Jan 25, 1986 - hypertrophic osteoarthropathy. There was bilateral gynaecomastia, testicular atrophy and a left hemichorea. Left arm and leg movements were ...
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'Longson M, Bailey AS, Klapper PE. Herpes encephalitis. Rec Adv Virol Clin 1980;2: 147-57. 2Klapper PE, Laing I, Longson M. Rapid noninvasive diagnosis of Herpes encephalitis. Lancet 1981 ;ii:607-9. 'Campbell M, Klapper PE, Longson M. Acyclovir in Herpes encephalitis. Lancet 1982;1:38. 4Longson M, Bailey AS. Herpes encephalitis. Rec Adv Clin Virol 1977;1:1-20. 5Holgate CS, Jackson P, Cowen PN, Bird CC. Immuno-gold silver staining: a new method of immunostaining with enhanced sensitivity. J Histochem Cytochem 1983;31:938-44. 6Springall DR, Hacker GW, Grimelins L, Polak JM. The potential of the immuno-gold silver staining method for paraffin sections. HistochemistrY 1984;81:603-8. Accepted 25 January 1986
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Carcinoma of the bronchus presenting with hemichorea
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Sir: We report the case of metastatic adenocarcinoma of the bronchus causing hemichorea. An 86-year-old man presented one month after suddenly developing uncontrollable jerking movements of his left arm and leg. He had lost 13 kg in weight over the previous year and for 4 months had had pain in his left wrist and ankle. He had given up his lifelong habit of smoking five years before. Examination revealing clubbing of fingers and toes and a swollen tender left wrist confirmed on radiographs to be due to hypertrophic osteoarthropathy. There was bilateral gynaecomastia, testicular atrophy and a left hemichorea. Left arm and leg movements were almost hemiballismic with abduction/adduction of the shoulder and flexion/extension of elbows and hands. Power tone and reflexes were normal, both plantars were flexor; there were no cerebellar signs. A chest radiograph showed possible right hilar enlargement but bronchoscopy was normal apart from slight narrowing of the right upper lobe bronchus consistent with extrinsic compression. Cytology and biopsies were however normal. Alkaline phosphatase was moderately raised at 127 IU/l (normal < 100) consistent with hypertrophic osteoarthropathy but all other biochemical and haematological values were normal. A CT scan of the brain with contrast (fig 1) showed an enhancing lesion in the region of the right thalamus and zona incerta
with surrounding oedema suggestive of a neoplasm. Before the results of the CT scan became available, the clinical diagnosis was of carcinoma of the lung with a coincidental vascular lesion involving the right caudate and subthalamic nuclei and he was given a trial of therapy with codergocrine mesylate (Hydergine). Within 48 hours the movements had completely resolved and did not recur after stopping the drug one week later. He was discharged after one month with no abnormal neurological signs. However, within 3 weeks of discharge he returned with urinary incontinence and had developed an extensor left plantar response but no other convincing pyramidal signs. Tomograms of his right upper lobe of lung confirmed the presence of a mass around the bronchus. Over the next four weeks he developed increasing weakness of his left side and a throbbing headache but no papilloedema. Dexamethasone improved his symptoms and signs but four weeks later he died at home. At necropsy a bronchial carcinoma, 40 mm in diameter was found occluding the right upper lobe bronchus. Histologically this was a primary moderately well differentiated adenocarcinoma. Metastases were present in the right adrenal gland, liver, cerebrum and dura of the right posterior cra-
Fig 1 CT Scan with showing enhancing lesion in right Thalamnus and zona incerta. contrast
nial fossa. The cerebral metastasis (fig 2) was a well circumscribed necrotic tumour, 30 mm in diameter, in the right inferior part of the thalamus at the level of the mamillary bodies. It extended for 15 mm anteroposteriorly. The tumour was infiltrating the internal capsule into the globus pallidus destroying the subthalamic nucleus and compressing and displacing the third ventricle to the left. Hemichorea and hemiballismus classically develop with lesions of the caudate nucleus and the subthalamic nucleus of Luys. The pathological process most frequently described is localised encephalomalacia,1 however lacunar infarction,2 3 small circumscribed haemorrhages and emboli,4 trauma,5 venous angiomas6 and arteriovenous angiomas' 8 have also been reported. There have been two previous reports of metastatic cancer and hemiballismus associated with widely disseminated breast carcinoma,9 and disseminated carcinoma of unknown primary.10 Legre et al" reported 57 cases of tumours of the central nuclei of the brain confirmed at operation or necropsy of which two were metastatic tumour. No details of clinical presentation are given. The rapid resolution of the movement disorder following the administration of codergocrine mesylate is difficult to explain. It
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Letters seems unlikely in retrospect that the drug played any significant role in the symptomatic improvement. A more likely explanation is that the improvement occurred coincidentally, particularly as the patient did not deteriorate again after stopping the drug. Experimentally destruction of 20% of the subthalamic nucleus produces hemiballismus, which may be reduced by further lesions in the internal segment of the globus pallidus; 2 in this case it is possible that .,extension of the tumour to involve these areas lead to resolution of his symptoms. That the tumour was progressively increasing in size is confirmed by the development of signs suggesting progressive involvement of the internal capsule. Carcinoma of the bronchus commonly metastasises to the brain; it is surprising ,,therefore that spread to the basal ganglia should be reported so infrequently. A RUDD, JG MCKENZIE, PH MILLARD,
Departments of Geriatric Medicine, and Histopathology, St Georges Hospital, Blackshaw Road, London SWJ7 ORE, UK
References '
Meyers R, Sweeny DB, Schwidde JT. Hemiballismus: Aetiology and surgical treatment. J Neurol Neurosurg Psychiatry 1950;13: 115-26.
Book reviews Psychopharmacology and Food. (British Association for Psychopharmacology Mono'graph No 7). Edited by Merton Sandler and Trevor Silverstone. (Pp 185; £2000.) Oxford: Oxford University Press, 1985. How many clinicians consider the effects of the drugs they prescribe on dietary intake? Perhaps even fewer consider the effects of dietary factors on the functioning of the "body itself. Some of the answers can be found in this volume which are the proceedings of a Symposium held by the British Association for Psychopharmacology in December 1983. The book contains excellent basic science chapters by Edmund Rolls dealing with the neurophysiology of feeding and by Steven SCooper covering neuropeptides and food
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Fig 2 Macroscopic appearances of tumour at
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2Kase CS, Maulsby GO, deJuan E, Mohr JP. 8Lobo-Antunes J, Yahr MD, Hilal SK. Extraand lacunar pyramidal dysfunction with cerebral arteHemichoreahemiballism riovenous malformations. J Neurol Neurosurg infarction in the basal ganglia. Neurology Psychiatry 1974;37:259-68. 1981 ;31:452-5. 3Saris S. Chorea caused by caudate infarction. 9Bremme H. Ein Beitrag zur Bindearmchorea. Monatschr. Psychiatr Neurol 1919;45:107-21. Arch Neurol 1983;40:590-1. 'Martin JP, Alcock NS. Hemichorea associated '°Bonhoeffer K, Ein Beitrag zur Localisation der choreatischen Bewegungen. Monatschr. with lesions of corpus luysii. Brain Psychiat. Neurol. 1897;1:6-41. 1934;57:504-16. Legre J, Paillas JE, Dufour M, Alliez B, Bucy PC. The Precentral Motor Cortex. UniverDebaene A. Tumeurs des noyaux grix censity Illinois Press, 1944: 361, 404. traux: Etude neuro-radiologique avec 6Burke L, Berenberg RA, Kim KS. Choreoballiverification anatomique. Acta Radiol Diag smus: A nonhemorrhagic complication of 1972;13: 135-49. venous angiomas. Surg Neurol 1984;21:245-8. 'Diamond MS, Huang YP, Yahr MD. Sudden 12Carpenter MB, Whittier JR, Mettler FA. Analonset of involuntary movement disorders with ysis of choreoid hyperkinesia in the rhesus monkey. J Comp Neurol 1950;92:293-332. arteriovenous malformations of the basal ganglia. Mt Sinai J Med (NY) 1982;49:438-42. Accepted 3 February 1986.
and water intake. These contribultions are accompanied by other chapters dea ling with the psychopharmacology of anoretic drugs and their clinical use and the drug ttreatment of anorexia and bulimia. Trevor Si lverstone covers the effects of psychotropic drugs on appeitite and body weight. From the other viewpoint, Geralkd Cruzon provides an example of dietary reguLilation of brain 5HT function by tryptophani. Merton Sandler and colleagues consider tIhe effects of dietary factors in the initiatio ,n of migraine attacks. The book is well prepared and contains much of interest to clinicians and basic scientists. It is a shame that it has takeEn almost two years from the time of the Syimposium to the publication of the proceedinggs. Such a delay must affect the impact a volurme of this nature has in terms of the scien tific contribution and the willingness of in dividuals to purchase it. P JENNER
Functional Mapping of the Brain in Vascular Disorders. Edited by Wolf-Dieter Heiss. (Pp 130; DM56.00.) Heidelberg: SpringerVerlag, 1985. This nice booklet deals with those tomographic scanning techniques which measure regional brain function, particularly in relation to patients with ischaemic brain disease. Visualisation of functional measurements in an anatomical setting is described as "functional mapping" in the title of the book. The difficulties connected with making functional measurements, which are based on all sorts of dynamic processes, from an "image" are addressed in the first chapter by Ter-Pogossian who compares magnetic resonance imaging (MRI) and positron emission tomography (PET) techniques. This is an excellent chapter, clearly written, and I think fully accessible to the non-expert, describing the strengths and limitations of both techniques. MRI is
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Carcinoma of the bronchus presenting with hemichorea. A Rudd, J G McKenzie and P H Millard J Neurol Neurosurg Psychiatry 1986 49: 1210-1211
doi: 10.1136/jnnp.49.10.1210
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