Demyelinating optic neuropathy with Miller-Fisher syndrome. The case for overlap syndromes with central and peripheral demyelination

Expanding Clinical Spectrum of Anti-GQ1b Antibody Syndrome: A Review

Importance

The discovery of the anti-GQ1b antibody has expanded the nosology of classic Miller Fisher syndrome to include Bickerstaff brainstem encephalitis, Guillain-Barré syndrome with ophthalmoplegia, and acute ophthalmoplegia without ataxia, which have been brought under the umbrella term anti-GQ1b antibody syndrome. It seems timely to define the phenotypes of anti-GQ1b antibody syndrome for the proper diagnosis of this syndrome with diverse clinical presentations. This review summarizes these syndromes and introduces recently identified subtypes.

Observations

Although ophthalmoplegia is a hallmark of anti-GQ1b antibody syndrome, recent studies have identified this antibody in patients with acute vestibular syndrome, optic neuropathy with disc swelling, and acute sensory ataxic neuropathy of atypical presentation. Ophthalmoplegia associated with anti-GQ1b antibody positivity is complete in more than half of the patients but may be monocular or comitant. The prognosis is mostly favorable; however, approximately 14% of patients experience relapse.

Conclusions and Relevance

Anti-GQ1b antibody syndrome may present diverse neurological manifestations, including ophthalmoplegia, ataxia, areflexia, central or peripheral vestibulopathy, and optic neuropathy. Understanding the wide clinical spectrum may aid in the differentiation and management of immune-mediated neuropathies with multiple presentations.

Intracranial Hypertension Associated With Poly-Cranio-Radicular-Neuropathies: A Case Report and Review of the Literature

INTRODUCTION

We present the case of a gentleman who developed rapidly progressive vision loss, ophthalmo-paresis, and flaccid quadriparesis in the context of severe intracranial hypertension. We reviewed the available cases in the literature to increase awareness of this rare clinical entity.Case Report:A 36-year-old man developed rapidly progressive vision loss, ophthalmo-paresis, and flaccid quadriparesis. He had an extensive workup, only notable for severe intracranial hypertension, >55 cm of H 2 O. No inflammatory features were present, and the patient responded to CSF diversion. Few similar cases are available in the literature, but all show markedly elevated intracranial pressure associated with extensive neuroaxis dysfunction. Similarly, these patients improved with CSF diversion but did not appear to respond to immune-based therapies.

CONCLUSIONS

We term this extensive neuroaxis dysfunction intracranial hypertension associated with poly-cranio-radicular-neuropathy (IHP) and distinguish it from similar immune-mediated clinical presentations. Clinicians should be aware of the different etiologies of this potentially devastating clinical presentation to inform appropriate and timely treatment.

Co-occurrence of polyneuritis crainials and visual impairment: a case report and literature review

BACKGROUND

Polyneuritis cranialis (PNC) with the disease characteristics of Guillain-Barré syndrome (GBS) in addition to both ocular and bulbar weakness in the absence of limb paralysis or ataxia is defined as an unusual variant of GBS. As evidence of central nervous system (CNS) involvement, visual impairment is an unusual finding complicating with GBS spectrum disorders and has never been reported in patients with PNC.

METHODS

We describe a very rare case who clinically presented with progressive multiple cranial nerve palsy and visual impairment. Furthermore, a literature search of concurrent GBS and optic neuritis (ON) as well as PNC attributed to GBS was conducted.

RESULTS

A diagnosis of PNC was considered due to the typical clinical characteristics as well as the presence of cerebrospinal fluid cytoalbumin dissociation and serum antibodies against gangliosides. The clinical manifestations and the bilateral optic nerve involvement in brain magnetic resonance imaging further suggested possible optic neuritis (ON). The patient received treatment with intravenous immunoglobulin followed by short-term use of corticosteroids and finally achieved a full recovery. Thirty-two previously reported cases (17 women, mean age 40) of concurrent GBS and ON and 20 cases of PNC (5 women, mean age 40) were analyzed. We further provided a comprehensive discussion on the potential etiologies, clinical features, therapeutic strategies, and prognosis.

CONCLUSIONS

This rare case with the co-occurrence of PNC and visual impairment and the related literature review may help clinicians advance the understanding of GBS spectrum disorders and make appropriate diagnoses and treatment decisions for the rare variants and CNS complications of GBS.

Acute vestibular syndrome associated with anti-GQ1b antibody

OBJECTIVES

To delineate the clinical features and ocular motor findings in acute vestibular syndrome (AVS) associated with anti-GQ1b antibodies.

METHODS

We reviewed 90 patients with positive serum anti-GQ1b antibody in association with various neurological syndromes at Seoul National University Bundang Hospital from 2004 to 2018. The diagnoses included typical Miller Fisher syndrome (n = 31), acute ophthalmoplegia without ataxia (n = 27), Guillain-Barre syndrome with ophthalmoplegia (n = 18), AVS (n = 11), and Bickerstaff brainstem encephalitis (n = 3). Of them, the 11 patients with AVS formed the basis of this study. We also conducted a systematic review on AVS reported in association with anti-GQ1b antibody.

RESULTS

Patients with AVS showed various ocular motor findings that included head-shaking nystagmus (n = 6), spontaneous nystagmus (n = 5), gaze-evoked nystagmus (n = 5), central positional nystagmus (n = 3), canal paresis (n = 2), and abnormal head-impulse tests (n = 1) without any internal or external ophthalmoplegia. Compared to those with other subtypes, patients with AVS mostly showed normal deep tendon reflexes (8 of 11 [73%], p = 0.002) and normal results on nerve conduction studies (4 of 4 [100%], p = 0.010). The clinical and laboratory findings resolved or improved markedly in all patients within 6 months of symptom onset. Systematic review further identified 7 patients with AVS and positive serum anti-GQ1b antibody who showed various ocular motor findings, including gaze-evoked nystagmus, saccadic dysmetria, central positional nystagmus, and ocular flutter or opsoclonus.

CONCLUSION

Anti-GQ1b antibody may cause acute vestibulopathy by involving either the central or peripheral vestibular structures. AVS may constitute a subtype of anti-GQ1b antibody syndrome.

Optic neuropathy and decorticate-like posture as presenting symptoms of Bickerstaff's brainstem encephalitis: A case report and literature review

A 72-year-old woman with a 10-day history of bilateral visual impairment after respiratory tract infection showed decorticate-like posture and progressive deterioration of consciousness leading to coma. Ophthalmoplegia was also noted and anti-GQ1b antibodies were positive, consistent with Bickerstaff's brainstem encephalitis. After intravenous immunoglobulin and steroid pulse therapy, her consciousness gradually improved. However, severe visual impairment at the level of hand motion was noticed, which gradually normalized after second steroid pulse therapy. Atypical findings including optic neuropathy and decorticate-like posture can be seen in patients with Bickerstaff's brainstem encephalitis, and early diagnosis is essential for adequate management.

Serum and CSF GQ1b antibodies in isolated ophthalmologic syndromes

OBJECTIVE

To establish the sensitivity and specificity of serum and CSF antibodies targeting the gangliosides GQ1b (GQ1bAb) in isolated ophthalmologic syndromes, such as acute ophthalmoplegia (AO) and optic neuritis (ON), caused by disorders other than Miller-Fisher syndrome (MFS).

METHODS

We measured serum and CSF GQ1bAb in patients with MFS and with AO or ON caused by other disorders than MFS.

RESULTS

Twenty-one patients with AO (21 serum, 9 CSF), 13 with ON (13 serum, 13 CSF), and 12 with MFS (12 serum, 10 CSF) were included in the study. There were no significant differences in age, sex, and CSF findings between the AO and MFS groups. Elevated serum GQ1b titers occurred in 11 of 12 patients with MFS but in only 1 of the 34 patients without MFS. Sensitivity was 92% (95% confidence interval [CI] 62%-100%) and specificity 97% (95% CI 85%-100%). In CSF, GQ1bAb were identified in 2 of 10 patients with MFS but in none with other disorders. Sensitivity was 20% (95% CI 2%-56%) and specificity 100% (95% CI 85%-100%).

CONCLUSIONS

Increased serum GQ1bAb are highly specific for MFS. Measurement of GQ1bAb in CSF does not improve diagnosis.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that serum GQ1bAb accurately distinguish MFS from other disorders (sensitivity 92%, 95% CI 62%-100%; specificity 97%, 95% CI 85%-100%).

Patterns and significance of concomitant central and peripheral inflammatory demyelination

Inflammatory demyelinating diseases comprise a spectrum of disorders that affect central nervous system (CNS) and peripheral nervous system (PNS) myelin. Most individuals have demyelinating disease restricted to one or the other compartment but patients with concomitant CNS and PNS inflammatory inflammatory demyelinating processes have been reported not infrequently. In most such patients, involvement of either the CNS or the PNS predominates the clinical picture. Involvement of the other compartment is usually mild or subclinical with unclear prognostic and therapeutic implications. Similarly, while experimentally induced demyelinating disease in animal models is usually CNS or PNS predominant, varying degrees of pathology in the other system can occur depending on the species, type of immunogen, and genetic background of the immunized animal. When CNS and PNS demyelinating diseases occur concurrently, effective treatment for CNS disease can be safely combined with effective treatment for PNS disease.

Optic neuropathy associated with CANOMAD: description of 2 cases

CANOMAD is a chronic ataxic neuropathy associated with IgM paraproteinemia and reactivity against disialosyl gangliosides. Ophthalmoplegia is a typical feature, but optic pathway involvement has not been reported previously. We describe 2 cases of CANOMAD associated with optic neuropathy. Severe visual loss was present in 1 case. We postulate that optic nerve damage may be related to antibody reactivity against gangliosides. Our report broadens the spectrum of cranial nerve involvement in this rare entity.

Visual evoked potentials in guillain-barré syndrome

BACKGROUND AND PURPOSE

Guillain-Barré syndrome (GBS) is an acute demyelinating polyneuropathy with various clinical features. Optic neuritis occurs in rare cases. In this study we determined the incidence and patterns of visual evoked potential (VEP) abnormality in GBS in association with ophthalmologic findings.

METHODS

Thirty-two patients with a diagnosis of GBS were included in the study. The correlation between pathologic VEPs and categories of neurologic deficit and electrophysiological findings were examined statistically.

RESULTS

The patients ranged in age from 19 to 77 years. Five cases (16%) had abnormal VEPs. All five of these patients exhibited increased P100 latency differences between the two eyes. Other abnormalities were prolonged p100 latency, increased interocular amplitude difference, and distorted p100 configuration. Pathologic signs on ophthalmologic examination were observed in 80% of patients with abnormal VEPs. VEP abnormality was never present in pure axonal forms. There was no significant correlation between pathologic VEP and cerebrospinal fluid protein level or categories of neurologic deficits.

CONCLUSIONS

Involvement of the optic pathways is not a frequent finding in GBS. When present it is always asymmetric and generally accompanied with pathologic findings on ophthalmologic examination. VEPs may be abnormal in different clinical variants of GBS, and especially in demyelinating forms.

Simultaneous Guillain-Barré syndrome and acute disseminated encephalomyelitis in the pediatric population

Few cases of simultaneous acute demyelination of the peripheral and central nervous systems are reported. Four patients diagnosed as having Guillain-Barré syndrome and acute disseminated encephalomyelitis during the same hospitalization are described herein. Two patients manifest an atypical form of Guillain-Barré syndrome, with magnetic resonance imaging of the head showing acute disseminated encephalomyelitis. A third patient has acute disseminated encephalomyelitis and develops Guillain-Barré syndrome during his hospitalization. A fourth patient demonstrates transverse myelitis that evolves into Guillain-Barré syndrome, with demyelination seen on brain magnetic resonance imaging. All patients are treated with intravenous immunoglobulins or corticosteroids. Three patients have a favorable outcome; 1 patient has a chronic inflammatory demyelinating polyradiculoneuropathy. Guillain-Barré syndrome and acute disseminated encephalomyelitis can occur simultaneously in the pediatric population. This may be explained by a shared epitope between peripheral and central nervous system myelin. Further research is necessary to better describe this entity and its prognosis.

Clinical and immunological spectrum of the Miller Fisher syndrome

The Miller Fisher syndrome (MFS), characterized by ataxia, areflexia, and ophthalmoplegia, was first recognized as a distinct clinical entity in 1956. MFS is mostly an acute, self-limiting condition, but there is anecdotal evidence of benefit with immunotherapy. Pathological data remain scarce. MFS can be associated with infectious, autoimmune, and neoplastic disorders. Radiological findings have suggested both central and peripheral involvement. The anti-GQ1b IgG antibody titer is most commonly elevated in MFS, but may also be increased in Guillain-Barré syndrome (GBS) and Bickerstaff's brainstem encephalitis (BBE). Molecular mimicry, particularly in relation to antecedent Campylobacter jejuni and Hemophilus influenzae infections, is likely the predominant pathogenic mechanism, but the roles of other biological factors remain to be established. Recent studies have demonstrated the presence of neuromuscular transmission defects in association with anti-GQ1b IgG antibody, both in vitro and in vivo. Collective findings from clinical, radiological, immunological, and electrophysiological techniques have helped to define MFS, GBS, and BBE as major disorders within the proposed spectrum of anti-GQ1b IgG antibody syndrome.

Understanding Guillain-Barré Syndrome and Central Nervous System Involvement

Guillain-Barré syndrome is a rare neurological disease that causes paralysis and may necessitate hospitalization for some patients in its acute stages. It primarily affects the peripheral nervous system, though recent research has shown that for some patients, the central nervous system is involved. The acute phase often requires intensive care services. Recognition is growing that recovery is not as smooth and free of symptoms as previously thought. Following "recovery" some people endure long-term residual symptoms, such as fatigue and pain. Nursing input can be of value by providing support, information, explanations, and empathy to reassure patients and families. A greater understanding of the nature and course of the disease and its ramifications can lead to more effective nursing management and a faster rehabilitation process.

Childhood Miller Fisher syndrome: case report and review of the literature

Three years ago Ray Buncic and I were having a break from the lectures at an ophthalmology meeting. Ray told me of his earnest desire to provide Canadian ophthalmologists with a series of updates in pediatric ophthalmology. After a few days we were both back to the "busi-ness" of medicine, with little time to devote to such a project. Then, along came the COS Council on Continuing Professional Development (CPD) and the MaintCert program--a bold initiative to draw talent of Canadian ophthalmology into a program of continuing medical education (CME). One initiative was to use the Canadian Journal of Ophthalmology as a CME tool. This article by Eedy Mezer and Ray Buncic is highlighted as a Section 3 learning activity (self-assessment). I am delighted to have seen Ray bring forward his idea in this manner. The Canadian Journal of Ophthalmology has initiated this project in conjunction with the Council on CPD. There are a number of questions that relate to this article that can be answered on the COS Web site (http://www.eyesite.ca). Participants will be provided with an aggregate score and a certificate that can be printed to allow them to record this activity for Section 3 credits with the Royal College of Physicians and Surgeons of Canada.

[Miller fisher syndrome and optic neuritis: case report]

We report a case of Miller Fisher syndrome and bilateral demyelinating optic neuropathy suggesting the possible involvement of central nervous system in this syndrome. The optic neuritis was confirmed by visual evoked potential.

Central nervous system involvement in multifocal demyelinating neuropathy with persistent conduction block

We report the case of a 27-year-old man treated for bilateral optic neuritis 5 and 3 years before who within a few months developed sensorimotor disorders of the arms and legs characterized by asymmetric distribution and distal prominence. In addition to sensorimotor defects, which were particularly marked in the left arm and right leg, clinical examination showed nearly generalized areflexia. Electrophysiological studies revealed a multifocal neuropathy with persistent distal and proximal conduction blocks associated with a considerable slowing of motor nerve conduction, as well as central nervous system involvement indicated by motor-, somatosensory-, and visual-evoked potentials. CSF analysis showed a mildly elevated protein level; anti-GM1 activity was negative. Sural nerve biopsy revealed onion-bulb-like formations, and cerebral MRI showed a small, isolated, and aspecific high signal for white matter. First described by Lewis and Sumner in 1982, multifocal neuropathy with persistent conduction blocks may be associated with central demyelination. Our case is compared with 3 similar ones in the literature, and the favorable effects of steroid therapy are emphasized.

An immunologic abnormality common to Bickerstaff's brain stem encephalitis and Fisher's syndrome

The nosological position of Bickerstaff's brain stem encephalitis (BBE) has yet to be established, and its etiology is not clear. Because anti-GQ1b antibody frequently occurs in patients with Fisher's syndrome (FS) and there are clinical similarities between FS and BBE, we investigated anti-ganglioside antibodies in sera from 3 BBE patients who had transient long tract signs in addition to acute ophthalmoplegia and cerebellar-like ataxia in order to clarify the etiology and nosological position of BBE. High IgG anti-GQ1b antibody titers were present in all 3 sera samples but decreased with the clinical course of the illness. In contrast, no anti-GQ1b antibody was found in sera from patients with other neurologic diseases which were able to produce transient brain stem disturbance: multiple sclerosis, neuro-Behçet's disease, brain stem infarction, herpes simplex virus encephalitis, and Wernicke's encephalopathy. The finding that BBE and FS shared common autoantibody suggests that autoimmune mechanism common to FS is likely in BBE, and that both conditions represent a distinct disease with a wide spectrum of symptoms that include ophthalmoplegia and ataxia.

A case of Miller Fisher syndrome: atypical findings and therapeutic considerations

The Miller Fisher syndrome (MFS) is generally considered to be a disease of the peripheral nervous system. In some cases contemporary involvement of the central nervous system has been described (CNS). We report a case in which it was possible to prove involvement of cranial nerves VII, VIII, IX and X and to exclude CNS involvement. We discuss the possible role of early plasmapheresis treatment on disease evolution.

Chronic multifocal demyelinating neuropathy associated with central nervous system demyelination

We have carried out a long-term study of lesions found in a man who had a demyelinating disease of both central and peripheral nervous systems. During the 10 years of his clinical course, he suffered from optic neuritis, multifocal myelitis, and chronic multifocal demyelinating neuropathy, with persistent conduction block. Our study revealed that both central and peripheral nervous system demyelination occurred repeatedly and simultaneously.

Guillain-Barré syndrome and pan-uveitis

A case history of a patient diagnosed as having Guillain-Barré syndrome who is also found to have a pan-uveitis which has caused significant deterioration in vision and which has been slow to resolve on treatment. This would appear to be the first such report in the literature.

Focal cranial nerve involvement in chronic inflammatory demyelinating polyneuropathy: clinical and MRI evidence of peripheral and central lesions

Five cases of chronic inflammatory demyelinating polyneuropathy are described in which cranial nerve involvement accompanied a more generalized neuropathy. Clinical, electrophysiological, radiological and nerve biopsy findings are presented. Cranial nerve lesions in this form of polyneuropathy may be related to lesions of the peripheral nerves or of the central nervous system, when they may be accompanied by MRI evidence of more widespread CNS demyelinating lesions. In cases of early onset, the occurrence of focal cranial nerve lesions may serve to distinguish chronic inflammatory from inherited demyelinating polyneuropathies.