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Page 2 of 6 Almedallah et al. Neuroimmunol Neuroinflammation 2018;5:48 I http://dx.doi.org/10.20517/2347-8659.2018.55

This is a case involving a patient who presented with an acute state of confusion and sleeping attacks. There
was an incidental finding of a left testicular tumor and brain magnetic resonance imaging (MRI) showed
signs of limbic encephalitis. The patient was later diagnosed with PLE secondary to testicular mixed germ
cell tumor; we are reporting a rare case of PLE due to testicular mixed germ cell tumor.

The aim is to guide neurologists to recognize the clinical manifestations of neurologic paraneoplastic
disorders, more specifically the PLE subtype, and to distinguish them from other causes of neurologic
dysfunction in cancer patients. Early diagnosis of paraneoplastic syndromes can maximize the likelihood of
[2]
favorable oncologic and neurologic outcome .

CASE REPORT
A 36-year-old right-handed Saudi male, with a medical history of hypertension and liver transplantation in
1995 maintained on tacrolimus, presented to the emergency department with a complaint of progressive im-
pairment in recent memory, excessive sleepiness, slurred speech, and depression for 3 weeks with an increase
in severity over the past few days. Neurologic examination revealed unbalanced gait but otherwise motor
and sensory functions were within normal limits. There was no history of abnormal movement, tongue bit-
ing, headache, neck pain or nuchal rigidity, fever, visual disturbances, weakness, sensory deficits, sphincter
dysfunction, or head trauma. In addition, there was no history of smoking, alcohol, or drug abuse.

On examination, the patient was vitally stable with a blood pressure 153/68 mmHg and oxygen saturation
100% on room air, and afebrile. He was conscious, alert, inattentive, and disoriented to time and place. His
Glasgow Coma Scale was 14/15. His pupils were 2 mm in size, with a sluggish reaction to light and vertical
gaze palsy. Mini mental state examination showed moderate cognitive impairment of 10.

Extensive biochemical, hematological, and radiological investigations were carried out. The basic laboratory
tests were not suggestive of any extracranial or infectious causes. Tumor markers screened included alpha-
fetoprotein 229 ng/mL which was markedly elevated. However, beta-human chronic gonadotropin and
carcinoembryonic antigen were of normal levels.

On admission, the patient was started on IV methylprednisolone (1 g/day for 5 days), and acyclovir (1.2 g for
1 day) until herpes encephalitis was ruled out. His level of consciousness improved with the administration
of steroids. However, he became agitated and developed visual hallucinations. These symptoms were
managed using haloperidol 2.5 mg intravenous and risperidone 0.5 mg orally.

Brain computed tomography (CT) without contrast was normal. Brain fluid-attenuated inversion recovery
(FLAIR) MRI [Figure 1] revealed abnormal signals involving the medial temporal lobes and hypothalamus
suggestive of limbic encephalitis. Cerebrospinal fluid was colorless and its analysis showed mild
lymphocytosis with a glucose level of 8.1 mmol/L, protein of 0.57 g/L, white blood cell count of 30 cells/µL
mostly lymphocytes. Central nervous system infection and metastasis were excluded.

With this clinical picture, paraneoplastic syndrome was in the top differentials and we sought to rule
out common cancers via investigating for tumor markers and imaging. CTs of the chest and abdomen,
in addition to renal, abdominal, and testicular ultrasounds were done. Testicular ultrasounds [Figure 2]
revealed a well-defined heterogeneous focal mass with cystic changes and micro-calcification in the left
testicle. The mass measured 5 cm by 2.7 cm in size. Pan-CT was performed pre- and post-contrast using a
triphasic study, and the scan showed multiple retroperitoneal lymph nodes that are most likely related to the
testicular tumor, with no suggestion of thoracic or abdominal metastasis.

The patient was now diagnosed with PLE secondary to testicular cancer. Subsequently, screening for
common antibodies associated with paraneoplastic encephalitis including anti-Ma2, anti-N-Methyl-D-