Voltage-gated Ca2+ channels are categorized as either high-voltage activated (HVA) or low-voltage activated (LVA), and a subtype (or subtypes) of HVA Ca2+ channels link the presynaptic depolarization to rapid neurotransmitter release. Reductions in transmitter release are characteristic of the autoimmune disorder, Lambert-Eaton syndrome (LES). Because antibodies from LES patients reduce Ca2+ influx in a variety of cell types and disrupt the intramembrane organization of active zones at neuromuscular synapses, specificity of LES antibodies for the Ca2+ channels that control transmitter release has been suggested as the mechanism for disease. We tested sera from four patients with LES. Serum samples from three of the four patients reduced both the maximal LVA and HVA Ca2+ conductances in murine dorsal root ganglion neurons. Thus, even though LES is expressed as a neuromuscular and autonomic disorder, our studies suggest that Ca2+ channels may be broadly affected in LES patients. To account for the specificity of disease expression, we suggest that incapacitation of only a fraction of the Ca2+ channels clustered at active zones would severely depress transmitter release. In particular, if several Ca2+ channels in a cluster are normally required to open simultaneously before transmitter release becomes likely, the loss of a few active zone Ca2+ channels would exponentially reduce the probability of transmitter release. This model may explain why LES is expressed as a neuromuscular disorder and can account for a clinical hallmark of LES, facilitation of neuromuscular transmission produced by vigorous voluntary effort.Lambert-Eaton myasthenic syndrome (LES) is a human autoimmune disorder characterized by autonomic dysfunction and muscle weakness resulting from reduced neurotransmitter release (1, 2). At neuromuscular junctions, transmitter release occurs at discrete sites called active zones (3, 4). In freezefracture views of neuromuscular synapses, intramembrane particles, which are thought to include Ca2+ channels, are organized in linear arrays at active zones (5-7). The hypothesis that LES antibodies target the Ca2+ channels that control transmitter release arose from the observation that LES antibodies decrease the number of active zones and disrupt active zone organization in mice and humans (8-10). Further support for this hypothesis has been based on the demonstration that LES antibodies decrease Ca2+ influx in transformed cells such as small cell lung carcinoma (11, 12), rat (13) and human (14) MATERIALS AND METHODS Serum Preparation. Serum obtained from four LES patients was dialyzed (exclusion of .100 kDa) for 24 hr against culture medium at a sample-to-dialysate ratio of approximately 1:100, with one dialysate change at about 8 hr (12). Initial experiments for Patient One used whole serum without dialysis; because no obvious differences were observed between whole and dialyzed serum, the results for this patient were pooled and averaged. Serum was added to the culture medium at approximately 1:20 ...