Clinical Pearls and the Future of LEMS

David Gerber, MD: Dr Vernino, do you have any thoughts on any pearls, take-home messages, closing comments, or future directions that our listeners should be aware of?

Steven Vernino, MD, PhD:There are several things that I wanted to mention in terms of the initial evaluation. One is the recognition that patients come in complaining of weakness, describing difficulty getting up and down, fatigue, and yet their neurologic examination of strength appears normal or quite normal. It’s remarkable for someone who clearly has a lot of difficulty in their ability to do things to get upstairs, etc, but if you test those proximal muscles directly, they are normal. There’s a lot of debate about why that is, but that should not turn you away from the diagnosis. If someone comes in complaining about weakness and you test them and they appear strong, you might think it is just fatigue. This is one of those examples and perhaps it’s facilitation because the way we test patients in the office is that we have them make a maximal effort, which may induce facilitation of strength. This is more for neurologists to be very careful about your reflex examination because the absence of reflex is a strong clue about the diagnosis.

The other pearl, which you’ve talked about a few times, is to establish a relationship with your local oncologist. Oncologists often need our help as neurologists, and we certainly need guidance from them as we manage cases like this and other paraneoplastic disorders.

David Gerber, MD: LEMS [Lambert-Eaton myasthenic syndrome] itself is a particularly rare condition, but it speaks to the principles of autoimmune paraneoplastic conditions and other neurologic issues that can arise in patients with cancer. Many things that we’ve discussed can be applied to those scenarios as well.

That brings us to the end of our session. Dr Vernino, thank you for your time and expertise, and to those of you who’ve tuned in, I hope this has been helpful.

Transcript edited for clarity.