Periodic alternating gaze: a case without any hemispheric lesion

A case of surgically-associated anti GQ1b antibody syndrome accompanied by saccadic ping pong gaze

Background

Periodic alternating ping-pong gaze (PPG) is a rare disease with few reports. To our knowledge, there was no report on anti GQ1b antibody syndrome accompanied by PPG. This paper reported a case of anti GQ1b antibody syndrome with Bickerstaff’s Encephalitis (BBE) overlapping classic Guillain-Barre Syndrome (GBS) after aortic valve replacement, accompanied by an excessive PPG in the course of diagnosis and treatment, this was indeed rarely.

Case presentation

A 55-year-old male patient was admitted to our hospital with intermittent chest tightness for 3 months, and his condition has worsened in the past 10 days. Aortic valve replacement was performed because of the existence of the moderate and severe stenosis of aortic valve. Horizontal movement of the eyeball was involuntarily slow. The eyeball hovered and returned from one side to the other horizontally for 3–4 s per cycle. In combination with the patient’s typical clinical and laboratory tests, the final diagnosis was anti GQ1b antibody syndrome BBE combined with GBS, accompanied by saccadic ping pong gaze. Intravenous immunoglobulin (0.4 g/kg) was given for immunomodulation, methylprednisolone (1000 mg) therapy and symptomatic treatment were performed in the patient.

Conclusions

The patients were discharged from hospital on the thirtieth day because of economic reasons. After 6 months of follow up, the patients left behind a lack of fluency in speech and limb mobility, but the basic life can be taken care of by himself.

Electronic supplementary material

The online version of this article (10.1186/s12883-019-1258-x) contains supplementary material, which is available to authorized users.

A closer look at ping-pong gaze: an observational study and literature review

BACKGROUND

Little is known about ping-pong gaze (PPG) outside of individual case reports. We aimed to describe PPG through an observational study and literature review.

METHODS

Consecutive patients with PPG at Shanghai General Hospital (SGH) from February 2016 to March 2018 were enrolled. A literature review through March 2018 was conducted.

RESULTS

Of the 14 patients with PPG in SGH, the median age was 60 years and 12 were males. The median Glasgow coma scale score was 7.5. The cycle of the PPG ranged from 1.5 to 6.5 s. The leading three etiologies were acute ischemic stroke in five patients, post-seizure state in three patients, and hypoxic-ischemic encephalopathy in two patients. A total of 88.9% (8/9) of the patients with consistent whole-field PPG had similar bilateral hemispheric damage, whereas 80.0% (4/5) of the patients with PPG in the hemifield had unilateral or extremely asymmetric bilateral hemispheric damage. The hemifiled side was the same side as the sole/dominant hemispheric lesion. The final clinical outcomes were neurologic remission for seven patients, vegetative state for one patient, and death for six patients.

CONCLUSIONS

PPG is a sign with localizing value that suggests hemispheric damage and asymmetric PPG might help to predict lateralization of the lesions. Acute ischemic stroke is the most common cause of PPG. Etiology and initial outcome are likely important prognostic factors of PPG.

Periodic alternating esotropia

Periodic alternating esotropia (PAE) is a rare ocular motility disturbance observed in association with periodic alternating gaze deviation (PAG) or periodic alternating nystagmus. We examined a 9-month-old developmentally delayed girl who showed PAE occurring synchronously with PAG. The ocular motility disorder consisted of rhythmic alternating fixation with the right eye in abduction, a left face turn and esotropia of the left eye (90 seconds), a changeover phase (10 to 15 seconds) during which the eyes are straight and the head is upright, then fixation with the left eye in abduction, a right face turn, and esotropia of the left eye (90 seconds). There was no spontaneous jerk nystagmus present. These findings continued incessantly during a follow-up period of 18 months. Magnetic resonance imaging revealed pronounced cerebellar vermis hypoplasia. Only three clinically similar cases have been previously reported, but none had been studied with modern neuroimaging techniques.

Effects of repeated botulinum toxin injections on orbicularis oculi muscle

Histologic evaluation was conducted on 12 orbicularis oculi specimens from 11 patients with essential blepharospasm and Meige's disease who had received an average of 11.3 injections of botulinum A toxin over 3.5 years. Denervation was demonstrated by the spread of acetylcholinesterase staining on muscle fibers when specimens were evaluated within 11 weeks of the last injection. When specimens were taken after 12 weeks, spread of acetylcholinesterase was confined to the neuromuscular junctions, with little fiber size variability resembling normal muscle. Fibrosis seen in three specimens could be correlated to prior surgery. Repeated injections of botulinum toxin into human muscle do not appear to cause irreversible muscle atrophy or other degenerative changes. Denervation changes (fiber size variability, acetylcholinesterase spread) appear to correlate to the time interval since the last injection.