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Lee SU, Kim HJ, Choi JY, Choi KD, Kim JS. Expanding Clinical Spectrum of Anti-GQ1b Antibody Syndrome: A Review. JAMA Neurol 2024; 81:762-770. [PMID: 38739407 DOI: 10.1001/jamaneurol.2024.1123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
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.
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Affiliation(s)
- Sun-Uk Lee
- Department of Neurology, Korea University Medical Center, Seoul, South Korea
- Neurotology and Neuro-ophthalmology Laboratory, Korea University Anam Hospital, Seoul, South Korea
| | - Hyo-Jung Kim
- Biomedical Research Institute, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jeong-Yoon Choi
- Dizziness Center, Clinical Neuroscience Center, Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea
- Deparment of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Kwang-Dong Choi
- Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Pusan, South Korea
| | - Ji-Soo Kim
- Dizziness Center, Clinical Neuroscience Center, Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea
- Deparment of Neurology, Seoul National University College of Medicine, Seoul, South Korea
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Kim KT, Park E, Lee SU, Kim B, Kim BJ, Kim JS. Clinical Features and Neurotologic Findings in Patients With Acute Unilateral Peripheral Vestibulopathy Associated With Antiganglioside Antibody. Neurology 2023; 101:e1913-e1921. [PMID: 37748887 PMCID: PMC10663017 DOI: 10.1212/wnl.0000000000207814] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/24/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Anecdotal studies have reported the presence of antiganglioside antibodies in acute unilateral peripheral vestibulopathy (AUPV). This study aimed to determine the prevalence, clinical characteristics, and neurotologic findings of AUPV associated with antiganglioside antibodies. METHODS Serum antigangliosides were measured in consecutive patients with AUPV according to the Bárány Society criteria during the acute and recovery phases in a referral-based university hospital in South Korea from September 2019 to January 2023. Clinical characteristics and neurotologic findings were compared between those with and without antiganglioside antibodies. The results of video-oculography, video head impulse and bithermal caloric tests, and other neurotologic evaluations including ocular and cervical vestibular-evoked myogenic potentials and subjective visual vertical were compared between the 2. MRIs dedicated to the inner ear were also conducted when considered necessary. RESULTS One hundred five patients (mean age ± SD = 60 ± 13 years, 57 male) were included for analyses. During the acute phase, 12 patients (12/105, 11%) were tested positive for serum antiganglioside antibodies, including anti-GQ1b immunoglobulin (Ig) G (n = 5) or IgM (n = 4), anti-GM1 IgM (n = 3), and anti-GD1a IgG (n = 1, including 1 patient with a positive anti-GQ1b antibody). Patients with antiganglioside antibodies showed lesser intensity of spontaneous nystagmus (median [interquartile range] = 1.8 [1.2-2.1] vs 3.4 [1.5-9.5], p = 0.003) and a lesser degree of canal paresis (30 [17-47] vs 58 [34-79], p = 0.028) and gain asymmetry of the vestibulo-ocular reflex for the horizontal semicircular canal during head impulse tests (0.07 [-0.04 to 0.61] vs 0.36 [0.18-0.47], p = 0.032) than those without antibodies. Negative conversion of antibodies and vestibular recovery were observed in most patients (6/8, 75%). Among 30 patients with AUPV with 4-hour delayed 3D fluid-attenuated inversion recovery dedicated to the inner ear, gadolinium enhancement was observed in 18 (18/30, 60%), either in the vestibule (n = 9), semicircular canal (n = 6), or vestibular nerve (n = 5). The positivity rates based on specific antibodies could not be determined due to limited sample sizes. DISCUSSION The association between antiganglioside antibodies and AUPV suggests an immune-mediated mechanism in acute vestibular failure and extends the clinical spectrum of antiganglioside antibody syndrome.
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Affiliation(s)
- Keun-Tae Kim
- From the Department of Neurology (K.-T.K., B.-J.K.), Korea University Medical Center; Department of Otorhinolaryngology-Head and Neck Surgery (E.P.), Korea University College of Medicine; Korea University Medical Center (S.-U.L.); Department of Radiology (B.K.), Korea University Anam Hospital; BK21 FOUR Program in Learning Health Systems (B.-J.K.), Korea University; Dizziness Center (J.-S.K.), Clinical Neuroscience Center, Seoul National University Bundang Hospital; and Department of Neurology (J.-S.K.), Seoul National University College of Medicine, South Korea
| | - Euyhyun Park
- From the Department of Neurology (K.-T.K., B.-J.K.), Korea University Medical Center; Department of Otorhinolaryngology-Head and Neck Surgery (E.P.), Korea University College of Medicine; Korea University Medical Center (S.-U.L.); Department of Radiology (B.K.), Korea University Anam Hospital; BK21 FOUR Program in Learning Health Systems (B.-J.K.), Korea University; Dizziness Center (J.-S.K.), Clinical Neuroscience Center, Seoul National University Bundang Hospital; and Department of Neurology (J.-S.K.), Seoul National University College of Medicine, South Korea
| | - Sun-Uk Lee
- From the Department of Neurology (K.-T.K., B.-J.K.), Korea University Medical Center; Department of Otorhinolaryngology-Head and Neck Surgery (E.P.), Korea University College of Medicine; Korea University Medical Center (S.-U.L.); Department of Radiology (B.K.), Korea University Anam Hospital; BK21 FOUR Program in Learning Health Systems (B.-J.K.), Korea University; Dizziness Center (J.-S.K.), Clinical Neuroscience Center, Seoul National University Bundang Hospital; and Department of Neurology (J.-S.K.), Seoul National University College of Medicine, South Korea.
| | - Byungjun Kim
- From the Department of Neurology (K.-T.K., B.-J.K.), Korea University Medical Center; Department of Otorhinolaryngology-Head and Neck Surgery (E.P.), Korea University College of Medicine; Korea University Medical Center (S.-U.L.); Department of Radiology (B.K.), Korea University Anam Hospital; BK21 FOUR Program in Learning Health Systems (B.-J.K.), Korea University; Dizziness Center (J.-S.K.), Clinical Neuroscience Center, Seoul National University Bundang Hospital; and Department of Neurology (J.-S.K.), Seoul National University College of Medicine, South Korea
| | - Byung-Jo Kim
- From the Department of Neurology (K.-T.K., B.-J.K.), Korea University Medical Center; Department of Otorhinolaryngology-Head and Neck Surgery (E.P.), Korea University College of Medicine; Korea University Medical Center (S.-U.L.); Department of Radiology (B.K.), Korea University Anam Hospital; BK21 FOUR Program in Learning Health Systems (B.-J.K.), Korea University; Dizziness Center (J.-S.K.), Clinical Neuroscience Center, Seoul National University Bundang Hospital; and Department of Neurology (J.-S.K.), Seoul National University College of Medicine, South Korea
| | - Ji-Soo Kim
- From the Department of Neurology (K.-T.K., B.-J.K.), Korea University Medical Center; Department of Otorhinolaryngology-Head and Neck Surgery (E.P.), Korea University College of Medicine; Korea University Medical Center (S.-U.L.); Department of Radiology (B.K.), Korea University Anam Hospital; BK21 FOUR Program in Learning Health Systems (B.-J.K.), Korea University; Dizziness Center (J.-S.K.), Clinical Neuroscience Center, Seoul National University Bundang Hospital; and Department of Neurology (J.-S.K.), Seoul National University College of Medicine, South Korea
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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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Lee SU, Kim HJ, Choi JY, Kim JK, Kim JS. Acute vestibular syndrome associated with anti-GQ1b antibody. Neurology 2019; 93:e1085-e1092. [PMID: 31399495 DOI: 10.1212/wnl.0000000000008107] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/18/2019] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Sun-Uk Lee
- From the Department of Neurology (S.-U.K.), Korea University Medical Center, Seoul; Department of Neurology (J.-Y.C., J.-S.K.), Seoul National University College of Medicine; Research Administration Team (H.-J.K.), Dizziness Center (J.-Y.C., J.-S.K.), Clinical Neuroscience Center, and Department of Neurology (J.-Y.C., J.-S.K.), Seoul National University Bundang Hospital, Seongnam; and Department of Neurology (J.K.K.), Dong-A University College of Medicine, Busan, South Korea
| | - Hyo-Jung Kim
- From the Department of Neurology (S.-U.K.), Korea University Medical Center, Seoul; Department of Neurology (J.-Y.C., J.-S.K.), Seoul National University College of Medicine; Research Administration Team (H.-J.K.), Dizziness Center (J.-Y.C., J.-S.K.), Clinical Neuroscience Center, and Department of Neurology (J.-Y.C., J.-S.K.), Seoul National University Bundang Hospital, Seongnam; and Department of Neurology (J.K.K.), Dong-A University College of Medicine, Busan, South Korea
| | - Jeong-Yoon Choi
- From the Department of Neurology (S.-U.K.), Korea University Medical Center, Seoul; Department of Neurology (J.-Y.C., J.-S.K.), Seoul National University College of Medicine; Research Administration Team (H.-J.K.), Dizziness Center (J.-Y.C., J.-S.K.), Clinical Neuroscience Center, and Department of Neurology (J.-Y.C., J.-S.K.), Seoul National University Bundang Hospital, Seongnam; and Department of Neurology (J.K.K.), Dong-A University College of Medicine, Busan, South Korea
| | - Jong Kuk Kim
- From the Department of Neurology (S.-U.K.), Korea University Medical Center, Seoul; Department of Neurology (J.-Y.C., J.-S.K.), Seoul National University College of Medicine; Research Administration Team (H.-J.K.), Dizziness Center (J.-Y.C., J.-S.K.), Clinical Neuroscience Center, and Department of Neurology (J.-Y.C., J.-S.K.), Seoul National University Bundang Hospital, Seongnam; and Department of Neurology (J.K.K.), Dong-A University College of Medicine, Busan, South Korea
| | - Ji-Soo Kim
- From the Department of Neurology (S.-U.K.), Korea University Medical Center, Seoul; Department of Neurology (J.-Y.C., J.-S.K.), Seoul National University College of Medicine; Research Administration Team (H.-J.K.), Dizziness Center (J.-Y.C., J.-S.K.), Clinical Neuroscience Center, and Department of Neurology (J.-Y.C., J.-S.K.), Seoul National University Bundang Hospital, Seongnam; and Department of Neurology (J.K.K.), Dong-A University College of Medicine, Busan, South Korea.
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Pellegrini F, Wang M, Romeo N, Lee AG. Bilateral Sixth Nerve Palsy and Nasal Voice in Two Sisters as a Variant of Guillan–Barré Syndrome. Neuroophthalmology 2018; 42:306-308. [DOI: 10.1080/01658107.2017.1420085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 12/13/2017] [Accepted: 12/18/2017] [Indexed: 10/18/2022] Open
Affiliation(s)
- Francesco Pellegrini
- Neuro-Ophthalmology Service, Department of Ophthalmology, “De Gironcoli” Hospital, Conegliano, TV, Italy
| | - Margaret Wang
- Blanton Eye Institute, Department of Ophthalmology, Houston Methodist Hospital, Houston, Texas, USA
| | - Napoleone Romeo
- Department of Ophthalmology, Livorno Hospital, Livorno, Italy
| | - Andrew G. Lee
- Blanton Eye Institute, Department of Ophthalmology, Houston Methodist Hospital, Houston, Texas, USA
- Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, USA
- Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, New York, USA
- Department of Ophthalmology, The University of Texas Medical Branch, Galveston, Texas, USA
- Ophthalmology Department, Texas A & M College of Medicine, College Station, Texas, USA
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Beh SC, Frohman TC, Frohman EM. Neuro-ophthalmic Manifestations of Cerebellar Disease. Neurol Clin 2014; 32:1009-80. [DOI: 10.1016/j.ncl.2014.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Shin C Beh
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Teresa C Frohman
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Elliot M Frohman
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA; Department of Ophthalmology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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Vermeersch G, Boschi A, Deggouj N, van Pesch V, Sindic C. Recurrent Miller Fisher Syndrome with Vestibular Involvement. Eur Neurol 2011; 66:210-4. [DOI: 10.1159/000331486] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 07/14/2011] [Indexed: 11/19/2022]
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Abstract
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.
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Affiliation(s)
- Y L Lo
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Outram Road, 169608 Singapore.
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Rosengren SM, McAngus Todd NP, Colebatch JG. Vestibular-evoked extraocular potentials produced by stimulation with bone-conducted sound. Clin Neurophysiol 2005; 116:1938-48. [PMID: 15979939 DOI: 10.1016/j.clinph.2005.03.019] [Citation(s) in RCA: 283] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2004] [Revised: 02/24/2005] [Accepted: 03/25/2005] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To investigate the origin, whether ocular or extraocular, of the short latency frontal potential (N15) reported by following vestibular stimulation. METHODS Fourteen subjects with low VEMP thresholds (V(T)) and 9 patients with vestibular or ocular disorders were stimulated at the mastoid with bone-conducted tone bursts (500 Hz, 8 ms) above vestibular threshold, using a B71 bone vibrator. Surface potentials were recorded from Fpz and around the eyes and referred to linked earlobes. RESULTS The N15 was present at Fpz, but was largest around the eyes (mean amplitude 2.6 microV, peak latency 13.4 ms, with stimulation at +18 dB above threshold) and was generally in phase above and below the eyes. The response was vestibular-dependent and modulated by alteration of gaze direction. The potentials were delayed in a patient with Miller Fisher syndrome and were larger in patients with superior canal dehiscence than in controls. CONCLUSIONS We report a new vestibular-evoked extraocular potential. Its properties are not consistent with an eye movement. It is likely to be produced, mainly or exclusively, by synchronous activity in extraocular muscles (i.e. a myogenic potential). SIGNIFICANCE Vestibular-evoked extraocular potentials extend the range of vestibular pathways that can be assessed electrophysiologically, and may be a useful additional test of vestibular function.
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Affiliation(s)
- S M Rosengren
- Institute of Neurological Sciences and UNSW Clinical School, Prince of Wales Hospital Randwick, Sydney, NSW 2031, Australia
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