Association of antineural autoantibodies in a patient with paraneoplastic cerebellar syndrome and small cell lung carcinoma

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The insulin-like growth factor I system in cerebellar degeneration

Brain insulin-like growth factor I (IGF-I) and its related molecules may be involved in neurodegenerative processes in which IGF-I-containing pathways are compromised. Since IGF-I is present in the olivocerebellar circuitry, two types of late-onset cerebellar ataxias (olivopontocerebellar and idiopathic cerebellar cortical atrophy) were chosen to test this hypothesis. The following significant changes in the peripheral IGF-I system of these patients were found: low IGF-I levels, and high IGF-binding protein 1 (BP-1), and BP-3 affinity for IGF-1. Sixty percent of the patients also had significantly low insulin levels. Patients suffering from other neurological diseases with cerebellar dysfunction and ataxia not involving the olivocerebellar pathway also had low IGF-I levels, while IGFBPs and insulin levels were normal. Our data indicate that degeneration of an IGF-I-containing neuronal pathway produces significant changes in the peripheral IGF system. This suggests strongly that the endocrine (bloodborne) and the paracrine/autocrine (brain) IGF systems are linked functionally. We propose that alterations in the blood IGF-I system may constitute a marker of some cerebellar diseases.

[61-year-old patient with rapidly progressive cerebellar symptoms]

The rare case of a paraneoplastic, cerebellar degeneration is reported. In addition to the valuable early diagnosis of tumor disease, this paraneoplastic occurrence can also lead to false diagnoses in regard to both the underlying disease and the staging of the tumor. In the cases of known tumor disease, the assumption of cerebral metastasis is also possible.

Polyglutamine expansion as a pathological epitope in Huntington's disease and four dominant cerebellar ataxias

A polyglutamine expansion (encoded by a CAG repeat) in specific proteins causes neurodegeneration in Huntington's disease (HD) and four other disorders, by an unknown mechanism thought to involve gain of function or toxicity of the mutated protein. The pathological threshold is 37-40 glutamines in three of these diseases, whereas the corresponding normal proteins contain polymorphic repeats of up to about 35 glutamines. The age of onset of clinical manifestations is inversely correlated to the length of the polyglutamine expansion. Here we report the characterization of a monoclonal antibody that selectively recognizes polyglutamine expansion in the proteins implicated in HD and in spinocerebellar ataxia (SCA) 1 and 3. The intensity of signal depends on the length of the polyglutamine expansion, and the antibody also detects specific pathological proteins expected to contain such expansion, in SCA2 and in autosomal dominant cerebellar ataxia with retinal degeneration, whose genes have not yet been identified.

[The detection of anti-cerebellar antibody western blot analysis in serum from a patient with Miller Fisher syndrome]

We here report a case of Miller Fisher syndrome (MFS) in which serum anti-cerebellar antibody was detected by Western blot analysis. The 32-year-old male studied suffered from diplopia, gait ataxia and sensory disturbance in the distal portion of the upper limbs preceded by cold-like symptoms. Neurological examination on admission revealed that he had external ophthalmoplegia with bilateral ptosis, cerebellar ataxia and areflexia. A cerebrospinal fluid examination showed albuminocytologic dissociation with a protein concentration of 60 mg/dl. Brain CT and MRI showed no significant abnormalities. The patient was diagnosed as MFS, and treated it with two sessions of immunoadsorption plasmapheresis (IAPP). After receiving IAPP therapy, the patient's neurological symptoms and signs were improved. Western blot analysis showed the existence of antibody directed against mouse cerebellum but not against mouse cerebrum, brain stem, and spinal cord in his serum, the level of which was decreased after the IAPP therapy. Serum anti-GQ1b antibody was also elevated. As far as we are aware, there have been no reports showing the existence of anti-cerebellar antibodies detected by Western blot analysis. Though the pathogenesis of MFS remains unclear, our findings suggest that anti-cerebellar antibody detected by Western blot analysis may be caused by cerebellar ataxia in MFS.

Suppressed T cell and macrophage function in the "reeler" (rl/rl) mutant, a murine strain with elevated cerebellar norepinephrine concentration

The effects of neurochemical alterations in specific brain regions on the immune system were examined in reeler (rl/rl) mice, a neurologic mutant strain having an abnormally high concentration of cerebellar norepinephrine (NE). Following immunization with sheep red blood cells, lower numbers of IgM-producing B cells were found in rl/rl mice than in B6C3Fea/a controls. Interleukin-1 (IL-1) production by splenic macrophages from rl/rl mice was reduced compared to B6C3F3a/a controls, as was the proliferative response of splenic T lymphocytes from rl/rl mice activated with an anti-CD3 monoclonal antibody. Levels of IL-4, interferon-gamma and IL-2 produced by splenic T lymphocytes from rl/rl mice were also lower than those of B6C3Fea/a controls. Rl/rl mice do not have an intrinsic defect in the ability to produce IgM, as lipopolysaccharide activated splenic lymphocytes from rl/rl mice produced levels of IgM similar to those of controls. This suggests that defective function in the T lymphocyte and/or macrophage population rather than in the B cell population may underlie the defect in IgM production. No significant alterations were observed in basal splenic levels of NE or neuropeptides in rl/rl mice relative to controls. The reeler mouse model shows that alterations in immune function are present in a strain with inherited alterations in cerebellar noradrenergic innervation and NE concentration.

Trial to establish an animal model of paraneoplastic cerebellar degeneration with anti-Yo antibody. 2. Passive transfer of murine mononuclear cells activated with recombinant Yo protein to paraneoplastic cerebellar degeneration lymphocytes in severe combined immunodeficiency mice

Passive transfer of serum IgG or mononuclear cells from peripheral blood of a patient with paraneoplastic cerebellar degeneration (PCD) to rodents was carried out in order to examine the role of anti-Purkinje cell antibody (anti-Yo antibody) present in serum and cerebrospinal fluid of PCD patients. After a single injection of IgG into mouse brain, it was taken up by Purkinje cells and remained there for more than 36 h without Purkinje cell loss. Injection of PCD IgG together with complement or lipopolysaccharide-activated human macrophages or rat mononuclear cells into rat ventricles did not cause Purkinje cell loss. We also studied passive transfer of the PCD patient's lymphocytes to mice with severe combined immunodeficiency (SCID). We constructed a recombinant Yo fusion protein that has the leucine-zipper protein (Yo protein), the common epitope for anti-Yo antibody for immunizing mice, and that resulted in production of significant amounts of anti-Yo antibody. Spleen cells from these Yo protein immunized mice were injected intravenously or intracerebrally into naive mice that subsequently showed no neurological symptoms or loss of Purkinje cells. We conclude that the anti-Yo antibody, either in combination with or without complement or activated mononuclear cells, cannot be the sole cause of Purkinje cell loss.

Trial to establish an animal model of paraneoplastic cerebellar degeneration with anti-Yo antibody. 1. Mouse strains bearing different MHC molecules produce antibodies on immunization with recombinant Yo protein, but do not cause Purkinje cell loss

Passive transfer of anti-Yo antibody from patients with paraneoplastic cerebellar degeneration (PCD) associated with gynecological or breast carcinoma has not been successful in inducing an animal model. We used active immunization with recombinant Yo protein of four strains of mice bearing different MHC molecules: BALB/c (H-2d), C3H (H-2k), C57BL/6 (H-2b), SJL/J (H-2s). All the strains produced high anti-Yo antibody titer but none developed cerebellar ataxia or showed Purkinje cell loss. Spleen cells from the immunized mice also reacted with recombinant protein. Because C57BL/6(nu/nu) mice produce no anti-Yo antibody, mature helper T cells are required for its production. Results suggest that antibody production in peripheral blood alone is not sufficient for the development of PCD and that MHC class II molecules function in the activation of T cells to help B cells to help B cells produce antibodies.

Absence of anti-Purkinje cell antibodies in patients with cerebellar ataxia following falciparum malaria

Immunological mechanisms have been implicated in the pathogenesis of delayed cerebellar ataxia following falciparum malaria (DCA). We tested serum and CSF samples obtained from 39 Sri Lankan patients with DCA for the presence of antibodies (Ab) directed against cerebellar Purkinje cells by an immunofluorescence (IF) technique and Western blot analysis. For the IF test 7 mu thick frozen sections of histologically normal cerebellum obtained at post mortem were used. Proteins obtained from crude preparations of Purkinje cells isolated from the cerebellum were used for Western blot analysis. Sera obtained from patients known to have antineuronal antibodies associated with cerebellar degenerations and paraneoplastic disorders (anti-Hu and anti-Yo Ab) and sera from normal blood donors served as positive and negative controls, respectively. All serum and CSF samples obtained from patients with DCA were negative for Ab directed against cerebellar Purkinje cells. Humoral mechanisms are, therefore, unlikely to be important in the pathogenesis of this delayed complication of falciparum malaria.

[Fisher syndrome and anti-GQ1b antibody]

Serum anti-GQ1b IgG antibody is specifically detected in almost all the patients with Fisher syndrome and those with Guillain-Barré syndrome with ophthalmoplegia in the acute phase. An anti-GQ1b mouse monoclonal antibody immunostained the paranodal regions of the extramedullary portion of the human oculomotor, trochlear and abducens nerves. Such immunostaining was not observed in the other cranial and peripheral nerves. Anti-GQ1b IgG antibody may be involved in the pathogenetic mechanism of ophthalmoplegia in Fisher syndrome and Guillain-Barré syndrome by binding to the paranodal regions of the oculomotor, trochlear and abducens nerves. Investigation of serum anti-GQ1b antibody is considered to be a useful diagnostic marker in Fisher syndrome and Guillain-Barré syndrome with ophthalmoplegia.

Molecular mimicry between GQ1b ganglioside and lipopolysaccharides of Campylobacter jejuni isolated from patients with Fisher's syndrome

We isolated Campylobacter jejuni from 2 patients with Fisher's syndrome subsequent to enteritis. Crude lipopolysaccharide fractions were extracted from the bacteria and separated by thin-layer chromatography. Monoclonal antibodies to GQ1b ganglioside (GMR13 and 7F5) reacted with both lipopolysaccharide fractions, indicating that the lipopolysaccharides bear the GQ1b epitope. This is the first report of molecular mimicry between neural tissue components and the antecedent infectious agents of Fisher's syndrome.

Ataxia in patients infected with Salmonella typhi phage type D2: clinical, biochemical and immunohistochemical studies

Reversible cerebellar dysfunction has been described in association with typhoid fever by a number of authors. Ataxia and tremors are relatively common manifestations of typhoid fever in Papua New Guinea. A series of 14 patients with typhoid fever and ataxia was compared with non-ataxic typhoid patients. Hyponatraemia and hypoalbuminaemia were common in both groups and more severe in the ataxic group. Hypotension was also more common in the ataxic group. These features may reflect more severe disease. All isolates of Salmonella typhi, from both ataxic and non-ataxic patients, were phage type D2 which is endemic around Port Moresby. Tests for autoantibodies cross-reacting with cerebellar tissue were negative. It is possible that cerebellar dysfunction in typhoid fever is more common in association with phage type D2.

Paraneoplastic opsoclonus-myoclonus associated with anti-Hu antibody

We report a 74-year-old woman with opsoclonus, myoclonus, ataxia, and encephalopathy who had small-cell lung cancer and high titers of anti-Hu antibody in her serum. At autopsy, there were perivascular inflammatory infiltrates in the brainstem, putamen, and meninges overlying the orbital frontal cortex. Immunohistochemical studies showed the expression of the Hu antigens by the tumor and the presence of deposits of anti-Hu IgG in the patient's cortex, brainstem, and cerebellum, suggesting that anti-Hu immune response was related to the patient's clinical syndrome. This case of paraneoplastic opsoclonus, myoclonus, ataxia, and encephalopathy expands the spectrum of neurologic dysfunction associated with the anti-Hu antibody.

Antineuronal antibodies in acute cerebellar ataxia following Epstein-Barr virus infection

A 29-year-old man developed acute cerebellar ataxia following Epstein-Barr virus infection. Serum IgG and IgM antibodies reacted with both nuclear and cytoplasmic elements of neurons. Western blot revealed IgG binding to the 34- and 29-kd bands and IgM binding to the 44-, 37-, and 29-kd bands. The IgM reactivity gradually reduced. There was no identifiable neoplasm and the ataxia gradually improved. These findings suggest a role for autoimmune mechanisms in the pathogenesis of acute cerebellar ataxia.

[Guillain-Barré syndrome associated with anti-GQ1b antibody--nosological relationship between Fisher's syndrome and Guillain-Barré syndrome]

A 15-year-old man developed diplopia, ataxic gait and bulbar palsy. Two days after the onset of neurological symptoms, neurological examination revealed external ophthalmoplegia, cerebellar ataxia, and areflexia. Muscle weakness in the areas innervated by cranial nerves and in the four limbs, and glove and stocking type sensory impairment were also observed. On the 13th hospital day, CSF protein was elevated with normal cellularity. Serum IgM anti-GQ1b antibody was increased, which decreased concurrently with the clinical improvement. Recent studies have revealed the frequent presence of serum anti-GQ1b antibody in Fisher's syndrome. Therefore, this patient showed Fisher's syndrome at the beginning, then evolved to Guillain-Barré syndrome associated with anti-GQ1b antibody, which would support close association between Fisher's syndrome and Guillain-Barré syndrome.

An immunologic abnormality common to Bickerstaff's brain stem encephalitis and Fisher's syndrome

The nosological position of Bickerstaff's brain stem encephalitis (BBE) has yet to be established, and its etiology is not clear. Because anti-GQ1b antibody frequently occurs in patients with Fisher's syndrome (FS) and there are clinical similarities between FS and BBE, we investigated anti-ganglioside antibodies in sera from 3 BBE patients who had transient long tract signs in addition to acute ophthalmoplegia and cerebellar-like ataxia in order to clarify the etiology and nosological position of BBE. High IgG anti-GQ1b antibody titers were present in all 3 sera samples but decreased with the clinical course of the illness. In contrast, no anti-GQ1b antibody was found in sera from patients with other neurologic diseases which were able to produce transient brain stem disturbance: multiple sclerosis, neuro-Behçet's disease, brain stem infarction, herpes simplex virus encephalitis, and Wernicke's encephalopathy. The finding that BBE and FS shared common autoantibody suggests that autoimmune mechanism common to FS is likely in BBE, and that both conditions represent a distinct disease with a wide spectrum of symptoms that include ophthalmoplegia and ataxia.

Paraneoplastic cerebellar degeneration: successful early detection and treatment of cancer through characterization of the anti-Purkinje cell antibody

Paraneoplastic cerebellar degeneration (PCD) is thought to be caused by an autoantibody against both tumor and neuronal tissue. Such autoantibodies are most frequently detected in patients with gynecological or breast cancer, and are designated as anti-Yo. We report here a patient with PCD whose underlying cancer could not be detected despite extensive tumor survey. IgG in her serum and cerebrospinal fluid reacted with the cytoplasm of cerebellar Purkinje cells immunohistochemically. On immunoelectron microscopy, the endoplasmic reticulum and Golgi complex were stained. Her IgG bound to the 58 kD band on immunoblots of cerebellar proteins. A reaction was also observed with the recombinant proteins deduced from the complementary DNA clone encoding a neuronal cell antigen reported by Sakai et al (Ann Neurol 28: 692, 1990). Based on these results, successful early resection of fallopian tube adenocarcinoma was performed. It is crucially important to characterize these PCD related autoantibodies for the early treatment of underlying malignant tumors.

Immune activation during cerebellar dysfunction following Plasmodium falciparum malaria

Evidence for immune activation was investigated in 12 patients with a rare syndrome of self-limiting, delayed onset cerebellar dysfunction following an attack of falciparum malaria which occurred 18-26 d previously. Concentrations of tumour necrosis factor, interleukin 6 and interleukin 2 were all significantly higher in serum samples of patients during cerebellar ataxia than in recovery sera and in the sera of 8 patients who did not develop delayed cerebellar dysfunction following an attack of falciparum malaria. Cytokine concentrations in the cerebrospinal fluid were also significantly higher in ataxic patients than in controls. These findings suggest that immunological mechanisms may play a role in delayed cerebellar dysfunction following falciparum malaria.

Late onset autosomal dominant cerebellar ataxia. A family description and linkage analysis with the HLA system

A family suffering an autosomal dominant form of late onset hereditary cerebellar ataxia is described. Eight affected family members were personally studied, and data from another four were obtained through anamnesis. The mean age of onset was 37.1 +/- 5.4 years (27-47 years). The clinical picture consisted basically of a pure ataxic cerebellar syndrome. CT-scan disclosed diffuse cerebellar atrophy with relative sparing of the brainstem and no involvement of supratentorial structures. Neurophysiological studies (nerve conduction, VEP and BAEP) were normal. Twenty-six individuals were typed for HLA histocompatibility antigens. Lod scores were calculated with the computer program LINKMAP. Close linkage of the ataxia gene with the HLA system in this family could be excluded--0 = 0.02, z = (-2.17)--and the overall analysis of the lod scores suggest another chromosomal location than chromosome 6.

Antibody to a zinc finger protein in a patient with paraneoplastic cerebellar degeneration

In some patients with paraneoplastic cerebellar degeneration (PCD), autoantibodies against neural components have been identified. Here, we demonstrate a major 58 kd protein antigen in an immunoblot of human cerebellum by serum from a patient with PCD. Immunohistochemically, the serum recognized neural cells especially Purkinje cells in a human brain. To identify the details of the target antigens for the antibody, we isolated a cDNA clone from a human cerebellar library. Homology searches revealed a similarity with the zinc finger proteins. PCD related proteins reported here may be important to maintain neural cells especially those in the cerebellum, and further studies on this molecule may help us elucidate the causes of degenerative or autoimmune diseases in the cerebellum.