Anti-aquaporin-4 immunoglobulin G/anti-myelin oligodendrocyte glycoprotein immunoglobulin G double-positive paraneoplastic neurological syndrome in a patient with triple-negative breast cancer.

We report a rare case of paraneoplastic neurological syndrome with dual seropositivity of anti-aquaporin-4 and myelin oligodendrocyte glycoprotein antibodies in a 40 year-old woman with metastatic triple-negative breast cancer. She received multiple lines of anti-neoplastic treatment, including immunotherapy with pembrolizumab, as well as cytotoxic chemotherapy. Paraneoplastic meningoencephalomyelitis developed 2 years after diagnosis of breast cancer and 1 year after discontinuation of immunotherapy with pembrolizumab. She first developed longitudinally extending transverse myelitis followed by left optic neuritis and meningoencephalitis with new enhancing lesions in the brain and spinal leptomeninges. Cerebrospinal fluid analysis during both episodes showed normal glucose and protein, and elevated white blood cell count. Cytology was negative for malignancy. Cerebrospinal fluid was positive for neuromyelitis optica immunoglobulin G antibody anti-aquaporin-4, and autoimmune myelopathy panel was positive for myelin oligodendrocyte glycoprotein antibody. The patient had significant clinical and radiographic improvement after completion of five cycles of plasmapheresis followed by intravenous immunoglobulin. She did not have recurrence of paraneoplastic syndrome with maintenance rituximab every 6 months and daily low-dose prednisone. She succumbed to progressive systemic metastatic disease 4.5 years after her breast cancer diagnosis. This case shows that these antibodies can occur concurrently and cause clinical features, such as both neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein antibody disease, in a patient with a singular type of cancer. We highlight the importance of testing for paraneoplastic etiology in cancer patients with radiographic menigoencephalomyelitis or meningitis with atypical symptoms of meningeal carcinomatosis and/or cerebrospinal fluid profile negative for leptomeningeal carcinomatosis.

Challenges Training Women in Neurology.

The challenges that current women neurologists in training face remain similar to a certain extent to those experienced by their women neurologists' mentors. The key challenge that often coincides with residency or fellowship is childbearing. This has the potential to prolong training time and delaying graduation. Women neurologists in training face additional challenges of juggling between family responsibilities--as caregivers--and professional roles.

Acute Neurological Complications of Brain Tumors and Immune Therapies, a Guideline for the Neuro-hospitalist.

PURPOSE OF REVIEW: Patients with brain tumors presenting to the emergency room with acute neurologic complications may warrant urgent investigations and emergent management. As the neuro-hospitalist will likely encounter this complex patient population, an understanding of the acute neurologic issues will have value. RECENT FINDINGS: We discuss updated information and management regarding various acute neurologic complications among neuro-oncology patients and neurologic complications of immunotherapy. Understanding of the acute neurologic complications associated with central nervous system tumors and with common contemporary cancer treatments will facilitate the neuro-hospitalist management of these patient populations. While there are aspects analogous to the diagnosis and management in the non-oncologic population, a number of unique features discussed in this review should be considered.

Intractable Hiccups.

PURPOSE OF REVIEW: Hiccups are a common problem that crosses multiple disciplines including neurology, gastroenterology and pulmonology, and primary care. There are no formal guidelines to the treatment of intractable hiccups and treatment is based on experience and anecdotal evidence often relying on older medications. We have reviewed the relevant literature with an emphasis on the last five years or so in management of intractable hiccups. RECENT FINDINGS: The production of hiccups is a complex mechanism which involves multiple neurotransmitters and anatomical structure within the central and peripheral nervous system. A number of medications and other therapy have been reported successful for intractable hiccups. Intractable hiccups can occur more often than we realize and present to multiple medical disciplines. A number of pharmacologic option have been found to be useful including dopamine-blocking medication, baclofen, and gabapentin along with anticonvulsants.

Neurological Complications of Therapeutic Monoclonal Antibodies: Trends from Oncology to Rheumatology.

PURPOSE OF REVIEW: This review is to describe the scope of neurological complications associated with monoclonal antibody-based therapies, applied across medical specialties, to demonstrate the common and rare neurological syndromes that may be encountered in clinical practice according to the therapeutic agent being receive, and to explain appropriate work-up, diagnosis, and management of drug complications, as supported by the literature. RECENT FINDINGS: The number of commercially available, evidence-based therapeutic monoclonal antibodies continues to expand. In oncology, immune checkpoint inhibitors are particularly important, as a wide range of central and peripheral nervous system complications are described. In rheumatology, anti-TNF alpha drugs remain associated with demyelinating syndromes. The number of therapeutic monoclonal antibodies encountered in practice continues to grow, as does the number of described neurological complications. Recognition of a possible drug complication is key, as these are typically complex patients at risk of other causes of neurological injury. Identification of a complication of therapy often leads to intervention and a change in management.