Bickerstaff's encephalitis and the Miller Fisher syndrome

Clinical characteristics of Guillain-Barré syndrome in patients with primary Sjögren's syndrome

To investigate the clinical characteristics of Guillain-Barré syndrome (GBS) in patients with primary Sjögren's syndrome (SS). Records of patients with positive anti-SSA antibodies hospitalized in the Beijing Tiantan Hospital between December 2011 and May 2020 were retrieved. Patients who fulfilled the criteria for diagnosis of GBS and primary SS were included, and their clinical data were analyzed. Among the 785 patients with positive anti-SSA, 52 patients were identified in this study. They were 27 males and 25 females with median age of 59 years old. Besides anti-SSA antibodies, multiple autoantibodies were detected in these patients including antinuclear antibody, anti-Ro52, anti-mitochondrial M2, anti-thyroid peroxidase and anti-thyroglobulin autoantibodies. Preceding infection was reported in 42 patients. Hyporeflexia/areflexia and limbs weakness were the most common manifestation and 35 patients presented cranial nerve injuries. GBS disability score of 3, 4 and 5 was scaled in 28 (53.8%), 15 (28.8%) and 3 (5.8%) patients respectively. Forty-six patients received intravenous immunoglobulin (IVIG) monotherapy, 5 patients were treated by IVIG plus glucocorticoids, and 51 patients improved during hospitalization. The frequency of male gender among the patients with both GBS and primary SS suggests an independent onset of GBS and the co-existence of these autoimmune diseases in patients with multiple autoantibodies. Majority of patients with GBS and primary SS experience benign disease course.

An unusual occurrence of opsoclonus and liver enzymes elevation in a patient with acute motor and sensory axonal neuropathy subtype of Guillain-Barré syndrome

Background

Acute motor and sensory axonal neuropathy (AMSAN) is a subtype of Guillain-Barré syndrome (GBS) differentiated by nerve conduction studies (NCS) and characterized by symmetric ascending paralysis often involving respiratory muscles. While opsoclonus, which is involuntary chaotic rapid eye movements, is not a common manifestation of GBS. Moreover, little published data are available on the relation between liver enzymes elevation and GBS.

Case presentation

A 42-year-old man presented to Al Mouwassat University Hospital with weakness in all limbs and dyspnea. Examination showed an elevated respiratory rate, hyporeflexia, and decreased strength of upper and lower limbs. Analysis of cerebrospinal fluid revealed an albuminocyto-dissociation suggesting the diagnosis of GBS and subsequent plasmapheresis. NCS confirmed a diagnosis of AMSAN. Elevation in liver enzymes was noticed prompting further exploration with no positive findings. Despite treatment efforts, the patient developed severe dyspnea, deterioration in cognitive abilities, and opsoclonus with a normal brain MRI. Unfortunately, he developed respiratory failure which lead to his death.

Conclusion

In this case, we highlight the occurrence of opsoclonus which is a rarely-encountered manifestation of GBS, in addition to an unexplained elevated liver enzyme, the thing that could contribute to larger research to further comprehend the pathophysiology of GBS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02599-0.

Young woman with Guillain-Barré syndrome and cervical transverse myelitis-A new GBS variant, not coincidence

A case of antibody proven Guillain Barré Syndrome in a previously healthy young female with extra clinical features, scans, and physical exam findings consistent with cervical spine and cervical medullary junction myelitis, together a new variant to consider.

Bickerstaff's brainstem encephalitis associated with ulcerative colitis

A 25-year-old Japanese man showed symptoms of common cold and digestive problems for 1 month. He later developed hypoesthesia ascending from the lower extremities and consulted the emergency outpatient department with the chief complaint of generalised dysesthesia. Because of a history of ulcerative colitis, his condition was initially treated as acute aggravation of the disease; however, after admission, his consciousness level gradually deteriorated. Physical findings showed weakened tendon reflexes, and anti-GQ1b antibodies were strongly positive in the cerebrospinal fluid. Therefore, the patient was diagnosed with Bickerstaff's brainstem encephalitis (BBE). Plasmapheresis was performed 8 times, resulting in an improvement of the symptoms; the patient was discharged 1 month later. Campylobacter infections are the main cause of BBE, and its incidence is high among patients with ulcerative colitis. Therefore, in cases where patients with ulcerative colitis develop disturbance in consciousness, BBE should be included in the differential diagnosis.

External and internal ophthalmoplegia, facial diplegia, ataxia and exaggerated deep tendon reflexes associated with anti-GQ1b antibodies: A new variant of acute ophthalmoparesis

We present the case report of a patient with antibodies to ganglioside GQ1b, who presented with pupillary areflexia, external ophthalmoplegia, ataxia, brisk deep tendon reflexes and facial muscle diplegia following a viral illness. The patient was diagnosed with acute ophthalmoparesis, which is a rare variant of Miller Fisher syndrome that has been characterised recently. We describe a unique presentation of this rare condition, and consider the range of presentations that can occur in association with antibodies to the GQ1b ganglioside.

A pediatric case of Fisher-Bickerstaff spectrum

Miller Fisher syndrome is classically described as an acute inflammatory polyneuropathy clinical variant, associating external ophthalmoplegia, ataxia and loss of tendon reflexes. Despite recent advances in the comprehension of this syndrome, with the description of anti-GQ1b anti-ganglioside antibodies associated with abnormal neuromuscular transmission in the serum of Miller Fisher syndrome patients, there is ongoing debate on the peripheral or central origin of the symptoms. Some authors argue that there is a brainstem and cerebellar involvement. Indeed, since description of the syndrome, numerous cases have been reported with electrophysiologic and imaging evidences of brainstem involvement in the syndrome. Described and discussed here is the case of a 4-year-old child with Miller Fisher syndrome and cerebral lesions evident on magnetic resonance imaging, suggesting a Fisher-Bickerstaff spectrum.

Idiopathic inflammatory-demyelinating diseases of the central nervous system

Idiopathic inflammatory-demyelinating diseases (IIDDs) include a broad spectrum of central nervous system disorders that can usually be differentiated on the basis of clinical, imaging, laboratory and pathological findings. However, there can be a considerable overlap between at least some of these disorders, leading to misdiagnoses or diagnostic uncertainty. The relapsing-remitting and secondary progressive forms of multiple sclerosis (MS) are the most common IIDDs. Other MS phenotypes include those with a progressive course from onset (primary progressive and progressive relapsing) or with a benign course continuing for years after onset (benign MS). Uncommon forms of IIDDs can be classified clinically into: (1) fulminant or acute IIDDs, such as the Marburg variant of MS, Baló's concentric sclerosis, Schilder's disease, and acute disseminated encephalomyelitis; (2) monosymptomatic IIDDs, such as those involving the spinal cord (transverse myelitis), optic nerve (optic neuritis) or brainstem and cerebellum; and (3) IIDDs with a restricted topographical distribution, including Devic's neuromyelitis optica, recurrent optic neuritis and relapsing transverse myelitis. Other forms of IIDD, which are classified clinically and radiologically as pseudotumoral, can have different forms of presentation and clinical courses. Although some of these uncommon IIDDs are variants of MS, others probably correspond to different entities. MR imaging of the brain and spine is the imaging technique of choice for diagnosing these disorders, and together with the clinical and laboratory findings can accurately classify them. Precise classification of these disorders may have relevant prognostic and treatment implications, and might be helpful in distinguishing them from tumoral or infectious lesions, avoiding unnecessary aggressive diagnostic or therapeutic procedures.

GQ1b antibody testing in Guillain-Barre syndrome and variants

Guillain-Barre syndrome (GBS) is characterized by an ascending muscle paralysis with progressive loss of muscle stretch reflexes. Annually, approximately 2.4 cases per 100,000 population of GBS are reported. Variant forms do exist. These include the Fisher syndrome, GBS with ophthalmoplegia, Bickerstaff's brainstem encephalitis (BBE), and acute ophthalmoparesis without ataxia. In the last 15 years, attention has been directed towards the association of the GQ1b IgG antibody and several GBS variants, particularly the Fisher syndrome and those associated with ophthalmoparesis. We present three cases of GBS variants. All three cases had associated ophthalmoplegia but only one of the three had a positive GQ1b antibody association.

Bickerstaff brainstem encephalitis associated with Mycoplasma pneumoniae infection

Bickerstaff brainstem encephalitis is a clinical syndrome of ophthalmoplegia, cerebellar ataxia, and central nervous system signs and is associated with the presence of anti-GQ1b antibodies. There is a clinical continuum between Bickerstaff brainstem encephalitis and Miller Fisher syndrome. We describe the case of an 11-year-old boy with encephalopathy, external ophthalmoplegia, brainstem signs, and ataxia with raised titers of anti-GQ1b antibodies. He presented following a respiratory illness and had laboratory evidence of recent infection with Mycoplasma pneumoniae. M pneumoniae infection has been associated with both Bickerstaff brainstem encephalitis and Miller Fisher syndrome. This is only the second case in the literature of Bickerstaff brainstem encephalitis with raised titers of anti-GQ1b antibodies described in association with M pneumoniae infection. The patient responded to intravenous immunoglobulin administration.

A case of Bickerstaff's brainstem encephalitis; the evidence of cerebellum involvement by SPM analysis using PET

Although the clinical manifestations such as drowsiness, brisk reflexes, extensor plantar responses and hemisensory disturbance usually are considered to suggest Bickerstaff's brainstem encephalitis (BBE) rather than Miller Fisher syndrome (MFS), the nosological relationship between BBE and MFS has yet to be established. Herein, we report upon a 58-year-old man who showed ophthalmoplegia, ataxia and consciousness disturbance. In the absence of any abnormality on brain MRI, electrophysiological studies and SPM analysis using (18)F-FDG PET showed evidence of brainstem and cerebellum involvements.

[Miller Fisher syndrome: case report and review with discussion of differential diagnosis and nosology]

We report a 52-year-old patient with Miller Fisher syndrome and discuss Wernicke's encephalopathy as one important differential diagnosis. This article focuses on diagnostic criteria and possible nosological relations between Miller Fisher syndrome, Guillain-Barré syndrome with ophthalmoplegia, Bickerstaff's brainstem encephalitis, and acute ophthalmoparesis without ataxia.

Acute ophthalmoparesis in the anti-GQ1b antibody syndrome: electrophysiological evidence of neuromuscular transmission defect in the orbicularis oculi

OBJECTIVE

To prospectively study anti-GQ1b antibody positive cases of acute ophthalmoparesis (AO) clinically and electrophysiologically.

METHODS

Nine consecutive cases presenting with predominantly acute ophthalmoplegia were assessed clinically and had stimulated single fibre electromyography (SFEMG) of the orbicularis oculi at presentation. All had magnetic resonance imaging brain scans and anti-GQ1b antibody titres determined.

RESULTS

Four cases had elevated anti-GQ1b antibody titres and abnormal SFEMG studies, which improved in tandem with clinical recovery over three months. Five other anti-GQ1b antibody negative cases were diagnosed as diabetic related cranial neuropathy, idiopathic cranial neuropathy, ocular myasthenia gravis, and Tolosa-Hunt syndrome. All five cases showed complete recovery over a three month period.

CONCLUSIONS

This study demonstrated electrophysiologically the dynamic improvement of neuromuscular transmission of anti-GQ1b antibody positive cases of AO, in tandem with clinical recovery. SFEMG is of value in differentiating weakness due to neuromuscular transmission defect from neuropathy in these clinical situations.

Immunotherapy of idiopathic inflammatory neuropathies

Evaluation of peripheral neuropathy is a common reason for referral to a neurologist. Recent advances in immunology have identified an inflammatory component in many neuropathies and have led to treatment trials using agents that attenuate this response. This article reviews the clinical presentation and treatment of the most common subacute inflammatory neuropathies, Guillain-Barré syndrome (GBS) and Fisher syndrome, and describes the lack of response to corticosteroids and the efficacy of treatment with plasma exchange and intravenous immunoglobulin (IVIG). Chronic inflammatory demyelinating polyneuropathy, although sharing some clinical, electrodiagnostic, and pathologic similarities to GBS, improves after treatment with plasma exchange and IVIG and numerous immunomodulatory agents. Controlled trials in multifocal motor neuropathy have shown benefit after treatment with IVIG and cyclophosphamide. Also discussed is the treatment of less common inflammatory neuropathies whose pathophysiology involves monoclonal proteins or antibodies directed against myelin-associated glycoprotein or sulfatide. Little treatment data exist to direct the clinician to proper management of rare inflammatory neuropathies resulting from osteosclerotic myeloma; POEMS syndrome; vasculitis; Sjögren's syndrome; and neoplasia (paraneoplastic neuropathy).

Miller Fisher syndrome and plasmapheresis

Treatment for Miller Fisher syndrome (MFS) is controversial, and even the natural history and prognosis are not fully understood. We retrospectively reviewed our cases of MFS for the last 3 years. The analysis of 4 MFS cases revealed that we had performed plasmapheresis or additional immunotherapy to each of 4 patients, and their symptoms resolved for up to 50 days after the onset (ataxia improved 20-35 days and ophthalmoplegia for 25-50 days) except for 1 patient, and that Guillain-Barré syndrome had been diagnosed in 1 patient who had developed profound muscle weakness. We also discovered that MFS patients had a deviated T-helper Type-1 (Th1)/T-helper Type-2 (Th2) polarization and that plasmapheresis can shift Th2-dominant status to Th1-dominant status in patients with MFS. Although plasmapheresis may remove humoral factors, including anti-GQ1b, and may induce a shift of the Th1/Th2 cytokine-producing cell balance in peripheral blood, the therapeutic rationale has not yet been established. Therefore, controlled clinical trials are required to show whether plasmapheresis leads to earlier recovery with fewer neurologic deficits in patients with MFS.

Fisher syndrome or Bickerstaff brainstem encephalitis? Anti-GQ1b IgG antibody syndrome involving both the peripheral and central nervous systems

We describe a 27-year-old woman who showed the clinical triad of Fisher syndrome (ophthalmoplegia, ataxia, and areflexia), a disturbance of consciousness, facial diplegia, and hemisensory loss. Her serum was positive for anti-GQ1b immunoglobulin G (IgG) antibody. The electroencephalographic findings (diffuse slow activity), median somatosensory evoked potential (absent cortical N20 with normal cervical N13), and blink reflex studies (absent R2) suggested central dysfunction, whereas results of facial nerve conduction studies (low amplitudes of compound muscle action potentials), F-wave and H-reflex studies (absent F-waves and soleus H-reflexes), and brainstem auditory evoked potentials (prolongation of wave I latency) suggested peripheral abnormalities. This case supports the hypothesized continuity between Fisher syndrome and Bickerstaff brainstem encephalitis. These two conditions may represent a single autoimmune disease mediated by anti-GQ1b antibody, usually involving the peripheral and occasionally the central nervous systems.