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Título

Acute dyskinesia and stroke in a patient with thymic carcinoma

RESUMO

CASE REPORT:
An 80-year-old woman under chemotherapy for thymic carcinoma and no history of movement disorder (MD) or antipsychotic use evolved with fever and focal seizure at home. Once admitted at emergency room, she presented a secondarily generalized seizure that led her to orotracheal intubation. Phenytoin was started in parallel to piperacillin/ tazobactam (for pneumonia) and acyclovir (for viral encephalitis). She was extubated and upon evaluation on 3 rd day she was torporous, obeyed simple commands despite plegic right hand and had orolingual dyskinesia and choreic movements of lower limbs. MRI disclosed left frontal leptomeningeal hypersignal with frontoparietal cortical hypersignal and restricted DWI in hand motor area. CSF revealed 373 cells (73% lymphomononuclear), 102mg/dL protein and no neoplastic cells. On 4 th day, CSF PCR and hemoculture were positive for Listeria monocytogenes and ampicillin was started. The hyperkinetic movements remitted in the 2 nd week of treatment but right hand remained plegic. Patient recovered conscious level but died after 3 months of internment.
DISCUSSION:
Listeriosis incidence is around 3-6 cases/million/year globally, although the prevalence is higher in the elderly and immunocompromised patients, and the mortality rate is about 30% whether neurological involvement. In a Chinese systematic review, dyskinesia was mentioned only in 3 cases of 163 non-perinatal patients with listeriosis. In other review, just 10 from 139 MRI lesions showed basal ganglia affection, and no dyskinesia was cited. We report an elderly oncologic patient with meningoencephalitis and no clear radiological substrate for hyperkinetic MD that evolved with acute orolingual dyskinesias and LL chorea that remitted during ampicillin employment. Moreover, the ischemia endorses the role of meningoencephalitis in vasculitic thrombotic infarction. Differential diagnosis would be a paraneoplastic syndrome (PS). An example of possible PS is anti-NMDA encephalitis that may present with dyskinesia but is not associated to thymic neoplasms (TN). Besides, thymic carcinomas, unlike thymoma, is not related to PS and dyskinesia was solved after ampicillin use.
FINAL COMMENTS:
We present a patient with thymic carcinoma undergoing chemotherapy who developed dyskinesia secondary to a neuroinfection. Despite MRI findings being isolated to frontal lobe, the MD allied to the cortical stroke suggest a diffuse vasculitis due to Listeria meningoencephalitis.

Palavras Chave

Dyskinesia; Listeria meningoencephalitis; Thymic carcinoma

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