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Du Y, Wang W, Zhang L, Li Y, Chen X, Yang H, Ding X. Case report on anti-GQ1b antibody syndrome: initial symptoms of pupil palsy and periorbital pain. Front Immunol 2024; 15:1474354. [PMID: 39742267 PMCID: PMC11685045 DOI: 10.3389/fimmu.2024.1474354] [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: 08/09/2024] [Accepted: 11/26/2024] [Indexed: 01/03/2025] Open
Abstract
Anti-GQ1b antibody syndrome is a spectrum of autoimmune disorders affecting nervous systems. We report a case of a 53-year-old woman presenting mydriasis with acute onset of periorbital pain, photophobia, and subsequently, diplopia. Despite weakly positive anti-GQ1b IgG antibody, the patient exhibited atypical features with isolated ophthalmoplegia and absence of classic Miller-Fisher syndrome triad. Symptoms improved spontaneously without specific immunotherapy. This case highlights the variable clinical presentations of anti-GQ1b antibody syndrome, emphasizing the importance of considering this diagnosis in patients with unexplained iris abnormalities and ophthalmoplegia.
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Affiliation(s)
- Yang Du
- Department of Neurology, Chengdu Second People's Hospital, Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Weidong Wang
- Department of Neurology, Chengdu Second People's Hospital, Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
- School of Clinical Medicine, Chengdu Medical College, Chengdu, Sichuan, China
| | - Lili Zhang
- Department of Neurology, Chengdu Second People's Hospital, Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Yuan Li
- Department of Neurology, Chengdu Second People's Hospital, Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
- School of Clinical Medicine, Chengdu Medical College, Chengdu, Sichuan, China
| | - Xiang Chen
- Department of Neurology, Chengdu Second People's Hospital, Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
- School of Clinical Medicine, Chengdu Medical College, Chengdu, Sichuan, China
| | - Hui Yang
- Department of Neurology, First AffiIiated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Xin Ding
- Department of Neurology, Chengdu Second People's Hospital, Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
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Lee SU, Kim HJ, Choi JY, Choi KD, Kim JS. Expanding Clinical Spectrum of Anti-GQ1b Antibody Syndrome: A Review. JAMA Neurol 2024; 81:762-770. [PMID: 38739407 DOI: 10.1001/jamaneurol.2024.1123] [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: 05/14/2024]
Abstract
Importance The discovery of the anti-GQ1b antibody has expanded the nosology of classic Miller Fisher syndrome to include Bickerstaff brainstem encephalitis, Guillain-Barré syndrome with ophthalmoplegia, and acute ophthalmoplegia without ataxia, which have been brought under the umbrella term anti-GQ1b antibody syndrome. It seems timely to define the phenotypes of anti-GQ1b antibody syndrome for the proper diagnosis of this syndrome with diverse clinical presentations. This review summarizes these syndromes and introduces recently identified subtypes. Observations Although ophthalmoplegia is a hallmark of anti-GQ1b antibody syndrome, recent studies have identified this antibody in patients with acute vestibular syndrome, optic neuropathy with disc swelling, and acute sensory ataxic neuropathy of atypical presentation. Ophthalmoplegia associated with anti-GQ1b antibody positivity is complete in more than half of the patients but may be monocular or comitant. The prognosis is mostly favorable; however, approximately 14% of patients experience relapse. Conclusions and Relevance Anti-GQ1b antibody syndrome may present diverse neurological manifestations, including ophthalmoplegia, ataxia, areflexia, central or peripheral vestibulopathy, and optic neuropathy. Understanding the wide clinical spectrum may aid in the differentiation and management of immune-mediated neuropathies with multiple presentations.
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Affiliation(s)
- Sun-Uk Lee
- Department of Neurology, Korea University Medical Center, Seoul, South Korea
- Neurotology and Neuro-ophthalmology Laboratory, Korea University Anam Hospital, Seoul, South Korea
| | - Hyo-Jung Kim
- Biomedical Research Institute, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jeong-Yoon Choi
- Dizziness Center, Clinical Neuroscience Center, Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea
- Deparment of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Kwang-Dong Choi
- Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Pusan, South Korea
| | - Ji-Soo Kim
- Dizziness Center, Clinical Neuroscience Center, Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea
- Deparment of Neurology, Seoul National University College of Medicine, Seoul, South Korea
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Willeford KT, Copel V, Rong H. A protocol to quantify cross-sectional and longitudinal differences in duction patterns. Front Neurosci 2024; 18:1324047. [PMID: 38919910 PMCID: PMC11196818 DOI: 10.3389/fnins.2024.1324047] [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] [Received: 10/18/2023] [Accepted: 05/27/2024] [Indexed: 06/27/2024] Open
Abstract
Currently, there is no established system for quantifying patterns of ocular ductions. This poses challenges in tracking the onset and evolution of ocular motility disorders, as current clinical methodologies rely on subjective observations of individual movements. We propose a protocol that integrates image processing, a statistical framework of summary indices, and criteria for evaluating both cross-sectional and longitudinal differences in ductions to address this methodological gap. We demonstrate that our protocol reliably transforms objective estimates of ocular rotations into normative patterns of total movement area and movement symmetry. This is a critical step towards clinical application in which our protocol could first diagnose and then track the progression and resolution of ocular motility disorders over time.
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Affiliation(s)
- Kevin T. Willeford
- Department of Optometric Sciences, NOVA Southeastern University College of Optometry, Fort Lauderdale, FL, United States
| | - Victoria Copel
- Department of Optometric Sciences, NOVA Southeastern University College of Optometry, Fort Lauderdale, FL, United States
| | - Hua Rong
- Tianjin International Joint Research and Development Centre of Ophthalmology and Vision Science, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
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Yu H, Ding M, Cao Q, Zhou R, Yao J, Fu R, Liu Y, Xiao Z, Lu Z. Clinical Features and Differences of Miller Fisher Syndrome in Southern China: Retrospective Analysis of 72 Patients in 13 Provinces of Southern China. J Clin Neurol 2023; 19:589-596. [PMID: 37455512 PMCID: PMC10622728 DOI: 10.3988/jcn.2022.0370] [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: 09/27/2022] [Revised: 01/20/2023] [Accepted: 03/20/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND AND PURPOSE We aimed to determine the clinical features of Miller Fisher syndrome (MFS) in southern China and compare them with those presenting in other countries. METHODS We collected the medical records of patients diagnosed with MFS during 2013-2016. We analyzed the age, sex, onset season, precursor events, clinical symptoms and signs, findings of nerve conduction studies (NCS), cerebrospinal fluid (CSF), therapeutic remedies, nadir time, and length of hospital stay of patients with MFS in southern China. We concurrently compared the differences between urban and rural areas and between patients with incomplete ophthalmoplegia (IO) and complete ophthalmoplegia (CO). RESULTS The study enrolled 72 patients: 36 from rural areas and 36 from urban areas, and 50 males and 22 females. The mean age at onset was 47.72 years, and 30 (41.7%) and 21 (29.2%) patients developed MFS in spring and winter, respectively. The typical triad of ophthalmoplegia, ataxia, and areflexia was observed in 50 (69.4%) patients. A history of upper respiratory tract infection 1 week before onset was found in 52.8% of the patients, while 5.6% experienced gastrointestinal infections and 48 (73.8%) exhibited albuminocytological dissociation in the CSF study. Only 26 (36.1%) patients presented abnormalities in NCS. Moreover, restricted outward eyeball movement presented in 83.5% of the patients with classic MFS and acute ophthalmoplegia, and bilateral symmetrical ophthalmoplegia presented in 64.2%. With the exception of the higher proportion of NCS abnormalities in urban areas (47.2% vs. 25.0%), urban and rural differences were insignificant regarding sex ratio, age at onset, high-incidence season, precursor events, disease characteristics, and albuminocytological dissociation in the CSF. Furthermore, patients with CO were older than those with IO (64.53±7.69 vs. 43.19±14.40 years [mean±standard deviation], p<0.001). CONCLUSIONS The patients with MFS were mostly male and middle-aged, and most presented in winter and (especially) spring. More than half of the patients had clear precursor events, most of which were classic MFS with the typical triad. More than 70% of the patients presented albuminocytological dissociation in the CSF. NCS abnormalities were uncommon in MFS. The age at onset was lower in patients with IO than in patients with CO; bilateral symmetrical extraocular muscle paralysis was the most common symptom, and the external rectus was the most frequently involved muscle.
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Affiliation(s)
- Hang Yu
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Man Ding
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qian Cao
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Rumeng Zhou
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jiajia Yao
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Rong Fu
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yue Liu
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zheman Xiao
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zuneng Lu
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China.
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Yvon C, Nee D, Chan D, Malhotra R. Ophthalmoplegia associated with anti-GQ1b antibodies: case report and review. Orbit 2023; 42:192-195. [PMID: 34493154 DOI: 10.1080/01676830.2021.1974495] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A 60-year-old man with longstanding bilateral asymmetrical ptosis presented with a partial third nerve palsy. His diplopia improved following an ice pack test. He did not report any symptoms related to the coronavirus disease 2019 (COVID-19), and nasopharyngeal swab was negative. Initial head imaging and blood work-up were normal except for a high titer of anti-GQ1b antibodies. The patient was subsequently diagnosed with acute ophthalmoparesis without ataxia which is part of the anti-GQ1b antibody syndrome spectrum. He made a spontaneous recovery over the following months without the need for immunotherapy. Clinical features, pathophysiology and a review of the literature are discussed herein. It is important to consider anti-GQ1b antibody syndrome in patients with symptoms of diplopia, ptosis or suspected ocular myasthenia.
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Affiliation(s)
- Camille Yvon
- Corneoplastics Unit, Queen Victoria Hospital NHS Trust, East Grinstead, UK
| | - Dominic Nee
- Neurology Department, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Dennis Chan
- Neurology Department, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Raman Malhotra
- Corneoplastics Unit, Queen Victoria Hospital NHS Trust, East Grinstead, UK
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Keene KR, Kan HE, van der Meeren S, Verbist BM, Tannemaat MR, Beenakker JM, Verschuuren JJ. Clinical and imaging clues to the diagnosis and follow-up of ptosis and ophthalmoparesis. J Cachexia Sarcopenia Muscle 2022; 13:2820-2834. [PMID: 36172973 PMCID: PMC9745561 DOI: 10.1002/jcsm.13089] [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: 04/29/2022] [Revised: 08/15/2022] [Accepted: 08/19/2022] [Indexed: 12/15/2022] Open
Abstract
Ophthalmoparesis and ptosis can be caused by a wide range of rare or more prevalent diseases, several of which can be successfully treated. In this review, we provide clues to aid in the diagnosis of these diseases, based on the clinical symptoms, the involvement pattern and imaging features of extra-ocular muscles (EOM). Dysfunction of EOM including the levator palpebrae can be due to muscle weakness, anatomical restrictions or pathology affecting the innervation. A comprehensive literature review was performed to find clinical and imaging clues for the diagnosis and follow-up of ptosis and ophthalmoparesis. We used five patterns as a framework for differential diagnostic reasoning and for pattern recognition in symptomatology, EOM involvement and imaging results of individual patients. The five patterns were characterized by the presence of combination of ptosis, ophthalmoparesis, diplopia, pain, proptosis, nystagmus, extra-orbital symptoms, symmetry or fluctuations in symptoms. Each pattern was linked to anatomical locations and either hereditary or acquired diseases. Hereditary muscle diseases often lead to ophthalmoparesis without diplopia as a predominant feature, while in acquired eye muscle diseases ophthalmoparesis is often asymmetrical and can be accompanied by proptosis and pain. Fluctuation is a hallmark of an acquired synaptic disease like myasthenia gravis. Nystagmus is indicative of a central nervous system lesion. Second, specific EOM involvement patterns can also provide valuable diagnostic clues. In hereditary muscle diseases like chronic progressive external ophthalmoplegia (CPEO) and oculo-pharyngeal muscular dystrophy (OPMD) the superior rectus is often involved. In neuropathic disease, the pattern of involvement of the EOM can be linked to specific cranial nerves. In myasthenia gravis this pattern is variable within patients over time. Lastly, orbital imaging can aid in the diagnosis. Fat replacement of the EOM is commonly observed in hereditary myopathic diseases, such as CPEO. In contrast, inflammation and volume increases are often observed in acquired muscle diseases such as Graves' orbitopathy. In diseases with ophthalmoparesis and ptosis specific patterns of clinical symptoms, the EOM involvement pattern and orbital imaging provide valuable information for diagnosis and could prove valuable in the follow-up of disease progression and the understanding of disease pathophysiology.
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Affiliation(s)
- Kevin R. Keene
- CJ Gorter MRI Center, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of NeurologyLeiden University Medical CenterLeidenThe Netherlands
| | - Hermien E. Kan
- CJ Gorter MRI Center, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
- Duchenne CenterThe Netherlands
| | - Stijn van der Meeren
- Department of OphthalmologyLeiden University Medical CenterLeidenThe Netherlands
- Orbital Center, Department of OphthalmologyAmsterdam University Medical CentersAmsterdamThe Netherlands
| | - Berit M. Verbist
- Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | | | - Jan‐Willem M. Beenakker
- CJ Gorter MRI Center, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of OphthalmologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Radiation OncologyLeiden University Medical CenterLeidenThe Netherlands
| | - Jan J.G.M. Verschuuren
- Department of NeurologyLeiden University Medical CenterLeidenThe Netherlands
- Duchenne CenterThe Netherlands
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Jones DL, Ma J, Yang M, Duong A, Richani K. Pediatric Ptosis: A Review of Less Common Causes. Int Ophthalmol Clin 2022; 62:177-202. [PMID: 34965234 DOI: 10.1097/iio.0000000000000389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ravlic MM, Knezevic L, Krolo I, Herman JS. Ocular Manifestations of Miller Fisher Syndrome: a Case Report. Med Arch 2021; 75:234-236. [PMID: 34483456 PMCID: PMC8385741 DOI: 10.5455/medarh.2021.75.234-236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 04/20/2021] [Indexed: 11/04/2022] Open
Abstract
Background: Miller Fisher syndrome (MFS) is a variant of Guillain-Barré syndrome and is characterised by a clinical triad of ophthalmoplegia, ataxia and areflexia. Objectives: This report presents an atypical case of MFS characterized by ocular and gastrointestinal involvement, and anti-ganglioside antibody-positivity. Methods: A 17-year old boy was referred to our ophthalmology emergency room with signs and symptoms of diplopia and upper lid ptosis of the right eye. He underwent a complete ophthalmologic examination with special reference to strabologic status, as well as a neuropediatric examination with serum antiganglioside antibody panel. Results: Strabologic examination showed horisontal diplopia (near and far), ptosis of the upper eyelid on the right and bilateral ophthalmoplegia (limited elevation). Orthoptic examination revealed esotropia of 8 prism dioptres (PD) at near and 18 PD at far distance. A pediatric neurologist found normal limb power, deep tendon reflexes and flexor plantar responses, but attenuated right patellar reflex. Serum anti-GQ1b IgG (+++), anti-GQ1b IgM (++) and anti-GD1a IgM(++) were positive. Positivity of anti-GQ1b IgG antibody confirmed the existence of incomplete MFS. We treated the patient with systemic intravenous immunoglobulins for five days, and after five months of follow-up, all symptoms resolved. Conclusion: MFS can present itself as a wide range of clinical features and its timely recognition is important. Despite the alarming nature of the disease, patients with MFS tend to have a good recovery of presented symptoms, and without any significant residual deficit.
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Affiliation(s)
- Maja Malenica Ravlic
- Department of Ophthalmology, University Hospital Center Sestre milosrdnice, Zagreb, Croatia
| | - Lana Knezevic
- Department of Ophthalmology, University Hospital Center Sestre milosrdnice, Zagreb, Croatia
| | - Iva Krolo
- Department of Ophthalmology, University Hospital Center Sestre milosrdnice, Zagreb, Croatia
| | - Jelena Skunca Herman
- Department of Ophthalmology, University Hospital Center Sestre milosrdnice, Zagreb, Croatia
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