Anti-GQ1b antibody syndrome: anti-ganglioside complex reactivity determines clinical spectrum

Miller-Fisher syndrome with positive anti-GD1b and anti-GM1 antibodies combined with multiple autoimmune antibodies: A case report

RATIONALE

Anti-ganglioside antibodies (AGA) play an essential role in the development of Miller-Fisher syndrome (MFS). The positive rate of ganglioside antibodies was exceptionally high in MFS, especially anti-GQ1b antibodies. However, the presence of other ganglioside antibodies does not exclude MFS.

PATIENT CONCERNS

We present a 48-year-old male patient who suddenly developed dizziness, visual rotation, nausea, and vomiting accompanied by unsteady gait and diplopia for 3 days before presentation to our clinic.

DIAGNOSES

On physical examination, the patient's right eye could not fully move to the right side and horizontal nystagmus was found. Coordination was also impaired in the upper and lower extremities with dysmetria and dysdiadochokinesia. The electromyography and cerebrospinal fluid examination results were normal. The serum anti-GQlb antibody test results were negative. However, serum anti-GD1b IgM and anti-GM1 IgM antibodies were positive. Meanwhile, the anti-thyroid peroxidase antibody was >600.00 IU/mL (0.00-34.00), and the anti-SS-A/Ro52 antibody was positive. He was diagnosed with MFS.

INTERVENTIONS

The patient received IVIg treatment for 5 days (0.4 g/kg/day) from day 2 to day 6 of hospitalization. On the 7th day of admission, the patient was administered intravenous methylprednisolone (500 mg/day), which was gradually reduced.

OUTCOMES

The patient's symptoms improved after treatment with immunoglobulins and hormones.

LESSONS

We report a case of MFS with positive anti-GD1b and anti-GM1 antibodies combined with multiple autoimmune antibodies. Positive ganglioside antibodies may be used as supporting evidence for the diagnosis; however, the diagnosis of MFS is more dependent on clinical symptoms.

Atypical anti-GQ1b antibody syndrome presenting with vomiting as the initial symptom: a case report and literature review

BACKGROUND

Anti-GQ1b antibody syndrome is a rare autoimmune neuropathy, and atypical cases are even more rare, only a few cases have been reported. Anti-GQ1b antibody syndrome is difficult in early diagnosis and prone to misdiagnosis. Generally,in children with anti-GQ1b antibody syndrome,extraocular muscle paralysis is the initial symptom. However, anti-GQ1b antibody syndrome with vomiting as the initial symptom followed by abnormal gait has not been reported.

CASE PRESENTATION

We reported a case of anti-GQ1b antibody syndrome with vomiting as the initial symptom, followed by abnormal gait. One day after vomiting, the child developed abnormal gait, which primarily manifested as a slight tilt of the upper body during walking as well as an opening and swaying of the legs at fast walking paces,then progressively aggravated, and finally he could not stand on his own.In the auxiliary examination, cerebrospinal fluid routine,biochemical and metagenomic Next-Generation Sequencing (DNA and RNA), brain + spinal cord contrast magnetic resonance imaging (MRI),magnetic Resonance angiography (MRA) and diffusion-weighted image (DWI), hip and knee joint ultrasound showed normal results. Anti-GQ1b antibody syndrome was not confirmed until the positive anti-GQ1b IgG antibody was detected in the serum. After treatment with intravenous immunoglobulin (IVIG) and glucocorticoid, the child recovered well, and a 3-month outpatient follow-up showed that the child was able to walk normally.

CONCLUSIONS

There are no previous reports of anti-GQ1b antibody syndrome with vomiting as the initial symptom, followed by abnormal gait. Therefore, this valuable case contributes to expanding the database of clinical manifestation of anti-GQ1b antibody syndrome, so as to improve pediatricians' awareness about such rare diseases and reduce misdiagnosis.

Brain death-like changes: A case report of anti-GQ1b antibody syndrome

RATIONALE

Anti-GQ1b antibody syndrome originates in the peripheral nervous system or the central nervous system. Various overlapping syndromes and atypical manifestations are also seen in clinic. It is rare to see multiple sites (almost all targets) of central and peripheral damage at the same time, resulting in brain death-like changes in patient.

PATIENT CONCERNS

This is a 55-year-old female patient, with a history of prodromal upper respiratory tract infection, began with headache, quickly developed body paralysis, eye paralysis, disturbance of consciousness, apnea, and tested positive for anti-GQ1b antibody. The patient is diagnosed clearly, the disease progresses rapidly, and almost all GQ1b sites in the central nervous system and peripheral nervous system are involved, which is rare.

DIAGNOSES

Anti-GQ1b antibody syndrome.

INTERVENTIONS AND OUTCOMES

The patient was treated with tracheal intubation, ventilator assisted breathing, and immunoglobulin. The patient recovered quickly and was discharged after about 30 days in hospital.

LESSONS

The concept of anti-GQ1b antibody syndrome is not only beneficial for clinical diagnosis, but also beneficial for understanding the continuous disease spectrum with the same etiology and different clinical manifestations. The pathogenesis of each subtype has not been fully defined. There are mild patients with isolated syndromes and severe patients with multiple subtypes overlapping. Encounter severe patients but also active response, the general prognosis is good.

Campylobacter jejuni-Associated Hemophagocytic Lymphohistiocytosis and Guillain-Barre Syndrome: A Case Report

Campylobacter jejuni (C. jejuni), a Gram-negative bacterium, belongs to microaerobic bacteria. We reported a 21-year-old male patient diagnosed with hemophagocytic lymphohistiocytosis (HLH) due to C. jejuni infection, who presented with multiple clinical manifestations of peripheral nerve injury, such as ophthalmoplegia, facial paralysis, and urinary retention during the treatment. Electromyography showed neurogenic injury and the final diagnosis was Guillain-Barre Syndrome (GBS). After treatment of dexamethasone combined with immunoglobulin, the patient was discharged from the hospital with partial recovery of neurological symptoms.

Comprehensive Analysis of Oligo/Polysialylglycoconjugates in Cancer Cell Lines

In cancer cells, cell-surface sialylation is altered, including a change in oligo/polysialic acid (oligo/polySia) structures. Since they are unique and rarely expressed in normal cells, oligo/polySia structures may serve as promising novel biomarkers and targets for therapies. For the diagnosis and treatment of the disease, a precise understanding of the oligo/polySia structures in cancer cells is necessary. In this study, flow cytometric analysis and gene expression datasets were obtained from sixteen different cancer cell lines. These datasets demonstrated the ability to predict glycan structures and their sialylation status. Our results also revealed that sialylation patterns are unique to each cancer cell line. Thus, we can suggest promising combinations of antibody and cancer cell for glycan prediction. However, the precise prediction of minor glycans need to be further explored.

[Pathophysiological and diagnostic aspects of Guillain-Barré syndrome]

Guillain-Barré syndrome (GBS) is the most common cause of acute neuropathy. It usually onset with a rapidly progressive ascending bilateral weakness with sensory disturbances, and patients may require intensive treatment and close monitoring as about 30% have a respiratory muscle weakness and about 10% have autonomic dysfunction. The diagnosis of GBS is based on clinical history and examination. Complementary examinations are performed to rule out a differential diagnosis and to secondarily confirm the diagnosis. GBS is usually preceded by an infectious event in ≈ 2/3 of cases. Infection leads to an immune response directed against carbohydrate antigens located on the infectious agent and the formation of anti-ganglioside antibodies. By molecular mimicry, these antibodies can target structurally similar carbohydrates found on host's nerves. Their binding results in nerve conduction failure or/and demyelination which can lead to axonal loss. Some anti-ganglioside antibodies are associated with particular variants of GBS: the Miller-Fisher syndrome, facial diplegia and paresthesias, the pharyngo-cervico-brachial variant, the paraparetic variant, and the Bickerstaff brainstem encephalitis. Their semiological differences might be explained by a distinct expression of gangliosides among nerves. The aim of this review is to present pathophysiological aspects and the diagnostic approach of GBS and its variants.

Characteristics of Guillain-Barré syndrome in a Lebanese tertiary care center

Guillain-Barré Syndrome (GBS) is a group of acute inflammatory disorders that share a clinical presentation of progressive polyradiculo-neuropathy. Data on GBS in the Middle East and Lebanon are scarce; hence, we explored the characteristics of patients presenting with GBS to a tertiary care center in Beirut, Lebanon. This was a single-centered retrospective study over a 12-year period. We reviewed the charts of patients presenting with GBS to the American University of Beirut medical center and examined their presentation, management and outcome. 61 patients were included, with the majority being males. 59% of the patients reported an infection prior to admission. 77% had sensory and motor symptoms and 69% were diagnosed with acute inflammatory demyelinating polyneuropathy (AIDP). 57% of patients had initial symptoms in the lower extremities, 25% experienced cranial neuropathies, and 26% complained of pain. 77% were managed by intravenous immunoglobulin with a median hospital stay of 6.5 days. AIDP was noted to be the most prevalent GBS variant in Lebanon. More than 50% had an unfavorable outcome at discharge, which raises the need for better treatment and management approaches.

Clinical Characterization of Anti-GQ1b Antibody Syndrome in Childhood

Objective: To delineate the comprehensive clinical features of anti-GQ1b antibody syndrome in childhood. Methods: The clinical data of children diagnosed with anti-GQ1b antibody syndrome at two Chinese tertiary pediatric neurology centers were collected and analyzed. We also conducted a systematic literature review on anti-GQ1b antibody syndrome in children. Results: This study included 78 children with anti-GQ1b antibody syndrome, consisting of 12 previously unreported cases from the two Chinese centers. The median onset age was 10 years (range, 2-18 years). The most common phenotype was acute ophthalmoparesis (32%), followed by classic Miller Fisher syndrome (15%), and Bickerstaff brainstem encephalitis (12%). External ophthalmoplegia (48%), sensory disturbance (9%), and bulbar palsy (9%) were the three most frequent onset symptom manifestations. Brain or spinal lesions on MRI and abnormal recordings by nerve conduction study were present in 18% (12/68) and 60% (27/45) of cases, respectively. There was CSF albuminocytologic dissociation in 34% of the patients (23/68). IV immunoglobulin alone or combined with steroids or plasma exchange was administered to 58% of patients (42/72). We did not find a significant correlation between early improvement up to 3 months and age onset and phenotype. All patients showed different degrees of recovery, and 81% (57/70) had complete recovery within 1 year. Conclusions: Acute ophthalmoparesis and classic Miller Fisher syndrome are the most common phenotypes of anti-GQ1b antibody syndrome in childhood. The majority of patients show good response to immunotherapy and have favorable prognosis.

What did he eat?

A 13-year-old boy reported acute horizontal binocular diplopia and headache. Ten days before these symptoms he suffered from a gastrointestinal infection. Ophthalmological examination revealed bilateral ophthalmoparesis and diffuse hyporeflexia. Magnetic resonance imaging of the brain was normal. Lumbar puncture revealed albumin-cytological dissociation. There were no anti-GQ1b antibodies, but serum anti-GM1 antibodies were detected. He received intravenous immunoglobulins and had fully recovered two weeks later. Miller Fisher syndrome and its atypical variants are uncommon in childhood; nevertheless, they should be considered in the differential diagnosis of bilateral acute ophthalmoparesis.

Clinical spectrum of the anti-GQ1b antibody syndrome: a case series of eight patients

Anti-GQ1b antibodies can be detected in the serum of patients with Miller Fisher syndrome (MFS) and its incomplete forms such as acute ophthalmoparesis (AO), acute ptosis, acute mydriasis, acute oropharyngeal palsy and acute ataxic neuropathy (AAN), as well as in pharyngeal-cervical-brachial weakness, Bickerstaff brainstem encephalitis (BBE) and in overlap syndromes with Guillain-Barré syndrome (MFS-GBS, BBE-GBS). We searched the laboratory medicine database at University Hospitals Leuven between 2002 and 2017 for serum samples with anti-GQ1b IgG antibodies. We identified eight patients with anti-GQ1b antibodies: 4 MFS, 2 AO, 1 MFS-GBS and 1 AAN. Mean age was 57 years and five patients were males. Preceding illness was present in all patients. At nadir, we observed most frequently gait disturbance, external ophthalmoplegia and absent/decreased reflexes. Albumino-cytological dissociation was present in four patients. Mean time between onset and nadir was 4 days, between onset and recovery 2.5 months. Five patients recovered completely and three had minor residual symptoms. Interestingly, one patient with AO experienced a second identical episode, approximately 1 year after the first one. Our data confirm the broad clinical spectrum associated with the presence of anti-GQ1b IgG antibodies. Incomplete MFS subtypes such as AO are a challenge for diagnosis, because of the limited (though invalidating) clinical presentation and the lack of confirming ancillary tests. Subacute onset of ophthalmoplegia and/or ataxia should urge the clinician to include the anti-GQ1b antibody syndrome in the differential diagnosis.

Clinical characterization of anti-GQ1b antibody syndrome in Korean children

Anti-GQ1b antibody syndrome encompasses Miller Fisher syndrome and its related disorders. We retrospectively identified 11 pediatric patients (5.4-18 years old) with anti-GQ1b antibody syndrome. Diagnoses of patients included acute ophthalmoparesis (n = 6), classical Miller Fisher syndrome (n = 2), Miller Fisher syndrome/Guillain-Barré syndrome (n = 1), acute ataxic neuropathy (n = 1), and pharyngeal-cervical-brachial weakness (n = 1). Nine patients (81.8%) fully recovered. Maturational change in GQ1b antigen expression and the accessibility of anti-GQ1b antibodies might be the cause of the difference of clinical manifestations in children with anti-GQ1b antibody syndrome.

Bickerstaff Brainstem Encephalitis and overlapping Guillain-Barré syndrome in children: Report of two cases and review of the literature

Bickerstaff Brainstem Encephalitis (BBE) is a rare autoimmune encephalitis, characterized by acute ophthalmoplegia, ataxia and altered state of consciousness. Together with Guillan-Barrè Syndrome (GBS) and Miller-Fisher Syndrome, it forms a spectrum of post-infectious demyelinating diseases. Overlapping forms between BBE and GBS (BBE/GBS) are described in patients with lower limbs weakness and typical signs of BBE, suggesting a combined involvement of Central and Peripheral Nervous System (PNS), but only few reported cases are focused on pediatric population. We reviewed all cases of pediatric BBE in the literature, to determine if any patient showed features suggestive for BBE/GBS. Data analysis focused on the diagnostic tests performed (e.g. anti-GQ1b antibodies), neuroimaging and nerve conduction studies (NCS). Further attention was given to the therapeutic management and to patients' outcome. We additionally present two previously unreported pediatric cases. Our review retrieved 19 cases of BBE/GBS, only 2 of which were originally and correctly diagnosed by the authors. The prevalence was higher in male subjects (ratio 3:1) and median age at diagnosis was 8 years. Anti-GQ1b were positive in 46% of the patients, while NCS were altered in 64%. Only 25% of the patients that underwent brain MRI showed abnormal findings. The incidence of BBE/GBS has been underrated in the past, mostly due to an underestimation of the PNS involvement. We therefore suggest to investigate all patients with a clinical picture suggestive of BBE/GBS through electroencephalogram, NCS, brain and spine MRI in order to promptly achieve the correct diagnosis.

Anti-ganglioside complex antibody profiles in a recurrent complicated case of GQ1b-seronegative miller fisher syndrome and Bickerstaff brainstem encephalitis: a case report

Background

Guillain-Barré syndrome (GBS), Miller Fisher syndrome (MFS) and Bickerstaff brainstem encephalitis (BBE) are a group of autoimmune neurological disorders (GBS spectrum disorder) that rarely recur. Recently, anti-ganglioside complex antibodies (GSC-Abs) were identified in patients with GBS spectrum disorder. However, there has been no case report describing GSC-Abs profiles in a recurrent case showing different phenotypes.

Case presentation

We report the case of a 33-year-old male patient with GQ1b-seronegative BBE-GBS after two prior episodes of MFS-GBS. Our patient showed ophthalmoplegia, ataxia, areflexia and a weakness of the extremities (MFS and GBS symptoms) in all episodes. In the episode reported here, our patient showed disturbed consciousness and an extensor response to cutaneous plantar stimulation was observed (BBE symptoms), with severe disability and requirement for artificial respiration management. GSC-Abs detected in previous episodes were also detected in the subsequent episodes, while new GSC-Abs emerged in each episode. Interestingly, whereas antibodies to GA1/GQ1b and GA1/GT1a, which are commonly identified in patients with GBS, MFS or BBE, appeared in all episodes, antibodies to GD1a/GD1b and GD1b/GT1b, which are predominantly associated with severe disability and the requirement for artificial respiration management in GBS, emerged for the first time in this episode.

Conclusion

This study reports novel phenomena about the GSC-Abs profiles and its relationship with clinical features in a case with recurrent GBS spectrum disorder, showing different phenotypes in different episodes. Further studies are required to reveal the significance of the GSC-Abs profiles in recurrent GBS spectrum disorder.

Unilateral Oculomotor Nerve Palsy Following Campylobacter Infection: A Mild Form of Miller Fisher Syndrome without Ataxia

Unilateral oculomotor nerve palsy can result from various neurological disorders. We herein report the case of a 68-year-old man with complete unilateral oculomotor nerve palsy following campylobacter infection. Based on the antecedent infection and the patient's decreased tendon reflexes, incomplete Miller Fisher syndrome (MFS) without ataxia was suspected. His serum tested positive for anti-GQ1b antibodies. He recovered over a period of 87 days without immunotherapy. We conclude that incomplete MFS following campylobacter infection can cause unilateral oculomotor nerve palsy without ataxia. Mild MFS should be considered in patients presenting with unilateral isolated ophthalmoplegia and decreased tendon reflexes.

Progress in inflammatory neuropathy -the legacy of Dr Jack Griffin

The past quarter of a century has brought incredible advances in our understanding of inflammatory neuropathies, and the insights into Guillain-Barré syndrome (GBS) began in the 1990s with the seminal work of Dr Jack Griffin and his colleagues. In this essay, we provide a tribute to Jack, and review the recent progress in a field that he termed his personal favourite. In particular, we discuss the new developments in our understanding and diagnosis of inflammatory neuropathies, the recent emergence of the node of Ranvier and the paranode as sites of intensive investigation, and the mechanistic evidence that is providing a platform for therapeutic development studies.