no-tumor groups. In
children with neuroblastoma, tumor resection or cancer chemotherapy did
not alter immunologic abnormalities.
CONCLUSIONS: CSF B- and T-cell recruitment is linked to neurologic signs
in pediatric OMS, which may relate to relapses and disease progression. Neurology, May 2004; 62: 1526 - 1532.

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CSF B-Cell Expansion in Opsoclonus-Myoclonus Syndrome:
A Biomarker of Disease Activity
Michael R. Pranzatelli, MD, Anna L. Travelstead, BS, MT (ASCP), Elizabeth D. Tate, FNP-C, MN, Tyler J. Allison, BS, and Steven J. Verhuist, PhD

ABSTRACT: Lack of a biomarker of disease activity has hindered the therapy of childhood opsoclonus-myoclonus syndrome (OMS), which is purported to be mediated humorally. To determine if the cerebrospinal fluid (CSF) B lymphocyte, which may traffic into the central nervous system (CNS) to produce antibody locally, is one such biomarker, B lymphocytes were immunophenotyped in the CSF and blood of 56 children with OMS and 26 pediatric controls by dual-laser flow cytometry. Neurological severity was rated blindly from videotapes using a validated 12-item motor evaluation scale. Children with OMS manifested a 4- to 7-fold higher percentage of total B cells in CSF (P < 0.0001), including CD5' (P = 0.001) and CD5-(P = 0.0004) B-cell subsets, compared with controls, in whom the percentages were negligible and unchanging with age. CSF expansion of both B-cell subsets increased with disease severity and decreased with disease duration (P <_ 0.0001, ANOVA). Previous treatment with conventional immunotherapies, chemotherapy, or tumor resection had not normalized B-cell percentages in those with lingering symptoms. These studies reveal that CSF B-cell expansion in OMS is characteristic and often. Presence of the autoreactive CD5' B-cell subset and correlations with neurological severity and disease duration suggest CSF B-cell expansion is a biomarker of disease activity and possible target for B cell-specific therapy. Immunophenotyping of CSF lymphocytes by flow cytometry yields valuable clinical information missed by routine studies and allows crucial treatment decisions to be made rapidly. O 2004 Movement Disorder Society Key words: paraneoplastic syndrome; Kinsbourne syndrome; B lymphocytes; B-cell trafficking; neuroblastoma; myoclonic disorders.

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Immunophenotype of Blood Lymphocytes in Neuroblastoma-Associated Opsoclonus-Myoclonus
Michael R. Pranzatelli, MD, Anna L. Travelstead, BS, MT (ASCP), Elizabeth D. Tate, FNP-C, MN, Tyler J. Allison, BS, Nadine D Lee, MD, PhD, Joan Fisher, MD, and Rama Jasty, MD.

OBJECTIVES: To determine whether the distribution of peripheral blood mononuclear cells (PBMCs) is altered in paraneoplastic opsoclonus-myoclonus (POM).

METHODS: PBMCs from 17 children with POM, 17 children with OM but no tumor, and 17 controls were immunophenotyped using a comprehensive panel of surface markers by dual-laser flow cytometry. All groups were matched for age and gender; POM and OM patients were matched for treatment.

RESULTS: In the POM patients, the CD4+ T-cell subset was smaller in both relative size (-18%, P = 0.02) and absolute size (-41%, P = 0.03) compared with controls. The CD4/CD8 ratio also was less (-29% to -44%) and was related to POM duration (P = 0.03). The absolute but not relative size of the )/S T-cell subset was reduced (-44%, P = 0.02). There were no significant abnormalities of CD19+ B-cells, CD3-, or CD3+ NK cells, HLA-DR+ or CD25+ T cells, or CD45RA+ or CD45RO+ T cells. Prior tumor chemotherapy, which was associated with a higher percentage but not' number of CD8+ T-cells, did not restore the CD4+ T-cell subset. When the POM and OM groups, which were not significantly different, were combined, chemotherapy decreased both the relative and absolute size of the CD 19+ B-cell pool and had small effects on other lymphocyte subsets.

CONCLUSION: POM is characterized by T-cell abnormalities of PBMCs, the most robust of which is reduction of the CD4+ T-cell subset and the CD4/CD8 ratio. Although this reduction was found previously in cerebrospinal fluid in POM patients, PBMC subsets did not otherwise reflect cerebrospinal fluid abnormalities. Longitudinal studies will be necessary to determine whether PBMC abnormalities could serve as treatment markers.

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IMMUNOLOGIC AND CLINICAL RESPONSES TO RITUXIMAB IN A CHILD WITH OPSOCLONUS-MYOCLONUS SYNDROME

Michael R. Pranzatelli, Elizabeth D. Tate, Anna L. Travelstead and Darryl Longee

ABSTRACT: Opsoclonus-myoclonus syndrome (OMS) is an autoimmune disorder with serious neurodevelopmental morbidity and limited treatment options. We treated a toddler with moderately severe OMS with rituximab, a monoclonal anti-B cell antibody. The patient's clinical response was documented on videotape and scored with the OMS Evaluation Scale. Cerebrospinal fluid lymphocyte subsets were evaluated by flow-cytometric immunophenotyping, with a comprehensive panel of monoclonal antibodies. Eradication of cerebrospinal fluid B cells, which previously were expanded, was associated with dramatic clinical improvement. There also were secondary changes in other lymphocyte subsets that might be relevant to the clinical response and lack of serious infections. In addition to clarifying the immune response to B-cell depletion, these data reveal a promising new therapy for OMS that warrants a phase I clinical trial.

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Screening for Autoantibodies in Children With Opsoclonus-Myoclonus-Ataxia

Michael R. Pranzatelli, MD, Elizabeth D. Tate, FNP, C, MN, Alisa Wheeler, BA,
Nancy Bass, MDt, Arnold P. Gold, MD, May L. Griebel, MD, Maria Gumbinas, MDII,
Peter T. Heydemann, MD1, Philip J. Holt, MD, Pierre Jacob, MDtt, Suresh Kotagal, MD, Chester J. Minarcik, MD, and Howard S. Schub, MDIIII

ABSTRACT: Various paraneoplastic autoantibodies have been linked to discrete neurologic syndromes and tumors in adults, but little is known about their incidence in children. We report a cross-sectional study of known paraneoplastic antibodies in 59 children with opsoclonus-myoclonus-ataxia, 86% of whom were moderately or severely symptomatic, and 68% of whom had relapsed at the time of testing. This total number of patients includes 18 children with low-stage neuroblastoma (tested after tumor resection), six of whom had never been treated with immunosuppressants. All were seronegative for anti-Hu, anti-Ri, and anti-Yo, the three paraneoplastic antibodies most associated with opsoclonus-myoclonus or ataxia in adults. These data contrast with reports of anti-Hu-positive sera in children with high-stage tumors and suggest that anti-Hu, anti-Ri, and anti-Yo do not explain relapses in pediatric opsoclonus-myoclonus-ataxia. They underscore the need to search for unique autoantibodies, as well as cellular mechanisms of pediatric paraneoplastic disease. © 2002 by Elsevier Science Inc. All rights reserved.

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Evidence of Cellular Immune Activation in Children With Opsoclonus-Myoclonus: Cerebrospinal Fluid Neopterin

Michael R. Pranzatelli, MD; Keith Hyland, PhD; Elizabeth D. Tate, CFNP, MN; Lauren A. Arnold, MS; Tyler J. Allison, BS; Gamini S. Soori, MD

ABSTRACT: To evaluate cellular immune activation in opsoclonus-myoclonus syndrome, we measured the inflammatory marker neopterin in the cerebrospinal fluid of 16 children with opsoclonus-myoclonus and neuroblastoma, 24 children with opsoclonus-myoclonus but no tumor, and 19 age-matched controls. The mean concentration in opsoclonus-myoclonus was 2.3-fold higher than in controls (P = .008). Neopterin was greatly elevated in four of the most neurologically severe cases, up to 8.3-fold above the highest control level. Thirteen of the 40 children with opsoclonus-myoclonus but no controls had a neopterin concentration > 2 SD above the control mean (P = .005). In this high neopterin subgroup, neurologic severity was significantly greater and the duration of neurologic symptoms was less. In 16 children re-examined on immunotherapy, including adrenocorticotropic hormone (ACTH) combination therapy, treatment was associated with a significant reduction in both neopterin and neurologic severity. Neopterin did not differ significantly between the tumor and non-tumor opsoclonus-myoclonus etiologies. No abnormalities of tetrahydrobiopterin were found. Although cerebrospinal fluid neopterin lacked the sensitivity to be a biomarker of disease activity in opsoclonus-myoclonus, elevated concentrations do support a role for T -cell activation and cell-mediated immunity in its pathophysiology. (J Child Neurol 2004;19;919-924).

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Myoclonus in Childhood

Michael R. Pranzatelli

ABSTRACT: The term "myoclonus" sounds esoteric, yet it is part of our normal physiology, occurring as a muscle jerk on drowsiness or falling asleep, during rapid eye movement (REM) sleep, and as hiccoughs. Myoclonus is also a developmental feature of the human nervous system, comprising some of the earliest fetal movements. In pathologic settings, myoclonus may be the only neurologic abnormality, as in essential myoclonus, but more often it is one symptom of a larger neurologic problem. The vast etiologic spectrum of symptomatic myoclonus can be bewildering, but defining the underlying problem may provide the opportunity to develop specific therapies. Otherwise, treatment is merely symptomatic. The approach to the patient should be to verify the nature of the movement disorder and establish a specific etiologic diagnosis. A battery of' neurophysiologic, neuroradiologic, and other laboratory studies is needed to localize the origin of the myoclonus and identify causative lesions. Drug treatment is largely empiric but must be systematic and aimed at restoring activities of everyday living. Unlike in epilepsies, in myoclonus multiple drugs usually must be combined to attain functional improvement.
© 2003 Elsevier Inc. All rights reserved.

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Forty-One-Year Follow-Up of Childhood-Onset Opsoclonus-Myodonus-Ataxia: Cerebellar Atrophy, Multiphasic Relapses, and Response to IVIG

Michael R. Pranzatelli, MD, Elizabeth D. Tate, FNP, MNC, Marcel Kinsbourne, MD, Verne S. Caviness, Jr., MD, PhD, and Bibhuti Mishra, MD

ABSTRACT: We report on an adult with opsoclonus-myoclonusataxia syndrome experiencing widely spaced neurological re-lapses, who was followed for 41 years. His responses to treatment are described. © 2002 Movement Disorder Society.

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Sleep Disturbance and Rage Attacks in Opsoclonus-Myoclonus Syndrome: Response to Trazodone

Michael R. Pranzatelli, MD, Elizabeth D. Tate, C-FNP, MN, William S. Dukart, MD, Mary Jo Flint, MD, Michael T. Hoffman, MD, and Amy E. Oksa, MD

ABSTRACT: Parents of children with opsoclonus-myoclonus syndrome (OMS) frequently describe poor sleep and rage attacks. We hypothesized that these manifestations are related and could result from underlying monoaminergic dysfunction.

Study design: We clinically characterized the sleep and behavioral characteristics of 51 young children with OMS; 19 of those with the most disruptive sleep patterns were treated with trazodone, a soporific serotonergic agent.

Results: Sleep disturbances, including prolonged sleep latency, fragmented sleep, reduced quantity of sleep, snoring, and nonrestorative sleep, were reported in 32 children, and frequent rage attacks were reported in 25. In 59% of the poor sleepers, parents felt that the problem was severe enough to warrant treatment. Children sleeping <10 hours/night had a higher rage frequency than those who slept more. Of the children who required trazodone, 84% were receiving corticosteroids or adrenocorticotropic hormone (corticotrophin), compared with 37% in the subgroup with normal sleep. Trazodone (3.0 ± 0.4 mg/kg/day) improved sleep and behavior in 95% of the children, significantly increasing total sleep time by 72%, decreasing the number of awakenings by 76%, and reducing rage attacks by 33%.

Conclusions: Children with OMS exhibited multiple types of sleep disturbances, which contributed to rage attacks. Trazodone was effective in improving sleep and decreasing rage attacks and was well tolerated, even in toddlers. (J Pediatr 2005;147:372-8)

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Cyclophosphamide Therapy in Pediatric Opsoclonus-Myoclonus Syndrome

Michael R. Pranzatelli, MD, Elizabeth D. Tate, FNP, MNC, A.L. Travelstead, N. Grana, J. Parkhurst, and C. Russell

ABSTRACT: OMS is an autoimmune disorder in need of more effective therapy. Procedure. An open-label pilot study of cyclophosphamide (CTX) plus standard treatment [corticotropin (ACTH)/intravenous immunoglobulins (IVIG)] compared to standard treatment alone in OMS. Cerebrospinal fluid (CSF) and blood lymphocytes from 18 children with OMS were immunophenotyped using a comprehensive panel of surface markers by dual-laser flow cytometry before and after treatment. OMS severity was scored from videotapes by a blinded observer using the OMS Evaluation Scale. Two CTX doses (750 or 1000mg/m2 X 6 cycles) were chosen from oncology protocols for OMS. Results. CTX reduced the percentage of CSF CD19± B cells by 60% at the higher dose only (p = 0.03). It had no significant effect on CSF T-cells (CD4+, CD8+, ey8±, NKT), T-cell activation (HLA-DR+ or CD25±), or maturation (CD45RA± or CD45R0+), or NK cells. In blood, it decreased absolute counts of CD4± T-cells by 66% (p = 0.002), further reducing the CD4/CD8 ratio (p = 0.012), and CD19+ B-cells by 54% (p = 0.007) compared to controls. Both treatment groups showed similar clinical improvement. The relapse rate after CTX (46%) was not significantly different from ACTH/IVIG alone. Conclusions. A dose effect was found for CSF B-cells, but CTX did not correct T-cell biomarkers of disease activity in OMS, improve on the clinical effects of ACTH/IVIG, or prevent relapses. Before a larger study is done, the effects of a higher dose or longer dosing schedule should be evaluated.

Annals of Neurology, 2005; Vol. 58; Suppl 9.