A Case with Anti-ganglioside Antibodies Showing Multiple Cranial Nerve Palsies Detected on Gadolinium-enhanced Magnetic Resonance Imaging

Abstract

The anti-GQ1b IgG antibody is often accompanied by other anti-ganglioside antibodies, which induces various neurological symptoms. We herein report a patient with anti-ganglioside antibodies, including anti-GQ1b IgG and anti-GT1a IgG antibodies, showing bilateral ophthalmoplegia, facial nerve palsies, dysarthria, dysphagia, dysesthesia in both hands, and enhancement of the bilateral oculomotor, abducens, and facial nerves on gadolinium (Gd)-enhanced T1-weighted brain magnetic resonance imaging (MRI). He was first treated with intravenous immunoglobulin, which improved ophthalmoplegia, bulbar palsies, and dysesthesia of hands, but the facial nerve palsies worsened, and Gd enhancement of the brain nerves persisted. High-dose methylprednisolone therapy subsequently improved the facial nerve palsies and Gd enhancement of the cranial nerves. This is the first case with anti-ganglioside antibodies presenting with multiple cranial nerve palsies that was followed to track the changes in the Gd enhancement of cranial nerves on MRI.

Keywords: Gd-enhancement; Miller Fisher syndrome; anti-ganglioside antibody; brain MRI; cranial nerve.

Figure.

(A) Eye movement of the present patient on admission, revealing horizontal restriction of the bilateral eye movements, predominantly in adduction, and impairment of the supraduction of the left eye. (B-D) Changes in the enhancement of oculomotor (B), abducens (C), and facial nerves (D) on Gd-enhanced T1-weighted MRI on admission (Day 1, left figures) and 18 days (Day 18, middle figures) and 104 days after admission (Day 104, right figures). Arrows show the enhancement of nerves, while arrowheads show no enhancement. (B) No enhancement of the oculomotor nerves was observed on Day 1 (arrowheads). Abnormal enhancement was detected in the right nerve (arrow), but not in the left nerve on Day 18 (arrowhead). No enhancement was detected at 104 days (arrowheads). (C) Abnormal enhancement of the bilateral abducens were detected on Day 1 (arrows). That of the left nerve disappeared (arrowhead), but that of the right nerve was detected on Day 18 (arrows). No enhancement was observed on Day 104 (arrowheads). (D) Mild enhancement of the bilateral facial nerves in the labyrinthine segment were detected on Day 1, findings that were emphasized on Day 18 (arrows) but ameliorated on Day 104 (arrows).