Autoantibodies to glutamic acid decarboxylase in palatal myoclonus and epilepsy

Glutamic acid decarboxylase autoantibodies in controlled and uncontrolled epilepsy: a pilot study

There have been anecdotal reports of raised glutamic acid decarboxylase (GAD) autoantibodies in patients with refractory epilepsy. We measured serum GAD autoantibodies in 105 patients with idiopathic or symptomatic epilepsy. There was no significant difference in the absolute titre of GAD autoantibody between patients with controlled and uncontrolled epilepsy. However, four female patients with uncontrolled epilepsy had levels that were over three times above the highest detected in the seizure-free group, three of whom also tested positive for pancreatic islet cell antibodies. Larger scale studies, perhaps comparing different epilepsy syndromes, are required to determine the exact clinical role of GAD autoantibodies in epilepsy.

Autoantibodies to glutamic acid decarboxylase in patients with therapy-resistant epilepsy

BACKGROUND

Autoantibodies to glutamic acid decarboxylase (GAD-A) are present in type 1 diabetes and stiff man syndrome (SMS), and have also been reported in cerebellar ataxia. Epilepsy was present in 4 of 19 patients with SMS and GAD-A, implying that epilepsy sometimes is associated with anti-GAD autoimmunity.

METHODS

The authors investigated the prevalence of GAD-A in patients with therapy-resistant localization-related epilepsy (n = 51) and generalized epilepsy (n = 49) by a radiobinding assay. The positive samples were confirmed by immunohistochemistry and immunoblotting of recombinant human GAD65.

RESULTS

GAD-A were found in eight patients with localization-related epilepsy, whereas none of the patients with generalized epilepsy, other neurologic disorders (n = 38), or the control subjects (n = 48) had GAD-A. Two patients had high levels of GAD-A, similar to SMS, whereas six patients had significantly lower titers, characteristic of type 1 diabetes. The two patients with high levels of GAD-A had GAD-A both in serum and CSF by immunohistochemistry and immunoblotting. Both of them had longstanding therapy-resistant temporal lobe epilepsy but did not have diabetes. One had a history of autoimmune disease, whereas the other had serologic evidence of multiple autoantibodies without any clinical signs of autoimmune disease.

CONCLUSIONS

GAD autoimmunity may be associated with refractory localization-related epilepsy.

Absence of glutamic acid decarboxylase antibodies in childhood epilepsies

Glutamic acid decarboxylase antibodies are present in some patients with therapy-resistant epilepsy. The authors measured glutamic acid decarboxylase antibodies in an unselected population of 114 children with different types of epilepsy. Three children with temporal lobe epilepsy and six children with various other types of epilepsy had intractable epilepsy. None of the children tested positive for glutamic acid decarboxylase antibodies. The study suggests that glutamic acid decarboxylase antibody testing cannot be recommended in unselected cases of childhood epilepsy.

Palatal Myoclonus as a Cause of Objective Tinnitus: A Report of Six Cases and a Review of the Literature

We describe 6 new cases of palatal myoclonus (PM), a rare disorder that is characterized by involuntary rhythmic contraction of the palatal musculature. Although it has been reported that PM is a lifelong condition, one of our patients experienced a complete resolution of PM, which casts doubt on the accepted beliefs about the persistence of PM. Included in this report is the first published case of voluntary PM with objective tinnitus.

Humoral and cellular immune parameters before and during immunosuppressive therapy of a patient with stiff-man syndrome and insulin dependent diabetes mellitus

OBJECTIVES

Humoral and cellular immune reactivity are reported for two neuroendocrine autoantigens-glutamic acid decarboxylase (GAD) and the protein tyrosine phosphatase IA-2-in a patient with the autoimmune type of stiff-man syndrome and insulin dependent diabetes (IDDM).

METHODS

Antibodies and T cell proliferation against GAD and IA-2 and cytokine release of antigen stimulated T cells (IFN-gamma) were determined before and several times during immunosuppressive therapy with prednisolone.

RESULTS

Raised GAD antibodies against full length GAD65 or chimeric constructs were detected before therapy and they remained at a high concentration despite a marked clinical improvement during cortisone treatment. Antibodies to IA-2 were undetectable, but weak T cell responses to both GAD and IA-2 were seen before therapy and once on reduction of high cortisone dosages when the patient showed signs of clinical deterioration. Cytokine profiles showed increased IFN-gamma production after stimulation with GAD or IA-2 suggesting increased activation of TH1 cells.

CONCLUSION

Immunosuppressive therapy --even with extremely high doses of 500 mg a day--does not lead to the reduction of antibody concentrations in the periphery nor to a switch in epitope recognition of such antibodies despite clinical improvement. The amount of T cell reactivity to various antigens, however, may be a useful marker to monitor the effectiveness of immunotherapy.

Stiff-leg syndrome: a focal form of stiff-man syndrome

We report on 2 patients who presented stiffness and spasms similar to those of stiff-man syndrome (SMS) that were limited to one leg for up to 11 years. Patients had serum glutamic acid decarboxylase (GAD) autoantibodies in high titer, clinical evidence of organ-specific autoimmunity, and electromyographic pattern of continuous motor unit activity with abnormally enhanced exteroceptive reflexes. The clinical and immunological profile suggests that this disorder may be a focal form of SMS.

Islet cell antigens in the prediction and prevention of insulin-dependent diabetes mellitus

Insulin-dependent diabetes mellitus (IDDM) is associated with both antibody and T-cell autoimmunity to pancreatic islet cell components. In recent years, considerable progress has been made in the identification of the molecular components of the pancreatic islets to which these immune responses are directed. These advances have led to the development of a number of immune markers for use in screening for individuals at risk for disease, and there is promise of antigen-specific immune intervention therapies to prevent diabetes in those identified as at risk. In this article, we review our current knowledge of autoantigens associated with IDDM and the implications this has on the prediction and prevention of the disease.

Antidyskinetic drug therapy for pediatric movement disorders

The pharmacologic armamentarium used to treat dyskinesias in childhood is increasing. Anticonvulsant drugs as a class are still some of the broadest-spectrum antidyskinetic agents, probably because the class includes so many differently acting drugs or because dyskinesias are manifestations of subcortical electrical events. This group is enhanced by recent developments in gamma-aminobutyric acid and glutamate receptor pharmacology, which promise new antidyskinetic drugs. Other drugs acting at receptors for monoamines (dopamine, norepinephrine, and serotonin), acetylcholine, opioids, or histamine may provide symptomatic improvement. Fewer pharmacotherapies address the underlying pathophysiology of movement disorders. Of these, drugs or biologicals for immunomodulation are the most developed, but the group also includes antioxidants, cofactors, metabolic inhibitors, and chelators. There is potential for drugs that block the neurotoxic effects of glutamate to treat movement disorders and reverse or prevent brain injury. Peripheral blockade of focal dyskinesias through botulinum toxin offers a useful alternative to drugs in some patients.

The insulin-dependent diabetes mellitus-associated ICA 105 autoantigen in stiff-man syndrome patients

The pathogenetic role of anti-glutamic acid decarboxylase (GAD) antibodies found in up to 60% of patients with stiff-man syndrome (SMS) is still controversial. GAD, in fact, is also one of the major target antigen of insulin-dependent diabetes mellitus (IDDM), a disease affecting one third of anti-GAD antibody-positive patients with SMS. To better define the role of autoimmunity in SMS we looked for molecular and immunological evidence of an autoimmune recognition of a second IDDM-associated autoantigen, the pancreatic 37/40 kDa IDDM-autoantigen, whose gene called ICA 105 has been recently cloned. By Northern blot analysis we found that tissue distribution of human ICA 105 is restricted to pancreas and brain and within the central nervous system (CNS) its distribution is similar to GAD. We also measured anti-ICA 105 antibodies in 11 SMS patients and 56 control patients with other neurological diseases (OND). Anti-ICA 105 antibodies were found in 4/11 (36%) patients with SMS (a frequency similar to that of anti-GAD-antibodies in our SMS population) but in only 2/56 (3%) patients with OND (P < 0.001). Anti-ICA 105 and anti-GAD antibodies were associated in 3/4 (75%) patients with SMS but in none of the 2 anti-ICA 105 antibody-positive OND patients. Among anti-ICA 105 antibody-positive patients with SMS, only 1 suffered also from IDDM. In contrast, the only 2 anti-ICA 105 antibody-positive with OND had IDDM. Our results indicate that ICA 105 represents another putative neuroendocrine autoantigen in SMS. The presence of circulating anti-GAD and/or anti-ICA 105 antibodies might help the diagnosis of SMS. The absence, however, of antibodies recognising specific CNS autoantigens (e.g. GAD, ICA 105) does not rule out SMS.

Stiff-person syndrome with anti-glutamic acid decarboxylase autoantibodies: complete remission of symptoms after intrathecal baclofen administration

A female patient, aged 61 years, who developed a severe immobilizing stiff-person syndrome in conjunction with insulin-dependent diabetes mellitus, is described. In addition to the typical clinical symptoms, diagnosis was proven by the presence of autoantibodies against glutamic acid decarboxylase in serum and cerebrospinal fluid. Symptomatic treatment with continuous intrathecal application of baclofen administered by a subcutaneous pump resulted in rapid clinical improvement so that the patient became ambulatory. Intermittent withdrawal from intrathecal baclofen therapy led to complete remanifestation of stiff-person syndrome within 18 h; after re-introduction of intrathecal therapy stiffness disappeared completely within 48 h. The clinical course has been stable now for over 24 months and stiffness has completely disappeared. The effect of baclofen in this patient is discussed in the light of the suggested pathophysiological mechanisms in stiff-person syndromes.