Opsoclonus as a presenting symptom in thymic carcinoma.

Opsoclonus as a presenting symptom in thymic carcinoma Opsoclonus is a rare paraneoplastic syndrome accompanying some malignant tumours (car-cinoma of the lung, uterus, breast, and neuroblastoma in children). We report a patient with opsoclonus combined with ataxia preceding the diagnosis of thymic carcinoma. A 65 year old man complained of dizziness and difficulties with walking before admission to hospital. This was followed by episodes of nocturnal sweating and diffuse abdominal pain. Medical, neurological and family history were normal. On admission examination showed the patient to be in a good general condition. The neurological examination revealed normal consciousness; speech and orientation for time and place were also normal. The most relevant finding was the patient's eye movements; there were rapid, chaotic and conjugate saccades of the eyes in all directions, considerably exacerbated by attempts to fix the gaze. The pupils were normal in size, reactive to light and accommodation and the fundoscopy showed normal optic discs. The examination of the rest of the cranial nerves was normal. Myoclonic seizures were not seen. Superficial and deep reflex testing did not reveal any abnormalities. Motor and sensory examinations were normal except for his gait which showed mild trunk ataxia. Finger-nose test, heel-to-knee and rapid alternating manoeuvres were within normal limits. The values of the count were within normal limits. Beta-human chorionic gonadotropin in the blood, alpha-feto-protein and 5-hydroxy-indol acetic acid in the urine were also within normal limits. The level of blood immunoglobulins was normal. Serological tests for syphilis were negative. The chest radiograph on admission revealed two mediastinal masses. Computer-ised tomography (CT) of the chest showed two masses in the right anterior mediastinal space, one of them attached to the pleura. Electroencephalogram, ECG, skull radio-graph, thyroid and liver scans and two CT scans of the brain were within normal limits. Lumbar puncture showed normal CSF pressure. A CSF analysis for total protein, glucose, chloride and cell count was normal the auditory brain stem evoked potentials. Bone biopsy and bone marrow did not reveal any malignant cells. The Tensilon test was negative. One month after admission the patient had a right anterior mediastinostomy for biopsy of the masses. The histology revealed mixed thymic carcinoma (lymphoepithelioma type, poorly differentiated squamous cell carcin-oma) with pleural metastases. The patient was treated with a combination chemo-therapy regime which is used in the treatment of malignant thymoma. Three weeks later there was a further deterioration in the patient's …