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Coly M, Adams D, Attarian S, Bouhour F, Camdessanché JP, Carey G, Cauquil C, Chanson JB, Chrétien P, Créange A, Delmont E, Fargeot G, Frachet S, Gendre T, Kuntzer T, Labeyrie C, Maisonobe T, Michaud M, Moulin M, Nicolas G, Noury JB, Péréon Y, Puma A, Sole G, Taithe F, Tard C, Théaudin M, Timsit S, Venditti L, Echaniz-Laguna A. Clinical, paraclinical and outcome features of 166 patients with acute anti-GQ1b antibody syndrome. J Neurol 2024:10.1007/s00415-024-12410-4. [PMID: 38767661 DOI: 10.1007/s00415-024-12410-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND & PURPOSE In this retrospective study, we aimed at defining the clinical, paraclinical and outcome features of acute neurological syndromes associated with anti-GQ1b antibodies. RESULTS We identified 166 patients with neurological symptoms appearing in less than 1 month and anti-GQ1b antibodies in serum between 2012 and 2022. Half were female (51%), mean age was 50 years (4-90), and the most frequent clinical features were areflexia (80% of patients), distal upper and lower limbs sensory symptoms (78%), ophthalmoplegia (68%), sensory ataxia (67%), limb muscle weakness (45%) and bulbar weakness (45%). Fifty-three patients (32%) presented with complete (21%) and incomplete (11%) Miller Fisher syndrome (MFS), thirty-six (22%) with Guillain-Barre syndrome (GBS), one (0.6%) with Bickerstaff encephalitis (BE), and seventy-three (44%) with mixed MFS, GBS & BE clinical features. Nerve conduction studies were normal in 46% of cases, showed demyelination in 28%, and axonal loss in 23%. Anti-GT1a antibodies were found in 56% of cases, increased cerebrospinal fluid protein content in 24%, and Campylobacter jejuni infection in 7%. Most patients (83%) were treated with intravenous immunoglobulins, and neurological recovery was complete in 69% of cases at 1 year follow-up. One patient died, and 15% of patients relapsed. Age > 70 years, initial Intensive Care Unit (ICU) admission, and absent anti-GQ1b IgG antibodies were predictors of incomplete recovery at 12 months. No predictors of relapse were identified. CONCLUSION This study from Western Europe shows acute anti-GQ1b antibody syndrome presents with a large clinical phenotype, a good outcome in 2/3 of cases, and frequent relapses.
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Affiliation(s)
- Martin Coly
- Neurology Department, Bicêtre University Hospital, 94276, Le Kremlin-Bicêtre, France
- French National Reference Center for Rare Neuropathies (CERAMIC), 94276, Le Kremlin-Bicêtre, France
- Sorbonne University, 75013, Paris, France
| | - David Adams
- Neurology Department, Bicêtre University Hospital, 94276, Le Kremlin-Bicêtre, France
- French National Reference Center for Rare Neuropathies (CERAMIC), 94276, Le Kremlin-Bicêtre, France
- INSERM U1195, Paris-Saclay University, 94276, Le Kremlin-Bicêtre, France
| | - Shahram Attarian
- Reference Centre for Neuromuscular Diseases PACA RARE, Filnemus, EURO-NMD, CHU Timone, 13005, Marseille, France
| | - Françoise Bouhour
- Reference Centre for Neuromuscular Diseases PACA RARE, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677, Bron Cedex, France
| | | | - Guillaume Carey
- Centre de Référence Des Maladies Neuromusculaires Nord/Est/Ile-de-France, Neurology Department, U1172, CHU Lille, 59000, Lille, France
| | - Cécile Cauquil
- Neurology Department, Bicêtre University Hospital, 94276, Le Kremlin-Bicêtre, France
- French National Reference Center for Rare Neuropathies (CERAMIC), 94276, Le Kremlin-Bicêtre, France
- INSERM U1195, Paris-Saclay University, 94276, Le Kremlin-Bicêtre, France
| | - Jean-Baptiste Chanson
- Department of Neurology, Reference Center for Neuromuscular Disorders NEIDF, European Reference Network for Neuromuscular Diseases EURO-NMD, University Hospital of Strasbourg, 67098, Strasbourg, France
| | - Pascale Chrétien
- Clinical Immunology Laboratory, Bicêtre University Hospital, 94276, Le Kremlin-Bicêtre, France
- Paris University, CNRS, INSERM, UTCBS, Paris, France
- Pathology Department, Bicêtre University Hospital, 94276, Le Kremlin-Bicêtre, France
| | - Alain Créange
- Neurology Department, Créteil University Hospital, UPEC, 94010, Créteil, France
| | - Emilien Delmont
- Reference Centre for Neuromuscular Diseases PACA RARE, Filnemus, EURO-NMD, CHU Timone, 13005, Marseille, France
| | - Guillaume Fargeot
- Neurology Department, Bicêtre University Hospital, 94276, Le Kremlin-Bicêtre, France
- French National Reference Center for Rare Neuropathies (CERAMIC), 94276, Le Kremlin-Bicêtre, France
| | - Simon Frachet
- Neurology Department, Limoges University Hospital, 87042, Limoges, France
| | - Thierry Gendre
- Neurology Department, Créteil University Hospital, UPEC, 94010, Créteil, France
| | - Thierry Kuntzer
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne, 1011, Lausanne, Switzerland
| | - Céline Labeyrie
- Neurology Department, Bicêtre University Hospital, 94276, Le Kremlin-Bicêtre, France
- French National Reference Center for Rare Neuropathies (CERAMIC), 94276, Le Kremlin-Bicêtre, France
- INSERM U1195, Paris-Saclay University, 94276, Le Kremlin-Bicêtre, France
| | - Thierry Maisonobe
- Department of Clinical Neurophysiology, Pitié-Salpêtrière University Hospital, 75013, Paris, France
| | - Maud Michaud
- Neurology Department, NEIDF Reference Center, Nancy University Hospital, 54000, Nancy, France
| | - Maximilien Moulin
- Neurology Department, Reims University Hospital, 51092, Reims, France
| | - Guillaume Nicolas
- Nord-Est/Ile-de-France Neuromuscular Reference Center, Neurology Department, Raymond Poincaré Hospital, UVSQ Paris-Saclay University, Garches, France
| | - Jean-Baptiste Noury
- Centre de Référence Des Maladies Neuromusculaires AOC, INSERM, LBAI, UMR1227, CHRU de Brest, Brest, France
| | - Yann Péréon
- Reference Centre for Neuromuscular Disorders AOC Filnemus, Euro-NMD, Hôtel-Dieu, CHU Nantes, 44000, Nantes, France
| | - Angela Puma
- Peripheral Nervous System and Muscle Department, Université Côte d'Azur, Pasteur 2 Hospital, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Guilhem Sole
- Reference Centre for Neuromuscular Diseases AOC, Filnemus, Euro-NMD, Neurology and Neuromuscular Diseases Department, Hôpital Pellegrin, CHU de Bordeaux, 33076, Bordeaux, France
| | - Frédéric Taithe
- Neurology Department, Clermont-Ferrand University Hospital, 63058, Clermont-Ferrand, France
| | - Céline Tard
- Centre de Référence Des Maladies Neuromusculaires Nord/Est/Ile-de-France, Neurology Department, U1172, CHU Lille, 59000, Lille, France
| | - Marie Théaudin
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne, 1011, Lausanne, Switzerland
| | - Serge Timsit
- Centre de Référence Des Maladies Neuromusculaires AOC, INSERM, LBAI, UMR1227, CHRU de Brest, Brest, France
| | - Laura Venditti
- Neurology Department, Bicêtre University Hospital, 94276, Le Kremlin-Bicêtre, France
- French National Reference Center for Rare Neuropathies (CERAMIC), 94276, Le Kremlin-Bicêtre, France
| | - Andoni Echaniz-Laguna
- Neurology Department, Bicêtre University Hospital, 94276, Le Kremlin-Bicêtre, France.
- French National Reference Center for Rare Neuropathies (CERAMIC), 94276, Le Kremlin-Bicêtre, France.
- INSERM U1195, Paris-Saclay University, 94276, Le Kremlin-Bicêtre, France.
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Aninang MT, Baltazar-Libiran MR, Damian LF. Utility of Brainstem Auditory Evoked Response as a Diagnostic Tool and Rituximab as a Treatment for Severe Bickerstaff Brainstem Encephalitis: A Case Report. Cureus 2024; 16:e57993. [PMID: 38738130 PMCID: PMC11088453 DOI: 10.7759/cureus.57993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2024] [Indexed: 05/14/2024] Open
Abstract
Bickerstaff brainstem encephalitis (BBE) is a rare disorder that is characterized by ophthalmoplegia, ataxia, and disturbance in consciousness. Definite diagnosis is made primarily through clinical presentation and serology testing with anti-GQ1b antibody. However, in a country where access to serologic testing is scarce, electrophysiologic tests such as brainstem auditory evoked response (BAER) may contribute to the diagnosis. Due to its rarity and generally good prognosis, there is no established consensus for the treatment of BBE. Immunomodulatory treatments such as intravenous immunoglobulin (IVIG), plasma exchange, steroids, or a combination of these therapies are often used with good response. However, there are severe cases that respond poorly to these conventional treatments. We report the case of a 26-year-old Filipino man who came in for sudden onset of diplopia, with a one-week history of upper respiratory tract infection. Subsequently, he developed paresthesias, quadriparesis, and an altered level of consciousness. On initial examination, he only had partial third nerve palsy, but eventually became quadriparetic and obtunded during admission. Initial electromyography and nerve conduction velocity (EMG-NCV) study showed a reduced recruitment pattern of the right rectus femoris, absent H reflexes of bilateral posterior tibial nerves, and no abnormal increase in temporal dispersion. Cranial MRI with contrast was unremarkable. Video electroencephalogram (video-EEG) showed intermittent generalized 5-6 Hz and 6-7 Hz theta slowing of the background activity in the stimulated state. BAER was done revealing bilateral partial dysfunction of the auditory pathways to support brainstem involvement of the disease. He received IVIG and methylprednisolone pulse therapy with no significant clinical improvement. Hence, he was given a rituximab infusion. One week post-rituximab, he had sustained wakefulness and was able to move his extremities.
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Affiliation(s)
- Myra T Aninang
- Neurology, Institute for Neurosciences, St. Luke's Medical Center, Quezon City, PHL
| | | | - Ludwig F Damian
- Neurology, Institute for Neurosciences, St. Luke's Medical Center, Quezon City, PHL
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Giaccari LG, Mastria D, Barbieri R, De Maglio R, Madaro F, Paiano G, Pace MC, Sansone P, Pulito G, Mascia L. Bickerstaff encephalitis in childhood: a review of 74 cases in the literature from 1951 to today. Front Neurol 2024; 15:1387505. [PMID: 38533411 PMCID: PMC10963475 DOI: 10.3389/fneur.2024.1387505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 03/01/2024] [Indexed: 03/28/2024] Open
Abstract
Bickerstaff brainstem encephalitis (BBE) is a rare autoimmune disease characterized by the subacute onset of bilateral external ophthalmoplegia, ataxia, and decreased level of consciousness. BBE is part of a group of rare autoimmune diseases in children that can affect the nervous system at any level. The onset of neurological deficits is often sudden and nonspecific. The diagnosis is based on clinical findings and abnormal findings on cerebrospinal fluid (CSF), electroencephalography (EEG), electromyography (EMG), and magnetic resonance imaging (MRI). BBE is associated with the presence of the antiganglioside antibody, anti-GQ1b and anti-GM1. Intravenous immunoglobulin (IVIg) and plasma exchange are often used as treatments for these patients. We conducted a review on clinical presentation, diagnosis, treatment and outcome of reported cases of BBE. 74 cases are reported in the literature from the first cases described in 1951 to today. The prevalence is unknown while the incidence is higher in males. In 50% of cases, BBE occurs following respiratory or gastrointestinal tract infections. The most frequent initial symptoms were consciousness disturbance, headache, vomiting, diplopia, gait disturbance, dysarthria and fever. During illness course, almost all the patients developed consciousness disturbance, external ophthalmoplegia, and ataxia. Lumbar puncture showed pleocytosis or cytoalbuminological dissociation. Abnormal EEG and MRI studies revealed abnormalities in most cases. Anti-GQ1b antibodies were detected in more than half of the patients; anti-GM1 antibodies were detected in almost 40% of patients. Treatment guidelines are missing. In our analysis, steroids and IVIg were administered alone or in combination; as last option, plasmapheresis was used. BBE has a good prognosis and recovery in childhood is faster than in adulthood; 70% of patients reported no sequelae in our analysis. Future studies need to investigate pathogenesis and possible triggers, and therapeutic possibilities.
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Affiliation(s)
| | - Donatella Mastria
- Department of Anesthesia and Intensive Care, “Vito Fazzi” Hospital, Lecce, Italy
| | - Rosella Barbieri
- Department of Anesthesia and Intensive Care, “Vito Fazzi” Hospital, Lecce, Italy
| | - Rossella De Maglio
- Department of Anesthesia and Intensive Care, “Vito Fazzi” Hospital, Lecce, Italy
| | - Francesca Madaro
- Department of Anesthesia and Intensive Care, “Vito Fazzi” Hospital, Lecce, Italy
| | - Gianfranco Paiano
- Department of Anesthesia and Intensive Care, “Vito Fazzi” Hospital, Lecce, Italy
| | - Maria Caterina Pace
- Department of Women, Child, General and Specialist Surgery, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Pasquale Sansone
- Department of Women, Child, General and Specialist Surgery, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Giuseppe Pulito
- Department of Anesthesia and Intensive Care, “Vito Fazzi” Hospital, Lecce, Italy
| | - Luciana Mascia
- Department of Experimental Medicine, University of Salento, Lecce, Italy
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Habib AA, Waheed W. Guillain-Barré Syndrome. Continuum (Minneap Minn) 2023; 29:1327-1356. [PMID: 37851033 DOI: 10.1212/con.0000000000001289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE This article summarizes the clinical features, diagnostic criteria, differential diagnosis, pathogenesis, and prognosis of Guillain-Barré syndrome (GBS), with insights into the current and future diagnostic and therapeutic interventions for this neuromuscular syndrome. LATEST DEVELOPMENTS GBS is an acute, inflammatory, immune-mediated polyradiculoneuropathy that encompasses many clinical variants and divergent pathogenic mechanisms that lead to axonal, demyelinating, or mixed findings on electrodiagnostic studies. The type of antecedent infection, the development of pathogenic cross-reactive antibodies via molecular mimicry, and the location of the target gangliosides affect the subtype and severity of the illness. The data from the International GBS Outcome Study have highlighted regional variances, provided new and internationally validated prognosis tools that are beneficial for counseling, and introduced a platform for discussion of GBS-related open questions. New research has been undertaken, including research on novel diagnostic and therapeutic biomarkers, which may lead to new therapies. ESSENTIAL POINTS GBS is among the most frequent life-threatening neuromuscular emergencies in the world. At least 20% of patients with GBS have a poor prognosis and significant residual deficits despite receiving available treatments. Research is ongoing to further understand the pathogenesis of the disorder, find new biomarkers, and develop more effective and specific treatments.
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Tavee J, Brannagan TH, Lenihan MW, Muppidi S, Kellermeyer L, D Donofrio P. Updated consensus statement: Intravenous immunoglobulin in the treatment of neuromuscular disorders report of the AANEM ad hoc committee. Muscle Nerve 2023; 68:356-374. [PMID: 37432872 DOI: 10.1002/mus.27922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/05/2023] [Indexed: 07/13/2023]
Abstract
Intravenous immune globulin (IVIG) is an immune-modulating biologic therapy that is increasingly being used in neuromuscular disorders despite the paucity of high-quality evidence for various specific diseases. To address this, the AANEM created the 2009 consensus statement to provide guidance on the use of IVIG in neuromuscular disorders. Since then, there have been several randomized controlled trials for IVIG, a new FDA-approved indication for dermatomyositis and a revised classification system for myositis, prompting the AANEM to convene an ad hoc panel to update the existing guidelines.New recommendations based on an updated systemic review of the literature were categorized as Class I-IV. Based on Class I evidence, IVIG is recommended in the treatment of chronic inflammatory demyelinating polyneuropathy, Guillain-Barré Syndrome (GBS) in adults, multifocal motor neuropathy, dermatomyositis, stiff-person syndrome and myasthenia gravis exacerbations but not stable disease. Based on Class II evidence, IVIG is also recommended for Lambert-Eaton myasthenic syndrome and pediatric GBS. In contrast, based on Class I evidence, IVIG is not recommended for inclusion body myositis, post-polio syndrome, IgM paraproteinemic neuropathy and small fiber neuropathy that is idiopathic or associated with tri-sulfated heparin disaccharide or fibroblast growth factor receptor-3 autoantibodies. Although only Class IV evidence exists for IVIG use in necrotizing autoimmune myopathy, it should be considered for anti-hydroxy-3-methyl-glutaryl-coenzyme A reductase myositis given the risk of long-term disability. Insufficient evidence exists for the use of IVIG in Miller-Fisher syndrome, IgG and IgA paraproteinemic neuropathy, autonomic neuropathy, chronic autoimmune neuropathy, polymyositis, idiopathic brachial plexopathy and diabetic lumbosacral radiculoplexopathy.
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Affiliation(s)
- Jinny Tavee
- National Jewish Health, Division of Neurology, Denver, Colorado, USA
| | - Thomas H Brannagan
- Vagelos College of Physicians and Surgeons, Neurological Institute, Columbia University, New York, New York, USA
| | | | - Sri Muppidi
- Stanford Neuroscience Health Center, Palo Alto, California, USA
| | | | - Peter D Donofrio
- Neurology Clinic, Vanderbilt University, Nashville, Tennessee, USA
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Shaath DS, Scheidt AF, Stiff HA. Sudden-Onset Bilateral Mydriasis in a Young Girl. JAMA Ophthalmol 2023; 141:792-793. [PMID: 37382931 DOI: 10.1001/jamaophthalmol.2023.2585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
A 3-year-old girl presented to the emergency department with 1 day of abnormal gait and bilateral mydriasis. Repeat magnetic resonance imaging demonstrated diffuse enhancement of the lower thoracic and cauda equina nerve roots and enhancement of the left oculomotor nerve.
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Affiliation(s)
- Deena S Shaath
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee
| | - Abigail F Scheidt
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee
| | - Heather A Stiff
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee
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Real-world treatment of adult patients with Guillain-Barré syndrome over the last two decades. Sci Rep 2021; 11:19170. [PMID: 34580356 PMCID: PMC8476500 DOI: 10.1038/s41598-021-98501-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/09/2021] [Indexed: 12/28/2022] Open
Abstract
This study investigated treatment characteristics of Guillain-Barré syndrome (GBS) in a real-world setting between 2000 and 2019. We analyzed clinical improvement between nadir and last follow-up in patients with severe GBS (defined as having a GBS disability scale > 2 at nadir) and aimed to detect clinical factors associated with multiple treatments. We included 121 patients (74 male; median age 48 [IQR 35-60]) with sensorimotor (63%), pure motor (15%), pure sensory (10%) and localized GBS (6%) as well as Miller Fisher syndrome (6%). 44% of patients were severely affected. All but one patient received at least one immunomodulatory treatment with initially either intravenous immunoglobulins (88%), plasma exchange (10%) or corticosteroids (1%), and 25% of patients received more than one treatment. Severe GBS but not age, sex, GBS subtype or date of diagnosis was associated with higher odds to receive more than one treatment (OR 4.22; 95%CI 1.36-13.10; p = 0.01). Receiving multiple treatments had no adjusted effect (OR 1.30, 95%CI 0.31-5.40, p = 0.72) on clinical improvement between nadir and last follow-up in patients with severe GBS. This treatment practice did not change over the last 20 years.
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Wong CK, Ng CF, Tan HJ, Mukari SAM. Bickerstaff brainstem encephalitis with Guillain-Barré syndrome overlap following chlamydia infection. BMJ Case Rep 2021; 14:14/5/e242090. [PMID: 34031085 DOI: 10.1136/bcr-2021-242090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Bickerstaff brainstem encephalitis (BBE) is a rare autoimmune encephalitis characterised by ataxia, ophthalmoplegia and altered consciousness. An overlap between BBE with Guillain-Barré syndrome (GBS) shows similar clinical and immunological features. We report a case of BBE with GBS overlap secondary to Chlamydia pneumoniae infection. The triad of altered consciousness, ataxia and ophthalmoplegia were present in the patient. The investigations included cerebrospinal fluid cytoalbuminological dissociation, nerve conduction test that showed prolonged or absent F wave latencies, hyperintensity in the left occipital region on brain MRI and diffuse slow activity on the electroencephalogram. The chlamydia serology was positive indicating a postinfectious cause of BBE syndrome. He required artificial ventilation as his consciousness level deteriorated with tetraparesis, oropharyngeal and respiratory muscle weakness. Immunotherapy with intravenous immunoglobulin and methylprednisolone was commenced. He made good recovery with the treatment. Prompt recognition of this rare condition following chlamydia infection is important to guide the management.
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Affiliation(s)
- Chee Keong Wong
- Department of Medicine, Hospital Pulau Pinang, Georgetown, Pulau Pinang, Malaysia
| | - Chen Fei Ng
- Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia
| | - Hui Jan Tan
- Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia
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Xie J, Zhang T, Liu T. First report of Bickerstaff's brainstem encephalitis caused by Salmonella Dublin: a case report. BMC Neurol 2021; 21:199. [PMID: 33992070 PMCID: PMC8122203 DOI: 10.1186/s12883-021-02230-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 05/10/2021] [Indexed: 11/12/2022] Open
Abstract
Background Diseases caused by nontyphoid Salmonella can range from mild, to self-limiting gastroenteritis and severe invasive infection. Relatively rarely, Salmonella may cause severe encephalopathy. Case presentation We report a suspected case of Bickerstaff’s brainstem encephalitis caused by Salmonella Dublin. A young man presented with impaired consciousness, ataxia, dysarthria, limb weakness, and restricted eyeball abduction. His clinical symptoms were consistent with Bickerstaff’s brainstem encephalitis. Conclusions This is the first case report of Bickerstaff’s brainstem encephalitis caused by Salmonella Dublin in the literature. After treatment, he recovered and was discharged. Early antibiotic treatment of sepsis may control the disease and avoid serious encephalopathy.
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Affiliation(s)
- Jiangbo Xie
- Department of Neurology, Weifang Traditional Chinese Hospital, Weifang, China
| | - Tingting Zhang
- Department of Neurology, Weifang Traditional Chinese Hospital, Weifang, China
| | - Tao Liu
- Department of Neurology, Weifang Traditional Chinese Hospital, Weifang, China.
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Shang P, Feng J, Wu W, Zhang HL. Intensive Care and Treatment of Severe Guillain-Barré Syndrome. Front Pharmacol 2021; 12:608130. [PMID: 33995011 PMCID: PMC8113987 DOI: 10.3389/fphar.2021.608130] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/27/2021] [Indexed: 12/12/2022] Open
Abstract
Guillain–Barré syndrome (GBS) is an acute polyneuropathy mostly characterized by acute flaccid paralysis with or without sensory/autonomous nerve dysfunction. Current immuno therapies including intravenous immunoglobulin (IVIg), plasma exchange (PE), and newly developed biological drugs benefit patients by alleviating hyperreactive immune responses. Up to 30% of patients develop respiratory failure during hospitalization and require mechanical ventilation and intensive care. Immunotherapies, mechanical ventilation, supportive care, and complication management during the intensive care unit (ICU) stay are equally emphasized. The most important aspect of intensive care and treatment of severe GBS, that is, mechanical ventilation, has been extensively reviewed elsewhere. In contrast to immunotherapies, care and treatment of GBS in the ICU setting are largely empirical. In this review, we intend to stress the importance of intensive care and treatment, other than mechanical ventilation in patients with severe GBS. We summarize the up-to-date knowledge of pharmacological therapies and ICU management of patients with severe GBS. We aim to answer some key clinical questions related to the management of severe GBS patients including but not limited to: Is IVIg better than PE or vice versa? Whether combinations of immune therapies benefit more? How about the emerging therapies promising for GBS? When to perform tracheal intubation or tracheostomy? How to provide multidisciplinary supportive care for severe cases? How to avert life-threatening complications in severe cases?
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Affiliation(s)
- Pei Shang
- Department of Neurology, First Hospital of Jilin University, Changchun, China.,Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic College of Medicine and Science, Rochester, MN, United States
| | - Jiachun Feng
- Department of Neurology, First Hospital of Jilin University, Changchun, China
| | - Wei Wu
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Hong-Liang Zhang
- Department of Life Sciences, National Natural Science Foundation of China, Beijing, China
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Ahn SH, Roh J, Woo KN, Kim HS, Park MG, Park KP, Baik SK, Shin JH. Refractory brainstem encephalitis mimicking progressive cerebral infarction: infliximab and methotrexate as a salvage immunotherapy. JOURNAL OF NEUROCRITICAL CARE 2021. [DOI: 10.18700/jnc.200025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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A Probable Case of Recurrent Bickerstaff Brainstem Encephalitis With Fulminant Course in a Pediatric Patient. Neurologist 2020; 25:14-16. [PMID: 31876654 DOI: 10.1097/nrl.0000000000000255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Bickerstaff brainstem encephalitis is a rare, often postinfectious, syndrome characterized by the clinical triad of ophthalmoplegia, ataxia, and altered consciousness. Here, we present a probable case of recurrent, pediatric Bickerstaff encephalitis, whereby the patient acutely developed loss of consciousness and eventually brain death despite optimal management. CASE REPORT A 3-year-old male patient initially presented to the emergency department with progressive ataxia, following history of upper respiratory tract infection. He deteriorated within 12 hours of hospitalization, requiring cardiopulmonary resuscitation. The patient had decreased consciousness thereafter, showing minimal signs of brain activity. He was then deemed to be suffering a second episode of Bickerstaff encephalitis, the first being a year prior, and intravenous immunoglobulins were administered immediately. Magnetic resonance imaging of the brain on day 2 of admission showed signs of diffuse, bilateral encephalitis in the brainstem, thalami, and basal ganglia. Brain death was confirmed on day 11 of admission, following 2 brain death examinations. CONCLUSION Although Bickerstaff brainstem encephalitis tends to involve the brainstem, outcomes of brain death have been rarely reported, even more so in the pediatric age group. This case report sheds light on, possibly, the first reported fatality of Bickerstaff encephalitis among children.
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Ramakrishna KN, Tambe V, Kattamanchi A, Dhamoon AS. Miller Fisher syndrome with bilateral vocal cord paralysis: a case report. J Med Case Rep 2020; 14:31. [PMID: 32070436 PMCID: PMC7029460 DOI: 10.1186/s13256-020-2357-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 01/26/2020] [Indexed: 11/24/2022] Open
Abstract
Background Miller Fisher syndrome is a variant of acute inflammatory demyelinating polyneuropathy classically characterized by ataxia, ophthalmoplegia, and areflexia. Miller Fisher syndrome can present with uncommon symptoms such as bulbar, facial, and somatic muscle palsies and micturition disturbance. Case presentation We describe the case of a 76-year-old white man with new-onset ataxia, stridor, areflexia, and upper and lower extremity weakness who required intubation at presentation. An initial work-up including imaging studies and serum tests was inconclusive. Eventually, neurophysiological testing and cerebrospinal fluid analysis suggested a diagnosis of Miller Fisher syndrome. Our patient responded to treatment with intravenous immunoglobulin and supportive therapy. Conclusion The occurrence of acute or subacute descending paralysis with involvement of bulbar muscles and respiratory failure can often divert clinicians to a diagnosis of neuromuscular junction disorders (such as botulism or myasthenia gravis), vascular causes like stroke, or electrolyte and metabolic abnormalities. Early identification of Miller Fisher syndrome with appropriate testing is essential to prompt treatment and prevention of further, potentially fatal, deterioration.
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Affiliation(s)
- Karan N Ramakrishna
- Department of Medicine, State University of New York (SUNY) Upstate Medical University, 750 East Adams Street, Room 5138, Syracuse, NY, 13210, USA.
| | - Vikrant Tambe
- Department of Medicine, State University of New York (SUNY) Upstate Medical University, 750 East Adams Street, Room 5138, Syracuse, NY, 13210, USA
| | - Adithya Kattamanchi
- Department of Medicine, State University of New York (SUNY) Upstate Medical University, 750 East Adams Street, Room 5138, Syracuse, NY, 13210, USA
| | - Amit S Dhamoon
- Department of Medicine, State University of New York (SUNY) Upstate Medical University, 750 East Adams Street, Room 5138, Syracuse, NY, 13210, USA
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Leonhard SE, Mandarakas MR, Gondim FAA, Bateman K, Ferreira MLB, Cornblath DR, van Doorn PA, Dourado ME, Hughes RAC, Islam B, Kusunoki S, Pardo CA, Reisin R, Sejvar JJ, Shahrizaila N, Soares C, Umapathi T, Wang Y, Yiu EM, Willison HJ, Jacobs BC. Diagnosis and management of Guillain-Barré syndrome in ten steps. Nat Rev Neurol 2019; 15:671-683. [PMID: 31541214 PMCID: PMC6821638 DOI: 10.1038/s41582-019-0250-9] [Citation(s) in RCA: 401] [Impact Index Per Article: 80.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2019] [Indexed: 12/20/2022]
Abstract
Guillain-Barré syndrome (GBS) is a rare, but potentially fatal, immune-mediated disease of the peripheral nerves and nerve roots that is usually triggered by infections. The incidence of GBS can therefore increase during outbreaks of infectious diseases, as was seen during the Zika virus epidemics in 2013 in French Polynesia and 2015 in Latin America. Diagnosis and management of GBS can be complicated as its clinical presentation and disease course are heterogeneous, and no international clinical guidelines are currently available. To support clinicians, especially in the context of an outbreak, we have developed a globally applicable guideline for the diagnosis and management of GBS. The guideline is based on current literature and expert consensus, and has a ten-step structure to facilitate its use in clinical practice. We first provide an introduction to the diagnostic criteria, clinical variants and differential diagnoses of GBS. The ten steps then cover early recognition and diagnosis of GBS, admission to the intensive care unit, treatment indication and selection, monitoring and treatment of disease progression, prediction of clinical course and outcome, and management of complications and sequelae.
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Affiliation(s)
- Sonja E Leonhard
- Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Melissa R Mandarakas
- Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Francisco A A Gondim
- Hospital Universitário Walter Cantidio, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | - Kathleen Bateman
- Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Maria L B Ferreira
- Department of Neurology, Hospital da Restauração, Recife, Pernambuco, Brazil
| | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pieter A van Doorn
- Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Mario E Dourado
- Department of Integrative Medicine, Hospital Universitário Onofre Lopes, Universidade Federal do Rio Grande do Norte, Natal, Brazil
| | - Richard A C Hughes
- UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Badrul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - James J Sejvar
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Cristiane Soares
- Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
| | | | - Yuzhong Wang
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, Shandong, China
| | - Eppie M Yiu
- Department of Neurology, The Royal Children's Hospital Melbourne, Melbourne, VIC, Australia
- Neurosciences Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Hugh J Willison
- College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Bart C Jacobs
- Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands.
- Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.
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15
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Chen Y, Wang C, Xu F, Ming F, Zhang H. Efficacy and Tolerability of Intravenous Immunoglobulin and Subcutaneous Immunoglobulin in Neurologic Diseases. Clin Ther 2019; 41:2112-2136. [PMID: 31445679 DOI: 10.1016/j.clinthera.2019.07.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 06/01/2019] [Accepted: 07/10/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE IV immunoglobulin (Ig) therapy has been widely used for the treatment of neurologic disorders, autoimmune diseases, immunodeficiency-related diseases, blood system diseases, and cancers. In this review, we summarize the efficacy and tolerability of IVIg and SCIg therapy in neurologic diseases. METHODS We summarized and analyzed the efficacy and tolerability of IVIg and SCIg in neurologic diseases, by analyzing the literature pertaining to the use of IVIg and SCIg to treat nervous system diseases. FINDINGS In clinical neurology practice, IVIg has been shown to be useful for the treatment of new-onset or recurrent immune diseases and for long-term maintenance treatment of chronic diseases. Moreover, IVIg may have applications in the management of intractable autoimmune epilepsy, paraneoplastic syndrome, autoimmune encephalitis, and neuromyelitis optica. SCIg is emerging as an alternative to IVIg treatment. Although SCIg has a composition similar to that of IVIg, the applications of this therapy are different. Notably, the bioavailability of SCIg is lower than that of IVIg, but the homeostasis level is more stable. Current studies have shown that these 2 therapies have pharmacodynamic equivalence. IMPLICATIONS In this review, we explored the efficacy of IVIg in the treatment of various neurologic disorders. IVIg administration still faces many challenges. Thus, it will be necessary to standardize the use of IVIg in the clinical setting. SCIg administration is a novel and feasible treatment option for neurologic and immune-related diseases, such as chronic inflammatory demyelinating polyradiculoneuropathy and idiopathic inflammatory myopathies. As our understanding of the mechanisms of action of IVIg improve, potential next-generation biologics can being developed.
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Affiliation(s)
- Yun Chen
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Chunyu Wang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Fanxi Xu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Fengyu Ming
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Hainan Zhang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China.
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Verboon C, Doets AY, Galassi G, Davidson A, Waheed W, Péréon Y, Shahrizaila N, Kusunoki S, Lehmann HC, Harbo T, Monges S, Van den Bergh P, Willison HJ, Cornblath DR, Jacobs BC. Current treatment practice of Guillain-Barré syndrome. Neurology 2019; 93:e59-e76. [PMID: 31175208 DOI: 10.1212/wnl.0000000000007719] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 02/13/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To define the current treatment practice of Guillain-Barré syndrome (GBS). METHODS The study was based on prospective observational data from the first 1,300 patients included in the International GBS Outcome Study. We described the treatment practice of GBS in general, and for (1) severe forms (unable to walk independently), (2) no recovery after initial treatment, (3) treatment-related fluctuations, (4) mild forms (able to walk independently), and (5) variant forms including Miller Fisher syndrome, taking patient characteristics and hospital type into account. RESULTS We excluded 88 (7%) patients because of missing data, protocol violation, or alternative diagnosis. Patients from Bangladesh (n = 189, 15%) were described separately because 83% were not treated. IV immunoglobulin (IVIg), plasma exchange (PE), or other immunotherapy was provided in 941 (92%) of the remaining 1,023 patients, including patients with severe GBS (724/743, 97%), mild GBS (126/168, 75%), Miller Fisher syndrome (53/70, 76%), and other variants (33/40, 83%). Of 235 (32%) patients who did not improve after their initial treatment, 82 (35%) received a second immune modulatory treatment. A treatment-related fluctuation was observed in 53 (5%) of 1,023 patients, of whom 36 (68%) were re-treated with IVIg or PE. CONCLUSIONS In current practice, patients with mild and variant forms of GBS, or with treatment-related fluctuations and treatment failures, are frequently treated, even in absence of trial data to support this choice. The variability in treatment practice can be explained in part by the lack of evidence and guidelines for effective treatment in these situations.
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Affiliation(s)
- Christine Verboon
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alex Y Doets
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Giuliana Galassi
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Amy Davidson
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Waqar Waheed
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yann Péréon
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nortina Shahrizaila
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Susumu Kusunoki
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Helmar C Lehmann
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Thomas Harbo
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Soledad Monges
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Peter Van den Bergh
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hugh J Willison
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - David R Cornblath
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bart C Jacobs
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD.
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de Castillo LLC, Diestro JDB, Ignacio KHD, Pasco PMD. A rare mimic of acute stroke: rapidly progressing Miller-Fisher Syndrome to acute motor and sensory axonal neuropathy variant of Guillain-Barre Syndrome. BMJ Case Rep 2019; 12:12/3/e228220. [PMID: 30936342 DOI: 10.1136/bcr-2018-228220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Ophthalmoplegia, ataxia and areflexia characterise the clinical triad of Miller-Fisher Syndrome (MFS). When the disease presents acutely, it can mimic posterior circulation stroke. We describe a case of an adult patient presenting with sudden dizziness, diplopia, vomiting, and loss of balance. She was initially managed as a case of a brainstem stroke, but the progression of craniopathies without deterioration in sensorium coupled with areflexia clinched the diagnosis of MFS two days into her admission. On the third day, her MFS progressed rapidly to acute motor and sensory axonal neuropathy (AMSAN) variant of Guillain-Barre Syndrome, a rare occurrence in patients with MFS, with only four reported cases including our own. Among the four cases, ours is the only one still non-ambulatory eight months after the initial onset of symptoms. The case highlights the importance of early recognition of MFS in patients with ophthalmoplegia and ataxia despite initially normal reflexes.
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Affiliation(s)
- Lennie Lynn Chua de Castillo
- Department of Neurosciences, University of the Philippines Manila College of Medicine and Philippine General Hospital, Manila, Philippines
| | - Jose Danilo Bengzon Diestro
- Department of Neurosciences, University of the Philippines Manila College of Medicine and Philippine General Hospital, Manila, Philippines
| | - Katrina Hannah Dizon Ignacio
- Department of Neurosciences, University of the Philippines Manila College of Medicine and Philippine General Hospital, Manila, Philippines
| | - Paul Matthew Dimaguila Pasco
- Department of Neurosciences, University of the Philippines Manila College of Medicine and Philippine General Hospital, Manila, Philippines
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Affiliation(s)
- Zea Munro
- From the Department of Ophthalmology (Z.M.), Canterbury District Health Board, Cashmere; and Department of Neurology (D.F.), Nelson Marlborough District Health Board, New Zealand.
| | - Desiree Fernandez
- From the Department of Ophthalmology (Z.M.), Canterbury District Health Board, Cashmere; and Department of Neurology (D.F.), Nelson Marlborough District Health Board, New Zealand
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Pediatric Bickerstaff brainstem encephalitis: a systematic review of literature and case series. J Neurol 2017; 265:141-150. [PMID: 29177548 DOI: 10.1007/s00415-017-8684-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 11/16/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To characterize the phenotype of pediatric Bickerstaff's brainstem encephalitis (BBE) and evaluate prognostic features in the clinical course, diagnostic studies, and treatment exposures. METHODS We systematically reviewed PubMed, Web of Science, and SCOPUS databases as well as medical records at the Lucile Packard Children's Hospital to identify cases of pediatric BBE. Inclusion required all of the following criteria: age ≤ 20 years, presence of somnolence or alterations in mental status at the time of presentation or developed within 7 days of presentation, ataxia, and ophthalmoplegia. RESULTS We reviewed 682 manuscripts, identifying a total of 47 pediatric BBE cases. We also describe five previously unreported cases. The phenotype of these pediatric patients was similar to previously published literature. Sixty-eight percent of patients demonstrated positive anti-GQ1b antibody titers, yet the presence of these antibodies was not associated with longer times to recovery. Patients with neuroimaging abnormalities featured a longer median time to recovery, but this was not statistically significant (p = 0.124). Overall, patients treated with any form of immunotherapy (intravenous immunoglobulin, steroids, or plasmapheresis) demonstrated shorter median time to resolution of symptoms compared to supportive therapy, although this trend was not statistically significant (p = 0.277). Post-hoc t tests revealed a trend towards use of immunotherapy against supportive care alone (p = 0.174). CONCLUSION Our study identified clinical, radiologic, and treatment features that may hold prognostic value for children with BBE. The role of immunotherapy remains under investigation but may prove of utility with further, randomized controlled studies in this rare disease.
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Abstract
Differentiating Guillain-Barré syndrome (GBS) from inherited neuropathies and other acquired peripheral neuropathies requires understanding the atypical presentations of GBS and its variant forms, as well as historical and physical features suggestive of inherited neuropathies. GBS is typically characterized by the acute onset of ascending flaccid paralysis, areflexia, and dysesthesia secondary to peripheral nerve fiber demyelination. The disorder usually arises following a benign gastrointestinal or respiratory illness, is monophasic, reaches a nadir with several weeks, and responds to immunomodulatory therapy. Inherited neuropathies with onset before adulthood, whose presentation may mimic Guillain-Barré syndrome, are reviewed.
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Affiliation(s)
- Brett J Bordini
- Department of Pediatrics, Section of Hospital Medicine, Nelson Service for Undiagnosed and Rare Diseases, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Priya Monrad
- Department of Child and Adolescent Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
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Rehabilitation of a patient with overlap of acute transverse myelitis and Bickerstaff's brainstem encephalitis: a case report. Spinal Cord Ser Cases 2017; 2:15032. [PMID: 28053734 DOI: 10.1038/scsandc.2015.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 10/12/2015] [Accepted: 10/28/2015] [Indexed: 11/09/2022] Open
Abstract
We report on one patient with Bickerstaff's brainstem encephalitis (BBE) and associated flaccid weakness. Counter to previous studies with BBE which indicate weakness due to Guillain-Barre syndrome, our patient's presentation of paraplegia following BBE is consistent with concomitant acute transverse myelitis. Her findings of BBE largely resolved, although she remained with T6 American Spinal Injury Association (ASIA) A paraplegia. Motor functional impairment measure scores improved from 20 at admission to 66 before discharge home with assistance. This case presents the first potential overlapping case of acute transverse myelitis with BBE and describes how acute inpatient rehabilitation can be effective in facilitating transition back to independence following tetraplegia with BBE.
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Case 40. Neuroophthalmology 2017. [DOI: 10.1007/978-1-4471-2410-8_40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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23
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Sadek AA, Abou-Taleb A, Ali WA. Outcome of Guillain - Barré Syndrome in Children: A prospective cohort study in a tertiary hospital in Upper Egypt. Electron Physician 2016; 8:3318-3324. [PMID: 28163843 PMCID: PMC5279961 DOI: 10.19082/3318] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 10/09/2016] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Guillain-Barré syndrome is the most common cause of acute flaccid paralysis in children, and defined as an acute inflammatory polyneuropathy. The objective of this study was to assess the clinico-laboratory profile, and outcome of Guillain-Barré syndrome in children at Sohag University Hospital. METHODS This prospective cohort observational study was conducted in 2014-2015. The included children were subjected to through medical history and detailed systemic and neurological examination. Nerve conduction studies and cerebrospinal fluid analysis were done for all patients. Follow up was done at three and six months both clinically and by nerve conduction studies. RESULTS This study included 50 patients (27 males/23 females) with median age of 2.92 years. Upper respiratory tract infections were the most common antecedent infections (50%) and the neurological findings were weakness of both lower limbs and pain in all patients (100%) followed by sphincteric dysfunction (26%) while cranial neuropathies were found in 4%. Nerve conduction study revealed that acute inflammatory demyelinating polyradiculoneuropathy was found in 52% of cases, acute motor axonal neuropathy in 36% of cases, whereas acute motor-sensory axonal neuropathy was found in 6% of cases. The outcome was good in about 78% of cases, Hughes motor scale revealed that 58% were healthy, 18% had minor signs or symptoms, 12% walked without support, 6% walked with support, and 6% were bed ridden. CONCLUSION The outcome was favorable, although a minority of patients suffered neurological deficit. Immediate administration of intravenous immunoglobulin reduced mortality and disability.
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Affiliation(s)
- Abdelrahim Abdrabou Sadek
- Assistant Professor, Head of Pediatric Neurology Unit, Pediatric Department, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Ashraf Abou-Taleb
- Lecturer, Pediatric Department, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Wafaa Ahmed Ali
- Resident, Pediatric Department, Faculty of Medicine, Sohag University, Sohag, Egypt
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Vergori A, Masi G, Donati D, Ginanneschi F, Annunziata P, Cerase A, Mencarelli M, Rossetti B, De Luca A, Zanelli G. Listeria meningoencephalitis and anti-GQ1b antibody syndrome. Infection 2016; 44:543-6. [PMID: 26825308 DOI: 10.1007/s15010-015-0862-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 11/23/2015] [Indexed: 01/20/2023]
Abstract
We report the first case of Listeria monocytogenes meningoencephalitis associated with anti-GQ1b antibody syndrome in an immunocompetent adult. A prompt diagnosis, made thanks to the multidisciplinary contribution, allowed a combined therapeutic approach leading to final favourable outcome, despite several intercurrent complications.
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Affiliation(s)
- A Vergori
- University Division of Infectious Diseases, Department of Medical Biotechnologies, University of Siena, 53100, Siena, Italy
| | - G Masi
- Department of Medicine, Surgery and Neurosciences, Clinical Neuroimmunology Unit, University of Siena, Siena, Italy
| | - D Donati
- Department of Medicine, Surgery and Neurosciences, Clinical Neuroimmunology Unit, University of Siena, Siena, Italy
| | - F Ginanneschi
- Department of Medicine, Surgery and Neurosciences, Clinical Neuroimmunology Unit, University of Siena, Siena, Italy
| | - P Annunziata
- Department of Medicine, Surgery and Neurosciences, Clinical Neuroimmunology Unit, University of Siena, Siena, Italy
| | - A Cerase
- Unit of Neuroimaging and Neurointervention, University Hospital of Siena, Siena, Italy
| | - M Mencarelli
- University Division of Infectious Diseases, Department of Medical Biotechnologies, University of Siena, 53100, Siena, Italy
| | - B Rossetti
- University Division of Infectious Diseases, Department of Medical Biotechnologies, University of Siena, 53100, Siena, Italy
| | - A De Luca
- University Division of Infectious Diseases, Department of Medical Biotechnologies, University of Siena, 53100, Siena, Italy
| | - G Zanelli
- University Division of Infectious Diseases, Department of Medical Biotechnologies, University of Siena, 53100, Siena, Italy.
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van den Berg B, Walgaard C, Drenthen J, Fokke C, Jacobs BC, van Doorn PA. Guillain–Barré syndrome: pathogenesis, diagnosis, treatment and prognosis. Nat Rev Neurol 2014; 10:469-82. [DOI: 10.1038/nrneurol.2014.121] [Citation(s) in RCA: 556] [Impact Index Per Article: 55.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Renaud M, Aupy J, Camuset G, Collongues N, Chanson JB, de Seze J, Blanc F. Chronic Bickerstaff's encephalitis with cognitive impairment, a reality? BMC Neurol 2014; 14:99. [PMID: 24885623 PMCID: PMC4040113 DOI: 10.1186/1471-2377-14-99] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 04/01/2014] [Indexed: 11/24/2022] Open
Abstract
Background Bickerstaff’s encephalitis (BE) is an acute post-infectious demyelinating disease with albuminocytological dissociation. A chronic form has rarely been described previously. Case presentation A 44-year-old man was hospitalized for drowsiness, cognitive complaint limb weakness, ataxia and sensory disturbance after diarrhea. Neuropsychological evaluation showed slowing, memory and executive function impairment, while analysis of the CSF showed albuminocytological dissociation. Immunologic tests showed positive anti-ganglioside antibodies (anti-GM1 IgM, anti-GD1a IgG and anti-GD1b IgM). Brain MRI was normal but SPECT showed bilateral temporal and frontal hypoperfusion. Outcome under immunoglobulin treatment (IVIG) was favorable with an initial improvement but was marked by worsening after a few weeks. Consequently, the patient was treated with IVIG every 2 months due to the recurrence of symptoms after 6 weeks. Conclusion This case raises the question of the existence of a chronic form of BE with cognitive impairment, in the same way as chronic inflammatory demyelinating polyneuropathy is considered to be a chronic form of Guillain–Barré syndrome.
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Affiliation(s)
| | | | | | | | | | | | - Frédéric Blanc
- University Hospital of Strasbourg, Neuropsychology Unit, Neurology Service and CMRR (Centre Mémoire de Ressources et de Recherche), 1 avenue Molière, 67098 Strasbourg Cedex, France.
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Abstract
Guillain-Barré syndrome (GBS) is characterized by rapidly evolving ascending weakness, mild sensory loss, and hyporeflexia or areflexia. Acute inflammatory demyelinating polyneuropathy was the first to be recognized over a century ago and is the most common form of GBS. Axonal motor and sensorimotor variants have been described in the last three decades and are mediated by molecular mimicry targeting peripheral nerve motor axons. Other rare phenotypic variants have been recently described with pure sensory variant, restricted autonomic manifestations, and the pharyngeal-cervical-brachial pattern. It is important to recognize GBS and its variants because of the availability of equally effective therapies in the form of plasmapheresis and intravenous immunoglobulins.
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Affiliation(s)
- Mazen M. Dimachkie
- Professor of Neurology Director, Neuromuscular Section Department of Neurology University of Kansas Medical Center 3599 Rainbow Blvd., Mail Stop 2012 Kansas City, KS 66160 Phone: 913.588.6094 Fax: 913.588.6948
| | - Richard J. Barohn
- Gertrude and Dewey Ziegler Professor of Neurology Chairman, Department of Neurology University of Kansas Medical Center 3599 Rainbow Blvd., Mail Stop 2012 Kansas City, KS 66160 Phone: 913.588.6094 Fax: 913.588.6948
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Murakami T, Yoshihara A, Kikuchi S, Yasuda M, Hoshi A, Ugawa Y. [A patient with Fisher syndrome and pharyngeal-cervical-brachial variant of Guillain-Barré syndrome having a complication of SIADH]. Rinsho Shinkeigaku 2013; 53:299-303. [PMID: 23603545 DOI: 10.5692/clinicalneurol.53.299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 69-year-old woman complained of diplopia and truncal titubation after upper respiratory infection. She presented with mydriasis and external opthalmoplegia of bilateral eyes, ataxia, hyporeflexia and cervical-brachial muscle weakness. The protein abnormally increased (49 mg/dl) in the cerebrospinal fluid, and the serum anti-GQ1b and anti-GT1a IgG antibodies were positive. The blood sodium level was 128 mmol/l indicating hyponatremia. She had low plasma osmolarity (251 mOsm/kg), high urine osmolarity (357 mOsm/kg) and high urine sodium level (129 mmol/l), while the blood level of antidiuretic hormone was not able to be measured. She was diagnosed to have Fisher syndrome (FS), pharyngeal-cervical-brachial variant of Guillain-Barré syndrome (PCB) and syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The hyponatremia improved with hyperosmotic saline infusion and restriction of water intake. Intravenous immunoglobulin therapy (IVIg) was effective only for ataxia, but the other symptoms mostly remained unchanged for a month. The serum anti-GQ1b IgG antibody was still positive even after one month. We performed high-dose intravenous steroid-pulse therapy. Then the mydriasis, external opthalmoplegia and cervical-brachial muscle weakness were immediately improved. This was a rare case of FS and PCB complicated with SIADH. IVIg, not steroid therapy, is generally chosen for FS since FS is considered as a variant of Guillain-Barré syndrome and steroid is not effective for Guillain-Barré syndrome as was proven by double-blind study. We suppose that the combined therapy of IVIg and steroid would be effective in patients with complicated symptoms and multiple antibodies.
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Abstract
The latest estimation for the frequency of Guillain-Barré syndrome (GBS) is 1.1 to 1.8 per 100000 persons per year. Guillain-Barré syndrome is today divided into two major subtypes: acute inflammatory demyelinating polyneuropathy (AIDP) and the axonal subtypes, acute motor axonal neuropathy (AMAN) and acute motor and sensory axonal neuropathy (AMSAN). The axonal forms of GBS are caused by certain autoimmune mechanisms, due to a molecular mimicry between antecedent bacterial infection (particularly Campylobacter jejuni) and human peripheral nerve gangliosides. Improvements in patient management in intensive care units has permitted a dramatic drop in mortality rates. Immunotherapy, including plasma exchange (PE) or intravenous immunoglobulin (IVIg), seems to shorten the time to recovery, but their effect remains limited. Further clinical investigations are needed to assess the effect of PE or IVIg on the GBS patients with mild affection, no response, or relapse.
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Affiliation(s)
- Harutoshi Fujimura
- Department of Neurology, Toneyama National Hospital, Toneyama, Toyonaka, Japan.
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Sheikh AS. Acute Complex Neuroplegia and Ophthalmoplegia
Associated with Anti-GQ1b Antibodies. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2012. [DOI: 10.29333/ejgm/82445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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von Geldern G, McPharlin T, Becker K. Immune mediated diseases and immune modulation in the neurocritical care unit. Neurotherapeutics 2012; 9:99-123. [PMID: 22161307 PMCID: PMC3271148 DOI: 10.1007/s13311-011-0096-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
This chapter will review the spectrum of immune-mediated diseases that affect the nervous system and may result in an admission to the neurological intensive care unit. Immunomodulatory strategies to treat acute exacerbations of neurological diseases caused by aberrant immune responses are discussed, but strategies for long-term immunosuppression are not presented. The recommendations for therapeutic intervention are based on a synthesis of the literature, and include recommendations by the Cochrane Collaborative, the American Academy of Neurology, and other key organizations. References from recent publications are provided for the disorders and therapies in which randomized clinical trials and large evidenced-based reviews do not exist. The chapter concludes with a brief review of the mechanisms of action, dosing, and side effects of commonly used immunosuppressive strategies in the neurocritical care unit.
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Affiliation(s)
- Gloria von Geldern
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD 21287 USA
| | - Thomas McPharlin
- University of Washington School of Pharmacy, Seattle, WA 98104 USA
| | - Kyra Becker
- Department of Neurology, University of Washington School of Medicine, Seattle, WA 98104 USA
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Abstract
We report the case history of a 41-year-old patient who, following bronchial infection, presented with progressive ophthalmoplegia in both eyes, dilated pupils unresponsive to light or convergence and ataxia. The suspected diagnosis of Miller-Fisher syndrome was confirmed by the detection of anti-ganglioside GQ1b antibodies.
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Affiliation(s)
- T Jehle
- Department of Ophthalmology, Norfolk and Norwich Universitiy Hospital, Norfolk and Norwich, UK.
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Meena AK, Khadilkar SV, Murthy JMK. Treatment guidelines for Guillain-Barré Syndrome. Ann Indian Acad Neurol 2011; 14:S73-81. [PMID: 21847334 PMCID: PMC3152164 DOI: 10.4103/0972-2327.83087] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Indexed: 11/25/2022] Open
Affiliation(s)
- A K Meena
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, India
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Abstract
OPINION STATEMENT Fisher syndrome is characterized by the clinical triad of ophthalmoplegia, ataxia, and areflexia. It is considered a variant form of Guillain-Barré syndrome, which is associated with anti-GQ1b antibodies. During initial examinations of patients, physicians must rule out other neurologic disorders or conditions that resemble Fisher syndrome, such as vitamin B1 deficiency (Wernicke's encephalopathy), vascular disease, multiple sclerosis, collagen disease, Behçet disease, sarcoidosis, neoplasm of the brainstem, and infectious diseases such as diphtheria, botulism, and viral infections (eg, herpes encephalitis). The acute phase of Fisher syndrome should be carefully observed to see if it occurs concomitantly with Guillain-Barré syndrome or if there is development to Bickerstaff brainstem encephalitis, as these require specific immune treatments. Typically, Fisher syndrome has a fairly good natural course. Although several reports have suggested the possible efficacy of immunotherapies such as plasmapheresis and intravenous immunoglobulins (IVIg) in treating Fisher syndrome, there have been no randomized controlled studies. Large retrospective studies have suggested that neither plasmapheresis nor IVIg alters the clinical outcome of patients with Fisher syndrome, probably because of the good spontaneous recovery in these patients. Therefore, Fisher syndrome alone does not necessarily require immunotherapy. To accelerate the start of recovery, IVIg can be given, but it is important to first obtain informed consent from patients after the potential risks of blood products are explained. When overlap with Guillain-Barré syndrome or development to Bickerstaff brainstem encephalitis occurs, plasma exchange or IVIg should be administered as early as possible because Guillain-Barré syndrome can cause respiratory failure or severe weakness with axonal degeneration, and Bickerstaff brainstem encephalitis may not have as good a natural course as Fisher syndrome alone. There have been no prospective, controlled studies (randomized or nonrandomized) of the use of immunotherapy to treat Fisher syndrome. To evaluate the efficacy of immunotherapies used to treat Fisher syndrome, large prospective studies are required.
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Affiliation(s)
- Masahiro Mori
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan,
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Stępień A, Korsak J, Kozubski W, Ryglewicz D, Losy J, Drozdowski W, Kotowicz J, Nyka W, Kwieciński H. Stanowisko grupy ekspertów dotyczące stosowania dożylnych immunoglobulin w leczeniu chorób układu nerwowego. Neurol Neurochir Pol 2011; 45:525-35. [DOI: 10.1016/s0028-3843(14)60119-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Acute bilateral ophthalmoparesis with pupilary areflexical mydriasis in miller-fisher syndrome treated with intravenous immunoglobulin. J Ophthalmol 2010; 2010. [PMID: 20871658 PMCID: PMC2939409 DOI: 10.1155/2010/291840] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Revised: 08/11/2010] [Accepted: 08/18/2010] [Indexed: 11/17/2022] Open
Abstract
Miller-Fisher syndrome (MFS) is a rare condition characterized by the classical triad of ophthalmoplegia, ataxia, and areflexia (Fisher, 1956). It is considered a variant of Guillain-Barré syndrome (GBS) with which it may overlap, or it can occur in more limited forms. We report a case of a thirty-five-year-old male who presented with a six-day history of diplopia, following a recent chest infection. On examination, he was found to have bilateral sixth nerve palsy, bilateral fourth nerve palsy, bilateral areflexical mydriasis, ataxia and total absence of reflexes. After excluding other conditions, a diagnosis of Miller-Fisher syndrome was made. The patient was administered intravenous immunoglobulin and made an uneventful recovery.
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Síndrome de Miller Fisher en la edad pediátrica: descripción de 3 casos. An Pediatr (Barc) 2009; 71:377-8. [DOI: 10.1016/j.anpedi.2009.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Revised: 06/30/2009] [Accepted: 07/01/2009] [Indexed: 11/22/2022] Open
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Liumbruno GM, Bennardello F, Lattanzio A, Piccoli P, Rossettias G. Recommendations for the use of albumin and immunoglobulins. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2009; 7:216-34. [PMID: 19657486 PMCID: PMC2719274 DOI: 10.2450/2009.0094-09] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Giancarlo Maria Liumbruno
- UU.OO.CC. di Immunoematologia e Medicina Trasfusionale e Patologia Clinica, Ospedale San Giovanni Calibita Fatebenefratelli, Roma, Italy.
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40
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Sonneville R, Klein I, de Broucker T, Wolff M. Post-infectious encephalitis in adults: diagnosis and management. J Infect 2009; 58:321-8. [PMID: 19368974 PMCID: PMC7125543 DOI: 10.1016/j.jinf.2009.02.011] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2008] [Revised: 02/18/2009] [Accepted: 02/22/2009] [Indexed: 11/25/2022]
Abstract
Many important central nervous system (CNS) syndromes can develop following microbial infections. The most severe forms of post-infectious encephalitis include acute disseminated encephalomyelitis (ADEM), acute hemorrhagic leukoencephalitis and Bickerstaff's brainstem encephalitis. ADEM is an inflammatory demyelinating disorder of the CNS. It typically follows a minor infection with a 2–30 days latency period and is thought to be immune-mediated. It is clinically characterized by the acute onset of focal neurological signs and encephalopathy. Patients can require intensive care unit admission because of coma, seizures or tetraplegia. Cerebrospinal fluid analysis usually shows lymphocytic pleocytosis but, unlike viral or bacterial encephalitis, no evidence of direct CNS infection is found. There are no biologic markers of the disease and cerebral magnetic resonance imaging is essential to diagnosis, detecting diffuse or multifocal asymmetrical lesions throughout the white matter on T2- and FLAIR-weighted sequences. High-dose intravenous steroids are accepted as first-line therapy and beneficial effects of plasma exchanges and intravenous immunoglobulins have also been reported. Outcome of ADEM is usually favorable but recurrent or multiphasic forms have been described.
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Affiliation(s)
- R Sonneville
- Department of Critical Care Medicine and Infectious Diseases, Bichat-Claude Bernard Hospital, Université Paris 7, 46 Rue Henri Huchard, 75877 Paris Cedex 18, France.
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van Doorn PA, Ruts L, Jacobs BC. Clinical features, pathogenesis, and treatment of Guillain-Barré syndrome. Lancet Neurol 2008; 7:939-50. [PMID: 18848313 DOI: 10.1016/s1474-4422(08)70215-1] [Citation(s) in RCA: 492] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Guillain-Barré syndrome (GBS) is an important cause of acute neuromuscular paralysis. Molecular mimicry and a cross-reactive immune response play a crucial part in its pathogenesis, at least in those cases with a preceding Campylobacter jejuni infection and with antibodies to gangliosides. The type of preceding infection and patient-related host factors seem to determine the form and severity of the disease. Intravenous immunoglobulin (IVIg) and plasma exchange are effective treatments in GBS; mainly for practical reasons, IVIg is the preferred treatment. Whether mildly affected patients or patients with Miller Fisher syndrome also benefit from IVIg is unclear. Despite medical treatment, GBS often remains a severe disease; 3-10% of patients die and 20% are still unable to walk after 6 months. In addition, many patients have pain and fatigue that can persist for months or years. Advances in prognostic modelling have resulted in the development of a new and simple prognostic outcome scale that might also help to guide new treatment options, particularly in patients with GBS who have a poor prognosis.
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Affiliation(s)
- Pieter A van Doorn
- Department of Neurology, Erasmus Medical Centre, Rotterdam, Netherlands.
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42
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Ito M, Kuwabara S, Odaka M, Misawa S, Koga M, Hirata K, Yuki N. Bickerstaff's brainstem encephalitis and Fisher syndrome form a continuous spectrum: clinical analysis of 581 cases. J Neurol 2008; 255:674-82. [PMID: 18274803 DOI: 10.1007/s00415-008-0775-0] [Citation(s) in RCA: 163] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Revised: 09/04/2007] [Accepted: 10/09/2007] [Indexed: 12/17/2022]
Abstract
Whether Bickerstaff's brainstem encephalitis (BBE) is a distinct disease or a subtype of Fisher syndrome (FS) is unclear as there have been no clinical studies with sufficiently large numbers of patients with FS or BBE. Our aim was to clarify the nosological relationship. Medical records of patients suffering acute ophthalmoplegia and ataxia within four weeks of onset were reviewed. BBE was the diagnosis for patients with impaired consciousness, FS for those with clear consciousness and areflexia. Clinical features, neuroimages, and laboratory findings were analyzed. Patients were grouped as having BBE (n = 53), FS (n = 466), or as unclassified (n = 62). The BBE and FS groups had similar features; positive serum anti-GQ1b IgG antibody (68 % versus 83 %), antecedent Campylobacter jejuni infection (23 % versus 21 %), CSF albuminocytological dissociation (46 % versus 76 %), brain MRI abnormality (11 % versus 2 %), and abnormal EEG findings (57 % versus 25 %). BBE (n = 4) and FS (n = 28) subgroups underwent detailed electrophysiological testing. Both groups frequently showed absent soleus H-reflexes, but normal sensory nerve conduction (75 % versus 74 %) and a 1-Hz power spectrum peak on postural body sway analysis (67 % versus 72 %). Common autoantibodies, antecedent infections, and MRI and neurophysiological results found in this large study offer conclusive evidence that Bickerstaff's brainstem encephalitis and Fisher syndrome form a continuous spectrum with variable CNS and PNS involvement.
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Affiliation(s)
- M Ito
- Dept. of Neurology, Dokkyo Medical University, Kitakobayashi 880, Mibu Shimotsuga, Tochigi 321-0293, Japan
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