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Grebenciucova et al. Etanercept-associated Miller-Fischer syndrome

Table 1: Literature cases of MFS in association with anti-TNFα agents
Anti TNF Underlying Duration of Symptoms at GQ1b
Reference Patient Treatment Outcomes
agent condition treatment onset titre
Kurmann 77 years/ Adalimumab Rheumatoid 2 infusions Ataxia, areflexia, Negative Steroids/ Gradual
et al. [9] female arthritis nystagmus azathioprine recovery over
1 year
Shin 56 years/ Infliximab Rheumatoid 10 infusions Ataxia, < 1:100 Steroids/ Independent
et al. [8] male arthritis nystagmus IVIG ambulation at
6 months
Ratnarajan 43 years/ Infliximab Ulcerative 2 infusions Ophthalmoplegia 1:6,400 No Full resolution
et al. [10] female colitis treatment at 10 weeks
Our patient 56 years/ Etanercept Psoriatic 3 infusions Ophthalmoplegia, 1:128,000 No Full recovery
male arthritis areflexia treatment 1 month
MFS: Miller-Fischer syndrome; TNF: tumor necrosis factor; GQ1b: ganglioside Q1b; IVIG: intravenous immunogloblin
contributing effect on the course or severity of the (syndrome of ophtalmoplegia ataxia and areflexia). N Eng J Med
disease. 1956;255:57-65.
2. Nishimoto Y, Odaka M, Hirata K, Yuki N. Usefulness of anti-GQ1b
This case illustrates the importance of considering IgG antibody testing in Fisher syndrome compared with cerebrospinal
MFS in patients presenting with ophthalmoplegia fluid examination. J Neuroimmunol 2004;148:200-5.
(even without ataxia) during use of an anti-TNFα 3. Arányi Z, Kovács T, Sipos I, Bereczki D. Miller Fisher syndrome:
agent. Further studies are necessary to understand brief overview and update with a focus on electrophysiological
the pathophysiological mechanisms of the aberrant findings. Eur J Neurol 2012;19:15-20.
immune responses leading to MFS, and the 4. Overell JR, Hsieh ST, Odaka M, Yuki N, Willison HJ. Treatment for
immunogenotypes of patients that may be at higher Fisher syndrome, Bickerstaff’s brainstem encephalitis and related
risk for immune dysregulation. disorders. Cochrane Database Syst Rev 2007;24:CD004761.
5. TNF neutralization in MS: results of a randomized, placebo-controlled
Authors’ contributions multicenter study. The Lenercept Multiple Sclerosis Study Group
Analyzed the data and drafted the manuscript: E. and The University of British Columbia MS/MRI Analysis Group.
Grebenciucova, J.H. Pula Neurology 1999;53:457-65.
6. Chen X, Oppenheim JJ. TNF-alpha: an activator of
Financial support and sponsorship CD4+FoxP3+TNFR2+ regulatory T cells. Curr Dir Autoimmun
None.
2010;11:119-34.
Conflicts of interest 7. Robinson WH, Genovese MC, Moreland LW. Demyelinating and
There are no conflicts of interest. neurologic events reported in association with tumor necrosis factor
alpha antagonism: by what mechanisms could tumor necrosis factor
Patient consent alpha antagonists improve rheumatoid arthritis but exacerbate multiple
According to the requirements of the affiliation, this sclerosis? Arthritis Rheum 2001;44:1977-83.
case report does not require patient consent. 8. Shin IS, Baer AN, Kwon HJ, Papadopoulos EJ, Siegel JN. Guillain-
Barré and Miller Fisher syndromes occurring with tumor necrosis
Ethics approval factor alpha antagonist therapy. Arthritis Rheum 2006;54:1429-34.
According to the requirements of the affiliation, this 9. Kurmann PT, Van Linthoudt D, So AK. Miller-Fisher syndrome in
case report does not require ethics approval. a patient with rheumatoid arthritis treated with adalimumab. Clin
Rheumatol 2009;28:93-4.
REFERENCES 10. Ratnarajan G, Thompson A, Dodridge C, Parry A, Elston J. Novel
variant of miller fisher syndrome occurring with tumor necrosis factor
1. Fisher M. An unusual variant of acute idiopathic polyneuritis α antagonist therapy. JAMA Neurol 2015;72:1377-8.

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