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Lambert Eaton Myasthenic Syndrome

LEMS

Lambert-Eaton myasthenic syndrome is an autoimmune disease characterized by production of antibodies against voltage-gated calcium channels at the neuromuscular junction and is most frequently associated with small cell lung carcinoma. Lower extremity muscle weakness, autonomic dysfunction and reduced reflexes are main symptoms. Clinical criteria, EMG and imaging studies are necessary for the diagnosis. 3,4 - diaminopyridine, corticosteroids, azathioprine, plasmapheresis and IVIG are all used in therapy.

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Presentation

As the release of acetylcholine at the neuromuscular junction is impaired, numerous symptoms may appear. Debilitating muscle weakness, which is the main clinical manifestation of patients suffering from LEMS [13], is accompanied by reduced or absent deep tendon reflexes [7], and by various autonomic disturbances such as constipation, impaired sexual functions, or dry mouth [5]. Muscle weakness usually starts at the proximal lower extremities and is progressive in nature, eventually spreading to both upper and lower distal extremities [1]. Respiratory failure may be observed in severe cases in whom the diagnosis is made when advanced stages of the disease have been reached. Ocular and bulbar symptoms may be present as well and their frequency ranges between 0-80% [1].

Weakness
  • Here, we describe a patient with a 5-year history of cervical myelopathy who presented with recurrent limb weakness of her limbs and complained of recent progressive weakness.[ncbi.nlm.nih.gov]
  • Currently there are limited treatment options for patients with this and other forms of neuromuscular weakness.[ncbi.nlm.nih.gov]
  • Interestingly, 3 patients were either undiagnosed or not treated for LEMS at the time of perioperative complication, and developed weakness after use of neuromuscular blocking drugs.[ncbi.nlm.nih.gov]
  • The weakness and malaise disappeared and her muscle strength recovered.[ncbi.nlm.nih.gov]
  • Conversely, LEMS patients never presented initially with ocular weakness; 5% presented with bulbar weakness, and 95% presented with limb weakness.[emedicine.medscape.com]
Fatigue
  • An African 41 years-old SLE patient presented with persisting fatigue, myalgia and dyspnea, abolished reflexes and a bilateral ptosis.[ncbi.nlm.nih.gov]
  • We report a 73 year-old lady who presented 10 years previously with stiffness of both calves, dry mouth, fatigue, proximal weakness and areflexia in lower limbs. Neurophysiological studies were consistent with LEMS.[ncbi.nlm.nih.gov]
  • A 27-year-old man as initially having the diagnosis of Addison's disease was admitted to the hospital because of fatigue, dry-mouthness and proximal limb weakness for 1 year. A diagnosis of LEMS was made from electrophysiological studies.[ncbi.nlm.nih.gov]
  • We report the case of a child with Wilms tumor who presented with generalized weakness, fatigue, ptosis, hypokinesis, dysarthria, urinary retention, facial diplegia, ophthalmoplegia, and autonomic dysfunction.[ncbi.nlm.nih.gov]
  • SIGNIFICANCE: PEE-D may be physiologically closest to the reversible myasthenic fatigue after exercise observed in LEMS patients. Copyright 2013 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd.[ncbi.nlm.nih.gov]
Pain
  • We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition. Last updated: January 30, 2019[patientslikeme.com]
  • Patients with LEMS typically suffer from fatigue, muscle pain, and stiffness. The weakness is generally more marked in the proximal muscles particularly of the legs and trunk.[biomarin.com]
  • Patients with LEMS typically present with fatigue, muscle pain and stiffness. The weakness is generally more marked in the lower extremity muscles, particularly of the legs and hip-girdle.[globalgenes.org]
  • Weakness or loss of movement that can be more or less severe, including: Difficulty climbing stairs, walking, or lifting things Muscle pain Drooping of the head The need to use the hands to get up from a sitting or lying position Problems talking Problems[nlm.nih.gov]
Weight Loss
  • RESULTS: Age at onset, smoking behavior, weight loss, Karnofsky performance status, bulbar involvement, male sexual impotence, and the presence of Sry-like high-mobility group box protein 1 serum antibodies were independent predictors for SCLC in LEMS[ncbi.nlm.nih.gov]
  • More than 50 years of age at onset of symptoms, positive history for smoking, weight loss, bulbar symptoms, male sexual impotence and Karnofsky performance status lower than 70 were established as valid predictors of SCLC, as the chances of 93.5%, 96.6%[symptoma.com]
  • The pupillary light reflex may be sluggish.In LEMS associated with lung cancer, most have no suggestive symptoms of cancer at the time, such as cough, coughing blood, and unintentional weight loss.[en.wikipedia.org]
Constipation
  • RATIONALE: The Lambert-Eaton myasthenic syndrome (LEMS) is a neuromuscular disease; its unique symptoms of LEMS include dry mouth with a metallic taste, constipation, and erectile dysfunction.[ncbi.nlm.nih.gov]
  • A significant proportion of patients also have dysfunction of the autonomic nervous system that may include dry mouth, constipation, blurred vision, impaired sweating, and orthostatic hypotension.[ncbi.nlm.nih.gov]
  • Symptoms such as muscle weakness, diminished tendon reflexes and impaired autonomic functions that manifest as dry mouth, constipation or erectile dysfunction are manifestations of LEMS.[symptoma.com]
  • Patients often report a dry mouth, impotence, and constipation. Very rarely these problems can be life-threatening when the weakness involves respiratory muscles. I have been undergoing infusions monthly for six years.[globalgenes.org]
  • Autonomic dysfunction includes dry mouth, constipation, and erectile dysfunction. Deep tendon reflexes are usually decreased or absent.[ime.acponline.org]
Xerostomia
  • A 68‑year‑old male patient presented with a 6‑month history of progressive weakness of the proximal limbs and a 2‑month history of xerostomia.[spandidos-publications.com]
Skin Lesion
  • We report the case of a 66-year-old hypertensive male smoker who presented progressive proximal muscular weakness and, in two months, evolved to dysphagia, dysphonia, and V-shaped skin lesions on the chest.[ncbi.nlm.nih.gov]
Alopecia
  • We report on a child with a family history of autoimmune defects, who presented at the age of 3(1/2) years with alopecia and Graves disease. He subsequently developed vitiligo and psoriasis.[ncbi.nlm.nih.gov]
Diplopia
  • She recently developed unilateral ptosis and diplopia which dramatically improved with pyridostigmine suggesting concomitant MG.[ncbi.nlm.nih.gov]
  • Ophthalmic symptoms included ptosis in 41 (23%), diplopia in 36 (20.5%), decreased vision in 24 (14%), and dry eye complaints in 12 (7%).[ncbi.nlm.nih.gov]
  • PATIENT CONCERNS: A 65-year-old man presented with alternating ptosis and diplopia. Isolated ocular muscle impairment had lasted for 6 years, and the patient was initially diagnosed with ocular myasthenia gravis (MG).[ncbi.nlm.nih.gov]
  • Some degree of eyelid ptosis or diplopia, usually mild, is found in 25% of patients. Occasionally, difficulty chewing, dysphagia, or dysarthria is present. Most patients have a dry mouth, eyes, or skin.[emedicine.medscape.com]
  • Less common features include oropharyngeal and ocular symptoms related to weakness, such as dysphagia, dysarthria, ptosis, and diplopia. The diagnosis is confirmed by electrodiagnostic studies and serology.[radiopaedia.org]
Muscle Weakness
  • The main clinical feature is potentially disabling limb muscle weakness. Clinical signs of autonomic nervous system involvement are frequent.[ncbi.nlm.nih.gov]
  • From Wikidata Jump to navigation Jump to search Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune, presynaptic disorder of neuromuscular transmission characterized by fluctuating muscle weakness and autonomic dysfunction frequently associated[wikidata.org]
  • STUDY OBJECTIVE: Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune disorder of the neuromuscular junction that manifests with muscle weakness, autonomic and bulbar dysfunction, and increased sensitivity to neuromuscular blocking drugs.[ncbi.nlm.nih.gov]
  • Patients with LEMS invariably experience progressive proximal muscle weakness, often accompanied by general fatigue and autonomic symptoms.[ncbi.nlm.nih.gov]
  • KEYWORDS: 3,4-diaminopyridine phosphate; Lambert-Eaton syndrome; anti-voltage-gated calcium channel antibodies; proximal muscle weakness[ncbi.nlm.nih.gov]
Myopathy
  • OBJECTIVE: Lambert-Eaton myasthenic syndrome (LEMS) is a rare condition, which may mimic myopathy.[ncbi.nlm.nih.gov]
  • Electromyography results were consistent with moderate myopathy accompanied with a pattern suggestive of Lambert-Eaton myasthenic syndrome.[ncbi.nlm.nih.gov]
  • EMG helps to differentiate LEMS from other causes of cancer-associated weakness, such as myopathy and polyneuropathy.[cmaj.ca]
  • […] additional information about LEMS, please visit the following websites and others listed in the Patient/Physician Resource Library: LEMS.com European Society for Immunodeficiencies Myasthenia Gravis Association (UK) Association Française contre les Myopathies[biomarin.com]
  • (seen in other diseases of neuromuscular transmission) and blocking.Blood tests may be performed to exclude other causes of muscle disease (elevated creatine kinase may indicate a myositis, and abnormal thyroid function tests may indicate thyrotoxic myopathy[en.wikipedia.org]
Proximal Muscle Weakness of the Lower Extremity
  • The most common initial complaint is proximal muscle weakness involving the lower extremities more than the upper extremities. Depressed deep tendon reflexes and autonomic dysfunction are frequently present.[ncbi.nlm.nih.gov]
Neck Weakness
  • Neurological examination revealed ptosis, dysarthria, neck weakness, hyporeflexia of all limbs, and autonomic failure. Electrophysiologic study showed a 400% increment response to high-rate repetitive nerve stimulation.[ncbi.nlm.nih.gov]
Dysarthria
  • We report the case of a child with Wilms tumor who presented with generalized weakness, fatigue, ptosis, hypokinesis, dysarthria, urinary retention, facial diplegia, ophthalmoplegia, and autonomic dysfunction.[ncbi.nlm.nih.gov]
  • Neurological examination revealed ptosis, dysarthria, neck weakness, hyporeflexia of all limbs, and autonomic failure. Electrophysiologic study showed a 400% increment response to high-rate repetitive nerve stimulation.[ncbi.nlm.nih.gov]
  • Abstract A 46-year-old woman suffering from lower extremity weakness, dysarthria, dysphagia, dyspnea, and dry mouth was suspected of having Lambert-Eaton myasthenic syndrome based on the characteristic electromyographic abnormalities of right ulnar nerve[ncbi.nlm.nih.gov]
  • Abstract Paraneoplastic syndrome (PNS) with two distinct neurological features was reported in a 50-year-old man who presented initially with vertigo, ataxia, dysarthria, tremor, confusion, urinary retention and hypotension.[ncbi.nlm.nih.gov]
  • A 78-year-old man presented with dysarthria, dysphagia, staggering gait, and lower extremity muscle fatigue.[ncbi.nlm.nih.gov]
Hyporeflexia
  • It is characterized by muscle weakness, hyporeflexia, and autonomic dysfunction. It is most often associated with small cell carcinomas of the lung. Rare cases have been reported in children.[ncbi.nlm.nih.gov]
  • Neurological examination revealed ptosis, dysarthria, neck weakness, hyporeflexia of all limbs, and autonomic failure. Electrophysiologic study showed a 400% increment response to high-rate repetitive nerve stimulation.[ncbi.nlm.nih.gov]
  • More often neurological findings were hyporeflexia or areflexia with a post-exercise improvement.[ncbi.nlm.nih.gov]
  • It is characterized clinically by muscle weakness, hyporeflexia or areflexia, and autonomic dysfunction.[cancerjournal.net]
  • .  This defining bedside clinical observation and should be part of the routine examination of a patient with proximal muscle weakness or even complaints of weakness, especially when hyporeflexia or areflexia are conjoined.  Thus with facilitation,[slideshare.net]
Limb Weakness
  • A 27-year-old man as initially having the diagnosis of Addison's disease was admitted to the hospital because of fatigue, dry-mouthness and proximal limb weakness for 1 year. A diagnosis of LEMS was made from electrophysiological studies.[ncbi.nlm.nih.gov]
  • Here, we describe a patient with a 5-year history of cervical myelopathy who presented with recurrent limb weakness of her limbs and complained of recent progressive weakness.[ncbi.nlm.nih.gov]
  • We report a case of small-cell lung cancer (SCLC) presenting with LEMS and ventilatory failure in a 67-year-old man who initially presented with progressive limb weakness for 6 months and tachypnea with shallow breathing for 1 week.[ncbi.nlm.nih.gov]
  • Comprehensive clinical and electrophysiological testing was performed on a 34-year-old woman with progressive limb weakness, before and after IVIg treatment.[ncbi.nlm.nih.gov]
  • . • Lambert-Eaton myasthenic syndrome typically presents with fatigue, proximal limb weakness, and diminished muscle stretch reflexes.[medlink.com]
Paresthesia
  • The side effects of 3,4-DAP are generally mild and most frequently consist of paresthesias, but epileptic seizures and arrhythmias have been described in patients using high doses.[ncbi.nlm.nih.gov]
  • Side effects are usually mild, and the most frequently reported are paresthesias. The most common serious adverse events are epileptic seizures. 3,4-DAP is currently the treatment of choice in patients with Lambert-Eaton myasthenic syndrome.[ncbi.nlm.nih.gov]
  • Side effects are usually mild, and the most frequently reported are paresthesias. The most common serious adverse events are epileptic seizures. 3,4-DAP is currently the treatment of choice in patients with Lambert–Eaton myasthenic syndrome.[doi.org]
Absent Deep Tendon Reflex
  • Debilitating muscle weakness, which is the main clinical manifestation of patients suffering from LEMS, is accompanied by reduced or absent deep tendon reflexes, and by various autonomic disturbances such as constipation, impaired sexual functions, or[symptoma.com]

Workup

The two most important steps in the diagnostic workup are a meticulous physical examination and EMG studies [5]. EMG will confirm a low CMAP, in which case further evaluation for SCLC through the use of chest CT, bronchoscopy and PET should be carried out as soon as possible [8]. Between 85-90% of patients test positive for VGCC antibodies, with numbers reaching 100% if LEMS is associated with SCLC [7]. Because SCLC and LEMS are strongly correlated, a prediction score has been proposed in order to aid physicians in making the diagnosis early on. More than 50 years of age at onset of symptoms, positive history for smoking, weight loss, bulbar symptoms, male sexual impotence and Karnofsky performance status lower than 70 were established as valid predictors of SCLC, as the chances of 93.5%, 96.6% and 100% for this malignancy were observed if patients had 4,5 or all 6 symptoms, respectively [9].

Treatment

Current treatment principles rely on symptomatic and causative therapy, with 3,4 - DAP being currently considered as first-line therapy [6] [14]. 3,4 - DAP acts by blocking voltage-gated potassium channels, thus causing a prolonged depolarization phase at the presynaptic terminal and providing more time for acetylcholine to be released into the synaptic cleft [10]. Recent studies have additionally suggested that this drug also directly influences the activity of VGCCs, but this theory remains to be solidifies [1]. Guidelines suggest dosages of 5 milligrams every 8 hours, but up to 60 mg/day can be given [10]. This drug, however, is contraindicated in patients who suffer from epilepsy, since seizures are the most significant adverse effect. Additionally, its combination with drugs that prolong the QT interval is prohibited [10], as the drug can further cause QT prolongation. It was shown that 3,4 diaminopyridine can improve muscle strength within days after its initiation, whereas positive effects were seen with intravenous immunoglobulins over the course of weeks [9]. Corticosteroids, used together with azathioprine or cyclosporine, have proved to be successful in long-term management [15]. In addition to described therapeutic agents, a novel calcium channel agonist (GV-58) has shown significant success in animal models, especially when used together with 3,4 DAP [13]. Efficient treatment of the underline malignant disease (if present) is equally important when it comes to long-term survival rates [6].

Prognosis

The prognosis varies from patient to patient, but the majority of individuals have a reduced life expectancy. Non neoplastic forms have been associated with a much better prognosis compared to those in whom SCLC was discovered as the underlying cause [11], but in any case, intensive immunosuppressive therapy is necessary to maintain an adequate quality of life [11]. Although between 20 and 50% of patients enter long-term remission with appropriate therapy, studies have confirmed that the severity of symptoms at the time of diagnosis is a valid predictor of outcome, which is why an diagnosis is essential in achieving better results [11].

Etiology

LEMS occurs due to suppressed presynaptic neurotransmitter release by antibodies acting on the VGCCs. Since the activity of these channels are essential for secretion of acetylcholine into the synaptic cleft, their inactivity will invariably lead to reduced signal transmission and cause numerous symptoms. In 50-90% of patients, some form of malignancy is discovered, by far the most common being SCLC [2], which is encountered in the vast majority of tumor-related LEMS [1]. Its exact role in the pathogenesis, however, remains unknown.

Epidemiology

LEMS is considered to be a rare disease, with prevalence rates of 2.3 per 1 million individuals and an incidence of 0.5 per 1 million [7]. Other studies suggest that this disease affects approximately 1 per 100,000 individuals in the United States and Europe [8]. SCLC is by far the most important risk factor and this condition is often divided into SCLC-induced and non-SCLC induced LEMS [11]. In patients with SCLC, The onset of symptoms is most frequent > 50 years of age, with a slight predilection toward male gender [7]. On the other hand, non-SCLC LEMS Is more frequently seen in women, with the onset being most common at 35 and 60 years of age [7]. Ethnic predilection has not been established, as this condition affect all races [12].

Sex distribution
Age distribution

Pathophysiology

Under physiological circumstances, neurotransmitter release at the neuromuscular junction is mediated by opening and closing of presynaptic P or Q type voltage-gated Ca+ channels (VGCCs), which are regulated by the activity and impulse of the presynaptic action potential [13]. In the setting of LEMS, the production of IgG-class antibodies that target the extracellular VGCCs leads to downregulation of calcium dependent release of acetylcholine in the presynaptic terminal [5]. Consequently, depressed tendon reflexes, proximal weakness and impairment of autonomic functions develop [11]. Apart from VGCC, other targets have been discussed, since up to 10-15% of patients have negative antibody titers, with the most prominent candidates being synaptotagmin (a synaptic vesicle protein) and muscarinic presynaptic acetylcholine receptors [8].

Prevention

Because almost 100% of patients with LEMS were diagnosed with SCLC within 1 year [3], and because the diagnosis is often made several years after the onset of symptoms [12], a screening protocol consisting of chest CT and PET scans has been proposed in order to facilitate an early diagnosis [3], which can significantly prolong survival rates and be even life-saving for many patients. The prevention of LEMS is currently not possible, as the exact cause of antibody production is unknown.

Summary

Since its initial description more than 50 years ago [1], much has been revealed about Lambert-Eaton myasthenic syndrome (LEMS), an autoimmune disease featured by production of antibodies against voltage-gated calcium channels (VGCCs) at the neuromuscular junction [2]. In a substantial amount of patients (50-90%, depending on the study) [2] [3] [4], the underlying cause was determined to be small cell lung carcinoma (SCLC) [1], one of the most aggressive lung tumors encountered in clinical practice. LEMS was established as the common paraneoplastic disorders identified in SCLC patients, with a prevalence rate reaching up to 6% [5]. On the other hand, a nonparaneoplastic form of LEMS (also known as non-SCLC LEMS) comprises 10-15% of cases [6], in which the underlying cause remains unknown. In these patient, anti-VGCC antibodies are not found, consequently leading to the search for other molecules involved in the pathogenesis [7]. So far, synaptotagmin (a protein involved in the formation of synaptic vesicles) and muscarinic acetylcholine receptors located on the presynaptic terminal have been listed as potential targets [8]. The pathogenesis of SCLC-LEMS starts with delayed presynaptic signaling as a result of antibody activity and suppression of VGCCs, leading to impaired conduction of action potentials and secretion of acetylcholine into the synaptic cleft [2]. As a result, numerous neurological deficits appear, most important being progressive muscle weakness, usually starting at the lower extremities, together with diminished or completely absent deep tendon reflexes and autonomic dysfunction that manifests as dry mouth, constipation and erectile dysfunction [1]. LEMS is rarely seen in medical practice, as studies have determined an incidence rate of 0.5 per 1 million individuals [7], whereas approximately 1 in 100,000 individuals in Europe and the United States were shown to suffer from this diseases [8]. SCLC is, by far, the single most important risk factor for LEMS, but the roles of gender and age are considered to be important as well. Males are more commonly affected by SCLC-related LEMS, while non-SCLC LEMS is more frequently observed among women [7]. In terms of age, SCLC-related cases appear almost universally after 50 years of age, while the remaining patients are diagnosed at two age peaks, 35 and 60 years [1], and the exact cause for such results remains unknown. To make the diagnosis, a thorough physical examination and various laboratory and imaging studies are necessary. Electromyography (EMG) results showing low compound muscle action potential (CMAP) and elevated serum values of VGCC antibodies are diagnostic hallmarks of LEMS, in which case a detailed and prompt inspection of the chest through computed tomography (CT), positron emission tomography (PET) and bronchoscopy is pivotal to confirm SCLC [1]. A recent study has composed a predictive score for SCLC in patients with suspected LEMS, including factors such as age of > 50 years at onset, smoking, erectile dysfunction, weight loss and functional impairment assessed through the Karnofsky scale, and has shown to be highly specific in the presence of 4 or more factors [9]. Treatment principles aim to suppress the activity of antibodies, primarily through use of 3,4 - diaminopyridine (3,4-DAP). Less effective drugs include intravenous immunoglobulins (IVIG) and plasmapheresis [10]. For chronic, long-term suppression, azathioprine and corticosteroids are of significant benefit [1]. If the presence of SCLC is confirmed, its management is equally important in ensuring longer survival rates. The severity of symptoms at the time of diagnosis is established to be the most valid predictor of life expectancy [11], which is why an early diagnosis based on high clinical suspicion is of essential importance.

Patient Information

Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune disease most frequently appearing in the presence of a malignant tumor, most commonly small lung cell carcinoma. LEMS is, in fact, considered to be the most common paraneoplastic syndrome in small lung cell carcinoma (SCLC). In a small subset of patients (10-15%), however, LEMS is not related to any malignant tumor and its cause remains unknown. For reasons yet to be determined, production of antibodies against calcium channels that are essential cogs in proper conduction of nervous signals occurs and these antibodies are identified in high titers in the vast majority of patients. When antibodies suppress the activity of these channel, the main neurotransmitter, acetylcholine, cannot perform its physiological function and diminished nervous signaling triggers numerous deficits. Symptoms such as muscle weakness, diminished tendon reflexes and impaired autonomic functions that manifest as dry mouth, constipation or erectile dysfunction are manifestations of LEMS. To make the diagnosis, it is important to perform a full physical examination, together with electromyography (EMG) and various imaging studies to confirm or exclude the presence of small lung cell carcinoma. Computed tomography (CT scan) of the chest, positron emission tomography (PET scan) and bronchoscopy are all indicated in the setting of high clinical suspicion toward LEMS. Treatment involves administration of various drugs, but 3,4 - diaminopyridine is considered as first-line therapy. Intravenous immunoglobulins and plasmapheresis are also considered as good alternatives, especially in patients suffering from epilepsy, in whom 3,4 -diaminopyrine is contraindicated due to the fact that its most prominent adverse effect is seizures. Corticosteroids and azathioprine are used for long-term suppression. The prognosis of LEMS significantly depends on the promptness of the diagnosis, as much longer survival rates have been observed in patients with milder symptoms at their initial presentation. Although LEMS is considered to be a rare disease, appearing in 2 per 1 million individuals, it should be taken into consideration in individuals older than 50 years of age who present with progressive muscle weakness and autonomic dysfunction as the underlying cause may lead to fatal outcomes if not recognized early on.

References

Article

  1. Titulaer, Maarten J et al. Lambert–Eaton myasthenic syndrome: from clinical characteristics to therapeutic strategies. Lancet Neurol. 2014;10(12):1098-1107.
  2. Wirtz PW, Bradshaw J, Wintzen AR, et al. Associated autoimmune diseases in patients with the Lambert-Eaton myasthenic syndrome and their families. J Neurol. 2004;251:1255-1259.
  3. Titulaer MJ, Wirtz PW, Willems LN, et al. Screening for small-cell lung cancer: a follow-up study of patients with Lambert-Eaton myasthenic syndrome. J Clin Oncol. 2008;26:4276-4281.
  4. Wirtz PW, Smallegange TM, Wintzen AR, et al. Differences in clinical features between the Lambert-Eaton myasthenic syndrome with and without cancer: an analysis of 227 published cases. Clin Neurol Neurosurg. 2002;104:359-363.
  5. Payne M, Bradbury P, Lang B, et al. Prospective study into the incidence of Lambert Eaton myasthenic syndrome in small cell lung cancer. J Thorac Oncol. 2010;5(1):34–38.
  6. Newsom-Davis J. Therapy in myasthenia gravis and Lambert-Eaton myasthenic syndrome. Semin Neurol. 2003;23:191-198.
  7. Bekircan-Kurt CE, Çiftçi ED, Kurne AT, et al. Voltage gated calcium channel antibody-related neurological diseases. World J Clin Cases. 2015;3(3):293–300.
  8. Keogh M, Sedehizadeh S, Maddison P. Treatment for Lambert-Eaton myasthenic syndrome. Cochrane Database Syst Rev. 2011;CD003279.
  9. Titulaer MJ, Maddison P, Sont JK et al. Clinical Dutch-English Lambert-Eaton myasthenic syndrome (LEMS) tumor association prediction score accurately predicts small-cell lung cancer in the LEMS. J Clin Oncol. 2011;29:902–908.
  10. Lindquist S, Stangel M. Update on treatment options for Lambert-Eaton myasthenic syndrome: focus on use of amifampridine. Neuropsychiatr Dis Treat. 2011;7:341–349
  11. Maddison P, Lang B, Mills K, et al. Long term outcome in Lambert-Eaton myasthenic syndrome without lung cancer. J Neurol Neurosurg Psychiatry. 2001;70:212-217.
  12. Harms L, Peter Sieb J-P, Williams AE, et al. Long-term disease history, clinical symptoms, health status, and healthcare utilization in patients suffering from Lambert Eaton myasthenic syndrome: results of a patient interview survey in Germany. J Med Econ. 2012;15(3):521–530.
  13. Tarr TB, Wipf P, Meriney SD. Synaptic Pathophysiology and Treatment of Lambert-Eaton Myasthenic Syndrome. Molecular Neurobiology Mol Neurobiol. 2014;52(1):456-463.
  14. Skeie GO, Apostolski S, Evoli A, et al. Guidelines for the treatment of autoimmune neuromuscular transmission disorders. Eur J Neurol. 2006;13:691-699.
  15. Newsom-Davis J. Lambert–Eaton myasthenic syndrome. Rev Neurol (Paris). 2004;160(2):177–180.

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Last updated: 2018-06-21 17:56