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McCormick C, Rosenthal CR, Miller TD, Maguire EA. Deciding what is possible and impossible following hippocampal damage in humans. Hippocampus 2017; 27:303-314. [PMID: 27997994 PMCID: PMC5324536 DOI: 10.1002/hipo.22694] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2016] [Indexed: 12/14/2022]
Abstract
There is currently much debate about whether the precise role of the hippocampus in scene processing is predominantly constructive, perceptual, or mnemonic. Here, we developed a novel experimental paradigm designed to control for general perceptual and mnemonic demands, thus enabling us to specifically vary the requirement for constructive processing. We tested the ability of patients with selective bilateral hippocampal damage and matched control participants to detect either semantic (e.g., an elephant with butterflies for ears) or constructive (e.g., an endless staircase) violations in realistic images of scenes. Thus, scenes could be semantically or constructively 'possible' or 'impossible'. Importantly, general perceptual and memory requirements were similar for both types of scene. We found that the patients performed comparably to control participants when deciding whether scenes were semantically possible or impossible, but were selectively impaired at judging if scenes were constructively possible or impossible. Post-task debriefing indicated that control participants constructed flexible mental representations of the scenes in order to make constructive judgements, whereas the patients were more constrained and typically focused on specific fragments of the scenes, with little indication of having constructed internal scene models. These results suggest that one contribution the hippocampus makes to scene processing is to construct internal representations of spatially coherent scenes, which may be vital for modelling the world during both perception and memory recall. © 2016 The Authors. Hippocampus Published by Wiley Periodicals, Inc.
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Affiliation(s)
- Cornelia McCormick
- Wellcome Trust Centre for Neuroimaging, University College London, London, United Kingdom
| | - Clive R Rosenthal
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Thomas D Miller
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Eleanor A Maguire
- Wellcome Trust Centre for Neuroimaging, University College London, London, United Kingdom
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102
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Lee SK, Lee ST. The Laboratory Diagnosis of Autoimmune Encephalitis. J Epilepsy Res 2016; 6:45-50. [PMID: 28101474 PMCID: PMC5206099 DOI: 10.14581/jer.16010] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 09/16/2016] [Indexed: 12/20/2022] Open
Abstract
Autoimmune encephalitis is a group of encephalitis syndromes that cause altered mentality, memory decline, or seizures in association with the presence of serum and cerebrospinal fluid (CSF) autoantibodies (auto-Abs). An early diagnosis enables early treatments. The detection of auto-Abs is a confirmatory diagnosis. Tissue-based assay, cell-based immunoassay, and immunoblotting are used to detect various autoantibodies. The CSF test for the presence of antibodies is important because it is more sensitive and reflects disease activity in many autoimmune encephalitis, although antibody tests can be negative even in the presence of autoimmune encephalitis. EEG is often abnormal, but nonspecific. A unilateral or bilateral medial temporal T2 high signal is a common finding in MRI. Fludeoxyglucose-positron emission tomography is sometimes useful for diagnosis in patients with normal MRI.
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Affiliation(s)
- Sang Kun Lee
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - Soon-Tae Lee
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
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103
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Jeltsch-David H, Muller S. Autoimmunity, neuroinflammation, pathogen load: A decisive crosstalk in neuropsychiatric SLE. J Autoimmun 2016; 74:13-26. [DOI: 10.1016/j.jaut.2016.04.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 04/21/2016] [Accepted: 04/24/2016] [Indexed: 12/23/2022]
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104
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James LM, Engdahl BE, Leuthold AC, Georgopoulos AP. Brain Correlates of Human Leukocyte Antigen (HLA) Protection in Gulf War Illness (GWI). EBioMedicine 2016; 13:72-79. [PMID: 27765642 PMCID: PMC5264269 DOI: 10.1016/j.ebiom.2016.10.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 10/12/2016] [Accepted: 10/13/2016] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND We recently reported that six alleles from class II genes of the Human Leukocyte Antigen (HLA) confer protection from Gulf War Illness (GWI) (Georgopoulos et al., 2015). The most significant effect is exerted on Neurological-Cognitive-Mood (NCM), Pain, and Fatigue symptoms, such that higher number of copies of the protective alleles are associated with lower symptom severity. Here we tested the hypothesis that this effect is exerted by modulating the strength of neural synchronicity. METHODS Eighty-one Gulf War veterans (65 with GWI and 16 healthy controls) underwent a magnetoencephalography (MEG) scan to assess the strength of brain synchronicity by computing zero-lag crosscorrelations (and their Fisher z transforms) between prewhitened MEG time series. A high-resolution HLA genotyping determined the number of copies, k, of the 6 protective alleles above in each participant. We tested the hypothesis above by regressing NCM, Pain and Fatigue symptom severity against the interaction term, k×z (HLA-related effect), while including z (non-HLA-related effect), gender and age as covariates. The k×z and z terms assessed HLA- and non-HLA-related effects, respectively, of neural synchronicity on symptom severity. The distributions of these effects in sensor space were visualized using statistical heatmaps. FINDINGS We found significant, graded HLA- and non-HLA-related effects: (a) NCM>Pain>Fatigue for HLA-related effects, (b) NCM>Fatigue>Pain for non-HLA-related effects, and (c) HLA-related>non-HLA-related effects for all symptoms. These effects had widespread but distinct distributions in sensor space that allowed the orderly separation of the 6 terms (3 symptom domains×2 HLA factors) in a multidimensional plot, where one dimension separated the symptoms and the other the HLA relation. INTERPRETATION These findings demonstrate the presence of substantial, widespread, distinct and orderly HLA- and non-HLA-related neural influences on NCM, Pain and Fatigue symptom severity in GWI. FUNDING U.S. Department of Veterans Affairs and University of Minnesota.
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Affiliation(s)
- Lisa M James
- Brain Sciences Center, Department of Veterans Affairs Health Care System, Minneapolis, MN 55417, USA; Center for Cognitive Sciences, University of Minnesota, Minneapolis, MN 55455, USA; Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Brian E Engdahl
- Brain Sciences Center, Department of Veterans Affairs Health Care System, Minneapolis, MN 55417, USA; Center for Cognitive Sciences, University of Minnesota, Minneapolis, MN 55455, USA; Department of Neuroscience, University of Minnesota Medical School, Minneapolis, MN 55455, USA; Department of Psychology, University of Minnesota, Minneapolis, MN 55455, USA
| | - Arthur C Leuthold
- Brain Sciences Center, Department of Veterans Affairs Health Care System, Minneapolis, MN 55417, USA; Department of Neuroscience, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Apostolos P Georgopoulos
- Brain Sciences Center, Department of Veterans Affairs Health Care System, Minneapolis, MN 55417, USA; Center for Cognitive Sciences, University of Minnesota, Minneapolis, MN 55455, USA; Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN 55455, USA; Department of Neuroscience, University of Minnesota Medical School, Minneapolis, MN 55455, USA; Department of Neurology, University of Minnesota Medical School, Minneapolis, MN 55455, USA.
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105
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Brunetti V, Testani E, Iorio R, Frisullo G, Luigetti M, Di Giuda D, Marca GD. Post-Encephalitic Parkinsonism and Sleep Disorder Responsive to Immunological Treatment: A Case Report. Clin EEG Neurosci 2016; 47:324-329. [PMID: 27118763 DOI: 10.1177/1550059416645706] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 03/20/2016] [Indexed: 12/15/2022]
Abstract
We describe a 70-year-old man who, after a viral encephalitis associated with pneumonia, progressively developed a parkinsonism associated with lethargy. Encephalitis manifested with persistent hiccups, seizures and impairment of consciousness. After 2 weeks, the initial neurologic symptoms subsided and the patient progressively developed movement disorders (rigidity and bradykinesia, resistant to L-DOPA), lethargy and behavioral hypersomnia. Magnetic resonance imaging showed thalamic and hippocampal signal abnormalities, immunohistochemistry on a mouse brain substrate revealed serum autoantibodies binding to the brainstem neuropil. Polysomnographic monitoring was consistent with a very severe disruption of sleep: the sleep-wake cycle was fragmented, and the NREM-REM ultradian cycle was irregular. Intravenous immune globulin therapy resulted in the complete reversal of the movement and the sleep disorders. Our observation confirms that parkinsonism and sleep disorders may be consequences of encephalitis, that an immune-mediated pathogenesis is likely, and, consequently, that immunotherapy can be beneficial in these patients. The polysomnographic monitoring suggests that lethargia, rather than a mere hypersomnia, is the result of a combination between sleep disruption and altered motor control.
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106
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Medepalli K, Lee CM, Benninger LA, Elwing JM. Psychosis: call a surgeon? A rare etiology of psychosis requiring resection. SAGE Open Med Case Rep 2016; 4:2050313X16670084. [PMID: 27708781 PMCID: PMC5034462 DOI: 10.1177/2050313x16670084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/11/2016] [Indexed: 11/15/2022] Open
Abstract
Objective: Anti–N-methyl-d-aspartate receptor encephalitis is a rare but emerging cause of autoimmune encephalitis. Our objective is to present a case of this rare disease while highlighting the importance of an aggressive search for underlying malignancy as well as the common mischaracterization of primary psychiatric illness that occurs in these patients. Methods: A young Caucasian female with no known psychiatric history presented with acute onset of seizures and psychosis. Results: Magnetic resonance imaging abdomen and pelvis showed a 6-mm ovarian teratoma which was not visualized on initial computed tomographic scans. Pathology was consistent with a mature teratoma. Both serum and cerebrospinal fluid N-methyl-d-aspartate receptor antibodies were positive. Conclusion: An exhaustive search for underlying malignancy and specifically ovarian teratoma in young women should be completed in these patients. Diagnosis often is delayed given the prominent psychiatric manifestations and providers should be aware and strongly consider this in younger women with acute onset of neuropsychiatric symptoms.
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Affiliation(s)
- Kantha Medepalli
- Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Cody M Lee
- Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Lauryn A Benninger
- Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Jean M Elwing
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
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107
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Waters P, Reindl M, Saiz A, Schanda K, Tuller F, Kral V, Nytrova P, Sobek O, Nielsen HH, Barington T, Lillevang ST, Illes Z, Rentzsch K, Berthele A, Berki T, Granieri L, Bertolotto A, Giometto B, Zuliani L, Hamann D, van Pelt ED, Hintzen R, Höftberger R, Costa C, Comabella M, Montalban X, Tintoré M, Siva A, Altintas A, Deniz G, Woodhall M, Palace J, Paul F, Hartung HP, Aktas O, Jarius S, Wildemann B, Vedeler C, Ruiz A, Leite MI, Trillenberg P, Probst M, Saschenbrecker S, Vincent A, Marignier R. Multicentre comparison of a diagnostic assay: aquaporin-4 antibodies in neuromyelitis optica. J Neurol Neurosurg Psychiatry 2016; 87:1005-15. [PMID: 27113605 PMCID: PMC5013123 DOI: 10.1136/jnnp-2015-312601] [Citation(s) in RCA: 186] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 02/06/2016] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Antibodies to cell surface central nervous system proteins help to diagnose conditions which often respond to immunotherapies. The assessment of antibody assays needs to reflect their clinical utility. We report the results of a multicentre study of aquaporin (AQP) 4 antibody (AQP4-Ab) assays in neuromyelitis optica spectrum disorders (NMOSD). METHODS Coded samples from patients with neuromyelitis optica (NMO) or NMOSD (101) and controls (92) were tested at 15 European diagnostic centres using 21 assays including live (n=3) or fixed cell-based assays (n=10), flow cytometry (n=4), immunohistochemistry (n=3) and ELISA (n=1). RESULTS Results of tests on 92 controls identified 12assays as highly specific (0-1 false-positive results). 32 samples from 50 (64%) NMO sera and 34 from 51 (67%) NMOSD sera were positive on at least two of the 12 highly specific assays, leaving 35 patients with seronegative NMO/spectrum disorder (SD). On the basis of a combination of clinical phenotype and the highly specific assays, 66 AQP4-Ab seropositive samples were used to establish the sensitivities (51.5-100%) of all 21 assays. The specificities (85.8-100%) were based on 92 control samples and 35 seronegative NMO/SD patient samples. CONCLUSIONS The cell-based assays were most sensitive and specific overall, but immunohistochemistry or flow cytometry could be equally accurate in specialist centres. Since patients with AQP4-Ab negative NMO/SD require different management, the use of both appropriate control samples and defined seronegative NMOSD samples is essential to evaluate these assays in a clinically meaningful way. The process described here can be applied to the evaluation of other antibody assays in the newly evolving field of autoimmune neurology.
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Affiliation(s)
- Patrick Waters
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Markus Reindl
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Albert Saiz
- Neuroimmunology Program, Hospital Clinic and Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Kathrin Schanda
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Friederike Tuller
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Vlastimil Kral
- Zdravotni ustav se sidlem v Usti nad Labem, Centrum imunologie a mikrobiologie, Usti nad Labem, Czech Republic
| | - Petra Nytrova
- Department of Neurology, Center of Clinical Neuroscience First Faculty of Medicine, General University Hospital and First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Ondrej Sobek
- Laboratory for CSF and Neuroimmunology, Topelex Ltd, Prague, Czech Republic
| | | | - Torben Barington
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - Søren T Lillevang
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - Zsolt Illes
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark Department of Neurology, University of Pécs, Pécs, Hungary
| | | | - Achim Berthele
- Klinikum rechts der Isar der TU München, Klinik für Neurologie, Munich, Germany
| | - Tímea Berki
- Department of Immunology and Biotechnology, University of Pécs, Pécs, Hungary
| | - Letizia Granieri
- Clinical Neurobiology Unit, Neuroscience Institute Cavalieri Ottolenghi (NICO), University Hospital San Luigi Gonzaga, Regional Referring Multiple Sclerosis Centre, Orbassano, Italy
| | - Antonio Bertolotto
- Clinical Neurobiology Unit, Neuroscience Institute Cavalieri Ottolenghi (NICO), University Hospital San Luigi Gonzaga, Regional Referring Multiple Sclerosis Centre, Orbassano, Italy
| | - Bruno Giometto
- Department of Neurology, Azienda ULSS 9 Treviso, Treviso, Italy
| | - Luigi Zuliani
- Department of Neurology, Azienda ULSS 9 Treviso, Treviso, Italy
| | - Dörte Hamann
- Sanquin Diagnostic Services, Department of Immunopathology and Blood Coagulation, Amsterdam, The Netherlands
| | - E Daniëlle van Pelt
- Department of Neurology, MS Centre ErasMS, Erasmus MC, Rotterdam, The Netherlands
| | - Rogier Hintzen
- Department of Neurology, MS Centre ErasMS, Erasmus MC, Rotterdam, The Netherlands
| | - Romana Höftberger
- Neuroimmunology Program, Hospital Clinic and Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Carme Costa
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Vall d'Hebron Institut de Recerca, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manuel Comabella
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Vall d'Hebron Institut de Recerca, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Xavier Montalban
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Vall d'Hebron Institut de Recerca, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mar Tintoré
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Vall d'Hebron Institut de Recerca, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Aksel Siva
- Neurology Department, Istanbul University, Cerrahpasa Medical School, Istanbul, Turkey
| | - Ayse Altintas
- Neurology Department, Istanbul University, Cerrahpasa Medical School, Istanbul, Turkey
| | - Günnur Deniz
- Department of Immunology, Istanbul University, Institute of Experimental Medicine, Istanbul, Turkey
| | - Mark Woodhall
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Friedemann Paul
- NeuroCure Clinical Research Center (NCRC), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Hans-Peter Hartung
- Medical Faculty, Department of Neurology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Orhan Aktas
- Medical Faculty, Department of Neurology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Germany
| | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Germany
| | - Christian Vedeler
- Department of Clinical Medicine, University of Bergen, Bergen, Norway Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Anne Ruiz
- Faculty of Medecine RTH Laennec, Lyon Neurosciences Research Centre, Neuro-inflammation and Neuro-oncology Team, Lyon, France
| | - M Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Peter Trillenberg
- Department of Neurology, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | | | | | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Romain Marignier
- Faculty of Medecine RTH Laennec, Lyon Neurosciences Research Centre, Neuro-inflammation and Neuro-oncology Team, Lyon, France
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Cognitive and Social Functioning Deficits after Anti-N-Methyl-D-Aspartate Receptor Encephalitis: An Exploratory Case Series. J Int Neuropsychol Soc 2016; 22:828-38. [PMID: 27546201 DOI: 10.1017/s1355617716000679] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a recently described life-threatening autoimmune disorder associated with a characteristic multi-stage neuropsychiatric syndrome. Although it is known that the majority of patients experience neuropsychological disturbance post-treatment, some aspects of the cognitive profile remain unclear. METHODS This study sought to investigate patterns of cognitive functioning in a sample of anti-NMDAR encephalitis patients. Seven (6F:1M; mean age, 26.4 years; range, 16-37 years) treated patients completed a comprehensive set of neurocognitive and social functioning measures. Performance was analyzed using normative data (where available), and comparison with matched controls (10F:4M; mean age, 25.8 years; range, 16-38 years). RESULTS Individual cognitive profiles ranged from within normal limits to extensive dysfunction. Relative to controls, the patient group's performance was affected in the domains of verbal/ visual memory, working memory, attention, processing speed, executive functioning, and social cognition. The patient group also reported significantly higher levels of anxiety compared to controls. CONCLUSIONS These results add to the accumulating evidence that neurocognitive deficits, consistent with the distribution and functions of the NMDAR system can persist during recovery from anti-NMDAR encephalitis. This is the first study to provide evidence of performance decrements on measures of social cognition, including some involving theory of mind. (JINS, 2016, 22, 828-838).
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109
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Gough JL, Coebergh J, Chandra B, Nilforooshan R. Electroconvulsive therapy and/or plasmapheresis in autoimmune encephalitis? World J Clin Cases 2016; 4:223-228. [PMID: 27574610 PMCID: PMC4983693 DOI: 10.12998/wjcc.v4.i8.223] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 04/01/2016] [Accepted: 06/16/2016] [Indexed: 02/05/2023] Open
Abstract
Autoimmune encephalitis is a poorly understood condition that can present with a combination of neurological and psychiatric symptoms, either of which may predominate. There are many autoantibodies associated with a variety of clinical syndromes - anti-N-Methyl-D-Aspartate receptor (NMDAR) is the commonest. Currently, the most widely used therapy is prompt plasmapheresis and steroid treatment (and tumour resection if indicated), followed by second line immunosuppression if this fails. Given the growing awareness of autoimmune encephalitis as an entity, it is increasingly important that we consider it as a potential diagnosis in order to provide timely, effective treatment. We discuss several previously published case reports and one new case. These reports examined the effects of electroconvulsive therapy (ECT) on patients with autoimmune encephalitis, particularly those in whom psychiatric symptoms are especially debilitating and refractory to standard treatment. We also discuss factors predicting good outcome and possible mechanisms by which ECT may be effective. Numerous cases, such as those presented by Wingfield, Tsutsui, Florance, Sansing, Braakman and Matsumoto, demonstrate effective use of ECT in anti-NMDAR encephalitis patients with severe psychiatric symptoms such as catatonia, psychosis, narcolepsy and stupor who had failed to respond to standard treatments alone. We also present a new case of a 71-year-old female who presented to a psychiatric unit initially with depression, which escalated to catatonia, delusions, nihilism and auditory hallucinations. After anti-NMDAR antibodies were isolated, she was treated by the neurology team with plasmapheresis and steroids, with a partial response. She received multiple sessions of ECT and her psychiatric symptoms completely resolved and she returned to her premorbid state. For this reason, we suggest that ECT should be considered, particularly in those patients who are non-responders to standard therapies.
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110
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Fraune J, Gerlach S, Rentzsch K, Teegen B, Lederer S, Affeldt K, Fechner K, Danckwardt M, Voigt J, Probst C, Komorowski L, Stöcker W. Multiparametric serological testing in autoimmune encephalitis using computer-aided immunofluorescence microscopy (CAIFM). Autoimmun Rev 2016; 15:937-42. [PMID: 27490202 DOI: 10.1016/j.autrev.2016.07.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 07/05/2016] [Indexed: 12/30/2022]
Abstract
Autoantibodies against neuronal cell surface antigens are tightly associated with immunotherapy-responsive autoimmune encephalitis, and a considerable number of corresponding autoantigens has been identified in recent years. Most patients initially present with overlapping symptoms, and a broad range of autoantibodies has to be considered to establish the correct diagnosis and initiate treatment as soon as possible to prevent irreversible and sometimes even life-threatening damage to the brain. Recombinant cell-based immunofluorescence allows to authentically present fragile membrane-associated surface antigens and, in combination with multiparametric analysis in the form of biochip mosaics, has turned out to be highly beneficial for parallel and prompt determination of anti-neuronal autoantibodies and comprehensive differential diagnostics. For the evaluation of recombinant cell-based IIFT, a semi-automated novel function was introduced into an established platform for computer-aided immunofluorescence microscopy. The system facilitates the microscopic analysis of the tests and supports the laboratory personnel in the rapid issuance of diagnostic findings, which is of major importance for autoimmune encephalitis patients since timely initiation of treatment may lead to their full recovery.
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Affiliation(s)
- Johanna Fraune
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Stefan Gerlach
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Kristin Rentzsch
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Bianca Teegen
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Sabine Lederer
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Kai Affeldt
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Kai Fechner
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Maick Danckwardt
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Jörn Voigt
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Christian Probst
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Lars Komorowski
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Winfried Stöcker
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany.
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111
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Anti-NMDA receptor encephalitis in a septuagenarian. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2016. [DOI: 10.1016/j.injms.2016.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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112
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Qiao S, Zhang YX, Zhang BJ, Lu RY, Lai QL, Chen LH, Wu J. Clinical, imaging, and follow-up observations of patients with anti-GABA B receptor encephalitis. Int J Neurosci 2016; 127:379-385. [PMID: 27066808 DOI: 10.1080/00207454.2016.1176922] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE Anti-gamma-aminobutyric acid B (anti-GABAB) receptor encephalitis is a newly described type of autoimmune encephalitis. We report a case series of patients diagnosed with anti-GABAB receptor encephalitis in China, focusing on their presentations, laboratory and imaging results, and outcomes, as well as the treatment strategies which were employed. METHODS Data from patients diagnosed with anti-GABAB receptor encephalitis in the Second Affiliated Hospital, School of Medicine, Zhejiang University, from January 2014 to June 2015 were retrospectively collected and analyzed. Based on specific diagnostic criteria, seven cases were included. RESULTS Six of the seven patients were males, and a median age at presentation of 56 years (range: 4-71 years). Seizures were the most common initial symptom, and all patients developed symptoms of typical limbic encephalitis during their disease course. Additional types of autoantibodies were identified in four patients. After presentation, three patients were found to have small cell lung cancer and one patient was eventually diagnosed with thymoma. All patients accepted first-line immune therapy, but only one chose tumor treatment. The three tumor-free patients had a good outcome, whereas those with tumors had a poor one. Finally, there were no relapses during follow-up. CONCLUSION Anti-GABAB receptor encephalitis is a rare, unique autoimmune disease, and is often associated with tumors. It should be considered in the differential diagnosis for middle and senior-aged patients who present with predominantly limbic encephalitis symptoms. Importantly, earlier recognition of this potentially treatable condition could improve its overall prognosis.
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Affiliation(s)
- Song Qiao
- a 1 Department of Neurology , Zhejiang Hospital , Hangzhou , China
| | - Yin-Xi Zhang
- b 2 Department of Neurology, Second Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Bi-Jun Zhang
- b 2 Department of Neurology, Second Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Ru-Yi Lu
- b 2 Department of Neurology, Second Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Qi-Lun Lai
- a 1 Department of Neurology , Zhejiang Hospital , Hangzhou , China.,b 2 Department of Neurology, Second Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Lin-Hui Chen
- a 1 Department of Neurology , Zhejiang Hospital , Hangzhou , China
| | - Jiong Wu
- a 1 Department of Neurology , Zhejiang Hospital , Hangzhou , China
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Byun JI, Lee ST, Jung KH, Sunwoo JS, Moon J, Lim JA, Lee DY, Shin YW, Kim TJ, Lee KJ, Lee WJ, Lee HS, Jun J, Kim DY, Kim MY, Kim H, Kim HJ, Suh HI, Lee Y, Kim DW, Jeong JH, Choi WC, Bae DW, Shin JW, Jeon D, Park KI, Jung KY, Chu K, Lee SK. Effect of Immunotherapy on Seizure Outcome in Patients with Autoimmune Encephalitis: A Prospective Observational Registry Study. PLoS One 2016; 11:e0146455. [PMID: 26771547 PMCID: PMC4714908 DOI: 10.1371/journal.pone.0146455] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 12/17/2015] [Indexed: 01/03/2023] Open
Abstract
Objective To evaluate the seizure characteristics and outcome after immunotherapy in adult patients with autoimmune encephalitis (AE) and new-onset seizure. Methods Adult (age ≥18 years) patients with AE and new-onset seizure who underwent immunotherapy and were followed-up for at least 6 months were included. Seizure frequency was evaluated at 2–4 weeks and 6 months after the onset of the initial immunotherapy and was categorized as “seizure remission”, “> 50% seizure reduction”, or “no change” based on the degree of its decrease. Results Forty-one AE patients who presented with new-onset seizure were analysed. At 2–4 weeks after the initial immunotherapy, 51.2% of the patients were seizure free, and 24.4% had significant seizure reduction. At 6 months, seizure remission was observed in 73.2% of the patients, although four patients died during hospitalization. Rituximab was used as a second-line immunotherapy in 12 patients who continued to have seizures despite the initial immunotherapy, and additional seizure remission was achieved in 66.6% of them. In particular, those who exhibited partial response to the initial immunotherapy had a better seizure outcome after rituximab, with low adverse events. Conclusion AE frequently presented as seizure, but only 18.9% of the living patients suffered from seizure at 6 months after immunotherapy. Aggressive immunotherapy can improve seizure outcome in patients with AE.
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Affiliation(s)
- Jung-Ick Byun
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Soon-Tae Lee
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Keun-Hwa Jung
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Jun-Sang Sunwoo
- Departments of Neurology, 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
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Doo Young Lee
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Yong-Won Shin
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Tae-Joon Kim
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Keon-Joo Lee
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Woo-Jin Lee
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Han-Sang Lee
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Jinsun Jun
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong-Yub Kim
- Departments of Neurology, Samsung Medical Center, Seoul, South Korea
| | - Man-Young Kim
- Departments of Neurology, Chosun University Hospital, Gwangju, South Korea
| | - Hyunjin Kim
- Departments of Neurology, Asan medical center, Seoul, South Korea
| | - Hyeon Jin Kim
- Departments of Neurology, Ewha Woman’s University Hospital, Seoul, South Korea
| | - Hong Il Suh
- Departments of Neurology, Ajou University Medical Center, Suwon, South Korea
| | - Yoojin Lee
- Departments of Neurology, Asan medical center, Seoul, South Korea
| | - Dong Wook Kim
- Departments of Neurology, Konkuk University Medical Center, Seoul, South Korea
| | - Jin Ho Jeong
- Departments of Neurology, Inje University Busan Paik Hospital, Busan, South Korea
| | - Woo Chan Choi
- Departments of Neurology, Kyungpook National University Hospital, Daegu, South Korea
| | - Dae Woong Bae
- Departments of Neurology, St. Mary's Hospital, Seoul, South Korea
| | - Jung-Won Shin
- Departments of Neurology, Cha university, CHA Bundang Medical Center, Seongnam, South Korea
| | - Daejong Jeon
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Kyung-Il Park
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Ki-Young Jung
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Kon Chu
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
- * E-mail: (KC); (SKL)
| | - Sang Kun Lee
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
- * E-mail: (KC); (SKL)
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De Bruijn MAAM, Titulaer MJ. Anti-NMDAR encephalitis and other glutamate and GABA receptor antibody encephalopathies. HANDBOOK OF CLINICAL NEUROLOGY 2016; 133:199-217. [PMID: 27112679 DOI: 10.1016/b978-0-444-63432-0.00012-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Over the last few year, antibodies to various central nervous system receptors, particularly the glutamate and γ-aminobutyric acid (GABA) receptors, have been found to be associated with autoimmune neurologic disorders. The receptors include the N-methyl-d-aspartate receptor (NMDAR), the alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR), the metabotropic glutamate receptors (mGluRs), and GABA type A and B receptors (respectively GABAAR and GABABR). Compared to the previously described paraneoplastic antibodies directed at intracellular targets, the patients with receptor antibodies are often younger, they less frequently have malignancies, and they respond better to immunotherapy. Many of the patients have limbic encephalitis with amnesia, disorientation, seizures, and psychological or psychiatric symptoms, but those with NMDAR antibodies usually develop a more widespread form of encephalitis, often leading to a decrease in consciousness and requirement for long-term intensive care treatment. The autoantibodies bind directly to the synaptic or extrasynaptic receptors on the membrane surface, and have direct effects on signal transduction in central synapses. These conditions are very important to recognize as the symptoms and complications can be fatal when not treated in time, whereas with immunotherapy many patients recover considerably.
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Affiliation(s)
| | - Maarten J Titulaer
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands.
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115
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Hohlfeld R, Dornmair K, Meinl E, Wekerle H. The search for the target antigens of multiple sclerosis, part 2: CD8+ T cells, B cells, and antibodies in the focus of reverse-translational research. Lancet Neurol 2015; 15:317-31. [PMID: 26724102 DOI: 10.1016/s1474-4422(15)00313-0] [Citation(s) in RCA: 143] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 10/13/2015] [Accepted: 10/22/2015] [Indexed: 01/16/2023]
Abstract
Interest in CD8+ T cells and B cells was initially inspired by observations in multiple sclerosis rather than in animal models: CD8+ T cells predominate in multiple sclerosis lesions, oligoclonal immunoglobulin bands in CSF have long been recognised as diagnostic and prognostic markers, and anti-B-cell therapies showed considerable efficacy in multiple sclerosis. Taking a reverse-translational approach, findings from human T-cell receptor (TCR) and B-cell receptor (BCR) repertoire studies provided strong evidence for antigen-driven clonal expansion in the brain and CSF. New methods allow the reconstruction of human TCRs and antibodies from tissue-infiltrating immune cells, which can be used for the unbiased screening of antigen libraries. Myelin oligodendrocyte glycoprotein (MOG) has received renewed attention as an antibody target in childhood multiple sclerosis and in a small subgroup of adult patients with multiple sclerosis. Furthermore, there is growing evidence that a separate condition in adults exists, tentatively called MOG-antibody-associated encephalomyelitis, which has clinical features that overlap with neuromyelitis optica spectrum disorder and multiple sclerosis. Although CD8+ T cells and B cells are thought to have a pathogenic role in some subgroups of patients, their target antigens have yet to be identified.
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Affiliation(s)
- Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Campus Martinsried-Grosshadern, Ludwig-Maximilians University, Munich, Germany; Munich Cluster of Systems Neurology (SyNergy), Munich, Germany.
| | - Klaus Dornmair
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Campus Martinsried-Grosshadern, Ludwig-Maximilians University, Munich, Germany
| | - Edgar Meinl
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Campus Martinsried-Grosshadern, Ludwig-Maximilians University, Munich, Germany
| | - Hartmut Wekerle
- HERTIE Senior Professor Group Neuroimmunology, Max Planck Institute of Neurobiology, Martinsried, Germany
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da Rocha AJ, Nunes RH, Maia ACM, do Amaral LLF. Recognizing Autoimmune-Mediated Encephalitis in the Differential Diagnosis of Limbic Disorders. AJNR Am J Neuroradiol 2015; 36:2196-205. [PMID: 26381566 DOI: 10.3174/ajnr.a4408] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Limbic encephalitis is far more common than previously thought. It is not always associated with cancer, and it is potentially treatable. Autoantibodies against various neuronal cell antigens may arise independently or in association with cancer and cause autoimmune damage to the limbic system. Neuroimaging plays a key role in the management of patients with suspected limbic encephalitis by supporting diagnosis and excluding differential possibilities. This article describes the main types of autoimmune limbic encephalitis and its mimic disorders, and emphasizes their major imaging features.
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Affiliation(s)
- A J da Rocha
- From the Division of Neuroradiology (A.J.d.R., R.H.N., A.C.M.M., L.L.F.d.A.), Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil Division of Neuroradiology (A.J.d.R., R.H.N., A.C.M.M.), Fleury Medicina e Saúde, São Paulo, Brazil
| | - R H Nunes
- From the Division of Neuroradiology (A.J.d.R., R.H.N., A.C.M.M., L.L.F.d.A.), Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil Division of Neuroradiology (A.J.d.R., R.H.N., A.C.M.M.), Fleury Medicina e Saúde, São Paulo, Brazil Research Fellow, University of North Carolina (R.H.N.), Chapel Hill, North Carolina
| | - A C M Maia
- From the Division of Neuroradiology (A.J.d.R., R.H.N., A.C.M.M., L.L.F.d.A.), Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil Division of Neuroradiology (A.J.d.R., R.H.N., A.C.M.M.), Fleury Medicina e Saúde, São Paulo, Brazil
| | - L L F do Amaral
- From the Division of Neuroradiology (A.J.d.R., R.H.N., A.C.M.M., L.L.F.d.A.), Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil Division of Neuroradiology (L.L.F.d.A.), Med Imagem, Hospital da Beneficência Portuguesa de São Paulo, São Paulo, Brazil
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Bradshaw MJ, Pawate S, Lennon VA, Bloch KC, Brown KM. Herpes simplex virus 1 encephalitis associated with voltage-gated calcium channel autoimmunity. Neurology 2015; 85:2176-7. [PMID: 26567268 DOI: 10.1212/wnl.0000000000002218] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 08/10/2015] [Indexed: 11/15/2022] Open
Affiliation(s)
- Michael J Bradshaw
- From the Department of Neurology (M.J.B., S.P., K.M.B.), and Departments of Medicine (Infectious Disease) and Health Policy (K.C.B.), Vanderbilt University Medical Center, Nashville, TN; and Department of Laboratory Medicine and Pathology (V.A.L.), Mayo Clinic, Rochester, MN.
| | - Siddharama Pawate
- From the Department of Neurology (M.J.B., S.P., K.M.B.), and Departments of Medicine (Infectious Disease) and Health Policy (K.C.B.), Vanderbilt University Medical Center, Nashville, TN; and Department of Laboratory Medicine and Pathology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Vanda A Lennon
- From the Department of Neurology (M.J.B., S.P., K.M.B.), and Departments of Medicine (Infectious Disease) and Health Policy (K.C.B.), Vanderbilt University Medical Center, Nashville, TN; and Department of Laboratory Medicine and Pathology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Karen C Bloch
- From the Department of Neurology (M.J.B., S.P., K.M.B.), and Departments of Medicine (Infectious Disease) and Health Policy (K.C.B.), Vanderbilt University Medical Center, Nashville, TN; and Department of Laboratory Medicine and Pathology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Kelly M Brown
- From the Department of Neurology (M.J.B., S.P., K.M.B.), and Departments of Medicine (Infectious Disease) and Health Policy (K.C.B.), Vanderbilt University Medical Center, Nashville, TN; and Department of Laboratory Medicine and Pathology (V.A.L.), Mayo Clinic, Rochester, MN
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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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Urbach H, Rauer S, Mader I, Paus S, Wagner J, Malter MP, Prüss H, Lewerenz J, Kassubek J, Hegen H, Auer M, Deisenhammer F, Ufer F, Bien CG, Baumgartner A. Supratentorial white matter blurring associated with voltage-gated potassium channel-complex limbic encephalitis. Neuroradiology 2015; 57:1203-9. [PMID: 26293130 DOI: 10.1007/s00234-015-1581-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 08/11/2015] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Limbic encephalitis (LE) associated with voltage-gated potassium channel-complex antibodies (VGKC-LE) is frequently non-paraneoplastic and associated with marked improvement following corticosteroid therapy. Mesial temporal lobe abnormalities are present in around 80 % of patients. If associated or preceded by faciobrachial dystonic seizures, basal ganglia signal changes may occur. In some patients, blurring of the supratentorial white matter on T2-weighted images (SWMB) may be seen. The purpose of this study was to evaluate the incidence of SWMB and whether it is specific for VGKC-LE. METHODS Two experienced neuroradiologists independently evaluated signal abnormalities on FLAIR MRI in 79 patients with LE while unaware on the antibody type. RESULTS SWMB was independently assessed as present in 10 of 36 (28 %) compared to 2 (5 %) of 43 non-VGKC patients (p = 0.009). It was not related to the presence of LGI1 or CASPR2 proteins of VGKC antibodies. MRI showed increased temporomesial FLAIR signal in 22 (61 %) VGKC compared to 14 (33 %) non-VGKC patients (p = 0.013), and extratemporomesial structures were affected in one VGKC (3 %) compared to 11 (26 %) non-VGKC patients (p = 0.005). CONCLUSION SWMB is a newly described MRI sign rather specific for VGKC-LE.
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Affiliation(s)
- H Urbach
- Department of Neuroradiology, University Medical Center Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - S Rauer
- Department of Neurology, University Medical Center Freiburg, Freiburg, Germany
| | - I Mader
- Department of Neuroradiology, University Medical Center Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - S Paus
- Department of Neurology, University Medical Center, Bonn, Germany
| | - J Wagner
- Department of Epileptology, University Medical Center, Bonn, Germany
| | - M P Malter
- Department of Neurology, University of Cologne, Cologne, Germany
| | - H Prüss
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - J Lewerenz
- Department of Neurology, Ulm University, Ulm, Germany
| | - J Kassubek
- Department of Neurology, Ulm University, Ulm, Germany
| | - H Hegen
- Department of Neurology, University Innsbruck, Innsbruck, Austria
| | - M Auer
- Department of Neurology, University Innsbruck, Innsbruck, Austria
| | - F Deisenhammer
- Department of Neurology, University Innsbruck, Innsbruck, Austria
| | - F Ufer
- Department of Neurology, University Medical Center, Hamburg, Germany
| | - C G Bien
- Epilepsy Centre Bethel, Bielefeld-Bethel, Germany
| | - A Baumgartner
- Department of Neurology, University Medical Center Freiburg, Freiburg, Germany
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Wang RJ, Chen BD, Qi D. Anti-N-methyl-D-aspartate receptor encephalitis concomitant with multifocal subcortical white matter lesions on magnetic resonance imaging: a case report and review of the literature. BMC Neurol 2015; 15:107. [PMID: 26152327 PMCID: PMC4495850 DOI: 10.1186/s12883-015-0366-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 06/28/2015] [Indexed: 02/03/2023] Open
Abstract
Background Anti-N-methyl-D-aspartate receptor encephalitis is a severe autoimmune disorder characterized by severe psychiatric symptoms, seizures, decreased consciousness, autonomic dysregulation, and dyskinesias. Multifocal subcortical white matter lesions on fluid-attenuated inversion recovery and diffuse weighted images have rarely been reported in previous literature, and serial magnetic resonance imaging changes after plasma exchange have not been presented before. Case presentation A previously healthy 24-year-old Chinese woman presented with acute psychiatric symptoms characterized by fear and agitation followed by decreased consciousness, dyskinesias, and seizures. Magnetic resonance imaging revealed hyperintense lesions on fluid-attenuated inversion recovery and diffuse weighted images in bilateral subcortical white matter. Cerebrospinal fluid analysis revealed a mild pleocytosis with lymphocytic predominance. Protein and glucose levels were normal. Aquaporin-4 antibodies in serum and cerebrospinal fluid were negative. Identification of anti-N-methyl-D-aspartate receptor antibodies in serum and cerebrospinal fluid confirmed the diagnosis of anti-N-methyl-D-aspartate receptor encephalitis. She was initially treated with combined intravenous immunoglobulin and methylprednisolone without improvement. Plasma exchange was then initiated with good response; the patient made a full recovery after several cycles of plasma exchange. Repeat magnetic resonance imaging performed 1 month after plasma exchange showed partial resolution of the hyperintense lesions in bilateral subcortical white matter, and follow-up magnetic resonance imaging 2 months after plasma exchange showed complete resolution. Conclusion Anti-N-methyl-D-aspartate receptor encephalitis may be concomitant with multifocal subcortical white matter lesions. Such lesions may resolve after appropriate immunotherapy.
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Affiliation(s)
- Rui-Jin Wang
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong-An Road, Xicheng District, Beijing, 100050, People's Republic of China.
| | - Bu-Dong Chen
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong-An Road, Xicheng District, Beijing, 100050, People's Republic of China.
| | - Dong Qi
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong-An Road, Xicheng District, Beijing, 100050, People's Republic of China.
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121
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Harrison JW, Cherukuri R, Buchan D. Renal Cell Carcinoma Presenting with Paraneoplastic Hallucinations and Cognitive Decline from Limbic Encephalitis. J Gen Intern Med 2015; 30:1037-40. [PMID: 25608740 PMCID: PMC4471013 DOI: 10.1007/s11606-014-3172-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 06/16/2014] [Accepted: 12/29/2014] [Indexed: 12/14/2022]
Abstract
We present a 66-year-old woman with 2 months of visual hallucinations, unintentional weight loss, and short-term memory decline, whose clinical presentation and EEG supported a diagnosis of limbic encephalitis. Subsequent evaluation for a paraneoplastic etiology revealed a renal mass, which was resected and identified as clear cell renal carcinoma. The patient's clinical condition improved after resection of the mass. When patients present with incongruous subacute neuropsychiatric symptoms, clinicians should be mindful of paraneoplastic neurological disorders, as early diagnosis and treatment of malignancy may lead to symptomatic improvement.
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Affiliation(s)
- Joshua W Harrison
- Department of Internal Medicine, Upstate Medical University, 750 East Adams St., Syracuse, NY, 13210, USA,
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Abstract
Paraneoplastic disorders of the nervous system (PNDs) are rare and unique disorders, where a specific pattern of neural damage occurs as a side effect of the interaction between the neoplasm and the host immune response. Clinical recognition of PNDs may be challenging but can lead to early detection of an occult neoplasm. Their study may lead to a better understanding of nervous system autoimmunity and even to devising novel immunotherapies against certain tumor types. Familiarity with the clinical syndromes, neuroradiological findings, autoantibodies, and tissue responses associated with PND may help arrive at a correct diagnosis in most cases.
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Affiliation(s)
- S Humayun Gultekin
- Department of Pathology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
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123
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Parkinson MH, Patel R, Davagnanam I, Wood NW, Giunti P. When the penny drops. Pract Neurol 2014; 14:409-14. [PMID: 24914025 PMCID: PMC4251201 DOI: 10.1136/practneurol-2014-000859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Michael H Parkinson
- Department of Molecular Neuroscience, UCL Institute of Neurology, and National Hospital for Neurology & Neurosurgery, London, UK
| | - Rayna Patel
- Department of Molecular Neuroscience, UCL Institute of Neurology, and National Hospital for Neurology & Neurosurgery, London, UK
| | - Indran Davagnanam
- Department of Molecular Neuroscience, UCL Institute of Neurology, and National Hospital for Neurology & Neurosurgery, London, UK
| | - Nicholas W Wood
- Department of Molecular Neuroscience, UCL Institute of Neurology, and National Hospital for Neurology & Neurosurgery, London, UK
| | - Paola Giunti
- Department of Molecular Neuroscience, UCL Institute of Neurology, and National Hospital for Neurology & Neurosurgery, London, UK
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Abstract
In the past few years, many autoimmune encephalitides have been identified, with specific clinical syndromes and associated antibodies against neuronal surface antigens. There is compelling evidence that many of these antibodies are pathogenic and most of these encephalitides are highly responsive to immunotherapies. The clinical spectra of some of these antibody-mediated syndromes, especially those reported in only a few patients, are evolving. Others, such as anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, are well characterized. Diagnosis involves recognizing the specific syndromes and identifying the antibody in a patient's cerebrospinal fluid (CSF) and/or serum. These syndromes are associated with variable abnormalities in CSF, magnetic resonance imaging, and electroencephalography. Treatment is often multidisciplinary and should be focused upon neutralizing the effects of antibodies and eliminating their source. Overlapping disorders have been noted, with some patients having more than one neurologic autoimmune disease. In other patients, viral infections such as herpes simplex virus encephalitis trigger robust antineuronal autoimmune responses.
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Affiliation(s)
- Jenny J. Linnoila
- Department of Neurology, Massachusetts General Hospital, Boston, Massachussetts
| | - Myrna R. Rosenfeld
- Department of Neurology, Hospital Clínic /Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre de Recerca Biomèdica CELLEX, Lab Neuroimmonologia P3A, Barcelona, Spain
- Department of Neurology, University of Pennsylvania; Philadelphia, Pennsylvania
| | - Josep Dalmau
- Centre de Recerca Biomèdica CELLEX, Lab Neuroimmonologia P3A, Barcelona, Spain
- Department of Neurology, University of Pennsylvania; Philadelphia, Pennsylvania
- Institució Catalana de Recerca i Estudis Avançats (ICREA) at Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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