[Late recurrence of Miller-Fischer syndrome. Physiopathogenic reflections about a case]

Anti-glutamic acid decarboxylase antibody positive neurological syndromes

A rare kind of antibody, known as anti-glutamic acid decarboxylase (GAD) autoantibody, is found in some patients. The antibody works against the GAD enzyme, which is essential in the formation of gamma aminobutyric acid (GABA), an inhibitory neurotransmitter found in the brain. Patients found with this antibody present with motor and cognitive problems due to low levels or lack of GABA, because in the absence or low levels of GABA patients exhibit motor and cognitive symptoms. The anti-GAD antibody is found in some neurological syndromes, including stiff-person syndrome, paraneoplastic stiff-person syndrome, Miller Fisher syndrome (MFS), limbic encephalopathy, cerebellar ataxia, eye movement disorders, and epilepsy. Previously, excluding MFS, these conditions were calledhyperexcitability disorders. However, collectively, these syndromes should be known as "anti-GAD positive neurological syndromes." An important limitation of this study is that the literature is lacking on the subject, and why patients with the above mentioned neurological problems present with different symptoms has not been studied in detail. Therefore, it is recommended that more research is conducted on this subject to obtain a better and deeper understanding of these anti-GAD antibody induced neurological syndromes.

Recurrent Miller Fisher syndrome: clinical and laboratory features

To present two patients with Miller Fisher syndrome (MFS) recurrence after 35 and 44 years and review of the literature on recurring MFS. All identified cases with recurrent MFS were evaluated. Age, gender, clinical features of first and recurrent MFS, course of disease, laboratory findings, therapy and outcome were transformed into tables. Twenty-eight patients (16 men, 12 women; mean age at the first episode 34 years (range 13-57 years); mean age at the latest episode 47 years (range 21-66 years) with a total of 70 MFS episodes were identified. Twenty-one patients had a single recurrence, five patients had two recurrences, one patient had four recurrences and one patient had seven recurrences. The mean interval between attacks was 9.45 years (3 months to 44 years). In 76% of the initial episodes and in 81% of the recurrent episodes, an infectious disease preceded MFS. Additional facial and bulbar symptoms and autonomic disturbances were frequent findings. Cerebrospinal fluid (CSF) and electrodiagnostic findings were unspecific. If tested, autoantibodies against GQ1b had been positive in all episodes. In about half of the patients, immunotherapy was applied. The outcome was favourable in most patients. Recurrence of MFS is a rare quite uniform condition with a mostly favourable prognosis.

Syndrome de Miller-Fisher récidivant

INTRODUCTION

Miller-Fisher syndrome (MFS) is a rare auto-immune post-infectious syndrome, characterized by an ataxia, an ophthalmoplegia and a generalized areflexia. It is considered as a clinical variant of Guillain-Barré syndrome (GBS). MFS is correlated with the presence of anti-GQ1b antibodies, elevated cerebrospinal fluid (CSF) protein levels, presence of mostly sensitive electrophysiological abnormalities and for some authors central involvement with increased signal intensity of brainstem and cerebellum on MRI. Recurrent MFS is extremely rare with only 21 cases since the first description in 1970.

CASE REPORT

A 54-year-old women presented MFS with two episodes in 19 years. Clinically, the first episode was a "classical" MFS, and the second an extensive MFS with tetraparesis and respiratory failure. CSF protein levels and cerebral MRI were normal. Anti-GQ1b antibodies were strongly positive and anti-GM1, anti-GM2 antibodies were slightly positive, campylobacter jejuni serology was negative. Electromyography showed isolated sensory abnormalities in median nerves territory.

CONCLUSION

We report a new case of recurrent MFS with unusual clinical, biological and electrophysiological features.

[Recurrent Miller Fisher syndrome and anti-GQ1b antibodies]

INTRODUCTION

Miller-Fisher syndrome is defined by the triad: ophthalmoplegia, ataxia and areflexia. This rare entity is generally regarded as a variant of the Guillain-Barré syndrome, although neurophysiological patterns differ. In the acute phase of the disease, sera of affected patients contain high titers of antiganglioside anti-GQ1b, which is a specific marker. Recurrences are exceptional.

EXEGESE

We report the case of a man with three recurrences of Miller-Fisher syndrome within 16 years. Anti-GQ1b antibody titers were elevated during an episode, decreasing but not completely and vanishing 2 years later. Intravenous human immunoglobulin treatment probably accelerated improvement at the two last episodes.

CONCLUSIONS

Some experimental and immunohistochemical data from the literature argue for a probable direct pathogenic role of antibodies against GQ1b ganglioside in this syndrome. This should be a rationale for the use of immunomodulating treatments.