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Li KC, Liao MF, Wu YR, Lyu RK. Isaacs' syndrome as the initial presentation of malignant thymoma and associated with double-positive voltage-gated potassium channel complex antibodies, a case report. BMC Neurol 2022; 22:74. [PMID: 35246046 PMCID: PMC8895773 DOI: 10.1186/s12883-022-02584-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 02/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Isaacs' syndrome is a peripheral nerve hyperexcitability (PNH) syndrome due to peripheral motor nerve instability. Acquired Isaacs' syndrome is recognized as a paraneoplastic autoimmune disease with possible pathogenic voltage-gated potassium channel (VGKC) complex antibodies. However, the longitudinal correlation between clinical symptoms, VGKC antibodies level, and drug response is still unclear. CASE PRESENTATION A 45-year-old man had progressive four limbs soreness, muscle twitching, cramps, and pain 4 months before admission. Electromyography (EMG) studies showed myokymic discharges, neuromyotonia, and an incremental response in the high-rate (50 Hz) repetitive nerve stimulation (RNS) test. Isaacs' syndrome was diagnosed based on clinical presentations and EMG reports. Serum studies showed positive VGKC complex antibodies, including leucine-rich glioma-inactivated 1 (LGI1) and contactin-associated protein-like 2 (CASPR2) antibodies. The acetylcholine receptor antibody was negative. Whole-body computed tomography (CT) and positron emission tomography revealed a mediastinal tumor with the great vessels encasement, right pleura, and diaphragm seeding. Biopsy confirmed a World Health Organization type B2 thymoma, with Masaoka stage IVa. His symptoms gradually improved and both LGI1 and CASPR2 antibodies titer became undetectable after concurrent chemoradiotherapy (CCRT) and high dose steroid treatment. However, his Isaacs' syndrome recurred after the steroid was reduced 5 months later. Follow-up chest CT showed probable thymoma progression. LGI1 antibody turned positive again while CASPR2 antibody remained undetectable. CONCLUSIONS Our patient demonstrates that Isaacs' syndrome could be the initial and only neuromuscular manifestation of malignant thymoma. His Isaacs' syndrome is correlated well with the LGI1 antibody level. With an unresectable thymoma, long-term immunosuppressant therapy may be necessary for the management of Isaacs' syndrome in addition to CCRT for thymoma.
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Affiliation(s)
- Kuan-Ching Li
- Department of Neurology, Chang Gung Memorial Hospital Linkou Medical Center and Chang Gung University College of Medicine, No.5, Fusing St., Gueishan Township, Taoyuan County, Taiwan
| | - Ming-Feng Liao
- Department of Neurology, Chang Gung Memorial Hospital Linkou Medical Center and Chang Gung University College of Medicine, No.5, Fusing St., Gueishan Township, Taoyuan County, Taiwan
| | - Yih-Ru Wu
- Department of Neurology, Chang Gung Memorial Hospital Linkou Medical Center and Chang Gung University College of Medicine, No.5, Fusing St., Gueishan Township, Taoyuan County, Taiwan
| | - Rong-Kuo Lyu
- Department of Neurology, Chang Gung Memorial Hospital Linkou Medical Center and Chang Gung University College of Medicine, No.5, Fusing St., Gueishan Township, Taoyuan County, Taiwan.
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2
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Zhao J, Bhatnagar V, Ding L, Atay SM, David EA, McFadden PM, Stamnes S, Lechtholz-Zey E, Wightman SC, Detterbeck FC, Kim AW. A systematic review of paraneoplastic syndromes associated with thymoma: Treatment modalities, recurrence, and outcomes in resected cases. J Thorac Cardiovasc Surg 2019; 160:306-314.e14. [PMID: 31982129 DOI: 10.1016/j.jtcvs.2019.11.052] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 11/05/2019] [Accepted: 11/06/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Paraneoplastic syndromes associated with thymomas remain incompletely understood. The objective was to examine the association between surgically resected thymomas and paraneoplastic syndromes over the past half century. METHODS A primary PubMed/MEDLINE search was used to identify published articles describing paraneoplastic syndromes associated with thymomas from 1960 to 2019. A secondary search identified additional articles referenced in the articles found in the primary search. Kaplan-Meier and log-rank test were used for time-to-event data analyses. RESULTS From 407 articles describing 507 patients, 123 different paraneoplastic syndromes were associated with thymoma. The 5 most common paraneoplastic syndromes were myasthenia gravis, pure red cell aplasia, lichen planus, Good syndrome, and limbic encephalitis. Complete or partial resolution of paraneoplastic syndrome symptoms after surgery was noted in 76% of patients, of whom 21% had a relapse or new paraneoplastic syndrome onset after surgery. The most common adjunctive therapy associated with resolution of paraneoplastic syndrome was corticosteroids (30%). For all patients after surgery, thymoma recurrence was observed in 17% of cases, whereas recurrence of paraneoplastic syndrome was observed in 34% of cases, and both were observed in approximately 11% of cases. The 5- and 10-year overall survivals were 78% and 66%, respectively. Improved overall survival was associated with patients who had total resolution from paraneoplastic syndrome. CONCLUSIONS A comprehensive assessment of publications over the past half century suggests that a multimodal treatment approach that includes surgical resection of thymomas is able to achieve paraneoplastic syndrome resolution in a majority of patients. Onset of new paraneoplastic syndromes after surgery is associated with the recurrence of the first paraneoplastic syndrome, and resolution of paraneoplastic syndrome is associated with improved overall survival.
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Affiliation(s)
- Jasmine Zhao
- Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Vikrant Bhatnagar
- Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio
| | - Li Ding
- Division of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Scott M Atay
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Elizabeth A David
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - P Michael McFadden
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Stephanie Stamnes
- Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | | | - Sean C Wightman
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | | | - Anthony W Kim
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif.
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Hashimoto S, Hayasaka K, Suzuki K, Endoh M, Yanagawa N, Shiono S. Thymic Small Cell Carcinoma Associated With Lambert-Eaton Myasthenic Syndrome. Ann Thorac Surg 2019; 109:e347-e348. [PMID: 31586614 DOI: 10.1016/j.athoracsur.2019.08.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 08/12/2019] [Accepted: 08/18/2019] [Indexed: 11/16/2022]
Abstract
Thymic small cell cancer is a very rare type of thymic epithelial tumor. Lambert-Eaton myasthenic syndrome is a rare paraneoplastic syndrome associated with thymic epithelial tumors. We report an extremely rare case of Lambert-Eaton myasthenic syndrome associated with thymic small cell carcinoma. A 71-year-old man was referred to our institution for a mediastinal tumor and a 2-month history of ptosis, fatigue, and gait disorder. Based on radiologic findings thymoma associated with Lambert-Eaton myasthenic syndrome was diagnosed, and extended thymectomy was performed. After surgery the patient's symptoms had not improved. Anticholinesterase treatment alleviated his symptoms.
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Affiliation(s)
- Saeko Hashimoto
- Department of Thoracic Surgery, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Kazuki Hayasaka
- Department of Thoracic Surgery, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Katsuyuki Suzuki
- Department of Thoracic Surgery, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Makoto Endoh
- Department of Thoracic Surgery, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Naoki Yanagawa
- Department of Pathology, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Satoshi Shiono
- Department of Thoracic Surgery, Yamagata Prefectural Central Hospital, Yamagata, Japan.
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4
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Sanadze AG, Sidnev DV, Tumurov DA. [Seronegative nonparaneoplastic Lambert-Eaton myasthenic syndrome]. Zh Nevrol Psikhiatr Im S S Korsakova 2017. [PMID: 28638036 DOI: 10.17116/jnevro20171175177-80] [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: 11/17/2022]
Abstract
The authors studied two patients with Lambert-Eaton myasthenic syndrome (LEMS) in whom the repeated examination did not find specific of LEMS P/Q type voltage-gates calcium channel autoantibodies. The results of clinical testing and electrophysiological examination showed the typical character of movement disorders with the absence of tendon reflexes and signs of disautonomia as well as a decrease in M-response amplitude and phenomena of decrement with low frequency- and increment with high frequency stimulation. Both patients revealed no signs of paraneoplastic process. Autoimmune character of the damage was confirmed by the effectiveness of treatment with glucocorticoid hormones.
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Affiliation(s)
- A G Sanadze
- Pirogov Russian National Medical Research University, Moscow, Russia; Moscow City Health Department, Moscow Myasthenia Center, SFHI Municipal Clinical Hospital #51, Moscow, Russia; Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - D V Sidnev
- Pirogov Russian National Medical Research University, Moscow, Russia; Moscow City Health Department, Moscow Myasthenia Center, SFHI Municipal Clinical Hospital #51, Moscow, Russia
| | - D A Tumurov
- Moscow City Health Department, Moscow Myasthenia Center, SFHI Municipal Clinical Hospital #51, Moscow, Russia; Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russia
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Review of the Diagnostic Challenges of Lambert–Eaton Syndrome Revealed Through Three Case Reports. Can J Neurol Sci 2016; 43:635-47. [DOI: 10.1017/cjn.2016.268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AbstractLambert–Eaton syndrome (LES) is a rare immune-mediated disorder characterized by proximal leg weakness, autonomic symptoms and hypoactive tendon reflexes. The paraneoplastic form is associated with small-cell lung cancer in 50-60% of cases, whereas the remaining cases are found in younger adults with a higher likelihood of coexisting autoimmune disease. The early recognition of LES is crucial for improving clinical outcomes but remains a major challenge. In this review, we analyze the clinical characteristics and diagnostic considerations in treating LES through a series of three case studies, one of which showed definitive response to pyridostigmine and corticosteroid combination therapy, followed by spontaneous remission. Patients were assessed by image-based screening, serological testing and electrophysiological evaluations, which included respiratory and autonomic testing. A better understanding of the common pitfalls in the clinical, serological and neurophysiologic diagnosis of LES through assessment of typical LES dysfunction throughout the nervous system should enable improved recognition and treatment of this syndrome.
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Abstract
INTRODUCTION To assess whether a myasthenia gravis (MG) Lambert-Eaton overlap syndrome (MLOS) exists. METHODS Case reports that met the universally accepted diagnostic criteria for MG and Lambert-Eaton myasthenic syndrome (LEMS) were sought through a PubMed search. Fifty-five possible cases of MLOS were identified. RESULTS Thirty-nine cases met the diagnostic criteria for MG and LEMS. Analysis of clinical features showed that these patients have common MG and LEMS symptoms: oculo-bulbar paresis and good response to anti-cholinesterase for MG and limb weakness and decreased or absent reflexes for LEMS. All had the classical LEMS pattern in the repetitive nerve stimulation test: low compound muscle action potential amplitude and incremental response > 60% with brief exercise or at high rate of stimulation. Eight patients had combined positive acetylcholine receptor antibody (AChR-ab) or muscle-specific kinase-ab and voltage-gated calcium channel- ab tests. CONCLUSIONS A myasthenia gravis Lambert-Eaton overlap syndrome (MLOS) does exist.
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Affiliation(s)
- Shin J Oh
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
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Nalbantoglu M, Kose L, Uzun N, Gunduz A, Hallac M, Kiziltan ME, Akalin MA. Lambert-Eaton myasthenic syndrome associated with thymic neuroendocrine carcinoma. Muscle Nerve 2015; 51:936-8. [DOI: 10.1002/mus.24610] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 02/07/2015] [Accepted: 02/10/2015] [Indexed: 12/27/2022]
Affiliation(s)
- Mecbure Nalbantoglu
- Department of Neurology; Istanbul University, Cerrahpasa School of Medicine; Istanbul Turkey
| | - Leyla Kose
- Department of Neurology; Istanbul University, Cerrahpasa School of Medicine; Istanbul Turkey
| | - Nurten Uzun
- Department of Neurology; Istanbul University, Cerrahpasa School of Medicine; Istanbul Turkey
| | - Aysegul Gunduz
- Department of Neurology; Istanbul University, Cerrahpasa School of Medicine; Istanbul Turkey
| | - Metin Hallac
- Department of Nuclear Medicine Istanbul University; Cerrahpasa School of Medicine; Istanbul Turkey
| | - Meral Erdemir Kiziltan
- Department of Neurology; Istanbul University, Cerrahpasa School of Medicine; Istanbul Turkey
| | - Mehmet Ali Akalin
- Department of Neurology; Istanbul University, Cerrahpasa School of Medicine; Istanbul Turkey
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Lambert–Eaton myasthenic syndrome – Diagnosis, pathogenesis and therapy. Clin Neurophysiol 2014; 125:2328-36. [DOI: 10.1016/j.clinph.2014.06.031] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 06/05/2014] [Accepted: 06/26/2014] [Indexed: 02/07/2023]
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Briggs SE, Gozzard P, Talbot DC. The association between Lambert-Eaton myasthenic syndrome and small cell lung carcinoma. Immunotargets Ther 2013; 2:31-7. [PMID: 27471686 PMCID: PMC4928366 DOI: 10.2147/itt.s31971] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune disorder mediated by autoantibodies to voltage-gated calcium channels. The disorder is diagnosed clinically on the basis of a triad of symptoms (proximal muscle weakness, hyporeflexia, and autonomic disturbance), supported by electrophysiological findings and the presence of autoantibodies. Between 40% and 62% of patients diagnosed with LEMS are found to have small-cell lung cancer (SCLC), almost all of whom develop neurological symptoms before their cancer is diagnosed. Prompt identification of LEMS and appropriate screening for SCLC is key to improving the outcome of both conditions. Here we review the pathophysiology and clinical management of LEMS, focusing particularly on the relationship with SCLC.
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Affiliation(s)
- Sarah Ew Briggs
- Department of Oncology, Oxford University Hospitals Trust, Churchill Hospital, Oxford, UK
| | - Paul Gozzard
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford UK
| | - Denis C Talbot
- Department of Oncology, Oxford University Hospitals Trust, Churchill Hospital, Oxford, UK
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Ansakorpi H, Rusanen H, Rytky S, Färkkilä M. Lambert-Eaton myasthenic syndrome following H1N1-influenza vaccination: a case report. Acta Neurol Scand 2012; 126:e25-8. [PMID: 22571392 DOI: 10.1111/j.1600-0404.2012.01675.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND The outbreak of influenza A (H1N1) pandemic during the year 2009 led to the development of several vaccinations against H1N1 virus. In Finland, 2.6 million citizens were vaccinated during pandemic 2009 - 2010 with adjuvanted influenza vaccine, Pandemrix(®) . CLINICAL PRESENTATION In this case report, we describe a patient with non-paraneoplastic Lambert-Eaton myasthenic syndrome following Pandemrix(®) vaccination. CONCLUSION Development of various autoimmune diseases in genetically predisposed subjects following exposure to certain environmental factors, including vaccinations, is a well-known entity. Clinicians should be aware of the possibility of the induction of autoimmune diseases following vaccinations and actively ask the relevant clinical history in a newly diagnosed patient with an autoimmune disorder.
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Affiliation(s)
- Hanna Ansakorpi
- Department of Neurology; Oulu University Hospital; Oulu; Finland
| | - Harri Rusanen
- Department of Neurology; Oulu University Hospital; Oulu; Finland
| | - Seppo Rytky
- Department of Clinical Neurophysiology; Oulu University Hospital; Oulu; Finland
| | - Markus Färkkilä
- Department of Neurology; Helsinki University Hospital; Helsinki; Finland
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Titulaer MJ, Lang B, Verschuuren JJ. Lambert-Eaton myasthenic syndrome: from clinical characteristics to therapeutic strategies. Lancet Neurol 2012; 10:1098-107. [PMID: 22094130 DOI: 10.1016/s1474-4422(11)70245-9] [Citation(s) in RCA: 190] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Lambert-Eaton myasthenic syndrome (LEMS) is a neuromuscular autoimmune disease that has served as a model for autoimmunity and tumour immunology. In LEMS, the characteristic muscle weakness is thought to be caused by pathogenic autoantibodies directed against voltage-gated calcium channels (VGCC) present on the presynaptic nerve terminal. Half of patients with LEMS have an associated tumour, small-cell lung carcinoma (SCLC), which also expresses functional VGCC. Knowledge of this association led to the discovery of a wide range of paraneoplastic and non-tumour-related neurological disorders of the peripheral and central nervous systems. Detailed clinical studies have improved our diagnostic skills and knowledge of the pathophysiological mechanisms and association of LEMS with SCLC, and have helped with the development of a protocol for early tumour detection.
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