1
|
Yamada K, Yaguchi H, Ishikawa K, Tanaka D, Oshima Y, Mizushima K, Uwatoko H, Shirai S, Takahashi-Iwata I, Matsushima M, Tanaka K, Yabe I. Lambert-Eaton Myasthenic Syndrome Complicated by Anti-GABA B Receptor Encephalitis. Intern Med 2024; 63:1295-1300. [PMID: 37743510 PMCID: PMC11116022 DOI: 10.2169/internalmedicine.2569-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/07/2023] [Indexed: 09/26/2023] Open
Abstract
A 74-year-old man experienced diplopia, generalized muscle weakness, and acute respiratory failure. He was diagnosed with Lambert-Eaton myasthenic syndrome (LEMS) and treated with immunotherapy, but no improvement was observed, and additional symptoms, including central apnea and hallucinations, appeared. Subsequent serum and cerebrospinal fluid (CSF) analyses confirmed the presence of GABAB receptor antibodies, indicating the coexistence of autoimmune encephalitis. Although there were no findings of malignancy, it is highly likely that occult small-cell lung carcinoma was present. When atypical symptoms occur in patients with LEMS, it is important to consider the possibility of concomitant autoimmune encephalitis.
Collapse
Affiliation(s)
- Kazuki Yamada
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Hiroaki Yaguchi
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Kaede Ishikawa
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Daiki Tanaka
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Yuki Oshima
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Keiichi Mizushima
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Hisashi Uwatoko
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Shinichi Shirai
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Ikuko Takahashi-Iwata
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Masaaki Matsushima
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Keiko Tanaka
- Department of Animal Model Development, Brain Research Institute, Niigata University, Japan
| | - Ichiro Yabe
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| |
Collapse
|
2
|
Li Q, Zhang X, Zeng T, Yang B, Duan J, Tang Y. Clinical characteristics and prognosis of anti-GABABR encephalitis: A single-center experience. Medicine (Baltimore) 2023; 102:e32956. [PMID: 36800611 PMCID: PMC9936044 DOI: 10.1097/md.0000000000032956] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
The purpose of this study was to assess the demographic data, clinical manifestations, cerebrospinal fluid (CSF), hematology, brain magnetic resonance imaging, electroencephalograms, and therapy and prognosis related to anti-gamma-aminobutyric acid B (anti-GABABR) encephalitis. We retrospectively examined the demographic data, clinical manifestations, laboratory results, brain magnetic resonance imaging, electroencephalograms, and therapy and prognosis of 6 patients with anti-GABABR encephalitis. We used the clinical data of patients with anti-GABABR encephalitis admitted to the Department of Neurology of Mianyang Central Hospital obtained from January 2017 to September 2020. Six patients with anti-GABABR encephalitis were included. Generalized tonic-clonic seizure was the first clinical symptom in 5 patients, while 1 patient first showed behavior disorder. After the first clinical symptom attack, 2 patients developed a memory deficit, 4 cases showed cognitive decline, 3 cases showed behavior disorder, 1 patient developed status epilepticus and only 1 patient returned to normal. CSF testing indicated normal intracranial pressure in 5 patients and elevated pressure in only 1 patient. Additionally, the cerebrospinal fluid tests revealed slight leukocytosis in all patients and elevated protein levels in 5 patients. The anti-GABABR antibody was positive in both serum and CSF in all patients. Brain magnetic resonance imaging showed limbic system lesions in 4 patients. Long-term electroencephalograms revealed abnormal waves in half of the patients. All patients were treated with high dosages of methylprednisolone, which was combined with intravenous immunoglobulin in 2 patients; symptoms were improved in 4 patients, 1 patient showed no significant change and 1 patient with status epilepticus died of severe pneumonia during hospitalization. Epilepsy is the most common initial symptom in patients of anti-GABABR encephalitis. Many patients are also affected by tumors. Early immunotherapy can achieve excellent effects, the long-term prognosis is good for most patients.
Collapse
Affiliation(s)
- Qiang Li
- Department of Neurology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Xianwen Zhang
- Department of Neurology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Ting Zeng
- Department of Neurology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Bufan Yang
- Department of Neurology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Jingfeng Duan
- Department of Neurology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Yufeng Tang
- Department of Neurology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
- * Correspondence: Yufeng Tang, Department of Neurology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China (e-mail: )
| |
Collapse
|
3
|
Ronchi NR, Silva GD. Comparison of the clinical syndromes of anti-GABAa versus anti-GABAb associated autoimmune encephalitis: A systematic review. J Neuroimmunol 2021; 363:577804. [PMID: 34995918 DOI: 10.1016/j.jneuroim.2021.577804] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/14/2021] [Accepted: 12/27/2021] [Indexed: 12/29/2022]
Abstract
The main objective of this article is to improve our understanding of the differences and similarities of these two anti-gamma-aminobutyric acid receptor encephalitis, anti-GABAaR and anti-GABAbR. The data were systematically collected and we found 26 studies: seven studies and 37 patients corresponded to anti-GABAaR encephalitis, and 21 manuscripts and 116 patients were diagnosed with anti-GABAbR encephalitis. Both anti-GABAR encephalitis were marked by prominent seizures. Anti-GABAaR patients were younger and showed multifocal encephalitis. On the other hand, anti-GABAbR patients were older and showed temporal limbic encephalitis. Tumor occurred in a fifth of anti-GABAaR encephalitis and in half of anti-GABAbR encephalitis. The main tumor associated with anti-GABAbR encephalitis is SCLC, whereas the most common tumor associated with anti-GABAaR encephalitis was thymoma. Our data confirms the differences in clinical features between both encephalitis.
Collapse
Affiliation(s)
- Nathalia Rossoni Ronchi
- Department of Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil.
| | - Guilherme Diogo Silva
- Department of Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| |
Collapse
|
4
|
Chen T. Clinical Reasoning: A 68-Year-Old Man With Proximal Weakness and Seizures. Neurology 2021; 97:e423-e428. [PMID: 33931546 DOI: 10.1212/wnl.0000000000012137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Tychicus Chen
- From the Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, Canada.
| |
Collapse
|
5
|
Wen X, Wang B, Wang C, Han C, Guo S. A Retrospective Study of Patients with GABA BR Encephalitis: Therapy, Disease Activity and Prognostic Factors. Neuropsychiatr Dis Treat 2021; 17:99-110. [PMID: 33500619 PMCID: PMC7822224 DOI: 10.2147/ndt.s289942] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 12/23/2020] [Indexed: 01/13/2023] Open
Abstract
PURPOSE To explore the effects of immunotherapy and tumour treatment on patients with GABABR encephalitis, evaluate the correlation between immune cell subsets and disease activity, and investigate effective prognostic factors. PATIENTS AND METHODS Twenty patients with γ-aminobutyric acid B receptor (GABABR) encephalitis were enrolled from December 2015 to April 2020. The clinical data, modified Rankin Scale (mRS) score, prognosis and percentage of serum lymphocytes were recorded. RESULTS All patients received first-line immunotherapy. The median mRS scores were 4 and 3 before and after first-line immunotherapy (P<0.01). Seven patients received second-line immunotherapy and had median mRS scores of 3 and 2 before and after second-line immunotherapy (P=0.015). Small-cell lung cancer was detected in twelve patients. Among the patients who died because of tumours, patients who received tumour treatment lived longer than patients who did not receive tumour treatment (P=0.025). All four surviving patients who received tumour treatment had good outcomes (mRS≤2). The median serum CD19+B cell percentage in sixteen patients were 20.00% and 13.42% prior first-line immunotherapy and at the last follow-up (P<0.01). After a maximum follow-up of 54 months (median: 12; range: 3-54), eleven patients (55%) had a poor prognosis (mRS>2). Predictors of a poor prognosis were older age (P=0.031), delayed initial improvement after immunotherapy (>4 weeks) (P=0.038) and respiratory failure (P=0.038). CONCLUSION Aggressive immunotherapy and tumour treatment contribute to improvements in neurological function and a better prognosis of patients with GABABR encephalitis. The serum CD19+B cell percentage may be an indicator of disease activity. Older age, delayed initial improvement after immunotherapy, and respiratory failure may be associated with poor outcomes.
Collapse
Affiliation(s)
- Xiangchuan Wen
- Department of Neurology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250021, People's Republic of China
| | - Baojie Wang
- Department of Neurology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250021, People's Republic of China
| | - Chunjuan Wang
- Department of Neurology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250021, People's Republic of China.,Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, People's Republic of China
| | - Chenglin Han
- Department of Urology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250021, People's Republic of China
| | - Shougang Guo
- Department of Neurology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250021, People's Republic of China.,Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, People's Republic of China
| |
Collapse
|
6
|
Maddison P, Gozzard P, Sadalage G, Ambrose PA, Chapman CJ, Murray A, Thomsen S, Berretta A, Lang B. Neuronal antibody detection and improved lung cancer prediction in Lambert-Eaton myasthenic syndrome. J Neuroimmunol 2020; 340:577149. [PMID: 31951874 DOI: 10.1016/j.jneuroim.2020.577149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/09/2020] [Accepted: 01/09/2020] [Indexed: 10/25/2022]
Abstract
Since approximately 50% of patients with Lambert-Eaton myasthenic syndrome (LEMS) subsequently develop small-cell lung cancer (SCLC), it is important to be able to predict cancer occurrence in these patients at neurological presentation. We aimed to determine whether circulating biomarkers were effective and objective predictors of cancer development in LEMS. We found that the presence of either SOX2, N-type voltage gated calcium channel or GABAb antibodies at LEMS diagnosis was highly sensitive (84%) and specific (87%) for the detection of SCLC. Screening for SOX2 and neuronal antibodies is a useful adjunct to clinical predictive scoring tools in predicting SCLC in LEMS.
Collapse
Affiliation(s)
- Paul Maddison
- Department of Neurology, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham NG7 2UH, UK.
| | - Paul Gozzard
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield S10 2JF, UK
| | - Girija Sadalage
- Division of Neurology, University of Nottingham, Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, UK
| | - Philip A Ambrose
- Division of Neurology, University of Nottingham, Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, UK
| | - Caroline J Chapman
- Department of Pathology, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | | | - Selina Thomsen
- Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, John Radcliffe Hospital, Oxford OX3 9DS, UK
| | - Antonio Berretta
- Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, John Radcliffe Hospital, Oxford OX3 9DS, UK
| | - Bethan Lang
- Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, John Radcliffe Hospital, Oxford OX3 9DS, UK
| |
Collapse
|
7
|
Lambert-Eaton Myasthenic Syndrome Plus. J Clin Neuromuscul Dis 2019; 21:119-121. [PMID: 31743258 DOI: 10.1097/cnd.0000000000000260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
8
|
Lin J, Li C, Li A, Liu X, Wang R, Chen C, Zhou D, Hong Z. Encephalitis With Antibodies Against the GABA B Receptor: High Mortality and Risk Factors. Front Neurol 2019; 10:1030. [PMID: 31681135 PMCID: PMC6798040 DOI: 10.3389/fneur.2019.01030] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 09/11/2019] [Indexed: 02/05/2023] Open
Abstract
Objective: To measure mortality, identify predictors of death and investigate causes of death in patients with anti-gamma-aminobutyric-acid B receptor (anti-GABABR) encephalitis. Methods: Prospective analysis of anti-GABABR encephalitis cases diagnosed between June 2013 and August 2018 in West China Hospital of Sichuan University, with assessment of factors associated with mortality. Results: A total of 28 patients (11 females) with anti-GABABR encephalitis were included in this study. After a maximum time of 52 months (median 11 months, range 2–52) of follow-up, 9 (32.1%) patients died, with a median survival time of 6.5 months. Five patients died of tumor progression, one patient died of convulsive status epilepticus, one patient died of septic shock, and two patients died of severe pneumonia. Predictors of death were older age at onset (P = 0.025), presence of a tumor (66.7 vs. 15.8%, P = 0.013), the number of complications (2.6 vs. 1.0, P = 0.009) and deep venous thrombosis (33.3% vs. 0, P = 0.026). Conclusion: Patients with GABABR encephalitis have a high mortality rate within 5 years. Older age at onset, presence a tumor, the number of complications, and deep venous thrombosis are associated with death.
Collapse
Affiliation(s)
- Jingfang Lin
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Chen Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China.,Department of Neurology, Nuclear Industry 416 Hospital, Chengdu, China
| | - Aiqing Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Xu Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Rui Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Chu Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhen Hong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China.,Department of Pathology, University of Washington School of Medicine, Seattle, WA, United States
| |
Collapse
|
9
|
Ivanovski T, Miralles F. Lambert-Eaton Myasthenic syndrome: early diagnosis is key. Degener Neurol Neuromuscul Dis 2019; 9:27-37. [PMID: 31191084 PMCID: PMC6524763 DOI: 10.2147/dnnd.s192588] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 03/18/2019] [Indexed: 12/12/2022] Open
Abstract
Lambert-Eaton myasthenic syndrome (LEMS) is an uncommon disorder of neuromuscular transmission with distinctive pathophysiological, clinical, electrophysiological and laboratory features. There are two forms of LEMS. The paraneoplastic (P-LEMS) form is associated with a malignant tumor that is most frequently a small cell lung carcinoma (SCLC), and the autoimmune (A-LEMS) form is often related to other dysimmune diseases. Approximately 90% of LEMS patients present antibodies against presynaptic membrane P/Q-type voltage-gated calcium channels (VGCC). These antibodies are directly implicated in the pathophysiology of the disorder, provoke reduced acetylcholine (ACh) at the nerve terminal and consequently lead to muscle weakness. LEMS is clinically characterized by proximal muscle weakness, autonomic dysfunction and areflexia. In clinically suspected cases, diagnoses are confirmed by serological and electrodiagnostic tests. The detection of P/Q-type VGCC antibodies is supportive when there is clinical suspicion but should be carefully interpreted in the absence of characteristic clinical or electrodiagnostic features. Typical electrodiagnostic findings (ie, reduced compound motor action potentials (CMAPs), significant decrements in the responses to low frequency stimulation and incremental responses after brief exercise or high-frequency stimulation) reflect the existence of a presynaptic transmission defect and are key confirmatory criteria. Diagnosis requires a high level of awareness and necessitates the initiation of a prompt screening and surveillance process to detect and treat malignant tumors. In clinically affected patients without cancer and after cancer treatment, symptomatic treatment with 3,4-diaminopyridine or immunosuppressive agents can significantly improve neurologic symptoms and the quality of life. We present a detailed review of LEMS with special emphasis on the pathophysiological mechanisms, clinical manifestation and diagnostic procedure.
Collapse
Affiliation(s)
- Trajche Ivanovski
- Neurology Department, Hospital Universitari Son Llatzer, Palma de Mallorca, Balearic Islands, Spain
| | - Francesc Miralles
- Neurology Department, Hospital Universitari Son Espases, Palma de Mallorca, Balearic Islands, Spain
| |
Collapse
|
10
|
Li H, Zhang A, Hao Y, Guan H, Lv Z. Coexistence of Lambert-Eaton myasthenic syndrome and autoimmune encephalitis with anti-CRMP5/CV2 and anti-GABAB receptor antibodies in small cell lung cancer: A case report. Medicine (Baltimore) 2018; 97:e0696. [PMID: 29742721 PMCID: PMC5959409 DOI: 10.1097/md.0000000000010696] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
RATIONALE Autoimmune encephalitis and Lambert-Eaton myasthenic syndrome are classic paraneoplastic neurological conditions common in patients with small cell lung cancer. PATIENT CONCERNS The patient complained of tiredness, fluctuating recent memory loss, and inability to find his home. His family members reported a change in character, irritability, and paranoia. One month later, the patient had 1 grand mal seizure lasting 5 minutes. DIAGNOSIS The patient was diagnosed with limbic encephalitis combined with Lambert-Eaton myasthenic syndrome. The gamma-aminobutyric acid B (GABAB) receptor and collapsin response mediator protein 5 (CRMP5, also called CV2) antibody test results were positive. Nine months after the onset of symptoms, the patient was diagnosed with small cell lung cancer. INTERVENTIONS The patient was administered intravenous immunoglobulin for 5 days. He was then treated with 60 mg prednisone once per day. The prednisone dose was gradually reduced by 1 tablet every 2 weeks. After the diagnosis, the patient underwent 6 courses of chemotherapy with cisplatin combined with sequential chemoradiation therapy. OUTCOMES The patient was able to take care of himself. Neurological examination revealed a lower limb proximal muscle strength level of 4 and a reduced limb tendon reflex. The patient had deficits in short-term memory, a Mini-Mental State Examination score of 26, Montreal Cognitive Assessment score of 24, Self-rating Depression Scale score of 54 (mild depression), and Self-Rating Anxiety Scale score of 42 (normal). LESSONS Autoimmune diseases of the peripheral and central nervous systems can be observed at the same time in patients with small cell lung cancer, even when magnetic resonance imaging findings are negative and immune therapy is effective.
Collapse
Affiliation(s)
- Hongfang Li
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining
| | - Aimei Zhang
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining
| | - Yanlei Hao
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Zhanyun Lv
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining
| |
Collapse
|