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Pascual-Goñi E, Caballero-Ávila M, Querol L. Antibodies in Autoimmune Neuropathies: What to Test, How to Test, Why to Test. Neurology 2024; 103:e209725. [PMID: 39088795 DOI: 10.1212/wnl.0000000000209725] [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: 08/03/2024] Open
Abstract
Autoimmune neuropathies are a heterogeneous group of immune-mediated disorders of the peripheral nerves. Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) are the archetypal acute and chronic forms. Over the past few decades, pathogenic antibodies targeting antigens of the peripheral nervous system and driving peripheral nerve damage in selected patients have been described. Moreover, the detection of these antibodies has diagnostic and therapeutic implications that have prompted a modification of the GBS and CIDP diagnostic algorithms. GBS diagnosis is based in clinical criteria, and systematic testing of anti-ganglioside antibodies is not required. Nonetheless, a positive anti-ganglioside antibody test may support the clinical suspicion when diagnosis of GBS (GM1 IgG), Miller Fisher (GQ1b IgG), or acute sensory-ataxic (GD1b IgG) syndromes is uncertain. Anti-myelin-associated glycoprotein (MAG) IgM and anti-disialosyl IgM antibodies are key in the diagnosis of anti-MAG neuropathy and chronic ataxic neuropathy, ophthalmoplegia, M-protein, cold agglutinins, and disialosyl antibodies spectrum neuropathies, respectively, and help differentiating these conditions from CIDP. Recently, the field has been boosted by the discovery of pathogenic antibodies targeting proteins of the node of Ranvier contactin-1, contactin-associated protein 1, and nodal and paranodal isoforms of neurofascin (NF140, NF186, or NF155). These antibodies define subgroups of patients with specific clinical (most importantly poor or partial response to conventional therapies and excellent response to anti-CD20 therapy) and pathologic (node of Ranvier disruption in the absence of inflammation) features that led to the definition of the "autoimmune nodopathy" diagnostic category and to the incorporation of nodal/paranodal antibodies to clinical routine testing. The purpose of this review was to provide a practical vision for the general neurologist of the use of antibodies in the clinical assessment of autoimmune neuropathies.
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Affiliation(s)
- Elba Pascual-Goñi
- From the Neuromuscular Diseases Unit (E.P.-G., M.C.-Á., L.Q.), Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona; ERN (European Reference Network) EURO-NMD (Neuromuscular Disorders); and Centro para la Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (E.P.-G., L.Q.), Madrid, Spain
| | - Marta Caballero-Ávila
- From the Neuromuscular Diseases Unit (E.P.-G., M.C.-Á., L.Q.), Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona; ERN (European Reference Network) EURO-NMD (Neuromuscular Disorders); and Centro para la Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (E.P.-G., L.Q.), Madrid, Spain
| | - Luis Querol
- From the Neuromuscular Diseases Unit (E.P.-G., M.C.-Á., L.Q.), Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona; ERN (European Reference Network) EURO-NMD (Neuromuscular Disorders); and Centro para la Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (E.P.-G., L.Q.), Madrid, Spain
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Coly M, Adams D, Attarian S, Bouhour F, Camdessanché JP, Carey G, Cauquil C, Chanson JB, Chrétien P, Créange A, Delmont E, Fargeot G, Frachet S, Gendre T, Kuntzer T, Labeyrie C, Maisonobe T, Michaud M, Moulin M, Nicolas G, Noury JB, Péréon Y, Puma A, Sole G, Taithe F, Tard C, Théaudin M, Timsit S, Venditti L, Echaniz-Laguna A. Clinical, paraclinical and outcome features of 166 patients with acute anti-GQ1b antibody syndrome. J Neurol 2024; 271:4982-4990. [PMID: 38767661 DOI: 10.1007/s00415-024-12410-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND & PURPOSE In this retrospective study, we aimed at defining the clinical, paraclinical and outcome features of acute neurological syndromes associated with anti-GQ1b antibodies. RESULTS We identified 166 patients with neurological symptoms appearing in less than 1 month and anti-GQ1b antibodies in serum between 2012 and 2022. Half were female (51%), mean age was 50 years (4-90), and the most frequent clinical features were areflexia (80% of patients), distal upper and lower limbs sensory symptoms (78%), ophthalmoplegia (68%), sensory ataxia (67%), limb muscle weakness (45%) and bulbar weakness (45%). Fifty-three patients (32%) presented with complete (21%) and incomplete (11%) Miller Fisher syndrome (MFS), thirty-six (22%) with Guillain-Barre syndrome (GBS), one (0.6%) with Bickerstaff encephalitis (BE), and seventy-three (44%) with mixed MFS, GBS & BE clinical features. Nerve conduction studies were normal in 46% of cases, showed demyelination in 28%, and axonal loss in 23%. Anti-GT1a antibodies were found in 56% of cases, increased cerebrospinal fluid protein content in 24%, and Campylobacter jejuni infection in 7%. Most patients (83%) were treated with intravenous immunoglobulins, and neurological recovery was complete in 69% of cases at 1 year follow-up. One patient died, and 15% of patients relapsed. Age > 70 years, initial Intensive Care Unit (ICU) admission, and absent anti-GQ1b IgG antibodies were predictors of incomplete recovery at 12 months. No predictors of relapse were identified. CONCLUSION This study from Western Europe shows acute anti-GQ1b antibody syndrome presents with a large clinical phenotype, a good outcome in 2/3 of cases, and frequent relapses.
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Affiliation(s)
- Martin Coly
- Neurology Department, Bicêtre University Hospital, 94276, Le Kremlin-Bicêtre, France
- French National Reference Center for Rare Neuropathies (CERAMIC), 94276, Le Kremlin-Bicêtre, France
- Sorbonne University, 75013, Paris, France
| | - David Adams
- Neurology Department, Bicêtre University Hospital, 94276, Le Kremlin-Bicêtre, France
- French National Reference Center for Rare Neuropathies (CERAMIC), 94276, Le Kremlin-Bicêtre, France
- INSERM U1195, Paris-Saclay University, 94276, Le Kremlin-Bicêtre, France
| | - Shahram Attarian
- Reference Centre for Neuromuscular Diseases PACA RARE, Filnemus, EURO-NMD, CHU Timone, 13005, Marseille, France
| | - Françoise Bouhour
- Reference Centre for Neuromuscular Diseases PACA RARE, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677, Bron Cedex, France
| | | | - Guillaume Carey
- Centre de Référence Des Maladies Neuromusculaires Nord/Est/Ile-de-France, Neurology Department, U1172, CHU Lille, 59000, Lille, France
| | - Cécile Cauquil
- Neurology Department, Bicêtre University Hospital, 94276, Le Kremlin-Bicêtre, France
- French National Reference Center for Rare Neuropathies (CERAMIC), 94276, Le Kremlin-Bicêtre, France
- INSERM U1195, Paris-Saclay University, 94276, Le Kremlin-Bicêtre, France
| | - Jean-Baptiste Chanson
- Department of Neurology, Reference Center for Neuromuscular Disorders NEIDF, European Reference Network for Neuromuscular Diseases EURO-NMD, University Hospital of Strasbourg, 67098, Strasbourg, France
| | - Pascale Chrétien
- Clinical Immunology Laboratory, Bicêtre University Hospital, 94276, Le Kremlin-Bicêtre, France
- Paris University, CNRS, INSERM, UTCBS, Paris, France
- Pathology Department, Bicêtre University Hospital, 94276, Le Kremlin-Bicêtre, France
| | - Alain Créange
- Neurology Department, Créteil University Hospital, UPEC, 94010, Créteil, France
| | - Emilien Delmont
- Reference Centre for Neuromuscular Diseases PACA RARE, Filnemus, EURO-NMD, CHU Timone, 13005, Marseille, France
| | - Guillaume Fargeot
- Neurology Department, Bicêtre University Hospital, 94276, Le Kremlin-Bicêtre, France
- French National Reference Center for Rare Neuropathies (CERAMIC), 94276, Le Kremlin-Bicêtre, France
| | - Simon Frachet
- Neurology Department, Limoges University Hospital, 87042, Limoges, France
| | - Thierry Gendre
- Neurology Department, Créteil University Hospital, UPEC, 94010, Créteil, France
| | - Thierry Kuntzer
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne, 1011, Lausanne, Switzerland
| | - Céline Labeyrie
- Neurology Department, Bicêtre University Hospital, 94276, Le Kremlin-Bicêtre, France
- French National Reference Center for Rare Neuropathies (CERAMIC), 94276, Le Kremlin-Bicêtre, France
- INSERM U1195, Paris-Saclay University, 94276, Le Kremlin-Bicêtre, France
| | - Thierry Maisonobe
- Department of Clinical Neurophysiology, Pitié-Salpêtrière University Hospital, 75013, Paris, France
| | - Maud Michaud
- Neurology Department, NEIDF Reference Center, Nancy University Hospital, 54000, Nancy, France
| | - Maximilien Moulin
- Neurology Department, Reims University Hospital, 51092, Reims, France
| | - Guillaume Nicolas
- Nord-Est/Ile-de-France Neuromuscular Reference Center, Neurology Department, Raymond Poincaré Hospital, UVSQ Paris-Saclay University, Garches, France
| | - Jean-Baptiste Noury
- Centre de Référence Des Maladies Neuromusculaires AOC, INSERM, LBAI, UMR1227, CHRU de Brest, Brest, France
| | - Yann Péréon
- Reference Centre for Neuromuscular Disorders AOC Filnemus, Euro-NMD, Hôtel-Dieu, CHU Nantes, 44000, Nantes, France
| | - Angela Puma
- Peripheral Nervous System and Muscle Department, Université Côte d'Azur, Pasteur 2 Hospital, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Guilhem Sole
- Reference Centre for Neuromuscular Diseases AOC, Filnemus, Euro-NMD, Neurology and Neuromuscular Diseases Department, Hôpital Pellegrin, CHU de Bordeaux, 33076, Bordeaux, France
| | - Frédéric Taithe
- Neurology Department, Clermont-Ferrand University Hospital, 63058, Clermont-Ferrand, France
| | - Céline Tard
- Centre de Référence Des Maladies Neuromusculaires Nord/Est/Ile-de-France, Neurology Department, U1172, CHU Lille, 59000, Lille, France
| | - Marie Théaudin
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne, 1011, Lausanne, Switzerland
| | - Serge Timsit
- Centre de Référence Des Maladies Neuromusculaires AOC, INSERM, LBAI, UMR1227, CHRU de Brest, Brest, France
| | - Laura Venditti
- Neurology Department, Bicêtre University Hospital, 94276, Le Kremlin-Bicêtre, France
- French National Reference Center for Rare Neuropathies (CERAMIC), 94276, Le Kremlin-Bicêtre, France
| | - Andoni Echaniz-Laguna
- Neurology Department, Bicêtre University Hospital, 94276, Le Kremlin-Bicêtre, France.
- French National Reference Center for Rare Neuropathies (CERAMIC), 94276, Le Kremlin-Bicêtre, France.
- INSERM U1195, Paris-Saclay University, 94276, Le Kremlin-Bicêtre, France.
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Bellanti R, Rinaldi S. Guillain-Barré syndrome: a comprehensive review. Eur J Neurol 2024; 31:e16365. [PMID: 38813755 PMCID: PMC11235944 DOI: 10.1111/ene.16365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/12/2024] [Accepted: 05/13/2024] [Indexed: 05/31/2024]
Abstract
Guillain-Barré syndrome (GBS) is a potentially devastating yet treatable disorder. A classically postinfectious, immune-mediated, monophasic polyradiculoneuropathy, it is the leading global cause of acquired neuromuscular paralysis. In most cases, the immunopathological process driving nerve injury is ill-defined. Diagnosis of GBS relies on clinical features, supported by laboratory findings and electrophysiology. Although previously divided into primary demyelinating or axonal variants, this dichotomy is increasingly challenged, and is not endorsed by the recent European Academy of Neurology (EAN)/Peripheral Nerve Society (PNS) guidelines. Intravenous immunoglobulin and plasma exchange remain the primary modalities of treatment, regardless of the electrophysiological subtype. Most patients recover, but approximately one-third require mechanical ventilation, and 5% die. Disease activity and treatment response are currently monitored through interval neurological examination and outcome measures, and the potential role of fluid biomarkers is under ongoing scrutiny. Novel potential therapies for GBS are being explored but none have yet modified clinical practice. This review provides a comprehensive update on the pathological and clinical aspects of GBS for clinicians and scientists.
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Affiliation(s)
- Roberto Bellanti
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
| | - Simon Rinaldi
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
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Tan FF, Liu HX, Huang XY, Yu CY, Yang XY. Atypical Guillain-Barré syndrome with positive anti-sulfatide, anti-GT1b, and anti-GT1a antibodies: A case report. World J Clin Cases 2024; 12:4372-4376. [PMID: 39015914 PMCID: PMC11235542 DOI: 10.12998/wjcc.v12.i20.4372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/13/2024] [Accepted: 05/21/2024] [Indexed: 06/30/2024] Open
Abstract
BACKGROUND The role of diverse antibodies in mediating peripheral nerve injury in Guillain-Barré syndrome (GBS) is becoming clearer, but positivity for multiple antibodies in one case is uncommon. To our knowledge, this is the first case involving GBS with positive anti-sulfatide, anti-GT1a, and anti-GT1b antibodies. CASE SUMMARY A 20-year-old female patient was admitted to the hospital due to weakness of limbs for 5 d, and deterioration of the weakness and muscle aches for 1 d. The patient's limbs were weak, but the tendon reflexes in the part of the limbs were normal. There was no comorbid peripheral nociception or deep sensory dysfunction. She was diagnosed with GBS and was discharged after receiving intravenous human immunoglobulin pulse therapy. CONCLUSION In this article, the clinical manifestations, neurophysiological examination, and auxiliary examination findings of a GBS patient positive for multiple antibodies were analyzed to improve the identification of the disease by clinical physicians at an early stage.
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Affiliation(s)
- Fei-Fei Tan
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - He-Xu Liu
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Xue-Yan Huang
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Chang-Yin Yu
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Xiao-Yan Yang
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
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Sprenger-Svačina A, Svačina MKR, Gao T, Zhang G, Sheikh KA. Emerging treatment landscape for Guillain-Barré Syndrome (GBS): what's new? Expert Opin Investig Drugs 2024:1-6. [PMID: 38980318 DOI: 10.1080/13543784.2024.2377323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 07/03/2024] [Indexed: 07/10/2024]
Abstract
INTRODUCTION Guillain-Barré syndrome (GBS) is a monophasic immune neuropathic disorder characterized by acute paralysis. A significant portion of patients are left with residual deficits, which presents a considerable global healthcare challenge. The precise mechanisms underlying GBS pathogenesis are not fully elucidated. Recent studies have focused on postinfectious molecular mimicry and identified involvement of IgG autoantibodies and innate immune effectors in GBS. Intravenous immunoglobulins (IVIg) and plasma exchange (PE) are two established evidence-based immunomodulatory treatments for GBS, but a significant proportion of GBS patients fails to respond adequately to either therapy. This emphasizes an urgent need for novel and more potent treatments. AREAS COVERED We discuss novel immunomodulatory therapies presently at different phases of preclinical and clinical investigation. Some drugs in development target pathophysiologic mechanisms such as IgG autoantibody catabolism and complement activation, which are relevant to GBS. EXPERT OPINION There is an unmet need for more effective immune therapies for GBS. New immunomodulatory therapies under development may provide more potent options for GBS patients who do not respond to IVIg or PE. Future directions may include incorporating neuroprotective interventions based on evolving understanding of mechanisms underlying nerve injury and axonal degeneration.
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Affiliation(s)
- Alina Sprenger-Svačina
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, USA
- Department of Neurology, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Martin K R Svačina
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, USA
- Department of Neurology, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Tong Gao
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Gang Zhang
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Kazim A Sheikh
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, USA
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Xu X, Wang Z, Su C, Cong L, Zheng D. Case report: Bilateral facial palsy with paresthesias and positive anti-GT1a antibodies. Front Immunol 2024; 15:1410634. [PMID: 38911860 PMCID: PMC11190294 DOI: 10.3389/fimmu.2024.1410634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 05/27/2024] [Indexed: 06/25/2024] Open
Abstract
Bilateral facial palsy with paresthesia (FDP) is a rare variant of GBS, characterized by simultaneous bilateral facial palsy and paresthesia of the distal limbs. Mounting evidence indicates that the presence of anti-GT1a IgG has a pathogenic role as an effector molecule in the development of cranial nerve palsies in certain patients with GBS, whereas anti-GT1a antibody is rarely presented positive in FDP. Here, we report the case of a 33-year-old male diagnosed with FDP presented with acute onset of bilateral facial palsy and slight paresthesias at the feet as the only neurological manifestation. An antecedent infection with no identifiable reason for the fever or skin eruptions was noted in the patient. He also exhibited cerebrospinal fluid albuminocytologic dissociation and abnormal nerve conduction studies. Notably, the testing of specific serum anti-gangliosides showed positive anti-GT1a IgG/IgM Ab. The patient responded well to intravenous immunoglobulin therapy. This case brings awareness to a rare variant of GBS, and provides the first indication that anti-GT1a antibodies play a causative role in the development of FDP. The case also suggests that prompt management with IVIG should be implemented if FDP is diagnosed.
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Affiliation(s)
| | | | | | | | - Dongming Zheng
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
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Dang HH, Nguyen HLT. Comparison of Clinical Features, Short-Term Outcome of Guillain-Barré Syndrome Between Adults and Children: A Retrospective Study in Vietnam. Pediatr Neurol 2024; 155:177-181. [PMID: 38669800 DOI: 10.1016/j.pediatrneurol.2024.03.034] [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: 02/03/2023] [Revised: 01/18/2024] [Accepted: 03/31/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Despite extensive research on Guillain-Barré syndrome (GBS) in adults and children, there is a lack of comparison regarding short-term outcomes in various age groups. Our study aims to elucidate the differences in clinical features and short-term outcomes in Vietnam. METHODS After retrospective data collection, we compared clinical features in patients with GBS aged ≤16 years at Children's Hospital 2 and aged >16 years at University Medical Center Ho Chi Minh City from 2017 to 2021. A positive short-term outcome was recorded if patients had a GBS Disability Score of 0 to 2 at hospital discharge. RESULTS We analyzed 109 adults (58.7% males; mean age 50.6 ± 17.7) and 111 children (58.6% males; mean age 7.2 ± 4.9). Comparable antecedent infection and immunization incidence in both groups were observed (35.8% vs 45.9%, P > 0.05). Pain and sensory disturbance were the most common onset symptom in adults (57.8%), whereas lower limb weakness predominated in children (61.3%). Ophthalmoplegia (18.3% vs 5.4%), pain, sensory disturbance (85.3% vs 67.6%), ataxia (33.0% vs 15.3%) were more prevalent in adults (P < 0.05). The axonal subtype was prominent in both adults (51.4%) and children (53.2%). Patients were classified into: classic GBS (49.5% and 68.5%), GBS variants (11.0% and 15.3%), classic Miller Fisher syndrome (MFS) (1.8% and 1.8%), MFS variants (2.8% and 0%), and GBS/MFS overlap (34.9% and 14.4%). Short-term outcomes did not significantly differ based on age. CONCLUSIONS Age-related variations in clinical features were observed, but adults and children exhibited similar short-term functional outcomes.
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Affiliation(s)
- Hung Hoang Dang
- Department of Neurology, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Hieu Le Trung Nguyen
- Department of Neurology, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam; Department of Neurology, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam; Department of Neurology, Children's Hospital 2, Ho Chi Minh City, Vietnam.
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Plante V, Basu M, Gettings JV, Luchette M, LaRovere KL. Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know. Semin Neurol 2024; 44:362-388. [PMID: 38788765 DOI: 10.1055/s-0044-1787047] [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: 05/26/2024]
Abstract
Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.
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Affiliation(s)
- Virginie Plante
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Meera Basu
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Matthew Luchette
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
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Taftaf A, Vera Cruz CA, Al-Qasmi H, Al-Qasmi M. Bilateral Facial Paralysis in an Atypical Clinical Onset of COVID-Associated Guillain-Barre Syndrome. Cureus 2024; 16:e63498. [PMID: 39081416 PMCID: PMC11287485 DOI: 10.7759/cureus.63498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2024] [Indexed: 08/02/2024] Open
Abstract
Coronavirus disease (COVID-19) has been associated with a diverse range of extrapulmonary manifestations since its global outbreak in 2019. One of its rare complications is Guillain-Barre Syndrome (GBS), a post-infectious neurological disorder that manifests with a characteristic ascending limb paralysis. Here, we describe the atypical case of a 42-year-old African American male who developed bilateral facial paralysis within five weeks of testing positive for COVID-19. Initial diagnostic imaging and blood studies were negative for acute pathology. Albuminocytological dissociation found in a subsequent analysis of the patient's cerebrospinal fluid and his appropriate therapeutic response to intravenous immunoglobulin (IVIg) indicated GBS as the most likely diagnosis.
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Affiliation(s)
- Ahmad Taftaf
- Internal Medicine, Hurley Medical Center, Flint, USA
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10
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Van Es MA. Amyotrophic lateral sclerosis; clinical features, differential diagnosis and pathology. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2024; 176:1-47. [PMID: 38802173 DOI: 10.1016/bs.irn.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Amyotrophic lateral sclerosis (ALS) is a late-onset syndrome characterized by the progressive degeneration of both upper motor neurons (UMN) and lower motor neurons (LMN). ALS forms a clinical continuum with frontotemporal dementia (FTD), in which there are progressive language deficits or behavioral changes. The genetics and pathology underlying both ALS and FTD overlap as well, with cytoplasmatic misvocalization of TDP-43 as the hallmark. ALS is diagnosed by exclusion. Over the years several diagnostic criteria have been proposed, which in essence all require a history of slowly progressive motor symptoms, with UMN and LMN signs on neurological examination, clear spread of symptoms through the body, the exclusion of other disorder that cause similar symptoms and an EMG that it is compatible with LMN loss. ALS is heterogeneous disorder that may present in multitude ways, which makes the diagnosis challenging. Therefore, a systematic approach in the diagnostic process is required in line with the most common presentations. Subsequently, assessing whether there are cognitive and/or behavioral changes within the spectrum of FTD and lastly determining the cause is genetic. This chapter, an outline on how to navigate this 3 step process.
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Affiliation(s)
- Michael A Van Es
- Department of Neurology, Brain Center UMC Utrecht, Utrecht, The Netherlands.
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Kalita J, Mahajan R, Kumar M. Effect of intravenous immunoglobulin and plasmapheresis on nerve conduction parameters compared to the natural course of Guillain-Barré syndrome. J Clin Neurosci 2024; 125:76-82. [PMID: 38759351 DOI: 10.1016/j.jocn.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Intravenous immunoglobulin (IVIg) and plasmapheresis (PLEX) are recommended in moderate to severe Guillain-Barré Syndrome (GBS), but there is paucity of studies evaluating its effect on nerve conduction studies (NCS). We report the effect of IVIg and PLEX on the NCS parameters and clinical outcomes compared to natural course (NC) of GBS patients. METHOD Moderate to severe GBS patients were included based on clinical, cerebrospinal fluid, and NCS finding. Six motor and sensory nerves were evaluated at admission, one month and 3 months, and NCS subtyping was done. Axonal and demyelination burden in motor nerves and early reversible conduction block (ERCB) were noted. Patients receiving IVIg, PLEX or on NC were noted. Outcome was defined at 3 months into complete, partial and poor using a 0-6 GBS Disability Scale (GBSDS). RESULT Seventy-two patients were included, whose median age was 36 years and 22(30.6 %) were females. 44 patients received IVIg, 9 PLEX and 19 were in NC, and they had comparable peak disability. AIDP was the dominant subtype at admission (58.3 %), which remained so at 3 months (50 %). The shift of subtypes was the highest from the equivocal group followed by AMAN and the least from AIDP. IVIg and PLEX group had more reduction in axonal burden and had ERCB compared to NC. 33(44 %) patients had complete recovery, and 40(55.5 %) patients had concordance in clinical and neurophysiological outcome. CONCLUSION Transition of GBS subtype may occur at follow-up from all the subtypes, the highest from the equivocal and the lowest from the AIDP group. IVIg/PLEX treatment may help in reducing conduction block and axonal burden.
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Affiliation(s)
- Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh 226014, India.
| | - Roopali Mahajan
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh 226014, India
| | - Mritunjai Kumar
- Department of Neurology, AIIMS Rishikesh, Uttarakhand 249203, India
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12
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Xue Y, Yu Z, Cheng M, Li X, Jiang L, Han W. Concomitant Central and Peripheral Nervous System Involvement Associated With Mycoplasma pneumoniae Infection in Pediatric Patients: Two Case Reports and Literature Review. Pediatr Infect Dis J 2024:00006454-990000000-00869. [PMID: 38754001 DOI: 10.1097/inf.0000000000004394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
BACKGROUND Mycoplasma pneumoniae (M. pneumoniae) is a common pathogen for community-acquired pneumonia and is also implicated in a broad array of extra-pulmonary manifestations. M. pneumoniae infection is rarely associated with concurrent central nervous system (CNS) and peripheral nervous system (PNS) involvement in children. METHODS We report 2 patients who presented with acute encephalitis and polyradiculitis due to M. pneumoniae infection and review the literature to discuss the pathogenesis and treatment of concomitant CNS and PNS involvement associated with M. pneumoniae infection. RESULTS We report two 6-year-old boys with M. pneumoniae antecedent infection who presented initially with impaired consciousness followed by limb weakness, limb pain and urinary retention, and responded well to immunotherapy. CONCLUSIONS We described 2 patients who presented symptomatic combined CNS and PNS involvement with persistent urinary retention associated with M. pneumoniae infection. We found autoimmunity plays an important role and recommend that antibiotics and immunomodulators should be administered with concurrent CNS and PNS involvement associated with M. pneumoniae.
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Affiliation(s)
- Yuan Xue
- From the Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders
- Ministry of Education Key Laboratory of Child Development and Disorders
- Chongqing Key Laboratory of Child Neurodevelopment and Cognitive Disorders, Chongqing, China
| | - Zhiwei Yu
- From the Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders
- Ministry of Education Key Laboratory of Child Development and Disorders
- Chongqing Key Laboratory of Child Neurodevelopment and Cognitive Disorders, Chongqing, China
| | - Min Cheng
- From the Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders
- Ministry of Education Key Laboratory of Child Development and Disorders
- Chongqing Key Laboratory of Child Neurodevelopment and Cognitive Disorders, Chongqing, China
| | - Xiujuan Li
- From the Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders
- Ministry of Education Key Laboratory of Child Development and Disorders
- Chongqing Key Laboratory of Child Neurodevelopment and Cognitive Disorders, Chongqing, China
| | - Li Jiang
- From the Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders
- Ministry of Education Key Laboratory of Child Development and Disorders
- Chongqing Key Laboratory of Child Neurodevelopment and Cognitive Disorders, Chongqing, China
| | - Wei Han
- From the Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders
- Ministry of Education Key Laboratory of Child Development and Disorders
- Chongqing Key Laboratory of Child Neurodevelopment and Cognitive Disorders, Chongqing, China
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13
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Li X, Zhang C. Guillain-Barré syndrome after surgery: a literature review. Front Neurol 2024; 15:1368706. [PMID: 38638310 PMCID: PMC11024248 DOI: 10.3389/fneur.2024.1368706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/26/2024] [Indexed: 04/20/2024] Open
Abstract
Guillain-Barré syndrome (GBS) is a rare postoperative complication that is sometimes characterized by serious motor weakness and prolonged weaning from mechanical ventilation. Although the exact nature of the relationship between GBS and the surgical procedure is still unclear, there is a clear increased incidence of GBS in post-surgical patients compared to non-surgical patients. GBS after surgery is unique in several ways. The course of post-surgical GBS unfolds more rapidly than in other situations where GBS develops, the condition is often more severe, and respiratory muscles are more commonly involved. Prompt diagnosis and appropriate treatment are essential, and the condition can worsen if treated inappropriately. Postoperative sedation, intubation, and restraint use make the diagnosis of GBS difficult, as the onset of symptoms of weakness or numbness in those contexts are not obvious. GBS is often misdiagnosed, being attributed to other postoperative complications, and subsequently mishandled. The lack of relevant information further obscures the clinical picture. We sought to better understand post-surgical GBS by performing an analysis of the relevant literature, focusing on clearly documenting the clinical characteristics, diagnosis, and management of GBS that emerges following surgery. We underscore the importance of physicians being aware of the possibility of GBS after major surgery and of performing a variety of laboratory clinical investigations early on in suspected cases.
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Affiliation(s)
| | - Chao Zhang
- Department of Neurology and Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
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14
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Shrestha GS, Nepal G, Prust ML. Developing Systems of Emergency and Inpatient Neurologic Care in Resource-Limited Settings. Semin Neurol 2024; 44:105-118. [PMID: 38485125 DOI: 10.1055/s-0043-1778638] [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: 04/19/2024]
Abstract
Neurologic diseases represent a significant global health challenge, leading to disability and mortality worldwide. Healthcare systems in low- and middle-income countries are disproportionally affected. In these resource-limited settings, numerous barriers hinder the effective delivery of emergency and inpatient neurologic care, including shortages of trained personnel, limited access to diagnostics and essential medications, inadequate facilities, and absence of rehabilitation services. Disparities in the neurology workforce, limited access to neuroimaging, and availability of acute interventions further exacerbate the problem. This article explores strategies to enhance global capacity for inpatient neurologic care, emphasizing the importance of workforce development, context-specific protocols, telehealth solutions, advocacy efforts, and collaborations.
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Affiliation(s)
- Gentle Sunder Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Gaurav Nepal
- Department of General Medicine, Rani Primary Healthcare Centre, Rani, Biratnagar, Nepal
| | - Morgan Lippitt Prust
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
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15
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Li H, Lu Z. Possible benefit of second intravenous immunoglobulin course in Guillain-Barré syndrome patients with potentially poor prognosis. Eur J Neurol 2024; 31:e16231. [PMID: 38312041 PMCID: PMC11235967 DOI: 10.1111/ene.16231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/19/2024] [Indexed: 02/06/2024]
Affiliation(s)
- Hai‐Feng Li
- Department of NeurologyXuanwu Hospital, Capital Medical UniversityBeijingChina
| | - Zuneng Lu
- Department of NeurologyRenmin Hospital of Wuhan UniversityHubeiChina
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16
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van Doorn PA, Van den Bergh PYK, Hadden RDM. Response to letter on European Academy of Neurology/Peripheral Nerve Society guideline on diagnosis and treatment of Guillain-Barré syndrome. Eur J Neurol 2024; 31:e16230. [PMID: 38327088 PMCID: PMC11235590 DOI: 10.1111/ene.16230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 02/09/2024]
Affiliation(s)
- Pieter A. van Doorn
- Department of Neurology, Erasmus MCUniversity Medical Center RotterdamRotterdamthe Netherlands
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17
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Chafiq K, Hadzine Y, Elmekkaoui A, Benlenda O, Rajad H, Wakrim S, Nassik H. Navigating the complexity of Guillain-Barré syndrome and Miller-Fisher syndrome overlap syndrome: a pediatric case report. Pan Afr Med J 2024; 47:127. [PMID: 38854867 PMCID: PMC11161700 DOI: 10.11604/pamj.2024.47.127.42985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/16/2024] [Indexed: 06/11/2024] Open
Abstract
Guillain-Barré syndrome/Miller-Fisher syndrome (GBS/MFS) overlap syndrome is an extremely rare variant of Guillain-Barré syndrome (GBS) in which Miller-Fisher syndrome (MFS) coexists with other characteristics of GBS, such as limb weakness, paresthesia, and facial paralysis. We report the clinical case of a 12-year-old patient, with no pathological history, who acutely presents with ophthalmoplegia, areflexia, facial diplegia, and swallowing and phonation disorders, followed by progressive, descending, and symmetrical paresis affecting first the upper limbs and then the lower limbs. An albuminocytological dissociation was found in the cerebrospinal fluid study. Magnetic resonance imaging of the spinal cord showed enhancement and thickening of the cauda equina roots. The patient was treated with immunoglobulins with a favorable clinical outcome.
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Affiliation(s)
- Kamal Chafiq
- Department of Anesthesiology and Reanimation, Faculty of Medicine and Pharmacy of Agadir, University Ibn Zohr, Agadir, Morocco
| | - Youssef Hadzine
- Department of Anesthesiology and Reanimation, Faculty of Medicine and Pharmacy of Agadir, University Ibn Zohr, Agadir, Morocco
| | - Adel Elmekkaoui
- Department of Anesthesiology and Reanimation, Faculty of Medicine and Pharmacy of Agadir, University Ibn Zohr, Agadir, Morocco
| | - Othmane Benlenda
- Department of Anesthesiology and Reanimation, Faculty of Medicine and Pharmacy of Agadir, University Ibn Zohr, Agadir, Morocco
| | - Houssam Rajad
- Department of Radiology, Faculty of Medicine and Pharmacy of Agadir, University Ibn Zohr, Agadir, Morocco
| | - Soukaina Wakrim
- Department of Radiology, Faculty of Medicine and Pharmacy of Agadir, University Ibn Zohr, Agadir, Morocco
| | - Hicham Nassik
- Department of Anesthesiology and Reanimation, Faculty of Medicine and Pharmacy of Agadir, University Ibn Zohr, Agadir, Morocco
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18
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Wijdicks EFM. Clinical observations in acute neurology: A historical explanation of the present. Eur J Neurol 2024:e16241. [PMID: 38403947 DOI: 10.1111/ene.16241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND The history of the development of acute neurologic disease as a biologic mechanism is of interest. Equally important is how it translated to the bedside and how the clinical examination differentiated itself. METHODS This paper reviews primary sources pertaining to acute neurologic conditions described mostly in the 19th and 20th century. A review of monographs, treatises, textbooks, and peer-reviewed articles was conducted. RESULTS The evolution of clinical signs and syndromes associated with dynamic intracranial pathologies was predicated on the idea that animal studies informed clinicians, who then linked clinical signs to these observations. A dominant theme is that innovative technologies could trace acute processes through all their various stages, affording a complete picture of the disease process. Just as clinical descriptors of central nervous system processes evolved, the presentation of acute neuromuscular respiratory failure became better defined. Once practices incorporated these acute clinical signs, textbooks cemented their "gold standard" status with relative impunity. CONCLUSIONS The practise of acute neurology and neurocritical care must find out what, historically, others were seeking but could not find. Patterns of clinical presentation in acute neurology are sufficiently recognizable to guide practise decisions. Although, the currently well-documented clinical syndromes of acute neurologic conditions (at presentation and during deterioration) have been taught for generations, practitioners have noted that they lack consistency and predictability. History also taught us that part of this improved knowledge came with designated units-a clear example of how protean systems (not always innovative neurologists or neuroscientists or technologies) shaped the history of neurology.
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Affiliation(s)
- Eelco F M Wijdicks
- Neurosciences Intensive Care Unit, Mayo Clinic Hospital Saint Marys, Rochester, Minnesota, USA
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19
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Smaoui E, Moalla KS, Bouattour N, Farhat N, Sakka S, Daoud S, Damak M, Mhiri C. Acute-onset chronic inflammatory demyelinating polyneuropathy following AstraZeneca COVID-19 vaccine: a case report. Pan Afr Med J 2024; 47:46. [PMID: 38681104 PMCID: PMC11055180 DOI: 10.11604/pamj.2024.47.46.42455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/22/2024] [Indexed: 05/01/2024] Open
Abstract
COVID-19 vaccination side effects have been increasingly reported, including new-onset autoimmune diseases such as chronic arthritis, thrombocytopenia, Guillain-Barré syndrome (GBS), and more recently chronic inflammatory demyelinating polyneuropathies (CIDP). Molecular mimicry and vaccine adjuvants appear to be important contributors to immune-mediated neuropathies. However, whether the link between the COVID-19 vaccine and these autoimmune disorders is coincidental or causal remains uncertain. We describe the ever-reported case of acute-onset CIDP following the Oxford/AstraZeneca vaccine in Tunisia. The patient is a 41-year-old man who presented with acute, worsening weakness of the four limbs. The symptoms appeared 15 days after his first dose of the AstraZeneca vaccine. The diagnosis of GBS was initially confirmed according to the clinical features, the albumino-cytological dissociation in the cerebrospinal fluid (CSF), and the electroneuromyography (ENMG) findings. Serum workup for all known infections associated with immune-mediated neuropathy was negative. The patient was treated with plasma exchange without initial improvement followed by aggravation of the symptomatology after an interval of four and a half months. Control ENMG showed signs of CIDP meeting the European Academy of Neurology/Peripheral Nerve Society (EAN/PNS) criteria of 2021. The patient was treated with maintenance intravenous immunoglobulin and oral corticosteroids. Neurological examination 3 months after discharge showed partial improvement. Worldwide, cases of demyelinating polyneuropathies post-COVID-19 vaccination are increasingly reported. The acute onset of CIDP might lead to a misdiagnosis of GBS. Awareness of this complication and distinction from GBS enables early relay with maintenance treatment to prevent relapses and severe complications. Post-COVID neuropathies are found to be more frequently linked to the AstraZeneca vaccine, however, temporal association does not confirm causal association.
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Affiliation(s)
- Emna Smaoui
- Neurology Department, Habib Bourguiba Hospital, Sfax, Tunisia
| | | | - Nadia Bouattour
- Neurology Department, Habib Bourguiba Hospital, Sfax, Tunisia
| | - Nouha Farhat
- Neurology Department, Habib Bourguiba Hospital, Sfax, Tunisia
| | - Salma Sakka
- Neurology Department, Habib Bourguiba Hospital, Sfax, Tunisia
| | - Sawsan Daoud
- Neurology Department, Habib Bourguiba Hospital, Sfax, Tunisia
| | - Mariem Damak
- Neurology Department, Habib Bourguiba Hospital, Sfax, Tunisia
| | - Chokri Mhiri
- Neurology Department, Habib Bourguiba Hospital, Sfax, Tunisia
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