Bickerstaff's encephalitis
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Bickerstaff's encephalitis is a rare inflammatory disorder of the central nervous system, first described by Edwin Bickerstaff in 1951.[1][2] It may also affect the peripheral nervous system, and has features in common with both Miller Fisher syndrome and Guillain-Barré syndrome.
Historical Perspective
Classification
Pathophysiology
The clinical features and course of the condition, the associated auto-antibodies against relevant antigens, and the response to treatment, all suggest that Bickerstaff's encephalitis is an autoimmune disease. However, each of these criteria fails to fit a substantial proportion of patients, and there is no single test or feature which is diagnostic of Bickerstaff's encephalitis. It is therefore possible that a proportion of cases are due to other causes, such as infection or lymphoma, but remain undiagnosed. It is also possible that there is more than one autoimmune disease that can cause an illness which would currently be diagnosed as Bickerstaff's. There is certainly overlap between Guillain-Barré syndrome, Miller Fisher syndrome and Bickerstaff's encephalitis, as well as other conditions associated with anti-ganglioside antibodies such as chronic ophthalmoplegia with anti-GQ1b antibody.[3] and the pharyngo-cervico-brachial variant of GBS.
Causes
Differentiating Bickerstaff's Encephalitis from Other Diseases
Epidemiology and Demographics
Age
Gender
Race
Risk Factors
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Criteria
Anti-GQ1b antibodies are found in two-thirds of patients with this condition. This antibody is also found in almost all cases of Miller Fisher syndrome. The EEG is often abnormal, but shows only slow wave activity, which also occurs in many other conditions, and so is of limited value in diagnosis. Similarly, raised CSF protein levels and pleocytosis are frequent but non-specific. It was originally thought[2] that raised CSF protein without pleocytosis ('albuminocytological dissociation') was a characteristic feature, as it is in Guillain-Barré syndrome, but this has not been supported in more recent work.[4] In only 30% of cases is a MRI brain scan abnormal. Nerve conduction studies may show an axonal polyneuropathy.
Symptoms
Physical Examination
In order to diagnose Bickerstaff's encephalitis, ataxia and ophthalmoplegia must be present. These are also diagnostic features of Miller Fisher syndrome, and so Bickerstaff's is only diagnosed if other features are present which exclude Miller Fisher syndrome. These may include drowsiness, coma or hyperreflexia. When the condition is defined in this way, a number of other features are commonly but not always found: among these are weakness of the limbs, the face, and/or the bulbar muscles; abnormalities of the pupils; and absent reflexes.[4][5]
Like some other autoimmune diseases, the condition usually follows a minor infection, such as a respiratory tract infection or gastroenteritis.
Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Most patients reported in the literature have been given treatments suitable for autoimmune neurological diseases, such as corticosteroids, plasmapheresis and/or intravenous immunoglobulin.[4]
Surgery
Prevention
References
- ↑ Bickerstaff ER (1951). "Mesencephalitis and rhombencephalitis". Br Med J. 2 (4723): 77–81. doi:10.1136/bmj.2.4723.77. PMC 2069534. PMID 14848512.
- ↑ 2.0 2.1 Bickerstaff ER (1957). "Brain-stem encephalitis: further observations on a grave syndrome with benign prognosis". Br Med J. 1 (5032): 1384–7. doi:10.1136/bmj.1.5032.1384. PMC 1973653. PMID 13436795.
- ↑ Reddel SW (2000). "Chronic ophthalmoplegia with anti-GQ1b antibody". Neurology. 54 (4): 1000–2. doi:10.1212/wnl.54.4.1000. PMID 10691005.
- ↑ 4.0 4.1 4.2 Odaka M (2003). "Bickerstaff's brainstem encephalitis: clinical features of 62 cases and a subgroup associated with Guillain-Barré syndrome". Brain. OUP. 126 (10): 2279–90. doi:10.1093/brain/awg233. PMID 12847079.
- ↑ Al-Din AN (1982). "Brainstem encephalitis and the syndrome of Miller Fisher: a clinical study". Brain. OUP. 105 (10): 481–95. doi:10.1093/brain/105.3.481. PMID 7104664.