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Zhao L, He H, Han W, Meng Y, Kang L, Chen Y. SOX-1 antibodies positive Lambert-Eaton myasthenic syndrome with occult small cell lung cancer: A case report. THE CLINICAL RESPIRATORY JOURNAL 2024; 18:e13740. [PMID: 38497229 PMCID: PMC10945390 DOI: 10.1111/crj.13740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/23/2024] [Accepted: 02/17/2024] [Indexed: 03/19/2024]
Abstract
Lambert-Eaton myasthenic syndrome (LEMS) is a rare paraneoplastic neurological syndrome of the neuromuscular transmission. The symptoms often progress slowly and can be misdiagnosed in early stage. Seropositive SOX-1 antibodies are support for the diagnosis of LEMS and have high specificity for small cell lung cancer (SCLC). In this paper, we report a case of a 56-year-old man with smoking history who was admitted to hospital with progressive muscle weakness of the proximal legs. LEMS was diagnosed by repetitive nerve stimulation (RNS) testing and seropositive SOX-1 antibodies. Primary screening with chest computed tomography (CT) and integrated PET/CT did not reveal any tumor. After continuous follow-up, SCLC was found by chest CT and confirmed with pathological examination 10 months after the diagnosis of LEMS. Long-term follow-up and screening for occult SCLC in LEMS patients with positive SOX-1 antibodies are very important.
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Affiliation(s)
- Liming Zhao
- Department of NeurologyHebei Chest HospitalShijiazhuangHebeiChina
| | - Hongyan He
- Department of NeurologyHebei Chest HospitalShijiazhuangHebeiChina
| | - Weixin Han
- Department of NeurologyHebei Chest HospitalShijiazhuangHebeiChina
| | - Yizhe Meng
- Department of NeurologyHebei Chest HospitalShijiazhuangHebeiChina
| | - Lifei Kang
- Department of PathologyHebei Chest HospitalShijiazhuangHebeiChina
| | - Yanqiang Chen
- Department of NeurologyHebei Chest HospitalShijiazhuangHebeiChina
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Arnold WD, Clark BC. Neuromuscular junction transmission failure in aging and sarcopenia: The nexus of the neurological and muscular systems. Ageing Res Rev 2023; 89:101966. [PMID: 37270145 PMCID: PMC10847753 DOI: 10.1016/j.arr.2023.101966] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/05/2023] [Accepted: 05/29/2023] [Indexed: 06/05/2023]
Abstract
Sarcopenia, or age-related decline in muscle form and function, exerts high personal, societal, and economic burdens when untreated. Integrity and function of the neuromuscular junction (NMJ), as the nexus between the nervous and muscular systems, is critical for input and dependable neural control of muscle force generation. As such, the NMJ has long been a site of keen interest in the context of skeletal muscle function deficits during aging and in the context of sarcopenia. Historically, changes of NMJ morphology during aging have been investigated extensively but primarily in aged rodent models. Aged rodents have consistently shown features of NMJ endplate fragmentation and denervation. Yet, the presence of NMJ changes in older humans remains controversial, and conflicting findings have been reported. This review article describes the physiological processes involved in NMJ transmission, discusses the evidence that supports NMJ transmission failure as a possible contributor to sarcopenia, and speculates on the potential of targeting these defects for therapeutic development. The technical approaches that are available for assessment of NMJ transmission, whether each approach has been applied in the context of aging and sarcopenia, and the associated findings are summarized. Like morphological studies, age-related NMJ transmission deficits have primarily been studied in rodents. In preclinical studies, isolated synaptic electrophysiology recordings of endplate currents or potentials have been mostly used, and paradoxically, have shown enhancement, rather than failure, with aging. Yet, in vivo assessment of single muscle fiber action potential generation using single fiber electromyography and nerve-stimulated muscle force measurements show evidence of NMJ failure in aged mice and rats. Together these findings suggest that endplate response enhancement may be a compensatory response to post-synaptic mechanisms of NMJ transmission failure in aged rodents. Possible, but underexplored, mechanisms of this failure are discussed including the simplification of post-synaptic folding and altered voltage-gated sodium channel clustering or function. In humans, there is limited clinical data that has selectively investigated single synaptic function in the context of aging. If sarcopenic older adults turn out to exhibit notable impairments in NMJ transmission (this has yet to be examined but based on available evidence appears to be plausible) then these NMJ transmission defects present a well-defined biological mechanism and offer a well-defined pathway for clinical implementation. Investigation of small molecules that are currently available clinically or being testing clinically in other disorders may provide a rapid route for development of interventions for older adults impacted by sarcopenia.
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Affiliation(s)
- W David Arnold
- NextGen Precision Health, University of Missouri System, Columbia, MO, USA; Department of Physical Medicine and Rehabilitation University of Missouri, Columbia, MO, USA.
| | - Brian C Clark
- Ohio Musculoskeletal and Neurological Institute (OMNI) Ohio University, Athens, OH, USA; Department of Biomedical Sciences, Ohio University, Athens, OH, USA.
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Abstract
PURPOSE OF REVIEW This article reviews the pathophysiology, epidemiology, clinical features, diagnosis, and treatment of Lambert-Eaton myasthenic syndrome (LEMS) and botulism, presynaptic disorders of neuromuscular transmission in which rapid diagnosis improves long-term outcomes. RECENT FINDINGS Therapy for LEMS has seen significant advances in recent years due to the approval of amifampridine-based compounds. LEMS is likely still underdiagnosed, particularly when no underlying malignancy is identified. Clinicians must have a strong suspicion for LEMS in any patient presenting with proximal weakness and autonomic dysfunction. Botulism is another rare disorder of presynaptic neuromuscular transmission that is most commonly associated with improper storage or preservation of food products. Over the past 2 decades, wound botulism has been increasingly reported among users of black tar heroin. A high degree of clinical suspicion and electrodiagnostic studies can be beneficial in distinguishing botulism from other acute neurologic disorders, and early involvement of state and federal health authorities may assist in confirming the diagnosis and obtaining treatment. When botulism is suspected, electrodiagnostic studies can provide clinical evidence of disordered neuromuscular transmission in advance of serologic confirmation, and providers should not wait for confirmation of the diagnosis to initiate treatment. SUMMARY A targeted clinical history and a thorough neurologic examination with support from serologic and electrodiagnostic studies are key to early diagnosis of LEMS and botulism. Early diagnosis of both conditions creates opportunities for therapy and improves outcomes.
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Yoshikawa H, Adachi Y, Nakamura Y, Kuriyama N, Murai H, Nomura Y, Sakai Y, Iwasa K, Furukawa Y, Kuwabara S, Matsui M. Nationwide survey of Lambert-Eaton myasthenic syndrome in Japan. BMJ Neurol Open 2022; 4:e000291. [PMID: 36110924 PMCID: PMC9445827 DOI: 10.1136/bmjno-2022-000291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 08/20/2022] [Indexed: 12/05/2022] Open
Abstract
Background There was no nationwide epidemiological study of Lambert-Eaton myasthenic syndrome (LEMS) in Japan; therefore, we conducted a nationwide survey. Methods For the first survey, we sent survey sheets to randomly selected medical departments (n=7545) to obtain the number of LEMS who visited medical departments between 1 January 2017 and 31 December 2017. For the second survey, we sent survey sheets to the corresponding medical departments to obtain clinical information on LEMS. Results We received 2708 responses (recovery rate: 35.9%) to the first survey. We estimated the number of LEMS as 348 (95% CI 247 to 449). The prevalence was 2.7 (95% CI 1.9 to 3.5) in 1 000 000 population. As a result of the second survey, we obtained 30 case records of 16 men and 14 women. Fourteen patients (46.7%) had a tumour, and 10 out of 14 tumours were small-cell lung carcinoma (71.4%). There was a predominance of men in the LEMS with tumour (paraneoplastic LEMS, P-LEMS) (n=11, 78.6%) and women in the LEMS without tumour (a primary autoimmune form of LEMS, AI-LEMS) (n=11, 68.8%) (p=0.0136). The onset age (mean (SD)) for the P-LEMS was 67.1 (9.0), and that for AI-LEMS was 57.8 (11.2) years old (p=0.0103). The disease duration (median) for P-LEMS was 2 years, and for AI-LEMS was 7.5 years (p=0.0134). Conclusions The prevalence of LEMS in Japan is similar to that in other countries. There are predominances of men in P-LEMS and women in AI-LEMS.
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Affiliation(s)
- Hiroaki Yoshikawa
- Health Service Center, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Yumi Adachi
- Health Service Center, Kanazawa University, Kanazawa, Ishikawa, Japan
| | | | - Nagato Kuriyama
- Department of Social Health Medicine, Shizuoka Graduate University of Public Health, Shizuoka, Japan
- Department of Epidemiology for Community Health and Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroyuki Murai
- Neurology, International University of Health and Welfare, Otawara, Tochigi, Japan
| | - Yoshiko Nomura
- Pediatric Neurology, Yoshiko Nomura Neurological Clinic for Children, Tokyo, Japan
| | - Yasunari Sakai
- Department of Pediatrics, Kyushu University, Fukuoka, Japan
| | - Kazuo Iwasa
- Health Science, Ishikawa Prefectural Nursing University, Kahoku-gun, Ishikawa, Japan
| | - Yutaka Furukawa
- Department of Neurology and Neurobiology of Aging, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Satoshi Kuwabara
- Neurology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
| | - Makoto Matsui
- Neurology, Kanazawa Medical University, Kahoku-gun, Ishikawa, Japan
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Cho HY, Chen PC, Chuang TH, Yu MC, Wu SN. Activation of Voltage-Gated Na+ Current by GV-58, a Known Activator of CaV Channels. Biomedicines 2022; 10:biomedicines10030721. [PMID: 35327523 PMCID: PMC8945347 DOI: 10.3390/biomedicines10030721] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/10/2022] [Accepted: 03/17/2022] [Indexed: 02/04/2023] Open
Abstract
GV-58 ((2R)-2-[(6-{[(5-methylthiophen-2-yl)methyl]amino}-9-propyl-9H-purin-2-yl)amino]butan-1-ol) is recognized to be an activator of N- and P/Q-type Ca2+ currents. However, its modulatory actions on other types of ionic currents in electrically excitable cells remain largely unanswered. This study was undertaken to explore the possible modifications caused by GV-58 in ionic currents (e.g., voltage-gated Na+ current [INa], A-type K+ current [IK(A)], and erg-mediated K+ current [IK(erg)]) identified from pituitary GH3 lactotrophs. GH3 cell exposure to GV-58 enhanced the transient and late components of INa with varying potencies; consequently, the EC50 values of GV-58 required for its differential increase in peak and late INa in GH3 cells were estimated to be 8.9 and 2.6 μM, respectively. The INa in response to brief depolarizing pulse was respectively stimulated or suppressed by GV-58 or tetrodotoxin, but it failed to be altered by ω-conotoxin MVIID. Cell exposure to this compound increased the recovery of INa inactivation evoked by two-pulse protocol based on a geometrics progression; however, in its presence, there was a slowing in the inactivation rate of current decay evoked by a train of depolarizing pulses. The existence of GV-58 also resulted in an increase in the amplitude of ramp-induced resurgent and window INa. The presence of this compound inhibited IK(A) magnitude, accompanied by a shortening in inactivation time course of the current; however, it mildly decreased IK(erg). Under current-clamp conditions, GV-58 increased the frequency of spontaneous action potentials in GH3 cells. Moreover, in NSC-34 motor neuron-like cells, the presence of GV-58 not only raised INa amplitude but also reduced current inactivation. Taken together, the overall work provides a noticeable yet unidentified finding which implies that, in addition to its agonistic effect on Ca2+ currents, GV-58 may concertedly modify the amplitude and gating kinetics of INa in electrically excitable cells, hence modifiying functional activities in these cells.
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Affiliation(s)
- Hsin-Yen Cho
- Department of Physiology, National Cheng Kung University Medical College, Tainan City 70101, Taiwan; (H.-Y.C.); (P.-C.C.); (T.-H.C.); (M.-C.Y.)
| | - Pei-Chun Chen
- Department of Physiology, National Cheng Kung University Medical College, Tainan City 70101, Taiwan; (H.-Y.C.); (P.-C.C.); (T.-H.C.); (M.-C.Y.)
- Institute of Basic Medical Sciences, National Cheng Kung University Medical College, Tainan City 70101, Taiwan
| | - Tzu-Hsien Chuang
- Department of Physiology, National Cheng Kung University Medical College, Tainan City 70101, Taiwan; (H.-Y.C.); (P.-C.C.); (T.-H.C.); (M.-C.Y.)
| | - Meng-Cheng Yu
- Department of Physiology, National Cheng Kung University Medical College, Tainan City 70101, Taiwan; (H.-Y.C.); (P.-C.C.); (T.-H.C.); (M.-C.Y.)
| | - Sheng-Nan Wu
- Department of Physiology, National Cheng Kung University Medical College, Tainan City 70101, Taiwan; (H.-Y.C.); (P.-C.C.); (T.-H.C.); (M.-C.Y.)
- Institute of Basic Medical Sciences, National Cheng Kung University Medical College, Tainan City 70101, Taiwan
- Correspondence: ; Tel.: +886-6-2353535-5334; Fax: +886-6-2362780
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Huijbers MG, Marx A, Plomp JJ, Le Panse R, Phillips WD. Advances in the understanding of disease mechanisms of autoimmune neuromuscular junction disorders. Lancet Neurol 2022; 21:163-175. [DOI: 10.1016/s1474-4422(21)00357-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/15/2021] [Accepted: 10/06/2021] [Indexed: 01/19/2023]
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An Extensive-stage Small-cell Lung Cancer Case With Preexisting Lambert-Eaton Myasthenic Syndrome Successfully Treated With an Immune Checkpoint Inhibitor. Clin Lung Cancer 2021; 23:e273-e275. [PMID: 34642096 DOI: 10.1016/j.cllc.2021.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/18/2021] [Accepted: 09/02/2021] [Indexed: 11/21/2022]
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Wang X, Burke SRA, Talmadge RJ, Voss AA, Rich MM. Depressed neuromuscular transmission causes weakness in mice lacking BK potassium channels. J Gen Physiol 2021; 152:151617. [PMID: 32243496 PMCID: PMC7201880 DOI: 10.1085/jgp.201912526] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 01/27/2020] [Accepted: 03/02/2020] [Indexed: 12/20/2022] Open
Abstract
Mice lacking functional large-conductance voltage- and Ca2+-activated K+ channels (BK channels) are viable but have motor deficits including ataxia and weakness. The cause of weakness is unknown. In this study, we discovered, in vivo, that skeletal muscle in mice lacking BK channels (BK−/−) was weak in response to nerve stimulation but not to direct muscle stimulation, suggesting a failure of neuromuscular transmission. Voltage-clamp studies of the BK−/− neuromuscular junction (NMJ) revealed a reduction in evoked endplate current amplitude and the frequency of spontaneous vesicle release compared with WT littermates. Responses to 50-Hz stimulation indicated a reduced probability of vesicle release in BK−/− mice, suggestive of lower presynaptic Ca2+ entry. Pharmacological block of BK channels in WT NMJs did not affect NMJ function, surprisingly suggesting that the reduced vesicle release in BK−/− NMJs was not due to loss of BK channel–mediated K+ current. Possible explanations for our data include an effect of BK channels on development of the NMJ, a role for BK channels in regulating presynaptic Ca2+ current or the effectiveness of Ca2+ in triggering release. Consistent with reduced Ca2+ entry or effectiveness of Ca2+ in triggering release, use of 3,4-diaminopyridine to widen action potentials normalized evoked release in BK−/− mice to WT levels. Intraperitoneal application of 3,4-diaminopyridine fully restored in vivo nerve-stimulated muscle force in BK−/− mice. Our work demonstrates that mice lacking BK channels have weakness due to a defect in vesicle release at the NMJ.
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Affiliation(s)
- Xueyong Wang
- Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, OH
| | - Steven R A Burke
- Department of Biological Sciences, Wright State University, Dayton, OH
| | - Robert J Talmadge
- Department of Biological Sciences, California State Polytechnic University, Pomona, Pomona, CA
| | - Andrew A Voss
- Department of Biological Sciences, Wright State University, Dayton, OH
| | - Mark M Rich
- Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, OH
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Guidon AC. Lambert-Eaton Myasthenic Syndrome, Botulism, and Immune Checkpoint Inhibitor-Related Myasthenia Gravis. Continuum (Minneap Minn) 2020; 25:1785-1806. [PMID: 31794471 DOI: 10.1212/con.0000000000000807] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW This article reviews the pathophysiology, epidemiology, clinical presentation, diagnosis, and treatment of Lambert-Eaton myasthenic syndrome (LEMS) and of botulism, and immune-related myasthenia gravis (MG) occurring in the context of immune checkpoint inhibitor therapy for cancer. RECENT FINDINGS The suspicion that LEMS is rare but also likely underdiagnosed is supported by recent epidemiologic data. A validated, LEMS-specific scale now exists to assess and monitor disease, and symptomatic and immunomodulatory treatments are available. As presynaptic disorders of neuromuscular transmission, LEMS and botulism share electrodiagnostic abnormalities but have important distinguishing features. Knowledge of the clinical features of botulism is needed, particularly with continued cases of infant botulism, the opioid epidemic increasing the incidence of wound botulism, and medical use of botulinum toxin, which may cause iatrogenic botulism. Foodborne botulism remains rare. Prompt recognition of botulism and administration of antitoxin can improve outcomes. MG may be exacerbated or may present de novo in the context of immune activation from immune checkpoint inhibitor therapies for cancer. Immune-related MG commonly overlaps with myositis and myocarditis. Corticosteroids typically result in improvement. However, immune-related MG can be more fulminant than its idiopathic counterpart and may cause permanent disability or death. SUMMARY The diagnosis of LEMS, botulism, or immune-related MG can generally be made from the patient's history, supplemented with directed questions, a physical examination designed to demonstrate abnormalities, and laboratory and electrodiagnostic testing. Early diagnosis and carefully selected treatment not only improve outcomes of the neuromuscular disease but can affect the prognosis of underlying malignancy, when present.
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What is in the Neuromuscular Junction Literature? J Clin Neuromuscul Dis 2018; 20:76-84. [PMID: 30439753 DOI: 10.1097/cnd.0000000000000218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This update begins with myasthenia gravis and the roles of anti-agrin and cortactin antibodies. Regarding diagnosis, a report on repeated ice pack testing is highlighted as are several reports on the close correlation of electrodiagnostic testing with clinical features and the response to treatment. The incidence of head drop and associated clinical and ventilatory features are gleaned from a retrospective study. We also discuss a study that assessed the predominantly symmetric and conjugate ocular findings in MuSK-myasthenia gravis. Other topics that are covered include quality of life and preoperative risk. We then summarize the positive treatment trials of subcutaneous immunoglobulin and eculizumab. Turning to Lambert-Eaton Myasthenic Syndrome, we report on an epidemiologic study performed on the veteran affairs population, the results of the DAPPER study of 3, 4 diaminopyridine, and look to the future for other treatment options involving calcium gating modifiers.
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