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Endres D, Meixensberger S, Dersch R, Feige B, Stich O, Venhoff N, Matysik M, Maier SJ, Michel M, Runge K, Nickel K, Urbach H, Domschke K, Prüss H, Tebartz van Elst L. Cerebrospinal fluid, antineuronal autoantibody, EEG, and MRI findings from 992 patients with schizophreniform and affective psychosis. Transl Psychiatry 2020; 10:279. [PMID: 32782247 PMCID: PMC7419532 DOI: 10.1038/s41398-020-00967-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/12/2020] [Accepted: 07/22/2020] [Indexed: 11/08/2022] Open
Abstract
The central role played by cerebrospinal-fluid (CSF) examinations including antineuronal autoantibody (Ab) testing is increasingly recognized in psychiatry. The rationale of this study was to present a multimodally investigated group of patients. In total, 992 patients were analyzed for CSF alterations: 456 patients with schizophreniform and 536 with affective syndromes. Ab measurement included testing for established antineuronal IgG-Abs against intracellular antigens in serum (Yo/Hu/Ri/cv2[CRMP5]/Ma1/Ma2/SOX1/TR[DNER]/Zic4/amphiphysin/GAD65) and for cell surface antigens in the CSF (NMDAR/AMPA-1/2-R/GABA-B-R/LGI1/CASPR2/DPPX). In 30 patients with "red flags" for autoimmune psychosis, "tissue tests" were performed. Additional diagnostics included MRI and EEG analyses. CSF white-blood-cell counts were increased in 4% and IgG indices in 2%; CSF-specific oligoclonal bands were detected in 4%; overall, 8% displayed signs of neuroinflammation. In addition, 18% revealed increased albumin quotients. Antineuronal Abs against intracellular antigens were detected in serum in 0.6%. Antineuronal Abs against established cell surface antigens were detected in serum of 1% and in the CSF of 0.3% (CSF samples were only questionably positive). Abnormal IgG binding in "tissue tests" was detected in serum of 23% and in CSF of 27%. In total, 92% of the Ab-positive patients demonstrated at least one sign of brain involvement in additional diagnostics using CSF, MRI, EEG, and FDG-PET. In summary, CSF basic analyses revealed signs of blood-brain-barrier dysfunction and neuroinflammation in relevant subgroups of patients. Established antineuronal IgG-Abs were rare in serum and even rarer in the CSF. "Tissue tests" revealed frequent occurrences of Ab-binding; therefore, novel antineuronal Abs could play a relevant role in psychiatry.
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Affiliation(s)
- Dominique Endres
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany.
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany.
| | - Sophie Meixensberger
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany
| | - Rick Dersch
- Clinic of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106, Freiburg, Germany
| | - Bernd Feige
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany
| | - Oliver Stich
- Clinic of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106, Freiburg, Germany
- Medical Care Center, Neurology, 78464, Konstanz, Germany
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106, Freiburg, Germany
| | - Miriam Matysik
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany
| | - Simon J Maier
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany
| | - Maike Michel
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany
| | - Kimon Runge
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany
| | - Kathrin Nickel
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106, Freiburg, Germany
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany
- Center for Basics in Neuromodulation, Faculty of Medicine, University of Freiburg, 79106, Freiburg, Germany
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, 10117, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE) Berlin, 10117, Berlin, Germany
| | - Ludger Tebartz van Elst
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79104, Freiburg, Germany
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102
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Garg D, Agarwal A, Bhagyawant R, Sikand TS, Singh AK. De novo nose-pinching stereotypy with somnolence: Clues to autoimmune encephalitis. J Neuroimmunol 2020; 347:577348. [PMID: 32745804 DOI: 10.1016/j.jneuroim.2020.577348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/23/2020] [Accepted: 07/23/2020] [Indexed: 12/20/2022]
Abstract
Autoimmune encephalitis (AE) is being increasingly recognized as a cause of new-onset movement disorders. Movement disorders in AE are diverse and range from hyperkinetic conditions such as oromandibular dyskinesias, tremors and chorea to hypokinetic ones such as bradykinesia and parkinsonism. Stereotypies have been described in association with anti-NMDAR encephalitis. Similarly, sleep dysfunction is an underrecognized feature in many AE subtypes, prominently anti-IgLON5 although the correlation of phenotype of sleep dysfunction with a particular antibody subtype in AE is unclear. Despite the recognition of both these features as part of an overreaching spectrum in any patient with AE, seldom are they the sole presenting manifestations. Additionally, the challenge is further compounded in a patient who has seronegative AE since neither sleep disturbances nor stereotypies have been well characterized with this condition yet, and the diagnosis is conditional to exhausting a list of ancillary supportive features. In this brief communication, we describe the case of a young man who presented with hypersomnolence and an unusual focal nose-pinching stereotypy of subacute onset who lacked the presence of other typical clinical characteristics such as cognitive/memory impairment and seizures and had negative autoimmune antibodies but responded to immune therapy dramatically. We propose that the presence of de novo hypersomnolence and stereotypy should inform a potential diagnosis of AE.
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Affiliation(s)
- Divyani Garg
- Department of Neurology, Lady Hardinge Medical College and Smt. SK Hospital, New Delhi, India
| | - Ayush Agarwal
- Department of Neurology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India.
| | - Ram Bhagyawant
- Department of Neurology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Trimaan Singh Sikand
- Department of Neurology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Ajai Kumar Singh
- Department of Neurology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
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103
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Parkinsonian Syndrome with Frontal Lobe Involvement and Anti-Glycine Receptor Antibodies. Brain Sci 2020; 10:brainsci10060399. [PMID: 32585946 PMCID: PMC7349831 DOI: 10.3390/brainsci10060399] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 01/15/2023] Open
Abstract
Background: Atypical Parkinsonian syndromes with prominent frontal lobe involvement can occur in the 4R-taupathies progressive supranuclear palsy (PSP) and corticobasal degeneration (CBD). Secondary forms of movement disorders may occur in the context of autoimmune encephalitis with antineuronal antibodies, such as anti-glycine receptor (anti-GlyR) antibodies, which are typically associated with Stiff-Person spectrum syndrome, or progressive encephalomyelitis with rigidity and myoclonus. Overlaps between neurodegenerative and immunological mechanisms have been recently suggested in anti-IgLON5 disease. In this case study, the authors describe a patient with a Parkinsonian syndrome with frontal lobe involvement and anti-GlyR antibodies. Case presentation: The patient presented was a 63-year-old female. Her symptoms had begun with insomnia at the age of 60, after which, since the age of 61, increasing personality changes developed, leading to a diagnosis of depression with delusional symptoms. Severe cognitive deficits emerged, along with a left-side accentuated Parkinsonian syndrome with postural instability. The personality changes involved frontal systems. Magnetic resonance imaging (MRI) showed low-grade mesencephalon atrophy. [18F]fluorodeoxyglucose positron emission tomography (FDG PET) depicted a moderate hypometabolism bilateral frontal and of the midbrain, while [123I]FPCIT single-photon emission computed tomography (SPECT) revealed severely reduced dopamine transporter availability in both striata, indicating pronounced nigrostriatal degeneration. In addition, anti-GlyR antibodies were repeatedly found in the serum of the patient (max. titer of 1:640, reference: <1:20). Therefore, an anti-inflammatory treatment with steroids and azathioprine was administered; this resulted in a decrease of antibody titers (to 1:80) but no detectable clinical improvement. The cerebrospinal fluid (CSF) and electroencephalography diagnostics showed inconspicuous findings, and negative CSF anti-GlyR antibody results. Conclusion: The patient presented here was suffering from a complex Parkinsonian syndrome with frontal lobe involvement. Because of the high anti-GlyR antibody titers, the presence of an autoimmune cause of the disorder was discussed. However, since no typical signs of autoimmune anti-GlyR antibody syndrome (e.g., hyperexcitability, anti-GlyR antibodies in CSF, or other inflammatory CSF changes) were detected, the possibility that the anti-GlyR antibodies might have been an unrelated bystander should be considered. Alternatively, the anti-GlyR antibodies might have developed secondarily to neurodegeneration (most likely a 4-repeat tauopathy, PSP or CBD) without exerting overt clinical effects, as in cases of anti-IgLON5 encephalopathy. In this case, such antibodies might also potentially modify the clinical course of classical movement disorders. Further research on the role of antineuronal antibodies in Parkinsonian syndromes is needed.
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104
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Steriade C, Britton J, Dale RC, Gadoth A, Irani SR, Linnoila J, McKeon A, Shao X, Venegas V, Bien CG. Acute symptomatic seizures secondary to autoimmune encephalitis and autoimmune‐associated epilepsy: Conceptual definitions. Epilepsia 2020; 61:1341-1351. [DOI: 10.1111/epi.16571] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 05/10/2020] [Accepted: 05/12/2020] [Indexed: 12/12/2022]
Affiliation(s)
| | - Jeffrey Britton
- Division of Epilepsy Department of Neurology Mayo Clinic Rochester MN USA
| | - Russell C. Dale
- The Children's Hospital at Westmead Kids Neuroscience Centre University of Sydney Sydney NSW Australia
| | - Avi Gadoth
- Department of Neurology Encephalitis Center Tel‐Aviv Medical Center Tel‐Aviv Israel
| | - Sarosh R. Irani
- Oxford Autoimmune Neurology Group Nuffield Department of Clinical Neurosciences University of Oxford Oxford UK
| | - Jenny Linnoila
- Department of Neurology Massachusetts General Hospital Boston MA USA
| | - Andrew McKeon
- Department of Neurology and Immunology Mayo Clinic Rochester MN USA
| | - Xiao‐Qiu Shao
- Department of Neurology Beijing Tiantan HospitalChina National Clinical Research Center for Neurological DiseasesCapital Medical University Beijing China
| | - Viviana Venegas
- Unit of Neuropediatrics Advanced Center of Epilepsy Clinica Alemana de Santiago Chile
- Unit of Neurophysiology Instituto de Neurocirugía Asenjo Santiago Chile
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105
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Endres D, Prüss H, Dressing A, Schneider J, Feige B, Schweizer T, Venhoff N, Nickel K, Meixensberger S, Matysik M, Maier SJ, Domschke K, Urbach H, Meyer PT, Tebartz van Elst L. Psychiatric Manifestation of Anti-LGI1 Encephalitis. Brain Sci 2020; 10:brainsci10060375. [PMID: 32560097 PMCID: PMC7348933 DOI: 10.3390/brainsci10060375] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 12/20/2022] Open
Abstract
Background: Anti-leucine-rich glioma-inactivated 1 (LGI1) encephalitis is typically characterized by limbic encephalitis, faciobrachial dystonic seizures and hyponatremia. The frequency with which milder forms of anti-LGI1 encephalitis mimic isolated psychiatric syndromes, such as psychoses, or may lead to dementia if untreated, is largely unknown. Case presentation: Here, the authors present a 50-year-old patient who had suffered from neurocognitive deficits and predominant delusions for over one and a half years. He reported a pronounced feeling of thirst, although he was drinking 10–20 liters of water each day, and he was absolutely convinced that he would die of thirst. Due to insomnia in the last five years, the patient took Z-drugs; later, he also abused alcohol. Two years prior to admission, he developed a status epilepticus which had been interpreted as a withdrawal seizure. In his serum, anti-LGI1 antibodies were repeatedly detected by different independent laboratories. Cerebrospinal fluid analyses revealed slightly increased white blood cell counts and evidence for blood–brain-barrier dysfunction. Magnetic resonance imaging showed hyperintensities mesio-temporally and in the right amygdala. In addition, there was a slight grey–white matter blurring. A cerebral [18F] fluorodeoxyglucose positron emission tomography (FDG-PET) examination of his brain showed moderate hypometabolism of the bilateral rostral mesial to medial frontal cortices. Treatment attempts with various psychotropic drugs remained unsuccessful in terms of symptom relief. After the diagnosis of probable chronified anti-LGI1 encephalitis was made, two glucocorticoid pulse treatments were performed, which led to a slight improvement of mood and neurocognitive deficits. Further therapy was not desired by the patient and his legally authorized parents. Conclusion: This case study describes a patient with anti-LGI1 encephalitis in the chronified stage and a predominant long-lasting psychiatric course with atypical symptoms of psychosis and typical neurocognitive deficits. The patient’s poor response to anti-inflammatory drugs was probably due to the delayed start of treatment. This delay in diagnosis and treatment may also have led to the FDG-PET findings, which were compatible with frontotemporal dementia (“state of damage”). In similar future cases, newly occurring epileptic seizures associated with psychiatric symptoms should trigger investigations for possible autoimmune encephalitis, even in patients with addiction or other pre-existing psychiatric conditions. This should in turn result in rapid organic clarification and—in positive cases—to anti-inflammatory treatment. Early treatment of anti-LGI1 encephalitis during the “inflammatory activity state” is crucial for overall prognosis and may avoid the development of dementia in some cases. Based on this case, the authors advocate the concept—long established in many chronic inflammatory diseases in rheumatology—of distinguishing between an “acute inflammatory state” and a “state of organ damage” in autoimmune psychosis resembling neurodegenerative mechanisms.
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Affiliation(s)
- Dominique Endres
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
- Correspondence: ; Tel.: +49-761-270-66360; Fax: +49-761-270-69390
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité, Universitätsmedizin Berlin, 10117 Berlin, Germany;
- German Center for Neurodegenerative Diseases (DZNE) Berlin, 10117 Berlin, Germany
| | - Andrea Dressing
- Clinic of Neurology and Neurophysiology, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Johanna Schneider
- Renal Division, Department of Medicine, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Bernd Feige
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
| | - Tina Schweizer
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Kathrin Nickel
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
| | - Sophie Meixensberger
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
| | - Miriam Matysik
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
| | - Simon J. Maier
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
- Center for Basics in Neuromodulation, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Philipp T. Meyer
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Ludger Tebartz van Elst
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
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Abstract
PURPOSE OF REVIEW To review sleep complaints reported in patients with autoimmune encephalitis, explore the relationship between sleep disturbances and subtypes of autoimmune encephalitis, and leverage knowledge concerning antibody-antigen specificity to inform the receptors, structures, and disseminated neural networks that contribute to sleep function in health and disease. RECENT FINDINGS Autoimmune encephalitis is an inflammatory brain disorder characterized by the subacute onset of psychiatric symptoms, cognitive impairment, and focal neurologic deficits or seizures. Sleep disturbances are detected in a majority of patients systematically screened for sleep complaints, may be the presenting symptom in patients with autoimmune encephalitis, and may compromise recovery in patients with autoimmune encephalitis. Early recognition of specific sleep disturbances in patients with subacute changes in behavior or cognition may support the diagnosis of autoimmune encephalitis. Similarly, recognition and treatment of sleep dysfunction in patients with known autoimmune encephalitis may speed recovery and improve long-term outcomes.
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Affiliation(s)
- Margaret S Blattner
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Gregory S Day
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, USA.
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107
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Hébert J, Gros P, Lapointe S, Amtashar FS, Steriade C, Maurice C, Wennberg RA, Day GS, Tang-Wai DF. Searching for autoimmune encephalitis: Beware of normal CSF. J Neuroimmunol 2020; 345:577285. [PMID: 32563126 DOI: 10.1016/j.jneuroim.2020.577285] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/17/2020] [Accepted: 06/02/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the prevalence of cerebrospinal fluid (CSF) markers associated with inflammation (i.e., elevated white blood cell count, protein concentration, and CSF-specific oligoclonal bands) in patients with early active autoimmune encephalitis (AE). METHODS CSF characteristics, including WBC count, protein concentration, and oligoclonal banding, were analyzed in patients diagnosed with AE at two tertiary care centers. RESULTS Ninety-five patients were included in the study. CSF white blood cell counts and protein levels were within normal limits for 27% (CI95%: 19-37) of patients with AE. When results of oligoclonal banding were added, 14% (CI95%: 6-16) of patients with AE had "normal" CSF. The median CSF white blood cell count was 8 cells/mm3 (range: 0-544) and the median CSF protein concentration was 0.42 g/L (range: 0.15-3.92). CONCLUSIONS White blood cell counts and protein levels were within normal limits in the CSF of a substantial proportion of patients with early active AE. Inclusion of CSF oligoclonal banding identified a higher proportion of patients with an inflammatory CSF profile, especially when CSF was sampled early in the disease process.
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Affiliation(s)
- Julien Hébert
- University of Toronto, Division of Neurology, Canada
| | - Priti Gros
- University of Toronto, Division of Neurology, Canada
| | - Sarah Lapointe
- University of Toronto, Division of Neurology, Canada; University Health Network, Toronto, Canada
| | - Fatima S Amtashar
- Washington University School of Medicine, Dept of Neurology, MO, USA
| | - Claude Steriade
- New York University Langone Comprehensive Epilepsy Center, NY, USA
| | - Catherine Maurice
- University of Toronto, Division of Neurology, Canada; University Health Network, Toronto, Canada
| | - Richard A Wennberg
- University of Toronto, Division of Neurology, Canada; University Health Network, Toronto, Canada
| | - Gregory S Day
- Mayo Clinic Florida, Department of Neurology, Jacksonville, FL, USA
| | - David F Tang-Wai
- University of Toronto, Division of Neurology, Canada; University Health Network, Toronto, Canada.
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108
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Zhu F, Shan W, Lv R, Li Z, Wang Q. Clinical Characteristics of Anti-GABA-B Receptor Encephalitis. Front Neurol 2020; 11:403. [PMID: 32508739 PMCID: PMC7253677 DOI: 10.3389/fneur.2020.00403] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/17/2020] [Indexed: 01/06/2023] Open
Abstract
Objective: Anti-GABA-B (gamma aminobutyric acid-B) receptor encephalitis is an autoimmune disease mediated by GABA-B-related antibodies. To fully understand the disease, we collected clinical data from patients with GABA-B receptor encephalitis and conducted an analysis to draw conclusions. Methods: All patients with GABA-B receptor encephalitis from the Neurology Department of Beijing Tiantan Hospital, affiliated with Capital Medical University, from August 2015 to September 2019 were accepted as study subjects. The clinical data of the patients were analyzed retrospectively and included the general demographic characteristics, clinical manifestations, and auxiliary examinations, including laboratory results, electroencephalograms (EEGs), brain magnetic resonance imaging (MRI), and positron emission tomography (PET-CT) results, as well as treatments. Results: From August 2015 to September 2019, 14 cases of anti-GABA-B receptor encephalitis were diagnosed. Among these patients, middle-aged and elderly men were the main demographic, with an average age of 52 years; moreover, the onset of the disease was relatively sudden, and the time from onset to diagnosis was ~1 month. The main clinical symptoms were frequent epileptic seizures, cognitive dysfunction, and mental behavioral disorders. In seven (50%) patients, the leukocyte in cerebrospinal fluid (CSF) were increased. Five (36%) patients had elevated cerebrospinal fluid protein. In most patients, the oligoclonal bands (83%) of CSF were positive, and 24 h IgG levels (92%) were increased. Anti-Hu or anti-Yo antibodies were positive in two (14%) patients. Tumor markers in 10 (71%) patients indicated that neuron-specific enolase, gastrin-releasing precursor, non-small cell lung cancer-related antigen, or carcinoembryonic antigen levels were increased. EEG results often indicated slow waves, sharp waves, or spike waves in temporal areas. Brain MRI always showed high T2 signals in the medial temporal lobe, hippocampus, and amygdala and swelling in the medial temporal lobe and hippocampus. PET-CT scans almost showed abnormal metabolism in the hippocampus and temporal lobe. Three (21%) patients who underwent systemic PET-CT showed hypermetabolism in pulmonary parenchymal nodules and enlargement of mediastinal lymph nodes. All patients underwent high-dose hormone therapy or immunoglobulin immunotherapy. After treatment, the symptoms of epilepsy, cognitive disorders, and mental behavioral disorders improved to varying degrees. However, one patient died of lung cancer. Conclusion: Anti-GABA-B receptor encephalitis mainly occurred in middle-aged and elderly men, and the disease onset was relatively sudden. Before disease onset, some patients experienced fever and non-specific respiratory symptoms, which mainly manifested as frequent epileptic seizures, cognitive dysfunction, and abnormal mental behavior. MRI and PET-CT revealed abnormal signals and local metabolism, respectively, in the temporal lobe. Moreover, the disease has a close relationship with lung cancer, which requires long-term follow-up observation.
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Affiliation(s)
- Fei Zhu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Wei Shan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
| | - Ruijuan Lv
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhimei Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
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Rössling R, Prüss H. SOP: antibody-associated autoimmune encephalitis. Neurol Res Pract 2020; 2:1. [PMID: 33324907 PMCID: PMC7650054 DOI: 10.1186/s42466-019-0048-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 11/28/2019] [Indexed: 01/17/2023] Open
Abstract
Background Antibody-mediated and paraneoplastic autoimmune encephalitides (AE) present with a broad spectrum of clinical symptoms. They often lead to progressing inflammatory changes of the central nervous system with subacute onset and can cause persistent brain damage. Thus, to promptly start the appropriate and AE-specific therapy, recognition of symptoms, initiation of relevant antibody diagnostics and confirmation of the clinical diagnosis are crucial, in particular as the diseases are relatively rare. Aim This standard operating procedure (SOP) should draw attention to the clinical presentation of AE, support the diagnostic approach to patients with suspected AE and guide through the necessary steps including therapeutic decisions, tumour screening and exclusion of differential diagnoses. Method Based on existing diagnostic algorithms, treatment recommendations and personal experiences, this SOP gives an overview of clinical presentation, diagnostic procedures and therapy in AE. Additional information is provided within an accompanying text and a table describing the most important autoantibodies and their characteristics. Results The initial steps of the AE flow chart are based on clinical symptoms and the patient’s history. Assignment to paraneoplastic or antibody-mediated AE is sometimes clinically possible. Diagnostics should include MRI, EEG and CSF analysis with antibody panel diagnostic. Definite AE can be diagnosed if the underlying antibody is compatible with the clinical presentation. Classification of probable AE may be possible even with negative anti-neuronal autoantibodies if the clinical presentation and laboratory abnormalities are highly suggestive of AE. The confirmed AE diagnosis requires immediate initiation of immunotherapy. Conclusion The SOP facilitates the recognition of patients with AE and presents the necessary diagnostic and therapeutic steps.
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Affiliation(s)
- Rosa Rössling
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, CharitéCrossOver, R 4-334 ,Charitéplatz 1, 10117 Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, CharitéCrossOver, R 4-334 ,Charitéplatz 1, 10117 Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
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110
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Zhang LP, Jia Y, Huang H, Li DW, Wang YP. Clinical Classifications of Children With Psychogenic Non-epileptic Seizure. Front Pediatr 2020; 8:596781. [PMID: 33569360 PMCID: PMC7868414 DOI: 10.3389/fped.2020.596781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 12/31/2020] [Indexed: 12/27/2022] Open
Abstract
Objective: To analyze the clinical features of children with psychogenic non-epileptic seizures in one tertiary center in China. Methods: Clinical data including medical records and video- electroencephalograph (video-EEG) monitoring records of 88 pediatric PNES patients hospitalized in the pediatric department of Xuanwu Hospital, Beijing, China from April, 2012 to April, 2018 were collected in this study. Demographic information of patients, semiological classification, duration, and frequency of symptoms, risk factors as well as comorbidity were summarized and analyzed. Results: For semiological classification, all PNES related symptoms were divided into different categories: motor symptoms, unresponsiveness, sensory symptoms, visceral symptoms, and abnormal behaviors, among which motor symptoms were the most prevalent form. Risk factors were reviewed and categorized into two groups: persistent factors and predisposing factors, and patients were most frequently affected by the influences of families. The duration and frequency of symptoms varied substantially within PNES patients while the average time of duration was relatively longer than epilepsy as reported previously. Epilepsy was considered as the most frequent comorbidity of PNES and PNES patients misdiagnosed as epilepsy often mistreated with antiseizure medication. Significance: Our study showed that motor PNES are the most frequent seizure type. Family issues were a risk factor for PNES. Epilepsy was the most frequent co-existing neurological comorbidity.
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Affiliation(s)
- Li-Ping Zhang
- Department of Pediatric, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yu Jia
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hao Huang
- Medical Records and Statistics Department, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Da-Wei Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yu-Ping Wang
- Department of Pediatric, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Autoimmune encephalitis as a differential diagnosis of schizophreniform psychosis: clinical symptomatology, pathophysiology, diagnostic approach, and therapeutic considerations. Eur Arch Psychiatry Clin Neurosci 2020; 270:803-818. [PMID: 32166503 PMCID: PMC7474714 DOI: 10.1007/s00406-020-01113-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 02/08/2020] [Indexed: 12/12/2022]
Abstract
Primary schizophreniform psychoses are thought to be caused by complex gene-environment interactions. Secondary forms are based on a clearly identifiable organic cause, in terms of either an etiological or a relevant pathogenetic factor. The secondary or "symptomatic" forms of psychosis have reentered the focus stimulated by the discovery of autoantibody (Ab)-associated autoimmune encephalitides (AEs), such as anti-NMDA-R encephalitis, which can at least initially mimic variants of primary psychosis. These newly described secondary, immune-mediated schizophreniform psychoses typically present with the acute onset of polymorphic psychotic symptoms. Over the course of the disease, other neurological phenomena, such as epileptic seizures, movement disorders, or reduced levels of consciousness, usually arise. Typical clinical signs for AEs are the acute onset of paranoid hallucinatory symptoms, atypical polymorphic presentation, psychotic episodes in the context of previous AE, and additional neurological and medical symptoms such as catatonia, seizure, dyskinesia, and autonomic instability. Predominant psychotic courses of AEs have also been described casuistically. The term autoimmune psychosis (AP) was recently suggested for these patients. Paraclinical alterations that can be observed in patients with AE/AP are inflammatory cerebrospinal fluid (CSF) pathologies, focal or generalized electroencephalographic slowing or epileptic activity, and/or suspicious "encephalitic" imaging findings. The antibody analyses in these patients include the testing of the most frequently found Abs against cell surface antigens (NMDA-R, CASPR2, LGI1, AMPA-R, GABAB-R), intracellular antigens (Hu, Ri, Yo, CV2/CRMP5, Ma2 [Ta], amphiphysin, GAD65), thyroid antigens (TG, TPO), and antinuclear Abs (ANA). Less frequent antineuronal Abs (e.g., against DPPX, GABAA-R, glycine-R, IgLON5) can be investigated in the second step when first step screening is negative and/or some specific clinical factors prevail. Beyond, tissue-based assays on brain slices of rodents may detect previously unknown antineuronal Abs in some cases. The detection of clinical and/or paraclinical pathologies (e.g., pleocytosis in CSF) in combination with antineuronal Abs and the exclusion of alternative causes may lead to the diagnosis of AE/AP and enable more causal therapeutic immunomodulatory opportunities.
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112
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Jang Y, Kim DW, Yang KI, Byun JI, Seo JG, No YJ, Kang KW, Kim D, Kim KT, Cho YW, Lee ST. Clinical Approach to Autoimmune Epilepsy. J Clin Neurol 2020; 16:519-529. [PMID: 33029957 PMCID: PMC7541993 DOI: 10.3988/jcn.2020.16.4.519] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/02/2020] [Accepted: 03/04/2020] [Indexed: 12/20/2022] Open
Abstract
Autoimmune epilepsy is a newly emerging area of epilepsy. The concept of “autoimmune” as an etiology has recently been revisited thanks to advances in autoimmune encephalitis and precision medicine with immunotherapies. Autoimmune epilepsy presents with specific clinical manifestations, and various diagnostic approaches including cerebrospinal fluid analysis, neuroimaging, and autoantibody tests are essential for its differential diagnosis. The diagnosis is often indeterminate despite performing a thorough evaluation, and therefore empirical immunotherapy may be applied according to the judgment of the clinician. Autoimmune epilepsy often manifests as new-onset refractory status epilepticus (NORSE). A patient classified as NORSE should receive empirical immunotherapy as soon as possible. On the other hand, a morecautious, stepwise approach is recommended for autoimmune epilepsy that presents with episodic events. The type of autoimmune epilepsy is also an important factor to consider when choosing from among various immunotherapy options. Clinicians should additionally take the characteristics of antiepileptic drugs into account when using them as an adjuvant therapy. This expert opinion discusses the diagnostic and treatment approaches for autoimmune epilepsy from a practical point of view.
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Affiliation(s)
- Yoonhyuk Jang
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Dong Wook Kim
- Department of Neurology, Konkuk University School of Medicine, Seoul, Korea
| | - Kwang Ik Yang
- Department of Neurology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Jung Ick Byun
- Department of Neurology, Kyunghee University Hospital at Gangdong, Seoul, Korea
| | - Jong Geun Seo
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Young Joo No
- Department of Neurology, Samsung Noble County, Yongin, Korea
| | - Kyung Wook Kang
- Department of Neurology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Daeyoung Kim
- Department of Neurology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Keun Tae Kim
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Yong Won Cho
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea.
| | - Soon Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea.
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113
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Peña-Salazar C, Erben T, Klötzsch C. Psychosis as an initial symptom of autoimmune encephalitis with negative antibodies. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2019; 14:72-73. [PMID: 31859110 DOI: 10.1016/j.rpsm.2019.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 10/04/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Carlos Peña-Salazar
- Unidad Especializada en Trastornos Psiquiátricos en personas con Discapacidad Intelectual (UHEDI), Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, España; Research and Development Unit, Institut de Recerca Sant Joan de Déu, Group of Health Technologies and Results in Primary Care and Mental Health (PRISMA), Barcelona, España; Consortium for Biomedical Research in Epidemiology & Public Health (CIBER in Epidemiology and Public Health - CIBERESP), Barcelona, España.
| | - Tanja Erben
- Research and Development Unit, Institut de Recerca Sant Joan de Déu, Group of Health Technologies and Results in Primary Care and Mental Health (PRISMA), Barcelona, España
| | - Christof Klötzsch
- Unidad de Neurología, Hegau Bodensee Klinikum Singen, Singen, Alemania
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