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

Authors

Amna Siddiqui, Department of Neurology of Loyola University Stritch School of Medicine, Maywood, Illinois, USA.
Dylan Ross, Department of Neurology of Loyola University Stritch School of Medicine, Maywood, Illinois, USA.
Ronak H. Jani, Department of Neurological Surgery of Loyola University Stritch School of Medicine, Maywood, Illinois, USA.
Vikram C. Prabhu, Department of Neurological Surgery of Loyola University Stritch School of Medicine, Maywood, Illinois, USA.
Shelly Lo, Cardinal Bernardin Cancer Center of Loyola University Stritch School of Medicine, Maywood, Illinois, USA.
Derek A. Wainwright, Department of Neurological Surgery of Loyola University Stritch School of Medicine, Maywood, Illinois, USA.
Stasia Rouse, Advocate Health - MidwestFollow
Tamer Refaat, Department of Radiation Oncology of Loyola University Stritch School of Medicine, Maywood, Illinois, USA.
Yirong Zhu, Cardinal Bernardin Cancer Center of Loyola University Stritch School of Medicine, Maywood, Illinois, USA.
Jigisha P. Thakkar, Department of Neurology of Loyola University Stritch School of Medicine, Maywood, Illinois, USA.

Recommended Citation

Siddiqui A, Ross D, Jani RH, et al. Anti-aquaporin-4 immunoglobulin G/anti-myelin oligodendrocyte glycoprotein immunoglobulin G double-positive paraneoplastic neurological syndrome in a patient with triple-negative breast cancer. Clin Exp Neuroimmunol. 2024;15(1):55-60. doi:10.1111/cen3.12767

Affiliations

Advocate Lutheran General Hospital

Abstract

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.

Document Type

Article

PubMed ID

38595690