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An antineuronal autoantibody in paraneoplastic opsoclonus.

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cell soma. The significance of this mechanism will remain unclear until direct experimental evidence of
nerve injury by anti-GM1 and GDlb M-antibodies can
be demonstrated.
This work was supported in part by the Swiss National Science
Foundation, the Swiss Multiple Sclerosis Society, and the Puccini
We thank Dr D. A. Figlewicz for help and Mrs G. Perruisseau for
technical assistance. We are grateful to Prof J. M. Schroeder,
Aachen, for providing the analysis of the nerve biopsy.
An Antineuronal
Autoantibody in
O psoclonus
Corinna Budde-Steffen, MD,*$
Neil E. Anderson, MB, ChB,'f
Mark K. Rosenblum, MD,'FS Francesc Graus, MD,P
David Ford, MD)' Beth J. L. Synek, MB, ChB,"
Shirley H. Wray, MD, PhD?
and Jerome B. Posner, MD't
1. Iatov N. Plasma cell dyscmias and motor neuron disease. In:
Rowland LF', ed. Human motor neuron disease. New York:
Raven, 1982:273-279
2. Shy ME, Rowland LP, Smith T, et al. Motor neuron disease and
plasma cell dyscrasia Neurology 1986;36:1429-1436
3. Rudnicki S, Chad DA, Drachman DA, et al. Motor neuron
disease and paraproteinemia Neurology 1987;37:335-337
4. Hunter WM. Preparation of Iodine-131 labelled human growth
hormone of high specific activity. Nature 1962;194:495-496
5. Folch J, Lees M, Sloane-Stanley FGH. A simple method for the
isolation and purification of total lipids from animal tissues. J
Biol Chem 1957;226:497-509
6. Ilyas AA, Quarles RH, MacIntosh TD, et al. IgM in human
neuropathy related to paraproteinemia binds to a carbohydrate
determinant in the myelin associated glycoprotein and to a ganghoside. Proc Natl Acad Sci USA 1984;81:1225-1229
7. Endo T, Scott DD, Stewart SS, et al. Antibodies to glycosphingolipids in patients with multiple sclerosis and SLE.J Immunol
8. Kinsky SC, Haxby JA, Zopf DA, et al. Complement dependent
damage to liposomes prepared from pure lipids and Forssmann
hapten. Biochemistry 1969;8:4149-4158
9. Sternberger LA. Immunocytochemistry. 2nd ed. New York:
Wiley, 1979
10. Bradley WG, Good P, Rasool CG, et al. Morphometric and
biochemical studies of peripheral nerves in amyotrophic lateral
sclerosis. Ann Neurol 1983;14:267-277
11. Staberg E. Electrophysiological studies of reinnervation in ALS.
In: Rowland LP,ed. Human motor neuron disease. New York
Raven, 1982:47-59
12. Freddo L, Yu RK,Latov N, et al. Ganghosides GM1 and GDlb
are antigens for IgM M-protein in a patient with motor neuron
disease. Neurology 1986;36:454-458
13. Feizi T. Demonstration by monoclonal antibodies that carbohydrate structures of glycoproteinsand glycolipids are onco-developmental antigens. Nature 1985;314:53-57
14. Walker RA. Mucoid carcinomas of the breast: a study using
mucin histochemistry and peanut lectin. Histopathology 1982;
15. h e v H, Rapport MM, Mahadik SP, Silverman AJ. Immunohistological localization of ganglioside in rat cerebellum. Brain Res
1978;157:136-14 1
16. Momoi T, Momoi MY, Kurata T. Peanut agglutinin receptor is
a marker of myelin in rat brain. Developmental changes in its
distribution.J Neurochem 1986;46:229-234
17. DhibJalbut S, Liwnict BH. Immunocytochemical binding of
serum IgG from a patient with oat cell tumor and paraneoplastic
motoneuron disease to normal human cerebral cortex and
molecular layer of the cerebellum. Acta Neuropathol (Berl)
1986;69:96- 102
18. Roisen FJ,B d e l d H, Nagele R, Yorke G. GangLoside stimulation of axonal sprouting in vitro. Science 1981;214:577-578
Sera from 7 patients with paraneoplastic opsoclonus
were examined for antineuronal autoantibodies. An
antibody against neuronal nuclei was found in serum
from a patient with breast cancer, opsoclonus, and
ataxia This antibody recognized 53- to 61-kDa and 79to 84-kDa antigens in imunoblots of neurons. Antineuronal antibodies were not found in other patients
with paraneoplastic opsoclonus.
Budde-Steffen C, Anderson NE, Rosenblum MK,
Graus F, Ford D, Synek BJL, Wray SH, Posner JB.
An antineuronal autoantibody in paraneoplastic
opsoclonus. Ann Neurol 1988;23:528-531
Opsoclonus, often associated with myoclonus, truncal
ataxia, and encephalopathy, occurs as a remote effect
of neuroblastomas in children El) and as a paraneoplastic syndrome in adults 121. The discovery of antineuronal autoantibodies in patients with other paraneoplastic syndromes has suggested that these diseases
may have an autoimmune etiology [3].To determine if
antineuronal antibodies occur in patients with paraneoplastic opsoclonus, we examined serum from 6 adults
and an infant with opsoclonus and a cancer.
Patients and Methods
Serum was obtained from 7 patients with paraneoplastic opsoclonus (Table). The clinical and pathological features of
Patients 2 through 6 with opsoclonus (see Table) have been
reported in detail elsewhere [Z,7]. Control subjects included
5 patients with opsoclonus or ocular flutter and ataxia but
without cancer; 1patient with small-cell lung carcinoma, subacute sensory neuropathy (SSN), and an anti-Hu antiFrom the Departments of 'Neurology and ?Pathology (Neuropathology), Memorial Sloan-Kettering Cancer Center and $Cornell
University Medical College, New York, NY; #the Department of
Neurology, Hospital Clinic i Provincial de Barcelona, Spain; "the
Department of Pathology, Auckland Hospital, Auckland, New Zealand; and the *Department of Neurology, Massachusetts General
Hospital, Boston, MA.
Received Aug 5, 1987, and in revised form Nov 17. Accepted for
publication Nov 18, 1987.
Address correspondence to Dr Posner, Department of Neurology,
Memorial Sloan-KetteringCancer Center, 1275 York Avenue, New
York, NY 10021.
528 Copyright 0 1988 by the American Neurological Association
Clinical Features of 7 Patients with Paraneoplastic Opsoclonus
Age, Sex
Truncal Ataxia
10 mos,
49 yrs,
46 yrs,
53 yrs,
59 yrs,
29 yrs,
58 yrs,
Lung (small cell)
Lung (small cell)
Lung (small cell)
Lung (small cell)
Thyroid (medullary carcinoma)
= present; 0 =
neuronal antibody {4, 57; 1 patient with breast carcinoma,
paraneoplastic cerebellar degeneration (PCD), and an antiPurkinje cell antibody (APCA) {b};and 1 normal subject.
Sera were diluted serially in 2% bovine serum albumin
(BSA) in phosphate-buffered saline (PBS) and incubated
with 5-pm frozen sections of normal human cerebral cortex,
hippocampus, mamillary body, cerebellum, midbrain, pons,
medulla, locus ceruleus, olive, substantia nigra, and spinal
cord; the breast carcinoma from Patient 7; and normal rat
and rabbit cerebral cortex by an indirect immunoperoxidase
(IIP) method {4]. Sections were also incubated with 2%
BSA in PBS without serum as a nonpatient control. Purkinje
cells and cerebral cortex neurons were isolated from normal
human brain by a modification 161 of the method reported
by Yanagihara and Hamberger 181.Aliquots containing 20
Fg total protein were electrophoresed on 10% acrylamide
gels with 4% acrylamide stacking gels [9} and then blotted
onto nitrocellulose [lo]. After incubation for 2 hours at
room temperature with sera diluted 1 to 2,000, the filters
were washed (3 times for 10 min) with PBS containing 0.1%
Tween 20. The nitrocelluose filters were then incubated with
1251-labeledprotein A (0.1 pCYm1) for 1 hour at room temperature. Filters were then washed with PBS containing
0.1% Tween 20 and apposed to x-ray film (XAR-5) at
-70°C for 16 hours. Sera from patients with cerebellar
ataxia not related to cancer (n = 67), other neurological
diseases not associated with cancer (n = 48), metastatic and
other nonmetastatic neurological complications of cancer
(n = 133), or cancer without neurological symptoms (n =
167), and normal subjects (n = 32) were screened for circulating antineuronal antibodies by testing with frozen sections from clinically relevant areas of the nervous system by
IIP and indirect immunofluorescence (IIF) methods [4].
No antineuronal antibody activity was detected in sera
from Patients 1 to 6 by immunohistochemical or immunoblotting methods. However, serum and cerebrospinal fluid from Patient 7 reacted with the nuclei of all
central nervous system neurons in human, rabbit, and
rat (Fig l), with less pronounced staining of the cytoplasm and no staining of nucleoli. Antibody activity
was present in serum and cerebrospinal fluid through
dilutions of 1:1,000 and 1:50, respectively, by the IIF
method. The antigen was not present in systemic tissues. This patient’s serum recognized two groups of
antigens with molecular weights of 53 to 61 kDa and
7 9 to 84 kDa in immunoblots of Purkinje and cerebral
cortex neurons (Fig 2). There was no reaction with the
35- to 40-kDa antigens identified by the anti-Hu antibody cs], although serum from the patient with smallcell lung carcinoma, SSN, and an anti-Hu antibody
also showed a weak reaction with the 53- to 61-kDa
antigens (see Fig 2). Sera from some of the other controls, including the normal subject, reacted with bands
with different molecular weights but none reacted with
the 53- to 61-kDa and 79- to 84-kDa antigens.
Eluates from the 53- to 61-kDa and 79- to 84-kDa
regions produced a pattern of staining on frozen sections of normal human cerebral cortex identical to that
observed when the patient’s serum was used. Incubation of serum from Patient 7 with frozen sections of
her breast tumor by the IIP method resulted in
nonspecific staining, which did not differ from the
reaction observed when tumor sections were tested
with normal serum or BSA in PBS.
Of 447 sera screened by IIF or IIP for autoantibodies against brain cells, an identical antibody was
found in two women with breast carcinoma and truncal
ataxia, but no opsoclonus. Serum from other patients
did not harbor this antibody.
The autoantibody identified in Patient 7 and in 2 other
patients with breast cancer and truncal ataxia but no
opsoclonus is different from the APCA found in
women with PCD and breast or ovarian tumors 161
and from anti-Hu, an antibody against neuronal nuclei
that is found in patients with small-cell carcinoma of
the lung and SSN or encephalomyelitis C4, 51. A similar antibody has been reported in another patient with
a breast carcinoma, opsoclonus, and a predominantly
truncal ataxia Ell, 12). The immunohistochemical distribution of the antigen recognized by the antibody in
this patient was similar to that observed for the antibody in Patient 7 , but other characteristicsof the antibody in this patient have not been reported.
The significance of detection of an autoantibody in a
limited number of patients is uncertain, since some
Brief Communication: Budde-Steffen et al: Paraneoplastic Opsoclonus
Fig 1. Frozen sections of normal human cerebellum and cerebral
cortex incubated with serum from Patient 7 (A,B ) and a norma1subject (C, D).The serum was diluted 1 :SO0 and stained
indirect immunoperoxiduse. The sections were counterstained
with hematoxylin. The nuclei of all neurons in cerebral cortex
and cerebellum reacted with the serum of Patient 7 but not with
the control. Purkinje cell nuclei are particularly well shown, and
sparing ofthe nucleolus can be discerned. There is a less intense
reaction in neuronal cytoplasm. Control serum did not react with
either nuclei or cytoplasm. ( x 2SO before 12% reduction [A,B,
C]or 18% reduction [D].)
530 Annals of Neurology Vol 23 No 5
May 1988
for the syndrome of opsoclonus and myoclonus seen in
infants with neuroblastomas. Serum antineurofilament
antibodies have been reported in two infants with opsoclonus and myoclonus but no neuroblastoma 1151,
but the significance of these observations is uncertain,
since antineurofilament antibodies have been found in
most normal persons {13]. Autoantibodies have not
been reported in other infants with opsoclonus, and
we did not detect an antineuronal antibody in the patient we tested.
Dr Anderson was supported by funds granted by the New Zealand
Neurological Foundation, the Norman and Rosita Winston Foundation, and the Michael and Ethel L. Cohen Foundation.
The technical assistance of James Woodruff is gratefully acknowledged.
Pig 2. Immunoblots of Purkinje celh (A)and cerebral cortex
neurons (B) mcted with serumfrom a patient with typical
paraneoplatic cmbellar degeneration with breast cancer (Lane I )
{6};Patient 7, with opsoclonus and breast carcinoma (lane 2);
a patient with smull-cell lung carcinomu, subacute sensory
neuronopathy (SSN),
and an anti-Hu antibody (lane 3) {S};
and a normal subject (lane4). Molecular weights (in kilodaltons) are shmn on kfi f i r A and right for B. Serum from Patient 7 (lane2) reacted with two groups of antigens, one with
molecular weight 79 to 84 kDa (upper arrow, A) and a stronger reaction with molecular weight 53 to 61 kDa in Purkinje
and cerebral cortex neurons; thew is no reaction with either 35to 40-kDa proteins recognized by serumfrom the patient with
small-cell lung carcinoma and SSN (lane 3) (arrow,B) or the
typical anti-Purkinje cell antigen(s)of62 to 64 kDa and
24 kDa (not seen in cerebral cortex neurons).Serum from the
patkt with S N showed a uwk ~
i with
mthe 53-to 61-kDa
antigens. Elution of the positive-staining band of Purkinje cell
neurons from lane I and Purkinje cells and cerebral cortexfrom
lane 3 elicited appropriate immunohistochmicalstaining as
described ehewhew. Elution of the 53-to 61-kDa and 79to 84-kDa regions fmm both Purkinje celh and cerebral
cortex neumns of lane 2 also produced appmpriate staining, as
indicated in the text. Elution from other areas did not produce
autoantibodies are found in normal persons fl31. Further experience is needed to determine if the antibody
described in this report is a marker for paraneoplastic
neurological diseases associated with breast cancer.
The possible role of this autoantibody in the pathogenesis of the neurological disorder is unknown. Currently, there is no evidence to support an immunological pathogenesis in patients with paraneoplastic
opsoclonus associated with other types of carcinoma.
A typical APCA has been identified in a woman
with breast cancer and PCD with opsoclonus { 141. Opsoclonus occasionally is a manifestation of otherwise
typical PCD, and this patient probably had typical
PCD with opsoclonus rather than the distinct clinicopathological syndrome of paraneoplastic opsoclonus [2].
An autoimmune etiology also has been suggested
1. Lon I, Kinsboume M. Myoclonic encephalopathy in infants.
In: Fahn S, Marsden CD, Van Woert MH, eds. Advances in
Neurology, vol43. Myoclonus. New York Raven, 1986:127136
2. Budde-Steffen C, Anderson NE, Graus F, Posner JB. Paraneoplastic opsoclonus in adults. Neurology 1987;37(suppl 1):302
3. Anderson NE, Cunningham JM, Posner JB. Autoimmune
pathogenesis of paraneoplastic neurological syndromes. CRC
Rev Clin Neurobiol 1987;3(3):245-299
4. G ra u P, Cordon-Cardo C, Posner JB. Neuronal antinuclear
antibody in sensory neuropathy from lung cancer. Neurology
5. Graus F, Elkon KE3, Cordon-Cardo C, Posner JB. Sensory
neuronopathy and small cell lung cancer. Antineuronal antibody
that also reacts with the tumor.Am J Med 1986;80:45-52
6. Cunningham J, Gram F, Anderson N, Posner JB. Partial characterization of the Purkinje cell antigens in paraneoplastic cerebellar degeneration. Neurology 1986;36:1163-1168
7. Dropcho E, Payne R. Paraneoplastic opsoclonus-myoclonus: association with medullary thyroid carcinoma and review of the
literature. Arch Neurol 1986;43:410-415
8. Yanagihara T, Hamberger A. A method for separation of Purkinje cell- and granular cell-enriched fractions from rabbit
cerebellum. Brain Res 1973;59:445-448
9. Laemmli UK. Cleavage of structural proteins during the assembly of the head of bacteriophageT4. Nature 1970;227:680-685
10. Towbin H, Staehelin T, Gordon J. Electrophoretic transfer of
proteins from polyacrylamide gels to nitrocellulose sheets: procedure and some applications. Proc Natl Acad Sci USA
11. Greenlee JE, Brashear HR,Rodniaky RL, et al. Fall in antineuronal antibody titers and improvement of neurologic deficit
following tumor removal in paraneoplastiq cerebellar degeneration. Neurology 1986;36(suppl 1):334
12. Digre KB. Opsoclonus in adults. Report of three cases and
review of the literature. Arch Neurol 1986;43:1165-1175
13. Stefansson K, Marton LS,Dieperink ME, et al. Circulating autoantibodies to the 200,000-dalton protein of neurofilaments in
the serum of healthy individuals. Science 1985;228:1117-1 119
14. Royal W, Galasko DR, McKhann GM, et al. Clinical course,
immunologic, and biochemical features of a patient with paraneoplastic cerebellar dysfunction. Neurology 1987;37(suppl
15. Noeael MJ, Cawley LP, James VL, et al. Anti-neurofilament
protein antibodies in opsoclonus-myoclonus. J Neuroimmunol
Brief Communication: Budde-Steffen et al: Paraneoplastic Opsoclonus 531
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