Dancing eyes-dancing feet Syndrome

Presenting Complaint
32y.o male presented with subacute onset of

nystagmus, myoclonic jerks and ataxia.

History Presenting Complaint

Had labyrinthitis for one week nausea and

vomiting, subjective vertigo, dizziness Lying on his right side alleviates symtoms Prescribed Prochlorperazine which relieves his symtoms Involuntary muscle and eye movements pronounced insomniac Loss of appetite and weight of 1 stone over 1 week

Past Medical History

Asthma

Hayfever
Bronchitis

Drug History
No allergies

Prochlorperazine(10mg)-TD
Never take recreational drugs Not taking vaccine recently

General Inspection and Examination

Resting tremor

Afrebile(36.4C)
Bradycardia (32 beats/minute)

Neurological examination
Cranial nerve examination- Square-wave

nystagmus (Video 1), reduced pupil size, diplopia, photophobia Limbs examination- Generalised myoclonus(Video 2), mild spasticity, areflexia, reduced plantar response Wide-based ataxic gait, Positive Romberg test

Summary
32 y.o male who is on Prochloperazine, presented

with 3-day history of worsening nystagmus and myoclonic jerks, preceded by labyrinthithis

Differential diagnoses
Cerebellar Disorder

Post-infectious Syndrome
Neoplastic Syndrome Side-effect of Prochlorperazine

Investigations
FBC-normal

U&E-normal
LFTs-normal CSF- IgG Oligoclonal bands, Lymphocytic

pleocytosis (99%) Viral Serology(blood and CSF)-negative Chest X-ray -No abnormality MRI-No abnormality

Treatment
Symtomatic- Clonazepam(0.5mg TD), Sodium

Valproate(100mg BD), IV Cyclizine (50mg TD) Improved significantly and discharged after 4 days

Literature review
Treatment IV Immunoglobulin Anticonvulsant(Clonazepam, Clorazepate) Corticosteroid(Prednisolone) Immunosuppressant(Azathioprine) Number of cases 6 5 3 1

Conservative 1 Table 1: Treatment of idiopathic Dancing eyes, dancing feet Syndrome

Dancing eyes, dancing feet Syndrome

A.k.a. Kinsbourne syndrome or opsoclonus-

myoclonus syndrome Causes Idiopathic Post-viral infection-Epstein-Barr, Varicella Zoster, enterovirus Neoplastic-breast cancer, sarcoidosis, small-cell lung cancer Vaccine (Rubella and Human Papillomavirus), Drug( amitriptyline, haloperidol, lithium, phenytoin, diazepam, and cocaine)

Take-home message
History-taking-ask about recent infection, drug

and vaccine intake Investigation- Chest X-ray and MRI to exclude any underlying malignancy

References

1. 2.

Morris E. Opsoclonus-myoclonus. MedLink Neurology. 2006. Imtiaz K, Vora J. Dancing eyes-dancing feet. Lancet. 1999;354(9176):390.

3. Candler P, Dale R, Griffin S, Church A, Wait R, Chapman M, et al. Post-streptococcal opsoclonus-myoclonus syndrome associated with anti-neuroleukin antibodies. Journal of Neurology, Neurosurgery & Psychiatry. 2006;77(4):507.

4. Veneselli E, Conte M, Biancheri R, Acquaviva A, De Bernardi B. Effect of steroid and high-dose immunoglobulin therapy on opsoclonus-myoclonus syndrome occurring in neuroblastoma. Medical and pediatric oncology. 1998;30(1):15-7.
5. Celebisoy N, Akyrekli , Colakoglu Z, Toygar A. Opsoclonus in adults: a report of four cases. Neuro-Ophthalmology. 1997;17(1):45-8. 6. Gwinn K, Caviness J. Electrophysiological observations in idiopathic opsoclonusmyoclonus syndrome. Movement Disorders. 1997;12(3):438-42. 7. Barto A, Pitha J. Opsoclonusmyoclonusdysequilibrium syndrome: cytological and immunological dynamics in the serial cerebrospinal fluid in two patients. Journal of neurology. 2003;250(12):1420-5. 8. Glatz K, Meinck H, Wildemann B. Parainfectious opsoclonus-myoclonus syndrome: high dose intravenous immunoglobulins are effective. Journal of Neurology, Neurosurgery & Psychiatry. 2003;74(2):279.

9. Bataller L, Graus F, Saiz A, Vilchez J. Clinical outcome in adult onset idiopathic or paraneoplastic opsoclonus-myoclonus. Brain. 2001;124(2):437.
10. Markakis I, Alexiou E, Xifaras M, Gekas G, Rombos A. Opsoclonus-myoclonus-ataxia syndrome with autoantibodies to glutamic acid decarboxylase. Clinical neurology and neurosurgery. 2008;110(6):619-21. 11. Pittock S, Lucchinetti C, Lennon V. Anti neuronal nuclear autoantibody type 2: Paraneoplastic accompaniments. Annals of neurology. 2003;53(5):580-7. 12. Luque F, Furneaux H, Ferziger R, Rosenblum M, Wray S, Schold Jr S, et al. Anti Ri: An antibody associated with paraneoplastic opsoclonus and breast cancer. Annals of neurology. 1991;29(3):241-51. 13. Lapenna F, Lochi L, de Mari M, Iliceto G, Lamberti P. Post-vaccinic opsoclonus-myoclonus syndrome: a case report. Parkinsonism & Related Disorders. 2000;6(4):241-2. 14. McCarthy J, Filiano J. Opsoclonus Myoclonus after human papilloma virus vaccine in a pediatric patient. Parkinsonism & Related Disorders. 2009;15(10):792. 15. Wong A, Musallam S, Tomlinson R, Shannon P, Sharpe J. Opsoclonus in three dimensions: oculographic, neuropathologic and modelling correlates. Journal of the neurological sciences. 2001;189(1-2):71-81. 16. Helmchen C, Rambold H, Sprenger A, Erdmann C, Binkofski F. Cerebellar activation in opsoclonus: an fMRI study. Neurology. 2003;61(3):412.

Acknowledgment