1
|
Oliveira S, Prezado A, Soares B, Ferreira M. Anesthetic Management of Patients With Morvan Syndrome: A Case Report and Literature Review. Cureus 2024; 16:e58762. [PMID: 38779241 PMCID: PMC11111158 DOI: 10.7759/cureus.58762] [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: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
Morvan syndrome is a rare condition distinguished by hyperactivity within the central, autonomic, and peripheral nervous systems. Due to the limited number of cases, this presents clinical challenges stemming from the scarcity of published literature. We present a successful anesthetic approach for a patient diagnosed with Morvan syndrome scheduled for elective major intra-thoracic surgery to remove metastases from a thymoma. The patient had previously undergone thymectomy, with the syndrome being diagnosed only one year after the surgery. Additionally, we conducted a literature review on the anesthetic management of this condition.
Collapse
Affiliation(s)
- Sarah Oliveira
- Anesthesiology, Unidade Local de Saúde Santa Maria, Lisbon, PRT
| | - Adriana Prezado
- Anesthesiology, Unidade Local de Saúde Alentejo Central, Évora, PRT
| | - Beatriz Soares
- Anesthesiology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, PRT
| | - Miguel Ferreira
- Anesthesiology, Unidade Local de Saúde Santa Maria, Lisbon, PRT
| |
Collapse
|
2
|
Xhaxho S, Vyshka G, Muharremi E, Kruja J. A case report of Morvan syndrome. Oxf Med Case Reports 2021; 2021:omab064. [PMID: 34408887 DOI: 10.1093/omcr/omab064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/31/2021] [Accepted: 07/06/2021] [Indexed: 11/13/2022] Open
Abstract
Authors describe the case of a 22-year-old Caucasian male who presented acutely with psychomotor agitation, insomnia and muscle twitching with painful cramps. Autonomic symptoms were as well present, with profuse sweating, blood pressure fluctuations and tachycardia. He presented a miliary rash in his left forearm as well as in the neck. Electromyography documented myokymic movements bilaterally at both gastrocnemii and pretibial muscles. Brain imaging had no abnormalities, and anti-LGI1 and anti-CASPR2 resulted positive; this data together with electrophysiological findings suggested a Morvan syndrome. High-dose steroid therapy and plasma exchange improved substantially the clinical picture of the patient.
Collapse
Affiliation(s)
- Sokrat Xhaxho
- Service of Neurology, University Hospital Center 'Mother Theresa', Tirana, Albania
| | - Gentian Vyshka
- Faculty of Medicine, Biomedical and Experimental Department, University of Medicine, Tirana, Albania
| | - Eti Muharremi
- Service of Neurology, University Hospital Center 'Mother Theresa', Tirana, Albania
| | - Jera Kruja
- Service of Neurology, University Hospital Center 'Mother Theresa', Tirana, Albania.,Faculty of Medicine, University of Medicine, Tirana, Albania
| |
Collapse
|
3
|
Panchin Y, Kovalzon VM. Total Wake: Natural, Pathological, and Experimental Limits to Sleep Reduction. Front Neurosci 2021; 15:643496. [PMID: 33897357 PMCID: PMC8058214 DOI: 10.3389/fnins.2021.643496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/26/2021] [Indexed: 11/16/2022] Open
Abstract
Sleep is not considered a pathological state, but it consumes a third of conscious human life. This share is much more than most optimistic life extension forecasts that biotechnologies or experimental and medical interventions can offer. Are there insurmountable physical or biological limitations to reducing the duration of sleep? How far can it be avoided without fatal consequences? What means can reduce the length of sleep? It is widely accepted that sleep is necessary for long-term survival. Here we review the limited yet intriguing evidence that is not consistent with this notion. We concentrate on clinical cases of complete and partial loss of sleep and on human mutations that result in a short sleep phenotype. These observations are supported by new animal studies and are discussed from the perspective of sleep evolution. Two separate hypotheses suggest distinct approaches for remodeling our sleep machinery. If sleep serves an unidentified vital physiological function, this indispensable function has to be identified before “sleep prosthesis” (technical, biological, or chemical) can be developed. If sleep has no vital function, but rather represents a timing mechanism for adaptive inactivity, sleep could be reduced by forging the sleep generation system itself, with no adverse effects.
Collapse
Affiliation(s)
- Yuri Panchin
- Institute for Information Transmission Problems, Russian Academy of Sciences, Moscow, Russia.,Department of Mathematical Methods in Biology, Belozersky Institute, Lomonosov Moscow State University, Moscow, Russia
| | - Vladimir M Kovalzon
- Institute for Information Transmission Problems, Russian Academy of Sciences, Moscow, Russia.,Severtsov Institute of Ecology and Evolution, Russian Academy of Sciences, Moscow, Russia
| |
Collapse
|
4
|
Sharma AK, Kaur M, Paul M. Morvan's syndrome with anti contactin associated protein like 2 - voltage gated potassium channel antibody presenting with syndrome of inappropriate antidiuretic hormone secretion. J Neurosci Rural Pract 2019; 7:577-579. [PMID: 27695240 PMCID: PMC5006472 DOI: 10.4103/0976-3147.188638] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Morvan's syndrome is a rare autoimmune disorder characterized by triad of peripheral nerve hyperexcitability, autonomic dysfunction, and central nervous system symptoms. Antibodies against contactin-associated protein-like 2 (CASPR2), a subtype of voltage-gated potassium channel (VGKC) complex, are found in a significant proportion of patients with Morvan's syndrome and are thought to play a key role in peripheral as well as central clinical manifestations. We report a patient of Morvan's syndrome with positive CASPR2–anti-VGKC antibody having syndrome of inappropriate antidiuretic hormone as a cause of persistent hyponatremia.
Collapse
Affiliation(s)
- Anjani Kumar Sharma
- Department of Neurology, Sawai ManSingh Medical College, Jaipur, Rajasthan, India
| | - Manminder Kaur
- Department of Neurology, Sawai ManSingh Medical College, Jaipur, Rajasthan, India
| | - Madhuparna Paul
- Department of Neurology, Sawai ManSingh Medical College, Jaipur, Rajasthan, India
| |
Collapse
|
5
|
|
6
|
Naides SJ. The role of the laboratory in the expanding field of neuroimmunology: Autoantibodies to neural targets. J Immunol Methods 2018; 463:1-20. [PMID: 30300607 DOI: 10.1016/j.jim.2018.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 04/12/2018] [Indexed: 12/15/2022]
Abstract
Accelerated identification of autoantibodies associated with previously idiopathic neurological disease has provided insights into disease mechanisms, enhanced understanding of neurological function, and opportunities for improved therapeutic interventions. The role of the laboratory in the expanding field of neuroimmunology is critical as specific autoantibody identification provides guidance to clinicians in diagnosis, prognosis, tumor search strategies, and therapeutic interventions. The number of specific autoantibodies identified continues to increase and newer testing strategies increase efficiencies in the laboratory and availability to clinicians. The need for broadly targeted efficient testing is underscored by the variability in clinical presentation and tumor associations attributable to a specific autoantibody, and conversely the various autoantibody specificities that can be the cause of a given clinical presentation. While many of the antineural antibodies were first recognized in the setting of neoplastic disease, idiopathic autoimmune neurological disease in the absence of underlying tumor is increasingly recognized. Appropriation of therapeutic modalities used to treat autoimmune disease to treat these autoantibody mediated neurological diseases has improved patient outcomes. Interaction between clinicians and laboratorians is critical to our understanding of these diseases and optimization of the clinical benefits of our increasing knowledge in neuroimmunology.
Collapse
Affiliation(s)
- Stanley J Naides
- Immunology R&D, Quest Diagnostics Nichols Institute, 33608 Ortega Highway, San Juan Capistrano, CA 92675, USA.
| |
Collapse
|
7
|
Antelmi E, Ferri R, Iranzo A, Arnulf I, Dauvilliers Y, Bhatia KP, Liguori R, Schenck CH, Plazzi G. From state dissociation to status dissociatus. Sleep Med Rev 2016; 28:5-17. [DOI: 10.1016/j.smrv.2015.07.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 07/11/2015] [Accepted: 07/18/2015] [Indexed: 01/10/2023]
|
8
|
Maskery M, Chhetri SK, Dayanandan R, Gall C, Emsley HCA. Morvan Syndrome: A Case Report With Patient Narrative and Video. Neurohospitalist 2016; 6:32-5. [PMID: 26740856 DOI: 10.1177/1941874415580597] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A 74-year-old gentleman was admitted to the regional neurosciences center with encephalopathy, myokymia, and dysautonomia. Chest imaging had previously identified an incidental mass in the anterior mediastinum, consistent with a primary thymic tumor. Antivoltage-gated potassium channel (anti-VGKC) antibodies were positive (titer 1273 pmol/L) and he was hypokalemic. Electromyogram and nerve conduction studies were in keeping with peripheral nerve hyperexcitability syndrome, and an electroencephalogram was consistent with encephalopathy. A diagnosis of Morvan syndrome was made, for which he was initially treated with high-dose steroids, followed by a 5-day course of intravenous immunoglobulin (IVIG) therapy. He also underwent thymectomy, followed by a postexcision flare of his symptoms requiring intensive care management. Further steroids, plasmapheresis, and IVIG achieved stabilization of his clinical condition, enabling transfer for inpatient neurorehabilitation. He was commenced on azathioprine and a prolonged oral steroid taper. A subsequent presumed incipient relapse responded well to further IVIG treatment. This case report documents a thymoma-associated presentation of anti-VGKC-positive Morvan syndrome supplemented by patient and carer narrative and video, both of which provide valuable further insights into this rare disorder. There are a limited number of publications surrounding this rare condition available in the English literature. This, combined with the heterogenous presentation, association with underlying malignancy, response to treatment, and prognosis, provides a diagnostic challenge. However, the association with anti-VGKC antibody-associated complexes and 2 recent case series have provided some scope for both accurate diagnosis and management.
Collapse
Affiliation(s)
- Mark Maskery
- University of Manchester, Manchester, United Kingdom
| | - Suresh K Chhetri
- Department of Neurology, Royal Preston Hospital, Preston, United Kingdom
| | - Rejith Dayanandan
- Department of Neurology, Royal Preston Hospital, Preston, United Kingdom
| | - Claire Gall
- Department of Neurology, Royal Preston Hospital, Preston, United Kingdom
| | - Hedley C A Emsley
- University of Manchester, Manchester, United Kingdom; Department of Neurology, Royal Preston Hospital, Preston, United Kingdom
| |
Collapse
|
9
|
Abstract
Isaacs syndrome is a peripheral nerve hyperexcitability (PNH) syndrome that presents as continuous motor activity. Clinical findings include cramps, fasciculations, and myokymia. Electrodiagnosis plays a key role in diagnosis by demonstrating after-discharges on nerve conduction studies, and fasciculation potentials, myokymic discharges, neuromyotonic discharges, and other types of abnormal spontaneous activity on needle examination. Etiopathogenesis involves the interaction of genetic, autoimmune, and paraneoplastic factors, which requires a broad-ranging evaluation for underlying causes. Initial treatment is symptomatic, but immune therapy is often needed and can be effective. The purpose of this review is to describe the syndrome and its pathogenesis, assist the reader in evaluating patients with suspected Isaacs syndrome and distinguishing it from other disorders of PNH, and suggest an approach to management, including both symptomatic and immunomodulating therapy.
Collapse
Affiliation(s)
- Aiesha Ahmed
- Department of Neurology, Penn State Hershey Medical Center, EC 037, 30 Hope Drive, Hershey, Pennsylvania, 17033, USA
| | - Zachary Simmons
- Department of Neurology, Penn State Hershey Medical Center, EC 037, 30 Hope Drive, Hershey, Pennsylvania, 17033, USA.,Department of Humanities, Penn State Hershey Medical Center, Hershey, Pennyslvania, USA
| |
Collapse
|
10
|
Affiliation(s)
- Sabeen Tufail
- Specialty Registrar, AnaestheticsUniversity Hospital WalesCardiffUnited Kingdom
| | - Mark Stacey
- Consultant, AnaestheticsUniversity Hospital WalesCardiffUnited Kingdom
| |
Collapse
|
11
|
Lee W, Day TJ, Williams DR. Clinical, laboratory and electrophysiological features of Morvan's fibrillary chorea. J Clin Neurosci 2013; 20:1246-9. [PMID: 23712055 DOI: 10.1016/j.jocn.2012.10.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2012] [Accepted: 10/31/2012] [Indexed: 11/16/2022]
Abstract
Morvan's Fibrillary Chorea (MFC) is a rare autoimmune disorder causally associated with auto-antibodies directed at the voltage-gated potassium channel (VGKC-Abs). It classically presents with sleep disturbances, neuromyotonia and dysautonomia. We aimed to systematically characterise the features of MFC by describing a patient and reviewing published literature. Case notes of 27 patients with MFC (one from our clinic and 26 from the literature) were reviewed and clinical data were extracted and analysed. We found that MFC mainly affects men (96%) and runs a subacute course over months. Neoplasia (56%), VGKC-Abs positivity (79%) and autoimmunity (41%) are frequent associations. Myokymia, insomnia and hyperhidrosis were almost universally described. Other autonomic features were present in 63% with the most common being cardiovascular and bowel disturbances. Clinical, radiological or electroencephalographical features of limbic encephalitis were present in 19% of patients. Outcome was fair with an overall recovery rate of 78%. All patients with malignancies underwent surgery. Immunotherapies including corticosteroids, intravenous immunoglobulins and plasma exchange were instituted in 22 patients and 19 (86%) responded. Of all symptomatic treatments tried, carbamazepine, phenytoin, sodium valproate, levetiracetam and niaprazine were found to be effective. The broad clinical spectrum of VGKC-Abs diseases can make early recognition of MFC difficult. Myokymia, insomnia and hyperhidrosis are invariably present. There may be abnormalities on cerebrospinal fluid testing and VGKC-Abs can occasionally be absent. Early initiation of immunotherapies and malignancy screening are important to prevent adverse outcomes in a condition that generally responds favourably to treatment.
Collapse
Affiliation(s)
- Will Lee
- Department of Neuroscience, Alfred Hospital, Commercial Road, Melbourne, Victoria 3004, Australia
| | | | | |
Collapse
|
12
|
Abstract
Morvan syndrome is characterized by central, autonomic, and peripheral hyperactivity. Examples of central hyperactivity include confusion, memory problems, hallucinations, insomnia, and myoclonus; examples of autonomic hyperactivity include hyperhidrosis and fluctuations in blood pressure; examples of peripheral hyperreactivity include clinical or electrophysiological evidence of painful cramps, myokymia, and neuromyotonia. We present a typical case of Morvan syndrome and the first detailed review of the clinical and therapeutic literature of all 27 cases from the English language literature. Morvan syndrome is considered to be an autoimmune disorder and antibodies against voltage-gated potassium channels are found in most cases. Oral immunomodulatory therapy, intravenous immunoglobulin, and plasmapharesis may be entertained. Thymoma is found in approximately 50% of cases and thymectomy may be curative as in our particular case.
Collapse
|
13
|
Loukaides P, Schiza N, Pettingill P, Palazis L, Vounou E, Vincent A, Kleopa KA. Morvan's syndrome associated with antibodies to multiple components of the voltage-gated potassium channel complex. J Neurol Sci 2012; 312:52-6. [DOI: 10.1016/j.jns.2011.08.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 08/11/2011] [Accepted: 08/16/2011] [Indexed: 10/17/2022]
|
14
|
Abstract
Needle electromyography (EMG) records electrical signals generated from muscle fibers and interprets the signals to characterize underlying pathologic changes that are occurring in motor units within muscles. Different types of spontaneously firing waveforms and motor unit potential changes occur with different neuromuscular disorders. The performance of reliable EMG studies depends on the technical skills of the physician in inserting, moving, recording with a needle electrode, and analyzing electric signals recorded from muscle. This article reviews the technique of needle EMG and recognition and interpretation of various EMG waveforms. The author presents several demonstrative videos at www.neurologic.theclinics.com.
Collapse
Affiliation(s)
- Devon I Rubin
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| |
Collapse
|
15
|
Autoantibodies associated with diseases of the CNS: new developments and future challenges. Lancet Neurol 2011; 10:759-72. [PMID: 21777830 DOI: 10.1016/s1474-4422(11)70096-5] [Citation(s) in RCA: 351] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
|
16
|
Melzer N, Classen J, Reiners K, Buttmann M. Fluctuating neuromuscular transmission defects and inverse acetazolamide response in episodic ataxia type 2 associated with the novel CaV2.1 single amino acid substitution R2090Q. J Neurol Sci 2010; 296:104-6. [PMID: 20663518 DOI: 10.1016/j.jns.2010.06.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2010] [Revised: 06/10/2010] [Accepted: 06/25/2010] [Indexed: 11/25/2022]
Abstract
We report on a 51-year-old woman with episodic ataxia type 2 (EA2) and a novel CaV2.1 C-terminal single amino acid substitution (R2090Q). She had a 4-year history of acute episodes with ataxia, hemihypesthesia and hemicrania. Furthermore, fluctuating neuromuscular transmission abnormalities rarely described in patients with EA2 were clinically and electrophysiologically documented in this patient. Upon initiation of acetazolamide treatment she experienced a dose-dependent severe increase of attack frequency and severity along with a shorter attack duration, while she responded well to subsequent therapy with 4-aminopyridine.
Collapse
Affiliation(s)
- Nico Melzer
- Department of Neurology, Julius Maximilian University, Würzburg, Germany
| | | | | | | |
Collapse
|
17
|
|
18
|
Abstract
Physiologic assessment of diseases of the motor unit from the anterior horn cells to the muscles relies on a combination of needle electromyography (EMG) and nerve conduction studies (NCS). Both require a unique combination of knowledge of peripheral nervous system anatomy, physiology, pathophysiology, diseases, techniques, and electricity is necessary. Successful, high-quality, reproducible EMG depends on the skills of a clinician in patient interaction during the physical insertion and movement of the needle while recording the electrical signals. These must be combined with the skill of analyzing electric signals recorded from muscle by auditory pattern recognition and semiquantitation.1052 This monograph reviews the techniques of needle EMG and waveform analysis and describes the types of EMG waveforms recorded during needle EMG.
Collapse
Affiliation(s)
- Jasper R Daube
- Mayo Clinic, Department of Neurology, Rochester, Minnesota, USA
| | | |
Collapse
|
19
|
Abstract
BACKGROUND Paraneoplastic neurologic syndromes (PNS) constitute a rare group of disorders resulting from damage to the nervous system in the setting of cancer physically unrelated to the tumor site. PNS are believed to result from an autoimmune attack of normal neuronal tissue, spurred by similar neuronal antigens ectopically expressed by tumor cells. REVIEW SUMMARY The most common PNS are reviewed and also their association with specific onconeural antibodies, some directly pathogenic, others whose role in the disease process is less clear-cut. This diversity in pathogenesis is likely due to the relative role of humoral versus cellular immunity in PNS. Virtually any cancer may result in PNS but certain tumors, small cell lung cancer, gynecologic cancers (breast and ovarian), thymoma, and plasma cell tumors are more frequently encountered. In most instances, immunosuppressive therapy is unhelpful and outcome is poor. CONCLUSIONS PNS have diverse presentations, affecting both the central and peripheral nervous system and commonly, it is the PNS, not cancer that is the presenting symptom. Only subsequently, after onconeural antibodies are discovered or cancer is found, is PNS diagnosed. Neurologists should familiarize themselves with these rare syndromes and treatment principles, as rapid detection and treatment of the underlying tumor offer the best chance for recovery or prevention of further neurologic deterioration.
Collapse
Affiliation(s)
- Thomas B Toothaker
- Department of Neurology and Neuroscience, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY 10021, USA.
| | | |
Collapse
|
20
|
Turner MR, Madkhana A, Ebers GC, Clover L, Vincent A, McGavin G, Sarrigiannis P, Kennett R, Warrell DA. Wasp sting induced autoimmune neuromyotonia. J Neurol Neurosurg Psychiatry 2006; 77:704-5. [PMID: 16614042 PMCID: PMC2117454 DOI: 10.1136/jnnp.2005.075283] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|