Panegyres and Graves Journal of Medical Case Reports 2012, 6:155 http://www.jmedicalcasereports.com/content/6/1/155 Case presentation A 75-year-old Caucasian woman reported a three-month period of general constitutional decline with the onset of vertiginous symptoms and vomiting one week prior to attending our emergency department. She had been liv- ing independently. Her medical history included parox- ysmal atrial fibrillation treated with amiodarone and warfarin, hypertension controlled with metoprolol and irbesartan/hydrochlorothiazide, and right knee osteo- arthritis. She does not have diabetes mellitus. Her initial neurological examination results were unremarkable. She received a putative diagnosis of viral labyrinthitis and was admitted for intravenous fluid replacement. Over the next week she experienced troublesome vertigo but was able to be mobile with use of a Zimmer frame. Her course was complicated one week after admission by a fracture of the lateral mass of C2 after falling whilst mobilizing to the toilet. This required hard-collar immobilization, which made further investigation prob- lematic. At this stage she manifested a clinical rapidly progressive cerebellar syndrome with nystagmus, past- pointing, dysdiadochokinesis, dysarthria, truncal ataxia and titubation. Her functional status deteriorated to a modified Rankin score of 5. A brain MRI scan revealed no structural abnormal- ities. Anti-Yo antibodies were found to be present in serum and CSF, as were anti-GAD antibodies (Table 1). The CSF showed 0 leukocytes/μL and 50 erythrocytes/ μL, gave negative results on Gram stain and negative results on culture, her protein level was 0.44 g/L and glucose level 3.2 mmol/L (concurrent blood glucose level 5.6 mmol/L), and cytology results were negative for malignant cells. Oligoclonal bands were not Table 1 Paraneoplastic cerebellar degeneration Page 2 of 4 detected. Her CSF was also positive for protein 14-3-3, with a single band identified on western blot immuno- detection. Ca 15–3 and Ca 125 titers were also mildly elevated in her blood. A positron emission tomography (PET) scan revealed a fludeoxyglucose-avid bulky lower uterus evident with diffuse cerebellar hypo-activity. Pelvic ultrasound revealed a 4 × 3 cm uterine cyst. A hysterectomy and bi- lateral salpingoophorectomy confirmed a clear cell car- cinoma of the endometrium. A diagnosis of stage II endometrial carcinoma involving and extending into the stroma of the cervix with vascular invasion and histo- logical grade 3 was made. She received five cycles of intravenous immunoglobulin (Ig) prior to surgery. The original C2 spinal injury and multiple infective compli- cations including aspiration pneumonia, line sepsis, per- cutaneous endoscopic gastrostomy (PEG) site infection and T8/9 discitis made her management difficult. Five months elapsed from presentation to diagnosis of her neoplasm. She was too frail for adjuvant chemotherapy. She was discharged to nursing home care in April 2009, where she remains to the present day. She was assessed in December 2009 in her nursing home where she was found to be bright and alert. She was dysarthric. She was able to engage in light-hearted conversation in relation to the performance of Austra- lian Rules football teams in English and Macedonian. She was mostly feeding by mouth. The PEG feed was rarely used. She required a hoist for transfers. She was able to place both hands against gravity under com- mand. There was mild tremor of her outstretched hands. There was impaired finger-to-nose testing that had improved from the examination of 21 April 2009. She Proteins Findings 14-3-3 Anti-Yo confirmed on immunoblot Date 1 August 2008 5 August 2008 1 September 2008 9 April 2009 23 December 2009 24 December 2010 7 November 2011 Fluid Serum CSF Serum CSF Serum Serum Antibodies Anti-Yo 2U (range 0 to 3) 1U Serum:CSF ratio = 2:1 Intravenous Ig 28 g (0.4 g/kg per day for five days) Laparotomy, hysterectomy, bilateral salpingoophorectomy 1U Undetectable 0 0 Anti-GAD 4.3U/mL (<1) 2.0U/mL Serum:CSF ratio = 2.15:1 0.2U/mL Undetectable <0.1U/mL <0.1U/mL Patient alive; Rankin score 5 Anti-Yo antibodies detected by indirect immunofluorescence on a composite block of primate cerebellum and cerebrum, and mouse stomach (titers expressed 0 = not detected; 1 = weak positive; 2 = moderate positive; 3 = strong positive). GAD antibodies (GAD 65) are measured using a radioimmunoassay and expressed in U/mL (reference range <1). CSF, cerebrospinal fluid; GAD, glutamic acid decarboxylase.