(Kiosk 4) New Bladder Malignancy Presenting with Paraneoplastic Movement Disorder: A Case Report

Case Diagnosis: 78-year-old man with movement disorder

Case Description or Program Description: The patient presented with subacute onset of involuntary movements of his arms and face. Initial brain imaging was unremarkable for intracranial pathology to explain his symptoms. Initial CSF studies were remarkable for pleocytosis. Abdominal imaging demonstrated a bladder mass which was found to be high-grade papillary urothelial carcinoma. Consulting neurologists determined that his presenting symptoms were likely due to paraneoplastic encephalitis. He was treated with IVIG and dexamethasone, as well as other symptomatic medications. He demonstrated significant improvement in his abnormal movements and was transferred to inpatient rehab where on arrival, he required moderate assistance for standing and moderate to maximum assistance for bed level activities of daily living.

Setting: Tertiary care inpatient rehabilitation hospital

Assessment/Results: In addition to improvements with medication, the patient’s function improved after a course of inpatient rehabilitation. Challenges to his rehabilitation course included balance of medications used to control involuntary movements with cognitive medication side effects, treatment of acute delirium related to medications and acute encephalitis, and length of stay considerations related to prognosis and need for further malignancy treatment in the outpatient setting. At the time of discharge, he was completing transfers with minimal to moderate assistance and ambulating with walker with maximum assistance. His family members were trained to provide necessary level of assistance.

Discussion (relevance): This case represents the importance of considering paraneoplastic syndromes in new movement disorders without a clear primary CNS cause. This case also underscores the role that inpatient rehabilitation may play following such diagnoses, as well as unique challenges to rehabilitation of persons with paraneoplastic neurologic syndromes.

Conclusions: Broadening workup of new movement disorders to include evaluation for malignancy may be crucial and after proper diagnosis, inpatient neurorehabilitation can be an important piece of the treatment of such conditions.