Background: Central nervous system lesions are rare causes of respiratory failure. Simple observation of the breathing pattern can help localize the lesion, but the examiner needs to be aware of potential pitfalls such as metabolic or pulmonary alterations. Methods: We describe 3 cases in which central neurogenic respiratory failure occurred simultaneously with other alterations or in an unusual presentation. Results: All patients were diagnosed with central neurogenic respiratory failure and treated for it with good recovery. Conclusion: Central neurogenic respiratory failure is a challenging diagnosis and needs to be reminded in difficult-to-wean patients carrying inconclusive evidences of metabolic or pulmonary alterations.

For many years, several reports have called attention for non-viral limbic encephalitis (LE), particularly with paraneoplastic etiology. However, an increasing number of data have demonstrated that some of those disorders are immune-mediated with antibodies to voltage-gated potassium channels (VGKC)1 . Herein, we present a case of VGKC antibody-associated LE and discuss the main phenotypic and imaging features of this unusual disease. CASEA 50-year-old man presented to our hospital with three months history of progressive personality change, sleep disturbance, memory impairment, visual hallucinations and seizures. Neurological examination showed disorientation, cognitive impairment (Mini Mental State Examination: 13) and memory dysfunction. Blood tests showed hyponatremia -130 mmol/L (135-145 mmol/L). Thyroid function, antibodies and serologic tests were normal. Cerebrospinal fluid showed high level of proteins (558 mg/dL) and mild lymphocytic pleocytosis. Brain magnetic resonance imaging (MRI) disclosed bilateral T2 and FLAIR hyperintensity of mesial temporal lobes (Figure). Cancer investigation resulted negative. VGKC serum level was higher than 650 pmol/L (normal range less than 450 pmol/L). These findings confirmed the diagnosis LE with VGKC antibodies. Methylprednisolone was started, with partial improvement. Three weeks later, immunoglobulin 0.4 g/Kg daily for five consecutive days was initiated. One week after immunoglob-