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Noioso CM, Bevilacqua L, Acerra GM, Valle PD, Serio M, Pecoraro A, Rienzo A, De Marca U, De Biasi G, Vinciguerra C, Piscosquito G, Toriello A, Tozza S, Barone P, Iovino A. The spectrum of anti-GQ1B antibody syndrome: beyond Miller Fisher syndrome and Bickerstaff brainstem encephalitis. Neurol Sci 2024:10.1007/s10072-024-07686-3. [PMID: 38987510 DOI: 10.1007/s10072-024-07686-3] [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: 01/18/2024] [Accepted: 07/03/2024] [Indexed: 07/12/2024]
Abstract
INTRODUCTION Since the initial identification of Miller Fisher syndrome (MFS) and Bickerstaff brainstem encephalitis (BBE),significant milestones have been achieved in understanding these diseases.Discoveries of common serum antibodies (IgG anti-GQ1b), antecedent infections, neurophysiological data, andneuroimaging suggested a shared autoimmune pathogenetic mechanism rather than distinct pathogenesis, leadingto the hypothesis that both diseases are part of a unified syndrome, termed "Fisher-Bickerstaff syndrome". The subsequent identification of atypical anti-GQ1b-positive forms expanded the classification to a broader condition known as "Anti-GQ1b-Antibody syndrome". METHODS An exhaustive literature review was conducted, analyzing a substantial body of research spanning from the initialdescriptions of the syndrome's components to recent developments in diagnostic classification and researchperspectives. RESULTS Anti-GQ1b syndrome encompasses a continuous spectrum of conditions defined by a common serological profilewith varying degrees of peripheral (PNS) and central nervous system (CNS) involvement. MFS and BBE represent theopposite ends of this spectrum, with MFS primarily affecting the PNS and BBE predominantly involving the CNS.Recently identified atypical forms, such as acute ophthalmoparesis, acute ataxic neuropathy withoutophthalmoparesis, Guillain-Barré syndrome (GBS) with ophthalmoparesis, MFS-GBS and BBE-GBS overlap syndromes,have broadened this spectrum. CONCLUSION This work aims to provide an extensive, detailed, and updated overview of all aspects of the anti-GQ1b syndromewith the intention of serving as a stepping stone for further shaping thereof. Special attention was given to therecently identified atypical forms, underscoring their significance in redefining the boundaries of the syndrome.
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Affiliation(s)
- Ciro Maria Noioso
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy.
| | - Liliana Bevilacqua
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Gabriella Maria Acerra
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Paola Della Valle
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Marina Serio
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Agnese Pecoraro
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Annalisa Rienzo
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Umberto De Marca
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Giuseppe De Biasi
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Claudia Vinciguerra
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Giuseppe Piscosquito
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Antonella Toriello
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Stefano Tozza
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Paolo Barone
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Aniello Iovino
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
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Handzic A, Margolin E. Bickerstaff Brainstem Encephalitis With Exceptionally Fast Recovery. J Neuroophthalmol 2024:00041327-990000000-00670. [PMID: 38924450 DOI: 10.1097/wno.0000000000002200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Armin Handzic
- Department of Ophthalmology and Vision Sciences (AH, EM), Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; and Department of Medicine (EM), Division of Neurology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Hayes LH, Darras BT. Neuromuscular problems of the critically Ill neonate and child. Semin Pediatr Neurol 2024; 49:101123. [PMID: 38677802 DOI: 10.1016/j.spen.2024.101123] [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: 03/10/2024] [Accepted: 04/08/2024] [Indexed: 04/29/2024]
Abstract
Acute neuromuscular disorders occasionally occur in the Pediatric Neurologic Intensive Care Unit. Many of these are primary disorders of the motor unit that may present acutely or exacerbate during an intercurrent illness. Additionally, acute neuromuscular disorders may develop during an acute systemic illness requiring intensive care management that predispose the child to another set of acute motor unit disorders. This chapter discusses acute neuromuscular crises in the infant, toddler, and adolescent, as well as neuromuscular disorders resulting from critical illness.
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Affiliation(s)
- Leslie H Hayes
- Department of Neurology, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, United States.
| | - Basil T Darras
- Department of Neurology, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, United States
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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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Lee J, Vishwanath V, Gill N. Dysphagia, Dysarthria, and Diplopia in a 14-year-old Boy. Pediatr Rev 2023; 44:592-594. [PMID: 37777648 DOI: 10.1542/pir.2021-005366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Affiliation(s)
- July Lee
- Division of Pediatric Emergency Medicine and Transport
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA
| | - Vijay Vishwanath
- Division of Pediatric Neurology
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA
- Clinical Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Natasha Gill
- Division of Pediatric Emergency Medicine and Transport
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA
- Clinical Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Kozyreva AA, Bembeeva RT, Druzhinina ES, Zavadenko NN. [Guillain-Barre syndrome in children]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:20-32. [PMID: 37942969 DOI: 10.17116/jnevro202312309220] [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] [Indexed: 11/10/2023]
Abstract
Guillain-Barré syndrome (GBS) is an immune-mediated disease of the peripheral nervous system that can occur in both children and adults. The classic presentation of GBS is characterized by progressive symmetrical, ascending muscle weakness. Patients with GBS require meticulous monitoring due to the risk of bulbar syndrome, respiratory failure and autonomic dysfunction, which can be life-threatening. Early diagnosis and timely prescription of pathogenetic therapy for GBS are particularly important, especially in young children. Meanwhile, the spectrum of disorders covered by GBS has expanded significantly; its eponym is now designate any variant of acute dysimmune polyneuropathy, and its atypical forms pose a serious diagnostic problem for clinicians. This review article provides an analysis of the data available in the medical literature on GBS in children and discusses the tactics for diagnosing and managing patients with GBS, taking into account the Russian and European clinical recommendations.
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Affiliation(s)
- A A Kozyreva
- Pirogov Russian National Research Medical University, Moscow, Russia
- Russian Children's Clinical Hospital, Moscow, Russia
| | - R Ts Bembeeva
- Pirogov Russian National Research Medical University, Moscow, Russia
- Russian Children's Clinical Hospital, Moscow, Russia
| | - E S Druzhinina
- Pirogov Russian National Research Medical University, Moscow, Russia
- Russian Children's Clinical Hospital, Moscow, Russia
| | - N N Zavadenko
- Pirogov Russian National Research Medical University, Moscow, Russia
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Fujii K, Shiohama T, Uchida T, Ikehara H, Fukuhara T, Sawada D, Aoyama H, Uchikawa H, Yoshii S, Arahata Y, Shimojo N, Misawa S, Kuwabara S. Nationwide survey of childhood Guillain-Barré syndrome, Fisher syndrome, and Bickerstaff brainstem encephalitis in Japan. Brain Dev 2023; 45:16-25. [PMID: 36511273 DOI: 10.1016/j.braindev.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 08/05/2022] [Accepted: 09/18/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Guillain-Barré syndrome (GBS), Fisher syndrome (FS), and Bickerstaff brainstem encephalitis (BBE) are immune-mediated neuropathies presenting with symptoms such as weakness, ophthalmoplegia, ataxia, and consciousness disturbances. Although the epidemiology of GBS and BBE in patients of all ages has been reported, childhood data have not been well-investigated. We aimed to determine the clinical features, therapeutics, and prognoses of childhood GBS, FS, and BBE in Japan. METHODS We sent questionnaires to 1068 pediatric neurologists in Japan from 2014 to 2016 to determine the number of children less than 15 years old with GBS, FS, or BBE and their age and sex. We subsequently performed a secondary survey to investigate the clinical features, laboratory data, treatment, and prognosis. RESULTS Five-hundred thirty-eight pediatric neurology specialists (50.4%) responded to the first survey. The total number of children with GBS, FS, and BBE in Japan from 2014 to 2016 were 87, 10, and 6, respectively. GBS was classified as acute inflammatory demyelinating neuropathy (35.6%), acute motor axonal neuropathy (20.7%), or acute motor-sensory axonal neuropathy (10.3%), with a male-to-female ratio of 1.29:1.0 and a wide distribution of onset ages. The disease severities of GBS, FS, and BBE were variable, but all children could walk within one year. CONCLUSION The prognoses of childhood GBS, FS, and BBE were generally favorable, as long as the patient was promptly treated with either intravenous immunoglobulin or plasma exchange.
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Affiliation(s)
- Katsunori Fujii
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Chiba, Japan; Department of Pediatrics, Graduate School of Medicine, International University of Health and Welfare, Narita, Japan.
| | - Tadashi Shiohama
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tomoko Uchida
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hajime Ikehara
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tomoyuki Fukuhara
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Daisuke Sawada
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiromi Aoyama
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hideki Uchikawa
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shoko Yoshii
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yukie Arahata
- Department of Pediatrics, Graduate School of Medicine, International University of Health and Welfare, Narita, Japan
| | - Naoki Shimojo
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Sonoko Misawa
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Monte G, Pro S, Ursitti F, Ferilli MAN, Moavero R, Papetti L, Sforza G, Bracaglia G, Vigevano F, Palma P, Valeriani M. Case report: A pediatric case of Bickerstaff brainstem encephalitis after COVID-19 vaccination and Mycoplasma pneumoniae infection: Looking for the culprit. Front Immunol 2022; 13:987968. [PMID: 36032138 PMCID: PMC9411636 DOI: 10.3389/fimmu.2022.987968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 07/25/2022] [Indexed: 01/17/2023] Open
Abstract
Bickerstaff brainstem encephalitis (BBE) is a rare, immune-mediated disease characterized by the acute onset of external ophthalmoplegia, ataxia, and consciousness disturbance. It has a complex multifactorial etiology, and a preceding infectious illness is seen in the majority of cases. Immune-mediated neurological syndromes following COVID-19 vaccination have been increasingly described. Here we report the case of a child developing BBE 2 weeks after COVID-19 vaccination. Despite nerve conduction studies and CSF analysis showing normal results, BBE was diagnosed on clinical ground and immunotherapy was started early with a complete recovery. Later, diagnosis was confirmed by positive anti-GQ1b IgG in serum. Even if there was a close temporal relationship between disease onset and COVID-19 vaccination, our patient also had evidence of a recent Mycoplasma pneumoniae infection that is associated with BBE. Indeed, the similarity between bacterial glycolipids and human myelin glycolipids, including gangliosides, could lead to an aberrantly immune activation against self-antigens (i.e., molecular mimicry). We considered the recent Mycoplasma pneumoniae infection a more plausible explanation of the disease onset. Our case report suggests that suspect cases of side effects related to COVID-19 vaccines need a careful evaluation in order to rule out well-known associated factors before claiming for a causal relationship.
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Affiliation(s)
- Gabriele Monte
- Neurology Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- *Correspondence: Gabriele Monte,
| | - Stefano Pro
- Neurology Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Fabiana Ursitti
- Neurology Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Michela Ada Noris Ferilli
- Neurology Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Romina Moavero
- Neurology Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Child Neurology and Psychiatry Unit, Department of System Medicine, Tor Vergata University of Rome, Rome, Italy
| | - Laura Papetti
- Neurology Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Giorgia Sforza
- Neurology Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Giorgia Bracaglia
- Department of Diagnostics and Laboratory Medicine, Medical Laboratory Unit, Unit of Allergy and Autoimmunity, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Federico Vigevano
- Neurology Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Paolo Palma
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Chair of Pediatrics, Department of Systems Medicine, Tor Vergata University of Rome, Rome, Italy
| | - Massimiliano Valeriani
- Neurology Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Center for Sensory-Motor Interaction, Aalborg University, Denmark Neurology Unit, Aalborg, Denmark
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Natsui H, Takahashi M, Nanatsue K, Itaya S, Abe K, Inaba A, Orimo S. Mother and son cases of Bickerstaff's brainstem encephalitis and fisher syndrome with serum anti-GQ1b IgG antibodies: a case report. BMC Neurol 2021; 21:130. [PMID: 33743625 PMCID: PMC7980323 DOI: 10.1186/s12883-021-02159-y] [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: 10/29/2020] [Accepted: 03/15/2021] [Indexed: 12/02/2022] Open
Abstract
Background Bickerstaff’s brainstem encephalitis (BBE) and Fisher syndrome (FS) are immune-mediated diseases associated with anti-ganglioside antibodies, specifically the anti-GQ1b IgG antibody. These two diseases potentially lie on a continuous spectrum with Guillain-Barré Syndrome (GBS). There are some reports of family cases of GBS and fewer of FS. However, there are no reports of family cases of BBE and FS. Case presentation We report a familial case of an 18-year-old son who had BBE and his 52-year-old mother diagnosed with FS within 10 days. The son showed impaired consciousness 1 week after presenting with upper respiratory symptoms and was brought to our hospital by his mother. He showed decreased tendon reflexes, limb ataxia, albuminocytologic dissociation in his spinal fluid, and positive serum anti-GQ1b antibodies. Haemophilus influenzae was cultured from his sputum. He was diagnosed with BBE and treated with intravenous immunoglobulin (IVIg) therapy, which led to an improvement in symptoms. The mother presented with upper respiratory symptoms 3 days after her son was hospitalized. Seven days later, she was admitted to the hospital with diplopia due to limited abduction of the left eye. She showed mild ataxia and decreased tendon reflexes. Her blood was positive for anti-GQ1b antibodies. She was diagnosed with FS and treated with IVIg, which also led to symptomatic improvement. Conclusions There are no previous reports of familial cases of BBE and FS; therefore, this valuable case may contribute to the elucidation of the relationship between genetic predisposition and the pathogenesis of BBE and FS.
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Affiliation(s)
- Hirokazu Natsui
- Department of Neurology, Kanto Central Hospital, 6-25-1 Kami-Yoga, Setagaya-ku, Tokyo, 158-8531, Japan
| | - Makoto Takahashi
- Department of Neurology, Kanto Central Hospital, 6-25-1 Kami-Yoga, Setagaya-ku, Tokyo, 158-8531, Japan.
| | - Kentaro Nanatsue
- Department of Neurology, Kanto Central Hospital, 6-25-1 Kami-Yoga, Setagaya-ku, Tokyo, 158-8531, Japan
| | - Sakiko Itaya
- Department of Neurology, Kanto Central Hospital, 6-25-1 Kami-Yoga, Setagaya-ku, Tokyo, 158-8531, Japan
| | - Keisuke Abe
- Department of Neurology, Kanto Central Hospital, 6-25-1 Kami-Yoga, Setagaya-ku, Tokyo, 158-8531, Japan
| | - Akira Inaba
- Department of Neurology, Kanto Central Hospital, 6-25-1 Kami-Yoga, Setagaya-ku, Tokyo, 158-8531, Japan
| | - Satoshi Orimo
- Department of Neurology, Kanto Central Hospital, 6-25-1 Kami-Yoga, Setagaya-ku, Tokyo, 158-8531, Japan
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Stubbs LA, Russo SN, Goldberg BR, Kamdar AA. Altered Mental Status, Ataxia, and Ophthalmoplegia in an 8-year-old Girl. Pediatr Rev 2021; 42:S78-S81. [PMID: 33386369 DOI: 10.1542/pir.2019-0161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | - Sam N Russo
- Division of Neurology, Department of Pediatrics
| | - Baruch R Goldberg
- Division of Pulmonary, Allergy, Immunology, and Rheumatology, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Ankur A Kamdar
- Division of Pulmonary, Allergy, Immunology, and Rheumatology, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
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11
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Ding Y, Yu L, Zhou S, Zhang L. Clinical Characteristic Analysis of Seven Children With Bickerstaff Brainstem Encephalitis in China. Front Neurol 2020; 11:557. [PMID: 32655484 PMCID: PMC7325930 DOI: 10.3389/fneur.2020.00557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 05/15/2020] [Indexed: 12/24/2022] Open
Abstract
Objective: To summarize the clinical, electrophysiological, neuroimaging, and immunological characteristics of seven cases of Bickerstaff brainstem encephalitis (BBE) in China and to determine whether certain clinical features suggestive of BBE can facilitate diagnosis and treatment. Patients and Methods: The clinical data of seven BBE patients treated at the Children's Hospital of Fudan University between 2016 and 2019 were retrospectively analyzed. The clinical and laboratory characteristics of the BBE patients were studied. Results: The seven patients in this study included four females and three males, and the median age at diagnosis was 5.3 years (interquartile range: 3.0–7.1 years). All seven patients had an acute onset with a preinfection history. Seven cases of acute extraocular paralysis, ataxia, and an impaired level of consciousness, two cases of tendon hyperreflexia, one case of positive pathology, and five cases of cranial nerve involvement (the facial nerve and oculomotor nerve) were noted. Cerebrospinal fluid (CSF) examination of five patients showed albuminocytologic dissociation. Electromyography (EMG) was used to examine seven patients; the results were normal in four patients, showed axonal involvement in two patients, and showed demyelination in one patient. The head magnetic resonance imaging (MRI) results of all seven patients were normal. Electroencephalogram (EEG) background activity in the five monitored patients was slowed down. Seven patients underwent serum antibody testing, three of whom were positive for anti-GQ1b antibody, while one was positive for anti-GM1 antibody. Three patients received glucocorticoid combined with intravenous immunoglobulin (IVIG) therapy, and four received only IVIG therapy. One patient required a nasal catheter for oxygen during the disease course, and left upper limb muscle dysfunction (grade III muscle strength of the left upper limb) was observed during the 6-month follow-up. The other six patients had a good prognosis and no dysfunction. Conclusion: Our study identified clinical, imaging, and treatment characteristics that may have prognostic value for pediatric BBE. The positive rate of head MRI was low, the positive rate of serum anti-GQ1b ganglioside antibody was low, and the therapeutic effect of IVIG therapy was good.
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Affiliation(s)
- Yifeng Ding
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Lifei Yu
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Shuizhen Zhou
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Linmei Zhang
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
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12
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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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Wong AMC, Yeh CH, Lin JJ, Chou IJ, Lin KL. Rhombencephalitis in Children: Diffusion Magnetic Resonance Imaging (MRI) Correlation With Clinical Outcomes. J Child Neurol 2020; 35:404-409. [PMID: 32124671 DOI: 10.1177/0883073820904480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In children with rhombencephalitis, neuroimaging abnormalities have been infrequently correlated with clinical outcome. We investigated whether magnetic resonance (MR) neuroimaging studies could predict clinical outcomes and disturbance of consciousness in patients with rhombencephalitis. We retrospectively analyzed the MR studies of 19 pediatric patients with rhombencephalitis (median age: 4.2 years, range 0.5-17; sex: 32% male). Fluid-attenuated inversion recovery imaging and diffusion-weighted imaging findings were graded to create imaging scores according to the extent of imaging abnormality. Clinical outcomes in the first week and 12th month were graded by using Glasgow Outcome Scale scores (1-5) and dichotomized to unfavorable or favorable outcome. Correlations of the imaging scores with the clinical outcomes and with disturbance of consciousness were assessed by using multivariate logistic regression analysis. No significant correlation was found between fluid-attenuated inversion recovery score or diffusion-weighted imaging score (P = .608, P = .132, respectively) and disturbance of consciousness. In the first week, the unfavorable outcome group (n = 11) had significantly higher diffusion-weighted imaging score than did the favorable outcome group (n = 8) (Mann-Whitney U test, P = .005). Multivariate logistic regression analysis showed that the diffusion-weighted imaging score (odds ratio, 18.182; 95% confidence interval: 1.36, 243.01; P = .028) was significantly associated with unfavorable outcome. In the 12th month, the fluid-attenuated inversion recovery score or diffusion-weighted imaging score (P = .994, P = .997, respectively) were not significantly associated with unfavorable outcome. Patients with rhombencephalitis who have a higher diffusion-weighted imaging score are more likely to have an unfavorable 1-week clinical outcome.
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Affiliation(s)
- Alex Mun-Ching Wong
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Keelung/Linkou, Chang Gung University, Taiwan
| | - Chih-Hua Yeh
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Keelung/Linkou, Chang Gung University, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - I-Jun Chou
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Children's Hospital, Chang Gung University, Linkou, Taiwan
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Children's Hospital, Chang Gung University, Linkou, Taiwan
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Santoro JD. Long-term Sequelae of Pediatric Bickerstaff Brainstem Encephalitis Includes Autonomic and Sleep Dysregulation. J Child Neurol 2019; 34:153-160. [PMID: 30604651 DOI: 10.1177/0883073818820488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Bickerstaff brainstem encephalitis is a rare, immune-mediated disorder of the brainstem and peripheral nervous system. Published knowledge of pediatric Bickerstaff brainstem encephalitis focuses on the acute phase of the disease process. This study evaluated long-term neurologic and immune sequelae of Bickerstaff brainstem encephalitis in children. A single-center retrospective chart review was performed. Clinical data, neuroimaging, polysomnograms, and serum data were reviewed. Five patients were included in this study. Four patients had no neurologic residua, and 1 patient continued to have mild bulbar dysfunction. There was neither recurrence of symptoms nor development of other neurologic or immunologic disorders at a median of 3 years after diagnosis. Review of systems was largely negative, although 2 patients endorsed symptoms consistent with mild orthostatic hypotension for 1 year after diagnosis, but these findings were not sustained. Four of 5 patients endorsed sleep dysregulation. Three patients met criteria for pediatric obstructive sleep apnea. Prognosis following pediatric Bickerstaff brainstem encephalitis is excellent although posttreatment autonomic and sleep dysregulation may reflect residua from acute phase inflammation in the peripheral nervous system and connections of the reticular activating formation of the brainstem, although this was time limited. Further prospective, multicenter, analysis is warranted.
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Affiliation(s)
- Jonathan D Santoro
- Division of Child Neurology, Department of Neurology, Stanford University, Palo Alto, CA, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Weidauer S, Hofmann C, Wagner M, Hattingen E. Neuroradiological and clinical features in ophthalmoplegia. Neuroradiology 2019; 61:365-387. [PMID: 30747268 DOI: 10.1007/s00234-019-02183-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 02/04/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Especially in acute onset of ophthalmoplegia, efficient neuroradiological evaluation is necessary to assist differential diagnosis, clinical course, and treatment options. METHODS Different manifestations of ophthalmoplegia are explained and illustrated by characteristic neuroradiological and clinical findings. RESULTS To present those ophthalmoplegic disorders in a clear manner, this review refers to different neuroanatomical structures and compartments. From neuroophthalmological point of view, diseases going ahead with ophthalmoplegia can be divided into (1) efferent infranuclear/peripheral disturbances involving oculomotor cranial nerves, (2) conjugate gaze abnormalities due to internuclear or supranuclear lesions, and (3) diseases of the extraocular eye muscles or their impairment due to intraorbital pathologies. CONCLUSION The knowledge of the relationship between neurological findings in ophthalmoplegia and involved neuroanatomical structures is crucial, and neuroradiology can be focused on circumscribed anatomical regions, using optimized investigation protocols.
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Affiliation(s)
- Stefan Weidauer
- Department of Neurology, Sankt Katharinen Hospital, Teaching Hospital of the Goethe University, Seckbacher Landstraße 65, 60389, Frankfurt am Main, Germany.
| | - Christian Hofmann
- Department of Ophthalmology, Neuroophthalmology, Goethe University, Frankfurt am Main, Germany
| | - Marlies Wagner
- Institute of Neuroradiology, Goethe University, Frankfurt am Main, Germany
| | - Elke Hattingen
- Institute of Neuroradiology, Goethe University, Frankfurt am Main, Germany
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Michev A, Musso P, Foiadelli T, Trabatti C, Lozza A, Franciotta D, Simoncelli AM, Savasta S. Bickerstaff Brainstem Encephalitis and overlapping Guillain-Barré syndrome in children: Report of two cases and review of the literature. Eur J Paediatr Neurol 2019; 23:43-52. [PMID: 30502045 DOI: 10.1016/j.ejpn.2018.11.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/09/2018] [Accepted: 11/13/2018] [Indexed: 12/11/2022]
Abstract
Bickerstaff Brainstem Encephalitis (BBE) is a rare autoimmune encephalitis, characterized by acute ophthalmoplegia, ataxia and altered state of consciousness. Together with Guillan-Barrè Syndrome (GBS) and Miller-Fisher Syndrome, it forms a spectrum of post-infectious demyelinating diseases. Overlapping forms between BBE and GBS (BBE/GBS) are described in patients with lower limbs weakness and typical signs of BBE, suggesting a combined involvement of Central and Peripheral Nervous System (PNS), but only few reported cases are focused on pediatric population. We reviewed all cases of pediatric BBE in the literature, to determine if any patient showed features suggestive for BBE/GBS. Data analysis focused on the diagnostic tests performed (e.g. anti-GQ1b antibodies), neuroimaging and nerve conduction studies (NCS). Further attention was given to the therapeutic management and to patients' outcome. We additionally present two previously unreported pediatric cases. Our review retrieved 19 cases of BBE/GBS, only 2 of which were originally and correctly diagnosed by the authors. The prevalence was higher in male subjects (ratio 3:1) and median age at diagnosis was 8 years. Anti-GQ1b were positive in 46% of the patients, while NCS were altered in 64%. Only 25% of the patients that underwent brain MRI showed abnormal findings. The incidence of BBE/GBS has been underrated in the past, mostly due to an underestimation of the PNS involvement. We therefore suggest to investigate all patients with a clinical picture suggestive of BBE/GBS through electroencephalogram, NCS, brain and spine MRI in order to promptly achieve the correct diagnosis.
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Affiliation(s)
- A Michev
- Pediatric Clinic, Foundation IRCCS Policlinico "San Matteo", University of Pavia, Pavia, Italy
| | - P Musso
- Pediatric Clinic, Foundation IRCCS Policlinico "San Matteo", University of Pavia, Pavia, Italy
| | - T Foiadelli
- Pediatric Clinic, Foundation IRCCS Policlinico "San Matteo", University of Pavia, Pavia, Italy; Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Italy.
| | - C Trabatti
- Pediatric Clinic, Foundation IRCCS Policlinico "San Matteo", University of Pavia, Pavia, Italy
| | - A Lozza
- Clinical Neurophysiology Service, IRCCS Mondino Foundation, Pavia, Italy
| | - D Franciotta
- Laboratory of Neuroimmunology, IRCCS Mondino Foundation, Pavia, Italy
| | - A M Simoncelli
- Department of Diagnostic Radiology and Interventional Radiology and Neuroradiology, Foundation IRCCS Policlinico "San Matteo", University of Pavia, Pavia, Italy
| | - S Savasta
- Pediatric Clinic, Foundation IRCCS Policlinico "San Matteo", University of Pavia, Pavia, Italy
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