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Wright S, Geerts AT, Jol-van der Zijde CM, Jacobson L, Lang B, Waters P, van Tol MJD, Stroink H, Neuteboom RF, Brouwer OF, Vincent A. Neuronal antibodies in pediatric epilepsy: Clinical features and long-term outcomes of a historical cohort not treated with immunotherapy. Epilepsia 2016; 57:823-31. [PMID: 26996997 PMCID: PMC4864754 DOI: 10.1111/epi.13356] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2016] [Indexed: 12/24/2022]
Abstract
OBJECTIVE In autoimmune encephalitis the etiologic role of neuronal cell-surface antibodies is clear; patients diagnosed and treated early have better outcomes. Neuronal antibodies have also been described in patients with pediatric epilepsy without encephalitis. The aim was to assess whether antibody presence had any effect on long-term outcomes in these patients. METHODS Patients (n = 178) were recruited between 1988 and 1992 as part of the prospective Dutch Study of Epilepsy in Childhood; none received immunotherapy. Healthy age-matched bone-marrow donors served as controls (n = 112). All sera were tested for serum N-methyl-d-aspartate receptor (NMDAR), alpha amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor, leucine rich glioma inactivated 1, contactin associated protein like 2 (CASPR2), contactin-2, glutamic acid decarboxylase, and voltage gated potassium channel (VGKC)-complex antibodies by standard techniques. No cerebrospinal fluid (CSF) samples were available. Results were correlated with clinical data collected over 15 years. RESULTS Seventeen patients (9.5%) were positive for VGKC complex (n = 3), NMDAR (n = 7), CASPR2 (n = 4), and contactin-2 (n = 3), compared to three (3/112; 2.6%) healthy controls (VGKC complex [n = 1], NMDAR [n = 2]; p = 0.03; Fisher's exact test). Titers were relatively low (≤1:100 for cell-surface antibodies), but 8 (47%) of the 17 positive samples bound to the surface of live hippocampal neurons consistent with a potential pathogenic antibody. Preexisting cognitive impairment was more frequent in antibody-positive patients (9/17 vs. 33/161; p = 0.01). Fourteen antibody-positive patients were treated with standard antiepileptic drugs (AEDs); three (17%) became intractable but this was not different from the 16 (10%) of 161 antibody-negative patients. In 96 patients with available follow-up samples at 6 and/or 12 months, 6 of 7 positive antibodies had disappeared and, conversely, antibodies had appeared for the first time in a further 7 patients. SIGNIFICANCE Neuronal antibodies were found at low levels in 9.5% of patients with new-onset pediatric epilepsy but did not necessarily persist over time, and the development of antibodies de novo in later samples suggests they could be due to a secondary response to neuronal damage or inflammation. Moreover, as the response to standard AEDs and the long-term outcome did not differ from those of antibody-negative pediatric patients, these findings suggest that routine neuronal antibody testing is unlikely to be helpful in pediatric epilepsy. However, the higher incidence of preexisting cognitive problems in the antibody-positive group, the CASPR2 and contactin-2 antibodies in 7 of 17 patients, and the binding of 8 of 17 of serum samples to live hippocampal neurons suggest that neuronal antibodies, even if secondary, could contribute to the comorbidities of pediatric epilepsy.
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Affiliation(s)
- Sukhvir Wright
- Nuffield Department of Clinical Neurosciences, John Radcliffe University Hospital, University of Oxford, Oxford, United Kingdom
| | - Ada T Geerts
- Department of Pediatric Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Leslie Jacobson
- Nuffield Department of Clinical Neurosciences, John Radcliffe University Hospital, University of Oxford, Oxford, United Kingdom
| | - Bethan Lang
- Nuffield Department of Clinical Neurosciences, John Radcliffe University Hospital, University of Oxford, Oxford, United Kingdom
| | - Patrick Waters
- Nuffield Department of Clinical Neurosciences, John Radcliffe University Hospital, University of Oxford, Oxford, United Kingdom
| | - Maarten J D van Tol
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Hans Stroink
- Departments of Pediatric Neurology and Neurology, Canisius Hospital, Nijmegen, The Netherlands
| | - Rinze F Neuteboom
- Department of Pediatric Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Oebele F Brouwer
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe University Hospital, University of Oxford, Oxford, United Kingdom
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Byun JI, Lee ST, Jung KH, Sunwoo JS, Moon J, Kim TJ, Lim JA, Kim S, Kim DY, Han SH, Jang H, Suh HI, Cho AH, Kim DW, Shin JW, Koo YS, Choi WC, Lee WW, Choi N, Kim S, Nam H, Koo DL, Kim M, Lim BC, Chae JH, Kim KJ, Jeon D, Park KI, Jung KY, Kim M, Chu K, Lee SK. Prevalence of antineuronal antibodies in patients with encephalopathy of unknown etiology: Data from a nationwide registry in Korea. J Neuroimmunol 2016; 293:34-38. [PMID: 27049559 DOI: 10.1016/j.jneuroim.2016.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/01/2016] [Accepted: 02/05/2016] [Indexed: 12/31/2022]
Abstract
We aimed to evaluate the prevalence of antineuronal antibodies in a nationwide cohort of patients with encephalopathy of unknown etiology. We screened 1699 patients with idiopathic encephalopathy who were referred from 70 hospitals across Korea for autoimmune synaptic and classic paraneoplastic antibodies. Those with cerebellar degeneration, sensory polyneuropathy or other paraneoplastic syndromes without encephalopathy were not included in this study. One-hundred and four patients (6.12%) had antibody-associated autoimmune encephalopathy. Autoimmune synaptic antibodies were identified in 89 patients (5.24%) and classic paraneoplastic antibodies were identified in 16 patients (0.94%). The patients with antibody-associated autoimmune encephalopathy comprised a small but significant portion of the total number of patients with encephalopathy of unknown cause.
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Affiliation(s)
- Jung-Ick Byun
- Department of Neurology, Laboratory of Neurotherapeutics, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Soon-Tae Lee
- Department of Neurology, Laboratory of Neurotherapeutics, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Keun-Hwa Jung
- Department of Neurology, Laboratory of Neurotherapeutics, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Jun-Sang Sunwoo
- Department of Neurology, Laboratory of Neurotherapeutics, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Jangsup Moon
- Department of Neurology, Laboratory of Neurotherapeutics, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea; Departments of Neurology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, South Korea
| | - Tae-Joon Kim
- Department of Neurology, Laboratory of Neurotherapeutics, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Jung-Ah Lim
- Department of Neurology, Laboratory of Neurotherapeutics, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Soyun Kim
- Department of Neurology, Laboratory of Neurotherapeutics, Seoul National University Hospital, Seoul, South Korea
| | - Do-Yong Kim
- Department of Neurology, Laboratory of Neurotherapeutics, Seoul National University Hospital, Seoul, South Korea
| | - Su-Hyun Han
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Hyemin Jang
- Department of Neurology, Samsung Medical Center, Seoul, South Korea
| | - Hong Il Suh
- Department of Neurology, Ajou University Medical Center, Suwon, South Korea
| | - A-Hyun Cho
- Department of Neurology, Catholic University of Korea Yeouido St. Mary's Hospital, Seoul, South Korea
| | - Dong Wook Kim
- Department of Neurology, Konkuk University, Seoul, South Korea
| | - Jung-Won Shin
- Department of Neurology, CHA University, CHA Bundang Medical Center, Seongnam, South Korea
| | - Yong Seo Koo
- Department of Neurology, Korea University Anam Hospital, Seoul, South Korea
| | - Woo Chan Choi
- Kyungpook National University School of Medicine, Daegu, South Korea
| | - Woong-Woo Lee
- Department of Neurology, Eulji General Hospital, Seoul, South Korea
| | - Nari Choi
- Department of Neurology, Soonchun Hyang University Hospital Cheonan, Cheonan, South Korea
| | - Seongheon Kim
- Department of Neurology, Kangwon National University Hospital, Chuncheon, South Korea
| | - Hyunwoo Nam
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Dae Lim Koo
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Minah Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul, South Korea
| | - Byung Chan Lim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Jong-Hee Chae
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Ki Joong Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Daejong Jeon
- Department of Neurology, Laboratory of Neurotherapeutics, Seoul National University Hospital, Seoul, South Korea
| | - Kyung-Il Park
- Department of Neurology, Laboratory of Neurotherapeutics, Seoul National University Hospital, Seoul, South Korea; Department of Neurology, Seoul National University Hospital Healthcare System Gangnam Center, South Korea
| | - Ki-Young Jung
- Department of Neurology, Laboratory of Neurotherapeutics, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Manho Kim
- Department of Neurology, Laboratory of Neurotherapeutics, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea; Protein Metabolism Research Center, Seoul National University College of Medicine, Seoul, South Korea
| | - Kon Chu
- Department of Neurology, Laboratory of Neurotherapeutics, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea.
| | - Sang Kun Lee
- Department of Neurology, Laboratory of Neurotherapeutics, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea.
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Morrow J. Autoimmune limbic encephalitis due to VGKC-Ab.Thanks for the memory. Leo Robin (Title of song, 1937). Pract Neurol 2016; 16:162-5. [DOI: 10.1136/practneurol-2015-001313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2015] [Indexed: 11/04/2022]
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Michael BD, Griffiths MJ, Granerod J, Brown D, Davies NWS, Borrow R, Solomon T. Characteristic Cytokine and Chemokine Profiles in Encephalitis of Infectious, Immune-Mediated, and Unknown Aetiology. PLoS One 2016; 11:e0146288. [PMID: 26808276 PMCID: PMC4726626 DOI: 10.1371/journal.pone.0146288] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 12/15/2015] [Indexed: 01/20/2023] Open
Abstract
Background Encephalitis is parenchymal brain inflammation due to infectious or immune-mediated processes. However, in 15–60% the cause remains unknown. This study aimed to determine if the cytokine/chemokine-mediated host response can distinguish infectious from immune-mediated cases, and whether this may give a clue to aetiology in those of unknown cause. Methods We measured 38 mediators in serum and cerebrospinal fluid (CSF) of patients from the Health Protection Agency Encephalitis Study. Of serum from 78 patients, 38 had infectious, 20 immune-mediated, and 20 unknown aetiology. Of CSF from 37 patients, 20 had infectious, nine immune-mediated and eight unknown aetiology. Results Heat-map analysis of CSF mediator interactions was different for infectious and immune-mediated cases, and that of the unknown aetiology group was similar to the infectious pattern. Higher myeloperoxidase (MPO) concentrations were found in infectious than immune-mediated cases, in serum and CSF (p = 0.01 and p = 0.006). Serum MPO was also higher in unknown than immune-mediated cases (p = 0.03). Multivariate analysis selected serum MPO; classifying 31 (91%) as infectious (p = 0.008) and 17 (85%) as unknown (p = 0.009) as opposed to immune-mediated. CSF data also selected MPO classifying 11 (85%) as infectious as opposed to immune-mediated (p = 0.036). CSF neutrophils were detected in eight (62%) infective and one (14%) immune-mediated cases (p = 0.004); CSF MPO correlated with neutrophils (p<0.0001). Conclusions Mediator profiles of infectious aetiology differed from immune-mediated encephalitis; and those of unknown cause were similar to infectious cases, raising the hypothesis of a possible undiagnosed infectious cause. Particularly, neutrophils and MPO merit further investigation.
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MESH Headings
- Adult
- Bacterial Infections/blood
- Bacterial Infections/cerebrospinal fluid
- Biomarkers
- Cell Adhesion Molecules/blood
- Cell Adhesion Molecules/cerebrospinal fluid
- Chemokines/cerebrospinal fluid
- Chemokines/classification
- Cytokines/blood
- Cytokines/cerebrospinal fluid
- Diagnosis, Differential
- Encephalitis/blood
- Encephalitis/cerebrospinal fluid
- Encephalitis/etiology
- Encephalitis/immunology
- Encephalitis, Viral/blood
- Encephalitis, Viral/cerebrospinal fluid
- Encephalitis, Viral/diagnosis
- England/epidemiology
- Female
- Humans
- Infectious Encephalitis/blood
- Infectious Encephalitis/cerebrospinal fluid
- Infectious Encephalitis/diagnosis
- Leukocyte Count
- Male
- Multicenter Studies as Topic
- Mycoses/blood
- Mycoses/cerebrospinal fluid
- Mycoses/diagnosis
- Paraneoplastic Syndromes, Nervous System/blood
- Paraneoplastic Syndromes, Nervous System/cerebrospinal fluid
- Paraneoplastic Syndromes, Nervous System/diagnosis
- Peroxidase/blood
- Peroxidase/cerebrospinal fluid
- Retrospective Studies
- Toxoplasmosis, Cerebral/blood
- Toxoplasmosis, Cerebral/cerebrospinal fluid
- Toxoplasmosis, Cerebral/diagnosis
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Affiliation(s)
- Benedict D. Michael
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
- The Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
- * E-mail:
| | - Michael J. Griffiths
- The Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
- Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | | | - David Brown
- Public Health England, London, United Kingdom
- Influenza and measles laboratory, IOC, Fiocruz, Rio de Janeiro, Brazil
| | | | - Ray Borrow
- Vaccine Evaluation Unit, Public Health England, Manchester, United Kingdom
| | - Tom Solomon
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
- The Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
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Abstract
Autoimmune dementia and encephalopathies (ADE) are complex disorders that can cause immune-mediated cognitive deficits and have confusing nomenclature. Presentation varies from acute limbic encephalitis to subacute or chronic disorders of cognition mimicking neurodegenerative dementia. It may occur as a paraneoplastic phenomenon or an idiopathic autoimmune phenomenon. The presence of a personal/family history of autoimmunity, inflammatory spinal fluid, serologic evidence of autoimmunity (neural or nonorgan-specific), or mesial temporal magnetic resonance imaging abnormalities are clues to diagnosis. Bedside cognitive assessment and/or detailed neuropsychologic testing are useful. Neural-specific autoantibodies, mostly discovered in the past two decades, may bind antigens on the cell surface (e.g., N-methyl-d-aspartate receptor autoantibodies) and are likely to be pathogenic, with treatment aimed at antibody-depleting agents often with success, while antibodies binding intracellular antigens (e.g., antineuronal nuclear autoantibody type 1 (ANNA1 or anti-Hu)) are a marker of a T-cell-mediated process and treated with T-cell-depleting immunotherapies, with variable responses. Detection and treatment of cancer (when present) are essential. High-dose corticosteroids are the initial treatment in most patients and may serve as a diagnostic test when the diagnosis is uncertain. Repeat cognitive testing after immunotherapy helps document objective improvements. Maintenance immunotherapy is recommended in those at risk for relapse. Prognosis is variable, but paraneoplastic ADE with antibodies to intracellular antigens have a worse prognosis. The field is still developing and future studies should provide guidelines for diagnosis and treatments.
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Abstract
Autoimmune neurologic diseases are of major clinical importance in children. Antibody-mediated diseases of the central nervous system are now increasingly recognized in childhood, where the antibodies bind to cell surface epitopes on neuronal or glial proteins, and the patients demonstrate either focal or more generalized clinical signs depending on the extent of brain regions targeted by the antibodies. The antibodies are directed towards ion channels, receptors, and membrane proteins; and the diseases include limbic encephalitis and N-methyl-d-aspartate receptor-antibody encephalitis, among many others. Additionally there are conditions where the wider immune system is implicated. Neurologic features like seizures, movement disorders, autonomic dysfunction, and sleep disorders, with neuroimaging and electrophysiologic features, may indicate a specific antibody-mediated or immune disorder. Often, phenotypic overlap is observed between these conditions, and phenotypic variation seen in children with the same condition. Nevertheless, many patients benefit from immunotherapy with substantial improvement, although huge efforts are still required to optimize the outcome for many patients. In many patients no antibodies have yet been identified, even though they respond to immunotherapies. Here we describe the known antibodies and associated diseases, discuss conditions that are thought to be immune-mediated but have no known immunologic biomarker, and provide guidelines for the investigation and classification of these disorders.
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107
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Pollak TA, Beck K, Irani SR, Howes OD, David AS, McGuire PK. Autoantibodies to central nervous system neuronal surface antigens: psychiatric symptoms and psychopharmacological implications. Psychopharmacology (Berl) 2016; 233:1605-21. [PMID: 26667479 PMCID: PMC4828500 DOI: 10.1007/s00213-015-4156-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 11/05/2015] [Indexed: 12/30/2022]
Abstract
RATIONALE Autoantibodies to central nervous system (CNS) neuronal surface antigens have been described in association with autoimmune encephalopathies which prominently feature psychiatric symptoms in addition to neurological symptoms. The potential role of these autoantibodies in primary psychiatric diseases such as schizophrenia or bipolar affective disorder is of increasing interest. OBJECTIVES We aimed to review the nature of psychiatric symptoms associated with neuronal surface autoantibodies, in the context of autoimmune encephalopathies as well as primary psychiatric disorders, and to review the mechanisms of action of these autoantibodies from a psychopharmacological perspective. RESULTS The functional effects of the autoantibodies on their target antigens are described; their clinical expression is at least in part mediated by their effects on neuronal receptor function, primarily at the synapse, usually resulting in receptor hypofunction. The psychiatric effects of the antibodies are related to known functions of the receptor target or its complexed proteins, with reference to supportive genetic and pharmacological evidence where relevant. Evidence for a causal role of these autoantibodies in primary psychiatric disease is increasing but remains controversial; relevant methodological controversies are outlined. Non-receptor-based mechanisms of autoantibody action, including neuroinflammatory mechanisms, and therapeutic implications are discussed. CONCLUSIONS An analysis of the autoantibodies from a psychopharmacological perspective, as endogenous, bioactive, highly specific, receptor-targeting molecules, provides a valuable opportunity to understand the neurobiological basis of associated psychiatric symptoms. Potentially, new treatment strategies will emerge from the improving understanding of antibody-antigen interaction within the CNS.
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Affiliation(s)
- T A Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK.
| | - K Beck
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
| | - S R Irani
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - O D Howes
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
| | - A S David
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
| | - P K McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
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Bradl M, Lassmann H. Neurologic autoimmunity: mechanisms revealed by animal models. HANDBOOK OF CLINICAL NEUROLOGY 2016; 133:121-43. [PMID: 27112675 DOI: 10.1016/b978-0-444-63432-0.00008-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Over the last decade, neurologic autoimmunity has become a major consideration in the diagnosis and management of patients with many neurologic presentations. The nature of the associated antibodies and their targets has led to appreciation of the importance of the accessibility of the target antigen to antibodies, and a partial understanding of the different mechanisms that can follow antibody binding. This chapter will first describe the basic principles of autoimmune inflammation and tissue damage in the central and peripheral nervous system, and will then demonstrate what has been learnt about neurologic autoimmunity from circumstantial clinical evidence and from passive, active, and occasionally spontaneous or genetic animal models. It will cover neurologic autoimmune diseases ranging from disorders of neuromuscular transmission, peripheral and ganglionic neuropathy, to diseases of the central nervous system, where autoantibodies are either pathogenic and cause destruction or changes in function of their targets, where they are harmless bystanders of T-cell-mediated tissue damage, or are not involved at all. Finally, this chapter will summarize the relevance of current animal models for studying the different neurologic autoimmune diseases, and it will identify aspects where future animal models need to be improved to better reflect the disease reality experienced by affected patients, e.g., the chronicity or the relapsing/remitting nature of their disease.
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Affiliation(s)
- Monika Bradl
- Department of Neuroimmunology, Center for Brain Research, Medical University Vienna, Vienna, Austria.
| | - Hans Lassmann
- Department of Neuroimmunology, Center for Brain Research, Medical University Vienna, Vienna, Austria
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Sunwoo JS, Chu K, Byun JI, Moon J, Lim JA, Kim TJ, Lee ST, Jung KH, Park KI, Jeon D, Jung KY, Kim M, Lee SK. Intrathecal-specific glutamic acid decarboxylase antibodies at low titers in autoimmune neurological disorders. J Neuroimmunol 2015; 290:15-21. [PMID: 26711563 DOI: 10.1016/j.jneuroim.2015.11.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Revised: 11/13/2015] [Accepted: 11/15/2015] [Indexed: 01/07/2023]
Abstract
Autoantibodies to glutamic acid decarboxylase (Gad-Abs) are implicated in various neurological syndromes. The present study aims to identify intrathecal-specific GAD-Abs and to determine clinical manifestations and treatment outcomes. Nineteen patients had GAD-Abs in cerebrospinal fluid but not in paired serum samples. Neurological syndromes included limbic encephalitis, temporal lobe epilepsy, cerebellar ataxia, autonomic dysfunction, and stiff-person syndrome. Immunotherapy had beneficial effects in 57.1% of patients, and the patients with limbic encephalitis responded especially well to immunotherapy. Intrathecal-specific antibodies to GAD at low titers may appear as nonspecific markers of immune activation within the central nervous system rather than pathogenic antibodies causing neuronal dysfunction.
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Affiliation(s)
- Jun-Sang Sunwoo
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Kon Chu
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea.
| | - Jung-Ick Byun
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Jangsup Moon
- Department of Neurology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, South Korea
| | - Jung-Ah Lim
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Tae-Joon Kim
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Soon-Tae Lee
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Keun-Hwa Jung
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung-Il Park
- Department of Neurology, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, South Korea
| | - Daejong Jeon
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Ki-Young Jung
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Manho Kim
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea; Protein Metabolism Medical Research Center, Seoul National University College of Medicine, Seoul, South Korea
| | - Sang Kun Lee
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea.
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Nosadini M, Mohammad SS, Ramanathan S, Brilot F, Dale RC. Immune therapy in autoimmune encephalitis: a systematic review. Expert Rev Neurother 2015; 15:1391-419. [DOI: 10.1586/14737175.2015.1115720] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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111
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Werner C, Pauli M, Doose S, Weishaupt A, Haselmann H, Grünewald B, Sauer M, Heckmann M, Toyka KV, Asan E, Sommer C, Geis C. Human autoantibodies to amphiphysin induce defective presynaptic vesicle dynamics and composition. Brain 2015; 139:365-79. [DOI: 10.1093/brain/awv324] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 09/25/2015] [Indexed: 12/16/2022] Open
Abstract
Abstract
See Irani (doi:10.1093/awv364) for a scientific commentary on this article.
Stiff-person syndrome is the prototype of a central nervous system disorder with autoantibodies targeting presynaptic antigens. Patients with paraneoplastic stiff-person syndrome may harbour autoantibodies to the BAR (Bin/Amphiphysin/Rvs) domain protein amphiphysin, which target its SH3 domain. These patients have neurophysiological signs of compromised central inhibition and respond to symptomatic treatment with medication enhancing GABAergic transmission. High frequency neurotransmission as observed in tonic GABAergic interneurons relies on fast exocytosis of neurotransmitters based on compensatory endocytosis. As amphiphysin is involved in clathrin-mediated endocytosis, patient autoantibodies are supposed to interfere with this function, leading to disinhibition by reduction of GABAergic neurotransmission. We here investigated the effects of human anti-amphiphysin autoantibodies on structural components of presynaptic boutons ex vivo and in vitro using electron microscopy and super-resolution direct stochastic optical reconstruction microscopy. Ultrastructural analysis of spinal cord presynaptic boutons was performed after in vivo intrathecal passive transfer of affinity-purified human anti-amphiphysin autoantibodies in rats and revealed signs of markedly disabled clathrin-mediated endocytosis. This was unmasked at high synaptic activity and characterized by a reduction of the presynaptic vesicle pool, clathrin coated intermediates, and endosome-like structures. Super-resolution microscopy of inhibitory GABAergic presynaptic boutons in primary neurons revealed that specific human anti-amphiphysin immunoglobulin G induced an increase of the essential vesicular protein synaptobrevin 2 and a reduction of synaptobrevin 7. This constellation suggests depletion of resting pool vesicles and trapping of releasable pool vesicular proteins at the plasma membrane. Similar effects were found in amphiphysin-deficient neurons from knockout mice. Application of specific patient antibodies did not show additional effects. Blocking alternative pathways of clathrin-independent endocytosis with brefeldin A reversed the autoantibody induced effects on molecular vesicle composition. Endophilin as an interaction partner of amphiphysin showed reduced clustering within presynaptic terminals. Collectively, these results point towards an autoantibody-induced structural disorganization in GABAergic synapses with profound changes in presynaptic vesicle pools, activation of alternative endocytic pathways, and potentially compensatory rearrangement of proteins involved in clathrin-mediated endocytosis. Our findings provide novel insights into synaptic pathomechanisms in a prototypic antibody-mediated central nervous system disease, which may serve as a proof-of-principle example in this evolving group of autoimmune disorders associated with autoantibodies to synaptic antigens.
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Affiliation(s)
- Christian Werner
- 1 Hans-Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
- 2 Department of Neurology, University of Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany
| | - Martin Pauli
- 3 Department of Neurophysiology, Institute of Physiology, University of Würzburg, Roentgenring 9, 97070 Würzburg, Germany
| | - Sören Doose
- 4 Department of Biotechnology and Biophysics, Biocenter, University of Würzburg, Am Hubland, 97074 Würzburg, Germany
| | - Andreas Weishaupt
- 2 Department of Neurology, University of Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany
| | - Holger Haselmann
- 1 Hans-Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
- 2 Department of Neurology, University of Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany
- 5 Center for Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - Benedikt Grünewald
- 1 Hans-Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
- 2 Department of Neurology, University of Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany
- 5 Center for Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - Markus Sauer
- 4 Department of Biotechnology and Biophysics, Biocenter, University of Würzburg, Am Hubland, 97074 Würzburg, Germany
| | - Manfred Heckmann
- 3 Department of Neurophysiology, Institute of Physiology, University of Würzburg, Roentgenring 9, 97070 Würzburg, Germany
| | - Klaus V. Toyka
- 2 Department of Neurology, University of Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany
| | - Esther Asan
- 6 Institute for Anatomy and Cell Biology, University of Würzburg, Koellikerstrasse 6, 97070 Würzburg, Germany
| | - Claudia Sommer
- 2 Department of Neurology, University of Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany
| | - Christian Geis
- 1 Hans-Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
- 2 Department of Neurology, University of Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany
- 5 Center for Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
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Heine J, Prüss H, Bartsch T, Ploner C, Paul F, Finke C. Imaging of autoimmune encephalitis – Relevance for clinical practice and hippocampal function. Neuroscience 2015; 309:68-83. [DOI: 10.1016/j.neuroscience.2015.05.037] [Citation(s) in RCA: 165] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 05/04/2015] [Accepted: 05/15/2015] [Indexed: 12/25/2022]
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Bamford A, Lim M. Autoimmune encephalitis following haematopoietic stem cell transplant: a new clinical entity or a previously unrecognised one? Transl Pediatr 2015; 4:327-30. [PMID: 26835396 PMCID: PMC4728994 DOI: 10.3978/j.issn.2224-4336.2015.10.04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Alasdair Bamford
- 1 Department of Paediatric Infectious Diseases and Immunology, 2 Children's Neurosciences, Evelina London Children's Hospital at Guy's & St Thomas' NHS Trust, Kings Health Partners Academic Health Science Centre, London, UK ; 3 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Ming Lim
- 1 Department of Paediatric Infectious Diseases and Immunology, 2 Children's Neurosciences, Evelina London Children's Hospital at Guy's & St Thomas' NHS Trust, Kings Health Partners Academic Health Science Centre, London, UK ; 3 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
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Venkatesan A, Benavides DR. Autoimmune encephalitis and its relation to infection. Curr Neurol Neurosci Rep 2015; 15:3. [PMID: 25637289 DOI: 10.1007/s11910-015-0529-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Encephalitis, an inflammatory condition of the brain that results in substantial morbidity and mortality, has numerous causes. Over the past decade, it has become increasingly recognized that autoimmune conditions contribute significantly to the spectrum of encephalitis causes. Clinical suspicion and early diagnosis of autoimmune etiologies are of particular importance due to the need for early institution of immune suppressive therapies to improve outcome. Emerging clinical observations suggest that the most commonly recognized cause of antibody-mediated autoimmune encephalitis, anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, may in some cases be triggered by herpes virus infection. Other conditions such as Rasmussen's encephalitis (RE) and febrile infection-related epilepsy syndrome (FIRES) have also been posited to be autoimmune conditions triggered by infectious agents. This review focuses on emerging concepts in central nervous system autoimmunity and addresses clinical and mechanistic findings linking autoimmune encephalitis and infections. Particular consideration will be given to anti-NMDA receptor encephalitis and its relation to herpes simplex encephalitis.
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Affiliation(s)
- Arun Venkatesan
- Johns Hopkins Encephalitis Center, Department of Neurology, Johns Hopkins University School of Medicine, Meyer 6-113, 600 N. Wolfe Street, Baltimore, MD, 21287, USA,
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Abstract
The hippocampus has a pivotal role in learning and in the formation and consolidation of memory and is critically involved in the regulation of emotion, fear, anxiety, and stress. Studies of the hippocampus have been central to the study of memory in humans and in recent years, the regional specialization and organization of hippocampal functions have been elucidated in experimental models and in human neurological and psychiatric diseases. The hippocampus has long been considered a classic model for the study of neuroplasticity as many examples of synaptic plasticity such as long-term potentiation and -depression have been identified and demonstrated in hippocampal circuits. Neuroplasticity is the ability to adapt and reorganize the structure or function to internal or external stimuli and occurs at the cellular, population, network or behavioral level and is reflected in the cytological and network architecture as well as in intrinsic properties of hippocampal neurons and circuits. The high degree of hippocampal neuroplasticity might, however, be also negatively reflected in the pronounced vulnerability of the hippocampus to deleterious conditions such as ischemia, epilepsy, chronic stress, neurodegeneration and aging targeting hippocampal structure and function and leading to cognitive deficits. Considering this framework of plasticity and vulnerability, we here review basic principles of hippocampal anatomy and neuroplasticity on various levels as well as recent findings regarding the functional organization of the hippocampus in light of the regional vulnerability in Alzheimer's disease, ischemia, epilepsy, neuroinflammation and aging.
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Affiliation(s)
- T Bartsch
- Department of Neurology, Memory Disorders and Plasticity Group, University Hospital Schleswig-Holstein, Kiel, Germany.
| | - P Wulff
- Institute of Physiology, Neurophysiology, University of Kiel, Olshausenstrasse 40, 24098 Kiel, Germany.
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Le Dault E, Lagarde S, Guedj E, Dufournet B, Rey C, Kaphan E, Tanguy G, Bregigeon M, Sagui E, Brosset C. [Unexplicated neuropsychiatric disorders: Do not ignore dysimmune encephalitis. A case report of a dysimmune encephalitis with anti-leucine rich glioma inactivated 1 (LGI-1) antibodies]. Rev Med Interne 2015; 37:127-30. [PMID: 26164401 DOI: 10.1016/j.revmed.2015.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 05/22/2015] [Accepted: 06/05/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Anti-leucine rich glioma inactivated 1 encephalitis is a common and a treatable etiology of autoimmune encephalitis. Its diagnosis is a challenge because the initial diagnostic work-up is often normal. CASE REPORT A 48-year-old man experienced cognitive and behavioral troubles, facio-brachial dystonic seizures and a syndrome of inappropriate antidiuretic hormone secretion. First line tests excluded infectious, neoplastic, systemic inflammatory, endrocrine or toxic etiologies. Cerebral (18)Fluoro-desoxy-glucose (FDG) position emission tomography and research of specific antibodies in cerebro-spinal fluid and serum led to diagnose an anti-leucine rich glioma inactivated 1 encephalitis. Intravenous immunoglobulins and corticosteroids were partially effective. Cyclophosphamid permitted a good recovery. CONCLUSION In the presence of acute neuropsychiatric disorders with a negative etiologic research, physician should think about dysimmune encephalitis. Facio-brachial dystonic seizures and syndrome of inappropriate antidiuretic hormone secretion are highly evocative of anti-leucine rich glioma inactivated 1 encephalitis. The diagnosis needs specific diagnostic tests (cerebral (18)FDG position emission tomography and antibodies research in cerebro-spinal fluid and in serum), after the exclusion of alternative diagnoses. Extensive and repeated diagnostic work-up for neoplasia is required. Immunosupressive therapies are effective in most cases.
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Affiliation(s)
- E Le Dault
- Service de pathologie infectieuse et tropicale, hôpital d'instruction des armées Laveran, 34, boulevard Alphonse-Laveran, 13014 Marseille, France.
| | - S Lagarde
- Service de neurologie, hôpital d'instruction des armées Laveran, 34, boulevard Alphonse-Laveran, 13014 Marseille, France
| | - E Guedj
- Service de médecine nucléaire, CHU La Timone, AP-HM, 264, rue Saint-Pierre, 13385 Marseille, France
| | - B Dufournet
- Service de neurologie, CHU La Timone, AP-HM, 264, rue Saint-Pierre, 13385 Marseille, France
| | - C Rey
- Service de neurologie, CHU La Timone, AP-HM, 264, rue Saint-Pierre, 13385 Marseille, France
| | - E Kaphan
- Service de neurologie, CHU La Timone, AP-HM, 264, rue Saint-Pierre, 13385 Marseille, France
| | - G Tanguy
- Service de neurologie, hôpital d'instruction des armées Laveran, 34, boulevard Alphonse-Laveran, 13014 Marseille, France
| | - M Bregigeon
- Service de neurologie, hôpital d'instruction des armées Laveran, 34, boulevard Alphonse-Laveran, 13014 Marseille, France
| | - E Sagui
- Service de neurologie, hôpital d'instruction des armées Laveran, 34, boulevard Alphonse-Laveran, 13014 Marseille, France
| | - C Brosset
- Service de neurologie, hôpital d'instruction des armées Laveran, 34, boulevard Alphonse-Laveran, 13014 Marseille, France
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Bale JF. Virus and Immune-Mediated Encephalitides: Epidemiology, Diagnosis, Treatment, and Prevention. Pediatr Neurol 2015; 53:3-12. [PMID: 25957806 DOI: 10.1016/j.pediatrneurol.2015.03.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 03/09/2015] [Accepted: 03/11/2015] [Indexed: 12/12/2022]
Abstract
Virus encephalitis remains a major cause of acute neurological dysfunction and permanent disability among children worldwide. Although some disorders, such as measles encephalomyelitis, subacute sclerosing panencephalitis, and varicella-zoster virus-associated neurological conditions, have largely disappeared in resource-rich regions because of widespread immunization programs, other disorders, such as herpes simplex virus encephalitis, West Nile virus-associated neuroinvasive disease, and nonpolio enterovirus-induced disorders of the nervous system, cannot be prevented. Moreover, emerging viral disorders pose new, potential threats to the child's nervous system. This review summarizes current information regarding the epidemiology of virus encephalitis, the diagnostic methods available to detect central nervous system infection and identify viral pathogens, and the available treatments. The review also describes immune-mediated disorders, including acute disseminated encephalomyelitis and N-methyl-D-aspartate receptor antibody encephalitis, conditions that mimic virus encephalitis and account for a substantial proportion of childhood encephalitis.
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Affiliation(s)
- James F Bale
- Division of Pediatric Neurology, Departments of Pediatrics and Neurology, University of Utah School of Medicine, Salt Lake City, Utah.
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Gozzard P, Woodhall M, Chapman C, Nibber A, Waters P, Vincent A, Lang B, Maddison P. Paraneoplastic neurologic disorders in small cell lung carcinoma: A prospective study. Neurology 2015; 85:235-9. [PMID: 26109714 DOI: 10.1212/wnl.0000000000001721] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 03/23/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the frequency and range of paraneoplastic neurologic disorders (PNDs) and neuronal antibodies in small cell lung carcinoma (SCLC). METHODS Two hundred sixty-four consecutive patients with biopsy-proven SCLC were recruited at the time of tumor diagnosis. All patients underwent full neurologic examination. Serum samples were taken prior to chemotherapy and analyzed for 15 neuronal antibodies. Thirty-eight healthy controls were analyzed in parallel. RESULTS PNDs were quite prevalent (n = 24, 9.4%), most frequently Lambert-Eaton myasthenic syndrome (3.8%), sensory neuronopathy (1.9%), and limbic encephalitis (1.5%). Eighty-seven percent of all patients with PNDs had antibodies to SOX2 (62.5%), HuD (41.7%), or P/Q VGCC (50%), irrespective of their syndrome. Other neuronal antibodies were found at lower frequencies (GABAb receptor [12.5%] and N-type VGCC [20.8%]) or very rarely (GAD65, amphiphysin, Ri, CRMP5, Ma2, Yo, VGKC complex, CASPR2, LGI1, and NMDA receptor [all <5%]). CONCLUSIONS The spectrum of PNDs is broader and the frequency is higher than previously appreciated, and selected antibody tests (SOX2, HuD, VGCC) can help determine the presence of an SCLC.
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Affiliation(s)
- Paul Gozzard
- From the Nuffield Department of Clinical Neurosciences (P.G., M.W., A.N., P.W., A.V., B.L.), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Division of Medical Sciences & Graduate Entry Medicine (C.C.), University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; and Division of Neurology (P.M.), Queen's Medical Centre, Nottingham, United Kingdom.
| | - Mark Woodhall
- From the Nuffield Department of Clinical Neurosciences (P.G., M.W., A.N., P.W., A.V., B.L.), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Division of Medical Sciences & Graduate Entry Medicine (C.C.), University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; and Division of Neurology (P.M.), Queen's Medical Centre, Nottingham, United Kingdom
| | - Caroline Chapman
- From the Nuffield Department of Clinical Neurosciences (P.G., M.W., A.N., P.W., A.V., B.L.), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Division of Medical Sciences & Graduate Entry Medicine (C.C.), University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; and Division of Neurology (P.M.), Queen's Medical Centre, Nottingham, United Kingdom
| | - Anjan Nibber
- From the Nuffield Department of Clinical Neurosciences (P.G., M.W., A.N., P.W., A.V., B.L.), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Division of Medical Sciences & Graduate Entry Medicine (C.C.), University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; and Division of Neurology (P.M.), Queen's Medical Centre, Nottingham, United Kingdom
| | - Patrick Waters
- From the Nuffield Department of Clinical Neurosciences (P.G., M.W., A.N., P.W., A.V., B.L.), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Division of Medical Sciences & Graduate Entry Medicine (C.C.), University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; and Division of Neurology (P.M.), Queen's Medical Centre, Nottingham, United Kingdom
| | - Angela Vincent
- From the Nuffield Department of Clinical Neurosciences (P.G., M.W., A.N., P.W., A.V., B.L.), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Division of Medical Sciences & Graduate Entry Medicine (C.C.), University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; and Division of Neurology (P.M.), Queen's Medical Centre, Nottingham, United Kingdom
| | - Bethan Lang
- From the Nuffield Department of Clinical Neurosciences (P.G., M.W., A.N., P.W., A.V., B.L.), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Division of Medical Sciences & Graduate Entry Medicine (C.C.), University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; and Division of Neurology (P.M.), Queen's Medical Centre, Nottingham, United Kingdom
| | - Paul Maddison
- From the Nuffield Department of Clinical Neurosciences (P.G., M.W., A.N., P.W., A.V., B.L.), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Division of Medical Sciences & Graduate Entry Medicine (C.C.), University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; and Division of Neurology (P.M.), Queen's Medical Centre, Nottingham, United Kingdom
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Sinmaz N, Amatoury M, Merheb V, Ramanathan S, Dale RC, Brilot F. Autoantibodies in movement and psychiatric disorders: updated concepts in detection methods, pathogenicity, and CNS entry. Ann N Y Acad Sci 2015; 1351:22-38. [DOI: 10.1111/nyas.12764] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Nese Sinmaz
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Mazen Amatoury
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Vera Merheb
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Sudarshini Ramanathan
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Russell C. Dale
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
- Discipline of Paediatrics and Child Health; Sydney Medical School, University of Sydney; Sydney Australia
| | - Fabienne Brilot
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
- Discipline of Paediatrics and Child Health; Sydney Medical School, University of Sydney; Sydney Australia
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Abstract
Antibody-mediated diseases of the central nervous system are a relatively new and challenging field in autoimmune neurologic disease and of major clinical importance in children and adults. The antibodies bind to cell-surface epitopes on neuronal or glial proteins, and the patients demonstrate either focal or more generalized clinical signs depending on the extent of brain regions targeted by the antibodies. The presence of seizures, movement disorders, autonomic dysfunction and sleep disorders, alongside neuroimaging and electrophysiological features may indicate a specific antibody-mediated disorder. However, phenotypic variation may be observed in children with the same antibody. Regardless, many patients benefit from immunotherapy with substantial improvement.
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Affiliation(s)
- Ming Lim
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Level 6, West Wing, Oxford 3 9DU, UK; Children's Neurosciences, Evelina Children's Hospital @ Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, Lambeth Palace Road, London SE1 7EH, UK.
| | - Yael Hacohen
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Level 6, West Wing, Oxford 3 9DU, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Level 6, West Wing, Oxford 3 9DU, UK.
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Suleiman J, Dale RC. The recognition and treatment of autoimmune epilepsy in children. Dev Med Child Neurol 2015; 57:431-40. [PMID: 25483277 DOI: 10.1111/dmcn.12647] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2014] [Indexed: 01/07/2023]
Abstract
There is emerging interest in autoimmune epilepsy, which represents a small but potentially treatable form of epilepsy. Most insights into autoimmune epilepsy derive from the recent descriptions of autoimmune encephalitis that takes two general forms: a focal encephalitis (such as limbic) or a diffuse encephalitis (such as anti-N-methyl-D-aspartate receptor [NMDAR] encephalitis). The features of autoimmune epilepsy include acute or subacute onset of seizures, usually in the context of encephalopathy, and inflammation of the central nervous system on testing cerebrospinal fluid or magnetic resonance imaging. Neuronal antibodies associated with autoimmune encephalitis and seizures in children include NMDAR, voltage-gated potassium channel complex, glycine receptor, γ-Aminobutyric acid type A receptor (GABA(A)R), γ-Aminobutyric acid type B receptor (GABA(B)R), and glutamic acid decarboxylase antibodies. These antibodies support the diagnosis of autoimmune epilepsy, but are not essential for diagnosis. When autoimmune epilepsy is suspected, first-line immune therapy with corticosteroids in addition to intravenous immunoglobulin or plasma exchange should be considered. Second-line therapy with rituximab or cyclophosphamide can be considered if the syndrome is severe. A response to immune therapy supports the diagnosis of autoimmune epilepsy. Neuronal antibodies are increasingly found in patients with focal epilepsy of unknown cause who do not have 'encephalitis'. Recent epidemiological studies support the link between epilepsy and autoimmune diseases. Future studies need to define the spectrum of autoimmune epilepsy and focus on early identification and treatment.
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Affiliation(s)
- Jehan Suleiman
- Department of Paediatrics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates; Paediatrics and Child Health Discipline, Clinical School, The Children's Hospital at Westmead, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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Wang R, Guan HZ, Ren HT, Wang W, Hong Z, Zhou D. CSF findings in patients with anti-N-methyl-D-aspartate receptor-encephalitis. Seizure 2015; 29:137-42. [PMID: 26076857 DOI: 10.1016/j.seizure.2015.04.005] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 04/12/2015] [Accepted: 04/14/2015] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Anti-NMDAR-encephalitis is a recently described form of autoimmune encephalitis. Here, we characterize CSF changes in Chinese patients with anti-NMDAR encephalitis, and explore the relationship between CSF findings and disease outcome. METHODS The presence of NMDAR antibodies in serum or CSF samples was evaluated in patients diagnosed with encephalitis between October 1, 2010 and August 1, 2014 at the West China Hospital. All patients fulfilling our diagnostic criteria were included and CSF findings were analyzed. Patient outcome was assessed after 4, 8, 12, 16, 20, and 24 months using the modified Rankin scale (mRS). RESULTS Out of 3000 people with encephalitis screened, 43 patients were anti-NMDAR antibody positive in CSF or serum and included in this study. 62.8% of the patients identified with positive CSFs had positive serum anti-NMDAR samples, while 100% patients with positive serum had positive CSF samples. In the CSF white cell counts were elevated in 58.1% of cases; protein was increased in 18.6%; QAlb>Qlim(Alb) of the blood-CSF barrier was found in 29.3%; intrathecal immunoglobulin synthesis was detected in 17.1%, and 39.5% patients exhibited increased CSF pressures. A longer follow-up period was associated with better outcomes. There was no relationship between changes in CSF findings and outcome. CONCLUSION The sensitivity of NMDA receptor antibody testing is higher in CSF compared to serum. Other CSF abnormalities are present in some patients with Anti-NMDAR-encephalitis, however these changes do not appear to affect prognosis.
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Affiliation(s)
- Rui Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.
| | - Hong-Zhi Guan
- Department of Neurology, Peking Union Medical College Hospital, People's Republic of China.
| | - Hai-Tao Ren
- Department of Neurology, Peking Union Medical College Hospital, People's Republic of China.
| | - Wei Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.
| | - Zhen Hong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.
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Rodriguez Cruz PM, Huda S, López-Ruiz P, Vincent A. Use of cell-based assays in myasthenia gravis and other antibody-mediated diseases. Exp Neurol 2015; 270:66-71. [PMID: 25783660 DOI: 10.1016/j.expneurol.2015.01.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 01/14/2015] [Indexed: 11/25/2022]
Abstract
The increasing demand on diagnostic assays that are sensitive and specific for pathogenic antibodies, and the interest in identifying new antigens, prompted the development of cell-based assays for the detection of autoantibodies in myasthenia gravis and other autoimmune disorders. Cell-based assays were initially used to show that clustering the AChR improved the positivity in myasthenia gravis, and similar assays have now been applied to detection of antibodies to neuromuscular junction candidate proteins such as LRP4 and agrin. In addition cell-based assays have been used in the routine detection of antibodies to proteins expressed on the surface of neurons (NMDAR, LGI1, CASPR2, AMPAR, GABA-A/B, GlyR, and DPPX) and glia (AQP4, MOG). Here, we summarize the findings in myasthenia and discuss the advantages, disadvantages and controversial issues of using cell-based assays in the detection of these antibodies, and their relevance to the testing of preclinical models of disease.
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Affiliation(s)
- P M Rodriguez Cruz
- Nuffield Department of Clinical Neurosciences and Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - S Huda
- Nuffield Department of Clinical Neurosciences and Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - P López-Ruiz
- Nuffield Department of Clinical Neurosciences and Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - A Vincent
- Nuffield Department of Clinical Neurosciences and Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK.
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Clinical manifestations of patients with CASPR2 antibodies. J Neuroimmunol 2015; 281:17-22. [PMID: 25867463 DOI: 10.1016/j.jneuroim.2015.03.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 03/03/2015] [Accepted: 03/04/2015] [Indexed: 01/02/2023]
Abstract
Contactin-associated protein-like 2 (CASPR2) is one of the target antigens of voltage-gated potassium channels (VGKC) complex antibodies. There has been relatively little information in the literature regarding CASPR2 autoimmunity, especially in Asian population. We investigated the presence of CASPR2 antibodies in patients with presumed autoimmune neurological disorders and described the clinical features, laboratory findings, and responses to immunotherapy. Five patients were identified to be positive for CASPR2 antibodies. The results obtained here suggested that CASPR2 antibodies might be the possible cause of epilepsy even in the absence of typical features of limbic encephalitis and that immunotherapy could provide a favorable outcome.
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Protein mutated in paroxysmal dyskinesia interacts with the active zone protein RIM and suppresses synaptic vesicle exocytosis. Proc Natl Acad Sci U S A 2015; 112:2935-41. [PMID: 25730884 DOI: 10.1073/pnas.1501364112] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Paroxysmal nonkinesigenic dyskinesia (PNKD) is an autosomal dominant episodic movement disorder precipitated by coffee, alcohol, and stress. We previously identified the causative gene but the function of the encoded protein remains unknown. We also generated a PNKD mouse model that revealed dysregulated dopamine signaling in vivo. Here, we show that PNKD interacts with synaptic active zone proteins Rab3-interacting molecule (RIM)1 and RIM2, localizes to synapses, and modulates neurotransmitter release. Overexpressed PNKD protein suppresses release, and mutant PNKD protein is less effective than wild-type at inhibiting exocytosis. In PNKD KO mice, RIM1/2 protein levels are reduced and synaptic strength is impaired. Thus, PNKD is a novel synaptic protein with a regulatory role in neurotransmitter release.
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Rao VR, Lim LE, Fong D, Garga NI, Parko KL. Multicentric Castleman's disease with voltage-gated potassium channel antibody-positive limbic encephalitis: a case report. BMC Neurol 2015; 15:4. [PMID: 25648431 PMCID: PMC4320461 DOI: 10.1186/s12883-015-0266-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 01/21/2015] [Indexed: 12/27/2022] Open
Abstract
Background Castleman’s disease is a rare lymphoproliferative disorder which occurs in localized and multicentric forms and can mimic lymphoma. Despite its well-known association with certain autoimmune diseases, including paraneoplastic pemphigus and myasthenia gravis, Castleman’s disease has not previously been associated with limbic encephalitis. Case presentation We report the case of a 47-year old Caucasian man who presented with subacute onset of constitutional symptoms, diffuse lymphadenopathy, and stereotyped spells involving olfactory aura, nausea, disorientation, and unresponsiveness. He was found to have focal dyscognitive seizures of temporal lobe origin, cerebrospinal fluid with lymphocytic pleocytosis, hyponatremia, and serum positive for voltage-gated potassium channel antibodies, consistent with limbic encephalitis. An extensive infectious workup was unrevealing, but lymph node biopsy revealed multicentric Castleman’s disease. His symptoms improved with antiepileptic drugs and immunotherapy. Conclusion This case highlights the clinical diversity of voltage-gated potassium channel autoimmunity and expands the association of Castleman’s disease and autoimmune syndromes to include limbic encephalitis. Clinicians should be aware that paraneoplastic disorders of the central nervous system can be related to underlying hematologic disorders such as Castleman’s disease.
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Affiliation(s)
- Vikram R Rao
- Department of Neurology, University of California, San Francisco, 400 Parnassus Ave, 8th Floor, San Francisco, CA, 94143, USA.
| | - Leland E Lim
- Neurology Service, Department of Veteran Affairs, Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA, 94304, USA. .,Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, 94305, USA.
| | - Dean Fong
- Pathology and Laboratory Medicine Service, Department of Veteran Affairs, Palo Alto Health Care System (113), 3801 Miranda Avenue, Palo Alto, CA, 94304, USA.
| | - Nina I Garga
- Epilepsy Center of Excellence, San Francisco Veteran Affairs Medical Center, 4150 Clement Street, Box 127E, San Francisco, CA, 94121, USA.
| | - Karen L Parko
- Epilepsy Center of Excellence, San Francisco Veteran Affairs Medical Center, 4150 Clement Street, Box 127E, San Francisco, CA, 94121, USA.
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Stathopoulos P, Alexopoulos H, Dalakas MC. Autoimmune antigenic targets at the node of Ranvier in demyelinating disorders. Nat Rev Neurol 2015; 11:143-56. [DOI: 10.1038/nrneurol.2014.260] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Xie L, Long Y, Yang N, Shan F, Fan Y, Zhong R, Wu L, Yin J, Gao Q, Cong G. No Overlap among Serum GAD65, NMDAR and AQP4 Antibodies in Patients with Neuromyelitis Optica Spectrum Disorders. Neuroimmunomodulation 2015; 22:337-41. [PMID: 25721331 DOI: 10.1159/000371492] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 12/05/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To evaluate whether serum glutamic acid decarboxylase (GAD), N-methyl-D-aspartate-receptor (NMDAR), and aquaporin-4 (AQP4) autoantibodies coexist in patients with neuromyelitis optica (NMO)/NMO spectrum disorders (NMOSD). METHODS Serum samples were collected from 98 patients with NMO/NMOSD. Serum GAD65, NMDAR and AQP4 antibodies were measured using a cell-based assay. RESULTS A total of 63 patients (64.3%) had myelitis and optic neuritis and satisfied the revised diagnostic criteria for NMO. Longitudinally extensive transverse myelitis was seen on spinal cord magnetic resonance imaging, showing continuous T2-weighted signal abnormalities in at least three vertebral segments in 26 patients (26.5%); 5 patients (5.1%) had recurrent optic neuritis, and 4 patients (4.1%) had brain syndromes with optic neuritis and myelitis. None of the 98 patients had diabetes, stiff-man syndrome, or epilepsy. All 98 patients tested positive for AQP4 antibody. No patients tested positive for GAD65 and NMDAR antibodies. CONCLUSIONS In the present study, we found no simultaneous presence of serum GAD65, NMDAR and AQP4 antibodies in patients with NMO/NMOSD.
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Affiliation(s)
- Longchang Xie
- Department of Neurology, Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Varley J, Vincent A, Irani SR. Clinical and experimental studies of potentially pathogenic brain-directed autoantibodies: current knowledge and future directions. J Neurol 2014; 262:1081-95. [PMID: 25491076 PMCID: PMC4412383 DOI: 10.1007/s00415-014-7600-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 11/27/2014] [Indexed: 02/06/2023]
Abstract
The field of neuronal surface-directed antibody-mediated diseases of the central nervous system has dramatically expanded in the last few years and now forms an important cluster of treatable neurological conditions. In this review, we focus on three areas. First, we review the demographics, clinical features and treatment responses of these conditions. Second, we consider their pathophysiology and compare autoantibody mechanisms and their effects to genetic or pharmacological disruptions of the target antigens. Third, we discuss areas of controversy within the field, propose possible resolutions, and explore new directions for neuronal surface antibody-mediated diseases.
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Affiliation(s)
- James Varley
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, West Wing, Level 6, Oxford, OX3 9DU UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, West Wing, Level 6, Oxford, OX3 9DU UK
| | - Sarosh R. Irani
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, West Wing, Level 6, Oxford, OX3 9DU UK
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