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Maddison P, Lang B, Thomsen S, Moloney TC, Gozzard P, Chapman CJ, Barnard V, Ferry B, Vincent A. Prospective study of cancer survival in patients with HuD-antibody-associated paraneoplastic neurological disorders. J Neurol Neurosurg Psychiatry 2021; 92:1350-1351. [PMID: 33785578 DOI: 10.1136/jnnp-2021-326067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/17/2021] [Accepted: 03/08/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Paul Maddison
- Department of Neurology, Nottingham University Hospitals NHS Trust, Nottingham, Nottingham, UK
| | - Bethan Lang
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Selina Thomsen
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Teresa C Moloney
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Paul Gozzard
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Caroline J Chapman
- Department of Pathology, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
| | - Victoria Barnard
- Clinical Laboratory Immunology, Churchill Hospital, Oxford, Oxfordshire, UK
| | - Berne Ferry
- Clinical Laboratory Immunology, Churchill Hospital, Oxford, Oxfordshire, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Department of Neurosciences, Weatherall Institute of Molecular Medicine, Oxford, Oxfordshire, UK
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Maddison P, Gozzard P, Sadalage G, Ambrose PA, Chapman CJ, Murray A, Thomsen S, Berretta A, Lang B. Neuronal antibody detection and improved lung cancer prediction in Lambert-Eaton myasthenic syndrome. J Neuroimmunol 2020; 340:577149. [PMID: 31951874 DOI: 10.1016/j.jneuroim.2020.577149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/09/2020] [Accepted: 01/09/2020] [Indexed: 10/25/2022]
Abstract
Since approximately 50% of patients with Lambert-Eaton myasthenic syndrome (LEMS) subsequently develop small-cell lung cancer (SCLC), it is important to be able to predict cancer occurrence in these patients at neurological presentation. We aimed to determine whether circulating biomarkers were effective and objective predictors of cancer development in LEMS. We found that the presence of either SOX2, N-type voltage gated calcium channel or GABAb antibodies at LEMS diagnosis was highly sensitive (84%) and specific (87%) for the detection of SCLC. Screening for SOX2 and neuronal antibodies is a useful adjunct to clinical predictive scoring tools in predicting SCLC in LEMS.
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Affiliation(s)
- Paul Maddison
- Department of Neurology, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham NG7 2UH, UK.
| | - Paul Gozzard
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield S10 2JF, UK
| | - Girija Sadalage
- Division of Neurology, University of Nottingham, Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, UK
| | - Philip A Ambrose
- Division of Neurology, University of Nottingham, Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, UK
| | - Caroline J Chapman
- Department of Pathology, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | | | - Selina Thomsen
- Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, John Radcliffe Hospital, Oxford OX3 9DS, UK
| | - Antonio Berretta
- Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, John Radcliffe Hospital, Oxford OX3 9DS, UK
| | - Bethan Lang
- Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, John Radcliffe Hospital, Oxford OX3 9DS, UK
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Das J, McKenzie S, Gozzard P, Pattrick M, O’Malley R, Payne T, Grunewald R, Harkness K. 286 Hyperacute stroke unit and hyperacute neurology unit under one roof. J Neurol Neurosurg Psychiatry 2018. [DOI: 10.1136/jnnp-2018-abn.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The Acute neurology unit (ANU), located at the Royal Hallamshire Hospital, Sheffield is a regional centre for a population of approximately 1.5 million. We are unusual, as our neurologists manage both hyperacute stroke and hyperacute neurology. HASU is located within our ANU. We had 4026 neurology ward admissions, 3265 emergency cases and 761 elective cases last year. We receive acute admissions from Trust A and E, direct admissions from general practitioners and urgent transfers from DGHs.We provide 24 hour stroke thrombolysis and a weekday working hours thrombectomy service. Overnight thrombolysis is supervised through a regional ‘Telemedicine’ system. A 2 week survey in July 2017 showed that only 59% patients, who were referred with suspected stroke, had stroke/TIA. Neurological conditions, such as migraine, seizure, syncope, acute vestibulopathy, Bell’s palsy and medically unexplained symptoms were common ‘stroke mimics’. 46% of patients with ‘stroke mimic’ were discharged on the day of admission. Average length of stay was 3 days. A separate survey of acute neurology referrals showed that 58% of patients did not require admission and were managed through an ambulatory care pathway. Patient satisfaction regarding their rapid assessment and diagnosis was high. Co-location of ANU and HASU allows rapid and effective management of ‘stroke mimics’.
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Maddison P, Sadalage G, Gozzard P, Thomsen S, Lang B. PO206 Lambert-eaton myasthenic syndrome – results from bnsu survey. J Neurol Neurosurg Psychiatry 2017. [DOI: 10.1136/jnnp-2017-abn.227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Maddison P, Gozzard P, Grainge MJ, Lang B. Long-term survival in paraneoplastic Lambert-Eaton myasthenic syndrome. Neurology 2017; 88:1334-1339. [DOI: 10.1212/wnl.0000000000003794] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 01/17/2017] [Indexed: 01/19/2023] Open
Abstract
Objective:To establish whether improved tumor survival in patients with Lambert-Eaton myasthenic syndrome (LEMS) and small-cell lung cancer (SCLC) was due to known prognostic risk factors or an effect of LEMS independently, perhaps as a result of circulating factors.Methods:We undertook a prospective observational cohort study of patients with LEMS attending Nottingham University Hospitals, UK, or via the British Neurological Surveillance Unit. In parallel, patients with a new diagnosis of biopsy-proven SCLC were enrolled, examined for neurologic illness, and followed up until death or study end.Results:Between May 2005 and November 2014, we recruited 31 patients with LEMS and SCLC and 279 patients with SCLC without neurologic illness. Allowing for known SCLC survival prognostic factors of disease extent, age, sex, performance status, and sodium values, multivariate Cox regression analysis showed that the presence of LEMS with SCLC conferred a significant survival advantage independently of the other prognostic variables (hazard ratio 1.756, 95% confidence interval 1.137–2.709, p = 0.011).Conclusions:Improved SCLC tumor survival seen in patients with LEMS and SCLC may not be due solely to lead time bias, given that survival advantage remains after allowing for other prognostic factors and that the same degree of survival advantage is not seen in patients with paraneoplastic neurologic syndromes other than LEMS presenting before SCLC diagnosis.
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Gozzard P, Chapman C, Vincent A, Lang B, Maddison P. Novel Humoral Prognostic Markers in Small-Cell Lung Carcinoma: A Prospective Study. PLoS One 2015; 10:e0143558. [PMID: 26606748 PMCID: PMC4659625 DOI: 10.1371/journal.pone.0143558] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 11/05/2015] [Indexed: 01/01/2023] Open
Abstract
Purpose Favourable small cell lung carcinoma (SCLC) survival outcomes have been reported in patients with paraneoplastic neurological disorders (PNDs) associated with neuronal antibodies (Neur-Abs), but the presence of a PND might have expedited diagnosis. Our aim was to establish whether neuronal antibodies, independent of clinical neurological features, correlate with SCLC survival. Experimental Design 262 consecutive SCLC patients were examined: of these, 24 with neurological disease were excluded from this study. The remaining 238 were tested for a broad array of Neur-Abs at the time of cancer diagnosis; survival time was established from follow-up clinical data. Results Median survival of the non-PND cohort (n = 238) was 9.5 months. 103 patients (43%) had one or more antigen-defined Neur-Abs. We found significantly longer median survival in 23 patients (10%) with HuD/anti-neuronal nuclear antibody type 1 (ANNA-1, 13.0 months P = 0.037), but not with any of the other antigen-defined antibodies, including the PND-related SOX2 (n = 56, 24%). An additional 28 patients (12%) had uncharacterised anti-neuronal nuclear antibodies (ANNA-U); their median survival time was longer still (15.0 months, P = 0.0048), contrasting with the survival time in patients with non-neuronal anti-nuclear antibodies (detected using HEp-2 cells, n = 23 (10%), 9.25 months). In multivariate analyses, both ANNA-1 and ANNA-U independently reduced the mortality hazard by a ratio of 0.532 (P = 0.01) and 0.430 (P<0.001) respectively. Conclusions ANNAs, including the newly described ANNA-U, may be key components of the SCLC immunome and have a potential role in predicting SCLC survival; screening for them could add prognostic value that is similar in magnitude to that of limited staging at diagnosis.
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Affiliation(s)
- Paul Gozzard
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
- * E-mail:
| | - Caroline Chapman
- Division of Medical Sciences & Graduate Entry Medicine, University of Nottingham, Royal Derby Hospital, Derby, United Kingdom
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Bethan Lang
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Paul Maddison
- Division of Clinical Neuroscience, University of Nottingham, Queen’s Medical Centre, Nottingham, United Kingdom
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Gozzard P, Woodhall M, Chapman C, Nibber A, Waters P, Vincent A, Lang B, Maddison P. Paraneoplastic neurologic disorders in small cell lung carcinoma: A prospective study. Neurology 2015; 85:235-9. [PMID: 26109714 DOI: 10.1212/wnl.0000000000001721] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 03/23/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the frequency and range of paraneoplastic neurologic disorders (PNDs) and neuronal antibodies in small cell lung carcinoma (SCLC). METHODS Two hundred sixty-four consecutive patients with biopsy-proven SCLC were recruited at the time of tumor diagnosis. All patients underwent full neurologic examination. Serum samples were taken prior to chemotherapy and analyzed for 15 neuronal antibodies. Thirty-eight healthy controls were analyzed in parallel. RESULTS PNDs were quite prevalent (n = 24, 9.4%), most frequently Lambert-Eaton myasthenic syndrome (3.8%), sensory neuronopathy (1.9%), and limbic encephalitis (1.5%). Eighty-seven percent of all patients with PNDs had antibodies to SOX2 (62.5%), HuD (41.7%), or P/Q VGCC (50%), irrespective of their syndrome. Other neuronal antibodies were found at lower frequencies (GABAb receptor [12.5%] and N-type VGCC [20.8%]) or very rarely (GAD65, amphiphysin, Ri, CRMP5, Ma2, Yo, VGKC complex, CASPR2, LGI1, and NMDA receptor [all <5%]). CONCLUSIONS The spectrum of PNDs is broader and the frequency is higher than previously appreciated, and selected antibody tests (SOX2, HuD, VGCC) can help determine the presence of an SCLC.
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Affiliation(s)
- Paul Gozzard
- From the Nuffield Department of Clinical Neurosciences (P.G., M.W., A.N., P.W., A.V., B.L.), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Division of Medical Sciences & Graduate Entry Medicine (C.C.), University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; and Division of Neurology (P.M.), Queen's Medical Centre, Nottingham, United Kingdom.
| | - Mark Woodhall
- From the Nuffield Department of Clinical Neurosciences (P.G., M.W., A.N., P.W., A.V., B.L.), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Division of Medical Sciences & Graduate Entry Medicine (C.C.), University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; and Division of Neurology (P.M.), Queen's Medical Centre, Nottingham, United Kingdom
| | - Caroline Chapman
- From the Nuffield Department of Clinical Neurosciences (P.G., M.W., A.N., P.W., A.V., B.L.), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Division of Medical Sciences & Graduate Entry Medicine (C.C.), University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; and Division of Neurology (P.M.), Queen's Medical Centre, Nottingham, United Kingdom
| | - Anjan Nibber
- From the Nuffield Department of Clinical Neurosciences (P.G., M.W., A.N., P.W., A.V., B.L.), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Division of Medical Sciences & Graduate Entry Medicine (C.C.), University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; and Division of Neurology (P.M.), Queen's Medical Centre, Nottingham, United Kingdom
| | - Patrick Waters
- From the Nuffield Department of Clinical Neurosciences (P.G., M.W., A.N., P.W., A.V., B.L.), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Division of Medical Sciences & Graduate Entry Medicine (C.C.), University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; and Division of Neurology (P.M.), Queen's Medical Centre, Nottingham, United Kingdom
| | - Angela Vincent
- From the Nuffield Department of Clinical Neurosciences (P.G., M.W., A.N., P.W., A.V., B.L.), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Division of Medical Sciences & Graduate Entry Medicine (C.C.), University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; and Division of Neurology (P.M.), Queen's Medical Centre, Nottingham, United Kingdom
| | - Bethan Lang
- From the Nuffield Department of Clinical Neurosciences (P.G., M.W., A.N., P.W., A.V., B.L.), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Division of Medical Sciences & Graduate Entry Medicine (C.C.), University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; and Division of Neurology (P.M.), Queen's Medical Centre, Nottingham, United Kingdom
| | - Paul Maddison
- From the Nuffield Department of Clinical Neurosciences (P.G., M.W., A.N., P.W., A.V., B.L.), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Division of Medical Sciences & Graduate Entry Medicine (C.C.), University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; and Division of Neurology (P.M.), Queen's Medical Centre, Nottingham, United Kingdom
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Kalra S, Gozzard P, Leonard A, Maddison P, Jacob S. PARANEOPLASTIC LIMBIC ENCEPHALITIS AND LAMBERT EATON MYASTHENIA–AN IMMUNOLOGICAL PROFILE OF A NEW SYNDROME? J Neurol Neurosurg Psychiatry 2013. [DOI: 10.1136/jnnp-2013-306573.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Maddison P, Gozzard P. LAMBERT–EATON MYASTHENIC SYNDROME–RESULTS FROM THE BNSU SURVEY. J Neurol Neurosurg Psychiatry 2013. [DOI: 10.1136/jnnp-2013-306573.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune disorder mediated by autoantibodies to voltage-gated calcium channels. The disorder is diagnosed clinically on the basis of a triad of symptoms (proximal muscle weakness, hyporeflexia, and autonomic disturbance), supported by electrophysiological findings and the presence of autoantibodies. Between 40% and 62% of patients diagnosed with LEMS are found to have small-cell lung cancer (SCLC), almost all of whom develop neurological symptoms before their cancer is diagnosed. Prompt identification of LEMS and appropriate screening for SCLC is key to improving the outcome of both conditions. Here we review the pathophysiology and clinical management of LEMS, focusing particularly on the relationship with SCLC.
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Affiliation(s)
- Sarah Ew Briggs
- Department of Oncology, Oxford University Hospitals Trust, Churchill Hospital, Oxford, UK
| | - Paul Gozzard
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford UK
| | - Denis C Talbot
- Department of Oncology, Oxford University Hospitals Trust, Churchill Hospital, Oxford, UK
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Barua A, Gozzard P, Martin-Ucar AE, Maddison P. Neuronal antibodies and paraneoplastic sensory neuropathy in thymoma. Interact Cardiovasc Thorac Surg 2012; 15:516-7. [PMID: 22617508 DOI: 10.1093/icvts/ivs207] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Thymoma, a common anterior mediastinal tumour, may present with paraneoplastic neurological symptoms. The presence of neuronal anti-Hu paraneoplastic antibodies in thymoma patients is very rare. Here, we describe a patient who presented with symptoms of a sensory peripheral neuropathy in the presence of onconeural antibodies cross-reactive with Hu antigen, in whom an underlying thymoma was diagnosed. Subsequent minimally invasive thymomectomy improved her neurological symptoms significantly.
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Affiliation(s)
- Anupama Barua
- Thoracic Surgery Department, Nottingham City Hospital, Nottingham, UK
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Maddison P, Gozzard P, Jaspan T. 0918 Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS): no evidence for antibodies to neuronal surface antigens. J Neurol Psychiatry 2012. [DOI: 10.1136/jnnp-2011-301993.42] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Maddison P, Titulaer MJ, Verschuuren JJG, Gozzard P, Lang B, Willcox N, Vincent A, Irani SR, Chapman CJ. 1600 The utility of SOX antibodies for cancer prediction in patients with paraneoplastic neurological disorders. J Neurol Neurosurg Psychiatry 2012. [DOI: 10.1136/jnnp-2011-301993.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Gozzard P, Orr D, Sanderson F, Sandberg M, Kennedy A. Acute transverse myelitis as a rare manifestation of Campylobacter diarrhoea with concomitant disruption of the blood brain barrier. J Clin Neurosci 2011; 19:316-8. [PMID: 22133816 DOI: 10.1016/j.jocn.2011.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Accepted: 07/08/2011] [Indexed: 12/17/2022]
Abstract
We describe a case of acute transverse myelitis following Campylobacter diarrhoea in an adult. The patient presented with diplegia due to a longitudinal spinal cord lesion. The CSF demonstrated an aseptic meningitis. Oligoclonal bands and C. jejuni-specific IgG were detected in serum and cerebrospinal fluid at the beginning of the neurological illness. The patient was treated with antimicrobial therapy and steroids. A near full recovery was made and there were no relapses. C. jejuni is strongly implicated in the aetiology of acute motor axonal neuropathy and Miller Fisher syndrome through molecular mimicry of neuronal gangliosides. These gangliosides are expressed throughout the nervous system yet C. jejuni related central nervous system disease is exceedingly rare. We conclude that disruption of the blood-brain barrier was the key event in the pathogenesis of immune mediated post-infectious myelitis in our patient.
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Affiliation(s)
- Paul Gozzard
- Department of Neurology, Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, UK.
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Abstract
Paraneoplastic neurological syndromes can be associated with the presence of onconeural antibodies. These antibodies are the result of an immune response against a tumour that is ectopically expressing a neuronal antigen. The 'classical' onconeural antibodies (anti-Hu, Yo, Ma2, CRMP-5, amphiphysin and Ri) are directed against intracellular antigens and are strongly associated with underlying malignancy. By contrast, onconeural antibodies directed against cell surface antigens (eg, anti-NMDA, VGKC, AChR) have a weaker tumour association. This article gives a practical overview of the tumour associations, and the neurological associations, of the onconeural antibodies. There is also guidance on how to investigate occult malignancy in antibody positive cases.
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Affiliation(s)
- Paul Gozzard
- Division of Clinical Neurology, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
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Gozzard P, Soon D, Vincent A, Lang B. POC19 Anti-Hu paraneoplastic sensory neuronopathy with underlying squamous cell carcinoma of the lung. Journal of Neurology, Neurosurgery & Psychiatry 2010. [DOI: 10.1136/jnnp.2010.226340.89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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