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113 a Case of Suspected Autoimmune Encephalitis Secondary to Nivolumab

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113 a Case of Suspected Autoimmune Encephalitis Secondary to Nivolumab Abstracts J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp-2019-anzan.100 on 29 July 2019. Downloaded from Results Out of the 235 patients that were reviewed, 71 112 AXONAL POLYNEUROPATHY WITH ONSET IN YOUNG patients either received thrombolysis and/or were sent for ADULTHOOD DUE TO TUBB3 MUTATION endovascular treatment, and 164 patients were not suitable for Po Sheng Yang*, Kimberley K Forrest, Ian B Wilson. Neurology, Cairns Base Hospital, hyperacute treatment. Using the triage tool, we identified that Cairns, QLD, Australia 26% (n=61) of the rapid clinical assessment and 32% (n=42) of CT perfusion scans performed could have been avoided. 10.1136/jnnp-2019-anzan.99 Conclusion Use of a web-based triage tool is not only effective to identify patients suitable for hyperacute management but Introduction The TUBB3 gene encodes the protein Beta-tubu- also to avoid over-investigation and prioritize rapid neurologi- lin isotype III, a component of the microtubule cytoskeleton. cal clinical assessments. Mutations in this gene have been associated with axonal poly- neuropathy, however usually associated with congenital fibrosis of the extraocular muscles (CFOEM) and other abnormalities of cerebral development.12We report a case of isolated neu- 111 RECURRENT HEADACHES WITH PSYCHOSIS, CSF ropathy associated with a TUBB3 mutation. LYMPHOCYTOSIS, VESSEL BEADING AND Methods Case report - clinical information and next genera- PAPILLOEDEMA- AUTOIMMUNE/VIRAL ENCEPHALITIS tion sequencing results were obtained. WITH VASCULOPATHY OR UNUSUAL PRESENTATION OF Results A 64 year old man presented with a severe, progres- REVERSIBLE CEREBRAL VASOCONSTRICTION sive, length dependent sensorimotor polyneuropathy which SYNDROME (RCVS)? commenced in his late twenties. There was no clinical involve- ment of the extraocular muscles and cognition was normal. 1Christopher J Coppin*, 2Michael Barnett, 3Lynette Masters, 4Amjed Aziz, Family history was limited, but there were no other members 5 1 Manisha Narasimhan*. Basic Physician Trainee, St George and Sutherland Hospitals, affected. 2 Sydney, NSW, Australia; Department of Neurology, Royal Prince Alfred Hospital; Brain and The patient had previously been extensively investigated Mind Centre (USyd), Sydney, NSW, Australia; 3Neuroradiologist, IMED Radiology, Sydney, including sural nerve biopsy, which confirmed axonal neuropa- NSW, Australia; 4Department of Critical Care Medicine, Sutherland Hospital, Sydney, NSW, Australia; 5Department of Neurology, Sutherland Hospital, Sydney, NSW, Australia thy without a specific diagnosis. Intravenous immunoglobulins and steroids had been trialled without benefit. 10.1136/jnnp-2019-anzan.98 A neuromuscular gene panel utilising next generation sequencing was performed and demonstrated heterozygosity Introduction Headache is a common Neurology presentation for a variant of the TUBB3 gene (D417N substitution). in both outpatient and ED settings. We present a challenging Case series describing TUBB3 mutations show a large heter- copyright. headache in a previously asymptomatic young female patient. ogeneity in phenotypic expression depending on the amino – Case A 27 year old female patient presented to ED with acid substitution.2 4 There is also heterogeneity in patients severe headache, vomiting and photophobia, after multiple with D417N mutations, although a small number have been presentations elsewhere, diagnosed as migraine, with normal reported to develop a polyneuropathy without CFOEM1. neurological examination and MRI. Episodes of excruciating Conclusions This case strengthens previous reports that headache were associated with writhing and vomiting but TUBB3 mutation can be associated with a pure, axonal, sen- spontaneously resolved with residual background pain. Indo- sorimotor polyneuropathy and highlights the use of next gen- methacin helped but she re-presented with headache and psy- eration sequencing in streamlining the diagnostic process. chosis requiring intubation and ICU admission. Investigations included CSF - protein 0.85, leucocytosis 58 REFERENCE cells (lymphocytic) and normal cerebral venography. Acyclovir 1. Tischfield M, et al. Human TUBB3 mutations perturb microtubule dynamics, kine- http://jnnp.bmj.com/ sin interactions, and axon guidance. Cell 2010;140(1):pp.74–87. was commenced but viral PCRs were negative and she was 2. Ncbi.nlm.nih.gov. (2019). Congenital fibrosis of the extraocular muscles - Condi- extubated. MRI was suspicious for subtle posterior sulcal tions - GTR - NCBI. [online] Available at: https://www.ncbi.nlm.nih.gov/gtr/condi- hyperintensity and beading in occipital and posterior cerebral tions/CN043677/ [Accessed 14 Feb. 2019]. arteries. 3. Omim.org. (2019). OMIM Entry - * 602661 - TUBULIN, BETA-3; TUBB3. [online] Available at: https://www.omim.org/entry/602661 [Accessed 14 Feb. 2019]. Another episode occurred ten days later requiring intuba- 4. Krupa, K. and Bekiesinska-Figatowska, M. (2013). Congenital and Acquired tion, examination showed papilloedema. CSF examination Abnormalities of the Corpus Callosum: A Pictorial Essay. BioMed Research Inter- showed raised pressure, normalproteinand48lympho- national, 2013, pp.1–14. on September 25, 2021 by guest. Protected cytes; flow cytometry and cytology were unrevealing. NMDA receptor antibody returned positive in serum but not CSF. Subtle beading in right PCA branches remained. IVIG and steroids were used with dramatic response. Fur- 113 A CASE OF SUSPECTED AUTOIMMUNE ENCEPHALITIS ther investigation revealed positive EBV serology only and SECONDARY TO NIVOLUMAB papilloedema resolved. Steroids were weaned and she 1 2 3 3 4 1 remains in remission. Jaimie Ho*, Yun Hwang, Martin Tio, Georgina Long, Eva Zhang. Gosford Hospital, Gosford, NSW, Australia; 2Neurology, Gosford Hospital, Gosford, NSW, Australia; Conclusion We present an interesting case of recurrent acute 3Melanoma Institute Australia, Sydney, NSW, Australia; 4Royal North Shore Hospital, headaches with intracranial hypertension, psychosis and CSF Sydney, NSW, Australia lymphocytosis. The recurrent headaches and vessel beading suggest RCVS, perhaps triggered by viral or autoimmune ence- 10.1136/jnnp-2019-anzan.100 phalitis. The NMDA receptor antibody result should be inter- preted with caution given the absence of antibody in CSF and Objective To describe a case of suspected immune encephalitis dramatic recovery. following nivolumab for metastatic melanoma. 36 of 43 J Neurol Neurosurg Psychiatry 2019;90:e7 Abstracts J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp-2019-anzan.100 on 29 July 2019. Downloaded from Methods Retrospective review of clinical records and diagnos- Depression was associated with younger age at diagnosis tic tests. (ave.60) versus anxiety(74) and agitation(75). Psychosis was Results A 78-year-old man with cerebral and lung melanoma in 14(10%) REM sleep behaviour disorder 6(5%). In the 12 metastases was treated with nivolumab, the newly developed months prior, falls were seen in 30(22%) and weight loss 29 monoclonal antibody which inhibits PD-1 deactivation of T- (21%). Allied health input occurred in 81% of dementia ver- cells. He showed good radiological response. sus 68% MCI cases. Three months after ceasing nivolumab, he presented to ED Conclusions Delay in diagnosis from first clinical manifesta- with acute confusion, aphasia, left-sided weakness and neglect tion, high rate of psychological and medical comorbidity, pres- as a stroke call. MRI demonstrated no evidence of stroke or ence of overlap syndromes, and allied health requirement, acute encephalitis. EEG showed diffuse slowing. Lumbar punc- support the need for integrated neurological services in ture was not performed as he was therapeutically anticoagu- dementia. lated and had begun to improve on empirical antibiotics and acyclovir. One week later, he suddenly deteriorated with fevers and reduced level of consciousness. Acyclovir was restarted. 115 IS MBS RESTRICTION ON EEGS TRULY BENEFICIAL? Repeat EEG revealed periodic epileptic discharges over the RETROSPECTIVE OBSERVATIONAL ANALYSIS OF EEG right hemisphere and MRI demonstrated hyperintense signal REFERRAL PATTERNS and diffusion restriction of the right mesial temporal lobe sug- 1 1 1,2 1 gestive of encephalitis. Subsequent lumbar puncture was nega- Chathri Ratnayake*, Ramja Kokulan, Patrick Carney. Department of Neurology, 2 tive for HSV, VZV, enterovirus, and autoimmune encephalitis Eastern Health, Box Hill, VIC, Australia; Eastern Health Clinical School, Faculty of Medicine antibodies. Dentistry and Health Sciences, Monash University, Box Hill, VIC, Australia ’ The patient s oncology team had been in support of a 10.1136/jnnp-2019-anzan.102 course of methylprednisone on suspicion of autoimmune ence- phalitis, but by the time the lumbar puncture results returned Introduction The November 2018 Medicare Benefits Schedule he was again improving. A diagnosis of suspected nivolumab- (MBS) Taskforce draft report recommends standardised induced encephalitis was made based on exclusion of other national referral form for routine electroencephalogram (EEG) possible diagnoses. requests to prevent low value clinician referrals. MBS defines Conclusions The rising use of immune checkpoint inhibitors twelve clinical presentations where routine EEG is of relatively heralds an array of new and unexpected neurological compli- low diagnostic value. We aim to identify proportion of MBS cations including autoimmune encephalitis. A nationwide regis- defined low diagnostic value EEGs
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