Breast cancer-associated paraneoplastic neuromyelitis optica with cervical cord compression and spondylosis requiring laminectomy: A case report

Abstract

Neuromyelitis optica, an autoimmune inflammatory disorder affecting the central nervous system, can occur in a paraneoplastic context, although rare. We report an intriguing case of a 71-year-old woman with a history of triple-negative infiltrating ductal breast carcinoma, manifesting with paraneoplastic neuromyelitis optica that led to significant respiratory failure and required a cervical laminectomy. The patient presented with pain in the left breast, weakness in the lower extremities, and neck pain. The neurological evaluation showed 2/5 muscle strength in all extremities, diffuse hyperreflexia, and loss of multimodal sensation below the shoulder. She developed acute respiratory failure that required mechanical ventilation. Magnetic resonance imaging highlighted a diffuse abnormal increase in T2 signal intensity throughout the posterior and central portion of the cervical and thoracic spinal cord consistent with longitudinally extensive transverse myelitis, and significant cervical cord compression at C3-C4. Magnetic resonance imaging of the brain showed non-enhancing T2/fluid-attenuated inversion recovery (FLAIR) white matter hyperintensities and cerebellar hemispheres. The serum cell-based assay study demonstrated a high anti-aquaporin-4 immunoglobulin G titer (>1:160) confirming the diagnosis of neuromyelitis optica. She was taken for bilateral laminectomy from C3 to C6. Despite intravenous methylprednisolone and plasmapheresis treatment, no significant recovery was achieved, necessitating tracheostomy and percutaneous endoscopic gastrostomy. Subsequent rituximab treatment led to a mild improvement, with no new lesions on repeat magnetic resonance imaging. This case raises suspicion of the potential for neuromyelitis optica to occur as a paraneoplastic phenomenon, strengthening the need for vigilance in patients with malignancies.

Keywords: AQP4; NMOSD; Paraneoplastic neuromyelitis optica; aquaporin-4; triple-negative breast cancer.

Figure 1.

(a) Anterior, (b) lateral, and (c) cross-sectional view of FDG-PET/CT showing FDG-avid left breast mass and axillary lymphadenopathy. FDG-PET/CT: fluorodeoxyglucose positron emission tomography-computered tomography.

Figure 2.

(a) T2/FLAIR sagittal sequence of the cervical spinal cord, (b) T1 sagittal sequence, and (c) T2 sagittal sequence of the thoracic spinal cord with non-enhancing hyperintense lesion extending from C1 to T6. (e) T2/FLAIR axial view at C1 and (f) T6 depicting a predominantly hyperintense lesion within the central cord. (d) T2/FLAIR sagittal sequence of the brain and (g) axial view showing non-enhancing hyperintensities involving the cerebrum, cerebellum, and cerebellar peduncles.