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Non-invasive evaluation of sudomotor function in patients with myasthenia gravis. Neurophysiol Clin 2019; 49:81-86. [DOI: 10.1016/j.neucli.2018.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 12/04/2018] [Accepted: 12/04/2018] [Indexed: 11/19/2022] Open
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Kocabas ZU, Kizilay F, Basarici I, Uysal H. Evaluation of cardiac autonomic functions in myasthenia gravis. Neurol Res 2018; 40:405-412. [PMID: 29607742 DOI: 10.1080/01616412.2018.1446690] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE We aimed to comprehensively evaluate cardiac autonomic function in patients with MG and to investigate the relationship between this disorder and disease duration, thymoma and acetylcholine receptor antibody positivity in cases of cardiac autonomic disorder. METHODS The study included 30 patients with MG and 30 age-matched healthy control subjects. Haemodynamic parameters (heart rate, systolic and diastolic blood pressure) and autonomic parameters (low frequency [LF], high-frequency [HF], sympathovagal balance [LF/HF], baroreceptor reflex sensitivity [BRS]) of the patients were automatically measured at rest and in a tilted position with the Task Force Monitor. RESULTS The mean systolic and diastolic blood pressure measurements obtained at rest and during the tilt test were higher in patients with MG. Sympathovagal balance has been disturbed in favour of sympathetic tone, and parasympathetic insufficiency has become more prominent. When baroreceptor sensitivity was used as the second parameter to evaluate autonomic heart functions, BRS at rest and during the tilt test was lower in the MG group compared with the control group. DISCUSSION These results suggest that sympathovagal balance has been disturbed in favour of sympathetic tone and that parasympathetic insufficiency has become more prominent. The current findings support the presence of cardiac autonomic involvement in patients with MG. The determination of cardiac autonomic function via noninvasive methods among patients with MG has high predictive value. The identification of autonomic dysfunction at an early stage and the early treatment of cardiovascular diseases can reduce morbidity and mortality.
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Affiliation(s)
- Zehra Uysal Kocabas
- a Department of Anesthesiology , Osmangazi University, Medical School Hospital , Eskisehir , Turkey
| | - Ferah Kizilay
- b Department of Neurology , Akdeniz University, Medical School Hospital , Antalya , Turkey
| | - Ibrahim Basarici
- c Department of Cardiology , Akdeniz University, Medical School Hospital , Antalya , Turkey
| | - Hilmi Uysal
- b Department of Neurology , Akdeniz University, Medical School Hospital , Antalya , Turkey
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Arai H, Inui K, Hashimoto K, Kan-O K, Nishii T, Kishida H, Okudela K, Tsuboi M, Nozawa A, Kaneko T, Masuda M. Lung adenocarcinoma with Lambert-Eaton myasthenic syndrome indicated by voltage-gated calcium channel: a case report. J Med Case Rep 2012; 6:281. [PMID: 22950670 PMCID: PMC3537700 DOI: 10.1186/1752-1947-6-281] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Accepted: 06/26/2012] [Indexed: 12/01/2022] Open
Abstract
Introduction Lambert–Eaton myasthenic syndrome is a rare disorder and it is known as a paraneoplastic neurological syndrome. Small cell lung cancer often accompanies this syndrome. Lambert–Eaton myasthenic syndrome associated with lung adenocarcinoma is extremely rare; there are only a few reported cases worldwide. Case presentation A 75-year-old Japanese man with a past history of chronic rheumatoid arthritis and Sjögren syndrome was diagnosed with Lambert–Eaton myasthenic syndrome by electromyography and serum anti-P/Q-type voltage-gated calcium channel antibody level preceding the diagnosis of lung cancer. A chest computed tomography to screen for malignant lesions revealed an abnormal shadow in the lung. Although a histopathological examination by bronchoscopic study could not reveal the malignancy, lung cancer was mostly suspected after the results of a chest computed tomography and [18F]-fluorodeoxyglucose positron emission tomography. An intraoperative diagnosis based on the frozen section obtained by tumor biopsy was adenocarcinoma so the patient underwent a lobectomy of the right lower lobe and lymph node dissection with video-assisted thoracoscopic surgery. The permanent pathological examination was the same as the frozen diagnosis (pT2aN1M0: Stage IIa: TNM staging 7th edition). Immunohistochemistry revealed that most of the cancer cells were positive for P/Q-type voltage-gated calcium channel. Conclusions Our case is a rare combination of Lambert–Eaton myasthenic syndrome associated with lung adenocarcinoma, rheumatoid arthritis and Sjögren syndrome, and to the best of our knowledge it is the first report that indicates the presence of voltage-gated calcium channel in lung adenocarcinoma by immunostaining.
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Affiliation(s)
- Hiromasa Arai
- Respiratory Disease Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan.
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Sadeghian H, Vernino S. Progress in the management of paraneoplastic neurological disorders. Ther Adv Neurol Disord 2011; 3:43-52. [PMID: 21180635 DOI: 10.1177/1756285609349521] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Paraneoplastic neurological disorders (PNDs) are a rare and diverse group of neurological conditions that can involve any part of the nervous system. Diagnosis is facilitated by finding well-recognized autoantibodies directed against neural antigens in the sera and the cerebrospinal fluid. Identifying and eliminating the underlying malignancy is the mainstay of treatment. Immunomodulatory treatment is gaining more acceptance especially, where a malignancy could not be identified, oncology treatment is completed, or along with cancer treatment. Literature review shows only a handful of systematic prospective case series. Multicenter, prospective controlled clinical trials are needed for future therapeutic advances.
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Affiliation(s)
- Hamid Sadeghian
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Abstract
Lambert Eaton myasthenic syndrome (LEMS) is a rare neuromuscular junction disease. Often, the signs and symptoms of LEMS are mistaken for myasthenia gravis and therefore the workup is misdirected. A physician must look for an occult malignancy when the diagnosis is made and then continue to search for a malignancy for at least 5 years after diagnosis. The diagnosis of LEMS can be confirmed with electrophysiologic studies or with serum calcium channel antibodies. In most patients with LEMS, 3,4-diaminopyridine will improve strength. In patients without malignancy, immunosuppressants do have a role in the treatment of LEMS. Patients and physicians must be aware that certain situations and drugs may exacerbate weakness.
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Affiliation(s)
- Maria B Weimer
- Maria B. Weimer, MD Louisiana State University Health Sciences Center, Department of Neurology, 200 Henry Clay Suite 3314, New Orleans, LA 70118, USA.
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Liu GT, Volpe NJ, Galetta SL. Eyelid and facial nerve disorders. Neuroophthalmology 2010. [DOI: 10.1016/b978-1-4160-2311-1.00014-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Mössner R, Tings T, Beckmann I, Neumann C, Paulus W, Reich K. A close look at autoimmune muscle disorders: association of Lambert–Eaton myasthenic syndrome with dermatomyositis. Scand J Rheumatol 2009; 33:271-5. [PMID: 15370725 DOI: 10.1080/03009740410005476] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Dermatomyositis/polymyositis (DM/PM) and Lambert-Eaton myasthenic syndrome (LEMS) are two autoimmune disorders that have very rarely been reported to occur together in the same patient. We report on two patients with DM who were later diagnosed with concomitant LEMS, and point out diagnostic challenges in identifying LEMS in patients with DM/PM. As specific treatment for LEMS is available, it is important to identify those DM/PM patients who suffer from concomitant LEMS.
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Vernino S. PARANEOPLASTIC DISORDERS AFFECTING THE NEUROMUSCULAR JUNCTION OR ANTERIOR HORN CELL. Continuum (Minneap Minn) 2009. [DOI: 10.1212/01.con.0000300011.79845.eb] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
Thirty years ago, antibodies against the muscle acetylcholine receptor (AChR) were recognized as the cause of myasthenia gravis. Since then, there has been great interest in identifying other neurological disorders associated with autoantibodies. Several other antibody-mediated neuromuscular disorders have been identified, each associated with an antibody against a ligand- or voltage-gated ion channel. The Lambert-Eaton syndrome is caused by antibodies against voltage-gated calcium channels and often occurs in patients with small cell lung cancer. Acquired neuromyotonia is caused by voltage-gated potassium channel antibodies, and autoimmune autonomic ganglionopathy is caused by antibodies against the neuronal AChR in autonomic ganglia. There is good evidence that antibodies in these disorders cause changes in synaptic function or neuronal excitability by directly inhibiting ion channel function. More recently, studies have identified ion channel antibodies in patients with certain CNS disorders, such as steroid-responsive encephalitis and paraneoplastic cerebellar ataxia. It remains unclear if antibodies can gain access to the CNS and directly cause ion channel dysfunction. Treatment of autoimmune channelopathies includes drugs that help restore normal neuronal function and treatments to remove pathogenic antibodies (plasma exchange) or modulate the immune response (steroids or immunosuppressants). These disabling neurological disorders may be dramatically responsive to immunomodulatory therapy. Future studies will likely lead to identification of other ion channel antibodies and other autoimmune channelopathies.
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Affiliation(s)
- Steven Vernino
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9036, USA.
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Lin JT, Lachmann E. Lambert-eaton myasthenic syndrome: a case report and review of the literature. J Womens Health (Larchmt) 2002; 11:849-55. [PMID: 12626085 DOI: 10.1089/154099902762203696] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Lambert-Eaton myasthenic syndrome (LEMS) is a type of paraneoplastic syndrome that may initially manifest with weakness and gait abnormalities. These symptoms may precede the diagnosis of malignancy by months or years, and morbidity and mortality may be significantly affected by early detection of the malignancy. A case report and review of the diagnosis, management, and treatment of these syndromes are presented, with particular emphasis on the rehabilitation management of these patients, often overlooked in medical treatment.
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Affiliation(s)
- Julie T Lin
- Physiatry Service, Hospital for Special Surgery, and Department of Rehabilitation Medicine, The New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York 10021, USA.
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Abstract
The autoantibodies that impair neuromuscular junction transmission in myasthenia gravis are specific for the nicotinic acetylcholine receptor (AChR) of muscle. Antibodies specific for AChRs in ganglionic neurons are found in a majority of patients with subacute autonomic neuropathy. Dysautonomia is not a recognized feature of myasthenia gravis, but there have been rare reports of myasthenia gravis coexisting with autonomic failure, usually in association with thymoma. Here we report seven patients who had myasthenia gravis with subacute autonomic failure. Their autonomic dysfunction ranged from isolated gastroparesis to severe panautonomic failure. Gastrointestinal dysmotility was a common feature. All had antibodies against muscle AChR, and three (all of whom had thymoma) had antibodies against neuronal ganglionic AChRs. In several patients, gastrointestinal function improved clinically after administration of an acetylcholinesterase inhibitor. These observations support a rare but definite clinical association between myasthenia gravis and autonomic failure and strengthen the concept that subacute autonomic neuropathy is an autoimmune disorder.
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Affiliation(s)
- S Vernino
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
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Correia-de-Sá P, Timóteo MA, Ribeiro JA. Influence of stimulation on Ca(2+) recruitment triggering [3H]acetylcholine release from the rat motor-nerve endings. Eur J Pharmacol 2000; 406:355-62. [PMID: 11040342 DOI: 10.1016/s0014-2999(00)00686-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The influence of rat phrenic nerve stimulation frequency (5-50 Hz) and of pulse duration (0.04-1 ms) on Ca(2+) mobilization triggering [3H]acetylcholine release was investigated. The P-type voltage-dependent Ca(2+) channel (VDCC) blocker, omega-agatoxin IVA (100 nM), decreased [3H]acetylcholine release evoked by pulses of 0. 04-ms duration delivered at 5 Hz frequency. When the stimulus pulse duration was increased to 1 ms (5 Hz frequency) or the stimulation frequency to 50 Hz (0.04-ms duration), inhibition of [3H]acetylcholine release became evident after blockade of L-type VDCC, with nifedipine (1 microM), and/or depletion of thapsigargin-sensitive internal stores. The inhibitory effect of thapsigargin (2 microM) was still observed in Ca(2+)-free medium. Neither omega-conotoxin GVIA (1 microM) nor omega-conotoxin MVIIC (150 nM) modified neurotransmitter release. The results suggest that, depending on the stimulus paradigm, both internal (thapsigargin-sensitive) and external (either P- or L-type channels) Ca(2+) pools can be mobilized to promote acetylcholine release from motor nerve terminals.
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Affiliation(s)
- P Correia-de-Sá
- Laboratório de Farmacologia, Instituto de Ciências Biomédicas de Abel Salazar (ICBAS) - Universidade do Porto, L. Prof. Abel Salazar, 2, 4099-003, Porto, Portugal.
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McLaughlin SA, Buchsbaum MS. Clinicopathological conference: weakness in the knees. Acad Emerg Med 2000; 7:919-24. [PMID: 10958134 DOI: 10.1111/j.1553-2712.2000.tb02072.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- S A McLaughlin
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque 87131-5246, USA.
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Affiliation(s)
- R Weinstein
- Department of Medicine, Division of Hematology/Oncology and Transfusion Medicine, St. Elizabeth's Medical Center of Boston, Tufts University School of Medicine, Boston, Massachusetts, USA.
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Meir A, Ginsburg S, Butkevich A, Kachalsky SG, Kaiserman I, Ahdut R, Demirgoren S, Rahamimoff R. Ion channels in presynaptic nerve terminals and control of transmitter release. Physiol Rev 1999; 79:1019-88. [PMID: 10390521 DOI: 10.1152/physrev.1999.79.3.1019] [Citation(s) in RCA: 220] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The primary function of the presynaptic nerve terminal is to release transmitter quanta and thus activate the postsynaptic target cell. In almost every step leading to the release of transmitter quanta, there is a substantial involvement of ion channels. In this review, the multitude of ion channels in the presynaptic terminal are surveyed. There are at least 12 different major categories of ion channels representing several tens of different ion channel types; the number of different ion channel molecules at presynaptic nerve terminals is many hundreds. We describe the different ion channel molecules at the surface membrane and inside the nerve terminal in the context of their possible role in the process of transmitter release. Frequently, a number of different ion channel molecules, with the same basic function, are present at the same nerve terminal. This is especially evident in the cases of calcium channels and potassium channels. This abundance of ion channels allows for a physiological and pharmacological fine tuning of the process of transmitter release and thus of synaptic transmission.
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Affiliation(s)
- A Meir
- Department of Physiology and the Bernard Katz Minerva Centre for Cell Biophysics, Hebrew University Hadassah Medical School, Jerusalem, Israel
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Oh SJ, Kim DS, Head TC, Claussen GC. Low-dose guanidine and pyridostigmine: relatively safe and effective long-term symptomatic therapy in Lambert-Eaton myasthenic syndrome. Muscle Nerve 1997; 20:1146-52. [PMID: 9270671 DOI: 10.1002/(sici)1097-4598(199709)20:9<1146::aid-mus9>3.0.co;2-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Guanidine hydrochloride is known to be highly effective in the symptomatic treatment of the Lambert-Eaton myasthenic syndrome (LEMS). However, because of its potentially dangerous side reactions of hematologic abnormalities and renal insufficiency, 3,4-diaminopyridine, which is not readily available in the United States, is recommended as the preferred drug for LEMS. We used low-dose guanidine and pyridostigmine combination therapy in 9 patients with LEMS and analyzed its long-term safety and effectiveness. In all patients, a liberal amount of pyridostigmine was used, while daily guanidine dose was kept below 1000 mg a day, and guanidine was given between pyridostigmine dosings. This combination therapy was used for 3-102 months (mean: 34.1 months) and improved clinical status in all patients. Although guanidine had to be discontinued due to severe gastrointestinal symptoms in 3 cases, no serious side reactions such as bone marrow suppressions or signs of renal insufficiency developed in any case. Thus, we conclude that low-dose guanidine therapy is relatively safe and effective for long-term symptomatic treatment of LEMS when it is combined with pyridostigmine.
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Affiliation(s)
- S J Oh
- Department of Neurology, University of Alabama at Birmingham 35294, USA
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Abstract
Although paraneoplastic syndromes are rare, a number of well- defined, neuromuscular paraneoplastic syndromes have been described and their pathophysiology listed. Many different malignancies have been associated with these syndromes, but small-cell lung cancer is the most common. Features shared by these conditions include onset of the underlying malignancy, rapid progression, severe disability, and the potential for some improvement, owing to treatment of the cancer. This article discusses Lambert-Eaton myasthenic syndrome, motor neuron disorders, peripheral neuropathies, and disorders of continuous muscle fiber activity, such as Stiffman syndrome.
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Affiliation(s)
- K H Levin
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Abstract
Two cases of Lambert-Eaton myasthenic syndrome (LEMS) who presented with primary respiratory failure are reported. In each case, although not initially suspected clinically, the electrophysiological findings, which included reduced compound muscle action potential amplitudes, decrement to 3-Hz stimulation, and potentiation after 40-Hz stimulation, led to the diagnosis in the critical care unit. Electrophysiological studies of the respiratory system, including repetitive nerve stimulation of the phrenic nerve, were extremely valuable in management. As shown by these cases, the severe respiratory failure in LEMS is reversible with treatment. Thus, LEMS should be considered in cases of unexplained respiratory failure, other clinical features of the disorder sought, and the electrophysiological hallmarks looked for including studies of the respiratory system.
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Affiliation(s)
- M W Nicolle
- Department of Clinical Neurological Sciences, Victoria Hospital, University of Western Ontario, London, Canada
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