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Masdeu JC, Dalmau J, Berman KF. NMDA Receptor Internalization by Autoantibodies: A Reversible Mechanism Underlying Psychosis? Trends Neurosci 2016; 39:300-310. [PMID: 27130657 DOI: 10.1016/j.tins.2016.02.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 02/13/2016] [Accepted: 02/22/2016] [Indexed: 12/31/2022]
Abstract
Since the early 1990s it has been postulated that hypofunction of N-methyl-d-aspartate (NMDA) receptors in brain networks supporting perception and cognition underlies schizophrenic psychosis. Recently, NMDA receptor hypofunction was described in patients with psychotic manifestations who exhibited autoantibodies binding the GluN1 subunit of the receptor, and who improved when the level of these antibodies was lowered by immunomodulation. In this disorder, NMDA receptor antibodies decrease the availability of NMDA receptors by internalizing them. In this opinion article, we review this mechanism as well as data supporting or refuting the possibility that this disorder or similar autoimmune disorders affecting synaptic proteins, which are therefore treatable with immunomodulation, could account for some cases of idiopathic psychosis. We also suggest methodological approaches to clarify this issue.
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Affiliation(s)
- Joseph C Masdeu
- Houston Methodist Neurological Institute and Department of Neurology, Weill Cornell Medical College, Houston, TX 77030, USA.
| | - Josep Dalmau
- ICREA-IDIBAPS, Hospital Clinic, Service of Neurology, University of Barcelona, Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Karen F Berman
- Clinical and Translational Neuroscience Branch, National Institutes of Health, NIMH Intramural Research Program, Bethesda, MD 20892, USA
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152
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Hoffmann C, Zong S, Mané-Damas M, Molenaar P, Losen M, Martinez-Martinez P. Autoantibodies in Neuropsychiatric Disorders. Antibodies (Basel) 2016; 5:antib5020009. [PMID: 31557990 PMCID: PMC6698850 DOI: 10.3390/antib5020009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/01/2016] [Accepted: 04/06/2016] [Indexed: 12/15/2022] Open
Abstract
Little is known about the etiology of neuropsychiatric disorders. The identification of autoantibodies targeting the N-methyl-d-aspartate receptor (NMDA-R), which causes neurological and psychiatric symptoms, has reinvigorated the hypothesis that other patient subgroups may also suffer from an underlying autoimmune condition. In recent years, a wide range of neuropsychiatric diseases and autoantibodies targeting ion-channels or neuronal receptors including NMDA-R, voltage gated potassium channel complex (VGKC complex), α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPA-R), γ-aminobutyric acid receptor (GABA-R) and dopamine receptor (DR) were studied and conflicting reports have been published regarding the seroprevalence of these autoantibodies. A clear causative role of autoantibodies on psychiatric symptoms has as yet only been shown for the NMDA-R. Several other autoantibodies have been related to the presence of certain symptoms and antibody effector mechanisms have been proposed. However, extensive clinical studies with large multicenter efforts to standardize diagnostic procedures for autoimmune etiology and animal studies are needed to confirm the pathogenicity of these autoantibodies. In this review, we discuss the current knowledge of neuronal autoantibodies in the major neuropsychiatric disorders: psychotic, major depression, autism spectrum, obsessive-compulsive and attention-deficit/hyperactivity disorders.
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Affiliation(s)
- Carolin Hoffmann
- Division Neurosciences, School for Mental Health and Neurosciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
| | - Shenghua Zong
- Division Neurosciences, School for Mental Health and Neurosciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
| | - Marina Mané-Damas
- Division Neurosciences, School for Mental Health and Neurosciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
| | - Peter Molenaar
- Division Neurosciences, School for Mental Health and Neurosciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
| | - Mario Losen
- Division Neurosciences, School for Mental Health and Neurosciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
| | - Pilar Martinez-Martinez
- Division Neurosciences, School for Mental Health and Neurosciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
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153
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Graus F, Titulaer MJ, Balu R, Benseler S, Bien CG, Cellucci T, Cortese I, Dale RC, Gelfand JM, Geschwind M, Glaser CA, Honnorat J, Höftberger R, Iizuka T, Irani SR, Lancaster E, Leypoldt F, Prüss H, Rae-Grant A, Reindl M, Rosenfeld MR, Rostásy K, Saiz A, Venkatesan A, Vincent A, Wandinger KP, Waters P, Dalmau J. A clinical approach to diagnosis of autoimmune encephalitis. Lancet Neurol 2016; 15:391-404. [PMID: 26906964 PMCID: PMC5066574 DOI: 10.1016/s1474-4422(15)00401-9] [Citation(s) in RCA: 2334] [Impact Index Per Article: 291.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 12/08/2015] [Accepted: 12/16/2015] [Indexed: 12/18/2022]
Abstract
Encephalitis is a severe inflammatory disorder of the brain with many possible causes and a complex differential diagnosis. Advances in autoimmune encephalitis research in the past 10 years have led to the identification of new syndromes and biomarkers that have transformed the diagnostic approach to these disorders. However, existing criteria for autoimmune encephalitis are too reliant on antibody testing and response to immunotherapy, which might delay the diagnosis. We reviewed the literature and gathered the experience of a team of experts with the aims of developing a practical, syndrome-based diagnostic approach to autoimmune encephalitis and providing guidelines to navigate through the differential diagnosis. Because autoantibody test results and response to therapy are not available at disease onset, we based the initial diagnostic approach on neurological assessment and conventional tests that are accessible to most clinicians. Through logical differential diagnosis, levels of evidence for autoimmune encephalitis (possible, probable, or definite) are achieved, which can lead to prompt immunotherapy.
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Affiliation(s)
- Francesc Graus
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Service of Neurology, Hospital Clinic, Barcelona, Spain.
| | | | - Ramani Balu
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Susanne Benseler
- Department of Pediatrics, Alberta Children Hospital, Calgary, AB, Canada
| | | | - Tania Cellucci
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - Irene Cortese
- Neuroimmunology Clinic, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Russell C Dale
- Neuroimmunology Group, Children's Hospital at Westmead, University of Sydney, Sydney, NSW, Australia
| | - Jeffrey M Gelfand
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Michael Geschwind
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Carol A Glaser
- Division of Pediatric Infectious Diseases, Kaiser Permanente, Oakland Medical Center and University of California, San Francisco, CA, USA
| | - Jerome Honnorat
- French Reference Center on Paraneoplastic Neurological Syndrome, Hospices Civils De Lyon, Hôpital Neurologique, Inserm U1028, CNRS UMR 5292, Lyon's Neurosciences Research Center, Université Claude-Bernard Lyon-1, Lyon, France
| | - Romana Höftberger
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Takahiro Iizuka
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Sarosh R Irani
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Eric Lancaster
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Frank Leypoldt
- Neuroimmunology, Institute of Clinical Chemistry, and Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Harald Prüss
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany; German Center for Neurodegenerative Disorders Berlin, Berlin, Germany
| | | | - Markus Reindl
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Myrna R Rosenfeld
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Kevin Rostásy
- Department of Pediatric Neurology, Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany
| | - Albert Saiz
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Service of Neurology, Hospital Clinic, Barcelona, Spain
| | - Arun Venkatesan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Klaus-Peter Wandinger
- Institute of Clinical Chemistry and Department of Neurology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Patrick Waters
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Josep Dalmau
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA; Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain.
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154
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Chefdeville A, Honnorat J, Hampe CS, Desestret V. Neuronal central nervous system syndromes probably mediated by autoantibodies. Eur J Neurosci 2016; 43:1535-52. [PMID: 26918657 DOI: 10.1111/ejn.13212] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 02/09/2016] [Accepted: 02/15/2016] [Indexed: 01/17/2023]
Abstract
In the last few years, a rapidly growing number of autoantibodies targeting neuronal cell-surface antigens have been identified in patients presenting with neurological symptoms. Targeted antigens include ionotropic receptors such as N-methyl-d-aspartate receptor or the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor, metabotropic receptors such as mGluR1 and mGluR5, and other synaptic proteins, some of them belonging to the voltage-gated potassium channel complex. Importantly, the cell-surface location of these antigens makes them vulnerable to direct antibody-mediated modulation. Some of these autoantibodies, generally targeting ionotropic channels or their partner proteins, define clinical syndromes resembling models of pharmacological or genetic disruption of the corresponding antigen, suggesting a direct pathogenic role of the associated autoantibodies. Moreover, the associated neurological symptoms are usually immunotherapy-responsive, further arguing for a pathogenic effect of the antibodies. Some studies have shown that some patients' antibodies may have structural and functional in vitro effects on the targeted antigens. Definite proof of the pathogenicity of these autoantibodies has been obtained for just a few through passive transfer experiments in animal models. In this review we present existing and converging evidence suggesting a pathogenic role of some autoantibodies directed against neuronal cell-surface antigens observed in patients with central nervous system disorders. We describe the main clinical symptoms characterizing the patients and discuss conflicting arguments regarding the pathogenicity of these antibodies.
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Affiliation(s)
- Aude Chefdeville
- Institut NeuroMyoGène, INSERM U1217/UMR CNRS 5310, Lyon, France.,Université de Lyon, Lyon, France
| | - Jérôme Honnorat
- Institut NeuroMyoGène, INSERM U1217/UMR CNRS 5310, Lyon, France.,Université de Lyon, Lyon, France.,French Reference Center on Paraneoplastic Neurological Syndrome, F-69677, Bron, France.,Department of Neurology, Hospices Civils de Lyon, Hôpital Neurologique, F-69677, Bron, France
| | | | - Virginie Desestret
- Institut NeuroMyoGène, INSERM U1217/UMR CNRS 5310, Lyon, France.,Université de Lyon, Lyon, France.,French Reference Center on Paraneoplastic Neurological Syndrome, F-69677, Bron, France.,Department of Neurology, Hospices Civils de Lyon, Hôpital Neurologique, F-69677, Bron, France
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155
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Sutcu M, Akturk H, Somer A, Tatli B, Torun SH, Yıldız EP, Şık G, Citak A, Agacfidan A, Salman N. Role of Autoantibodies to N-Methyl-d-Aspartate (NMDA) Receptor in Relapsing Herpes Simplex Encephalitis: A Retrospective, One-Center Experience. J Child Neurol 2016; 31:345-50. [PMID: 26184485 DOI: 10.1177/0883073815595079] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 06/10/2015] [Indexed: 11/16/2022]
Abstract
Post-herpes simplex virus encephalitis relapses have been recently associated with autoimmunity driven by autoantibodies against N-methyl-d-aspartate (NMDA) receptors. Because it offers different treatment options, determination of this condition is important. Between 2011 and 2014, 7 children with proven diagnosis of herpes simplex virus encephalitis were identified in a university hospital of Istanbul. Two patients had neurologic relapse characterized mainly by movement disorders 2 to 3 weeks after initial encephalitis. The first patient received a second 14 days of acyclovir treatment together with antiepileptic drugs and left with severe neurologic sequelae. The second patient was found to be NMDA receptors antibody positive in the cerebrospinal fluid. She was treated with intravenous immunoglobulin and prednisolone. She showed substantial improvement, gradually regaining lost neurologic abilities. Post-herpes simplex virus encephalitis relapses may frequently be immune-mediated rather than a viral reactivation, particularly in children displaying movement disorders like choreoathetosis. Immunotherapy may provide benefit for this potentially devastating condition, like the case described in this report.
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Affiliation(s)
- Murat Sutcu
- Department of Pediatric Infectious Diseases, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Hacer Akturk
- Department of Pediatric Infectious Diseases, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ayper Somer
- Department of Pediatric Infectious Diseases, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Burak Tatli
- Department of Pediatric Neurology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Selda Hancerli Torun
- Department of Pediatric Infectious Diseases, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Edibe Pembegul Yıldız
- Department of Pediatric Neurology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Guntulu Şık
- Department of Pediatric Intensive Care, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Agop Citak
- Department of Pediatric Intensive Care, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ali Agacfidan
- Department of Microbiology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Nuran Salman
- Department of Pediatric Infectious Diseases, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
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156
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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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157
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Pollak TA, Beck K, Irani SR, Howes OD, David AS, McGuire PK. Autoantibodies to central nervous system neuronal surface antigens: psychiatric symptoms and psychopharmacological implications. Psychopharmacology (Berl) 2016; 233:1605-21. [PMID: 26667479 PMCID: PMC4828500 DOI: 10.1007/s00213-015-4156-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 11/05/2015] [Indexed: 12/30/2022]
Abstract
RATIONALE Autoantibodies to central nervous system (CNS) neuronal surface antigens have been described in association with autoimmune encephalopathies which prominently feature psychiatric symptoms in addition to neurological symptoms. The potential role of these autoantibodies in primary psychiatric diseases such as schizophrenia or bipolar affective disorder is of increasing interest. OBJECTIVES We aimed to review the nature of psychiatric symptoms associated with neuronal surface autoantibodies, in the context of autoimmune encephalopathies as well as primary psychiatric disorders, and to review the mechanisms of action of these autoantibodies from a psychopharmacological perspective. RESULTS The functional effects of the autoantibodies on their target antigens are described; their clinical expression is at least in part mediated by their effects on neuronal receptor function, primarily at the synapse, usually resulting in receptor hypofunction. The psychiatric effects of the antibodies are related to known functions of the receptor target or its complexed proteins, with reference to supportive genetic and pharmacological evidence where relevant. Evidence for a causal role of these autoantibodies in primary psychiatric disease is increasing but remains controversial; relevant methodological controversies are outlined. Non-receptor-based mechanisms of autoantibody action, including neuroinflammatory mechanisms, and therapeutic implications are discussed. CONCLUSIONS An analysis of the autoantibodies from a psychopharmacological perspective, as endogenous, bioactive, highly specific, receptor-targeting molecules, provides a valuable opportunity to understand the neurobiological basis of associated psychiatric symptoms. Potentially, new treatment strategies will emerge from the improving understanding of antibody-antigen interaction within the CNS.
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Affiliation(s)
- T A Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK.
| | - K Beck
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
| | - S R Irani
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - O D Howes
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
| | - A S David
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
| | - P K McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
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158
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Würdemann T, Kersten M, Tokay T, Guli X, Kober M, Rohde M, Porath K, Sellmann T, Bien CG, Köhling R, Kirschstein T. Stereotactic injection of cerebrospinal fluid from anti-NMDA receptor encephalitis into rat dentate gyrus impairs NMDA receptor function. Brain Res 2015; 1633:10-18. [PMID: 26721688 DOI: 10.1016/j.brainres.2015.12.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 10/24/2015] [Accepted: 12/15/2015] [Indexed: 01/17/2023]
Abstract
Autoimmune encephalitis is increasingly recognized in patients with otherwise unexplained encephalopathy with epilepsy. Among these, patients with anti-N-methyl D-aspartate receptor (NMDAR) encephalitis present epileptic seizures, memory deficits, and psychiatric symptoms. However, the functional consequences of such autoantibodies are poorly understood. In order to investigate the pathophysiology of this disease, we stereotactically injected either cerebrospinal fluid (CSF) from three anti-NMDAR encephalitis patients or commercially available anti-NMDAR1 into the dentate gyrus of adult female rats. Control animals were injected with either CSF obtained from three epilepsy patients (ganglioglioma, posttraumatic epilepsy, focal cortical dysplasia) lacking anti-NMDAR or saline. Intracellular recordings from dentate gyrus granule cells showed a significant reduction of the NMDAR-evoked excitatory postsynaptic potentials (NMDAR-EPSPs) in animals treated with anti-NMDAR. As a consequence of this, action potential firing in these cells by NMDAR-EPSPs was significantly impaired. Long-term potentiation in the dentate gyrus was also significantly reduced in rats injected with anti-NMDAR as compared to control animals. This was accompanied by a significantly impaired learning performance in the Morris water maze hidden platform task when the animals had been injected with anti-NMDAR antibody-containing CSF. Our findings suggest that anti-NMDAR lead to reduced NMDAR function in vivo which could contribute to the memory impairment found in patients with anti-NMDAR encephalitis.
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Affiliation(s)
- Till Würdemann
- Oscar Langendorff Institute of Physiology, University of Rostock, Germany
| | - Maxi Kersten
- Oscar Langendorff Institute of Physiology, University of Rostock, Germany
| | - Tursonjan Tokay
- Oscar Langendorff Institute of Physiology, University of Rostock, Germany
| | - Xiati Guli
- Oscar Langendorff Institute of Physiology, University of Rostock, Germany
| | - Maria Kober
- Oscar Langendorff Institute of Physiology, University of Rostock, Germany
| | - Marco Rohde
- Oscar Langendorff Institute of Physiology, University of Rostock, Germany
| | - Katrin Porath
- Oscar Langendorff Institute of Physiology, University of Rostock, Germany
| | - Tina Sellmann
- Oscar Langendorff Institute of Physiology, University of Rostock, Germany
| | | | - Rüdiger Köhling
- Oscar Langendorff Institute of Physiology, University of Rostock, Germany
| | - Timo Kirschstein
- Oscar Langendorff Institute of Physiology, University of Rostock, Germany.
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159
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Kamei S. [Current topics of primary management for encephalitis]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2015; 104:2595-2601. [PMID: 28530377 DOI: 10.2169/naika.104.2595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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160
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Werner C, Pauli M, Doose S, Weishaupt A, Haselmann H, Grünewald B, Sauer M, Heckmann M, Toyka KV, Asan E, Sommer C, Geis C. Human autoantibodies to amphiphysin induce defective presynaptic vesicle dynamics and composition. Brain 2015; 139:365-79. [DOI: 10.1093/brain/awv324] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 09/25/2015] [Indexed: 12/16/2022] Open
Abstract
Abstract
See Irani (doi:10.1093/awv364) for a scientific commentary on this article.
Stiff-person syndrome is the prototype of a central nervous system disorder with autoantibodies targeting presynaptic antigens. Patients with paraneoplastic stiff-person syndrome may harbour autoantibodies to the BAR (Bin/Amphiphysin/Rvs) domain protein amphiphysin, which target its SH3 domain. These patients have neurophysiological signs of compromised central inhibition and respond to symptomatic treatment with medication enhancing GABAergic transmission. High frequency neurotransmission as observed in tonic GABAergic interneurons relies on fast exocytosis of neurotransmitters based on compensatory endocytosis. As amphiphysin is involved in clathrin-mediated endocytosis, patient autoantibodies are supposed to interfere with this function, leading to disinhibition by reduction of GABAergic neurotransmission. We here investigated the effects of human anti-amphiphysin autoantibodies on structural components of presynaptic boutons ex vivo and in vitro using electron microscopy and super-resolution direct stochastic optical reconstruction microscopy. Ultrastructural analysis of spinal cord presynaptic boutons was performed after in vivo intrathecal passive transfer of affinity-purified human anti-amphiphysin autoantibodies in rats and revealed signs of markedly disabled clathrin-mediated endocytosis. This was unmasked at high synaptic activity and characterized by a reduction of the presynaptic vesicle pool, clathrin coated intermediates, and endosome-like structures. Super-resolution microscopy of inhibitory GABAergic presynaptic boutons in primary neurons revealed that specific human anti-amphiphysin immunoglobulin G induced an increase of the essential vesicular protein synaptobrevin 2 and a reduction of synaptobrevin 7. This constellation suggests depletion of resting pool vesicles and trapping of releasable pool vesicular proteins at the plasma membrane. Similar effects were found in amphiphysin-deficient neurons from knockout mice. Application of specific patient antibodies did not show additional effects. Blocking alternative pathways of clathrin-independent endocytosis with brefeldin A reversed the autoantibody induced effects on molecular vesicle composition. Endophilin as an interaction partner of amphiphysin showed reduced clustering within presynaptic terminals. Collectively, these results point towards an autoantibody-induced structural disorganization in GABAergic synapses with profound changes in presynaptic vesicle pools, activation of alternative endocytic pathways, and potentially compensatory rearrangement of proteins involved in clathrin-mediated endocytosis. Our findings provide novel insights into synaptic pathomechanisms in a prototypic antibody-mediated central nervous system disease, which may serve as a proof-of-principle example in this evolving group of autoimmune disorders associated with autoantibodies to synaptic antigens.
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Affiliation(s)
- Christian Werner
- 1 Hans-Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
- 2 Department of Neurology, University of Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany
| | - Martin Pauli
- 3 Department of Neurophysiology, Institute of Physiology, University of Würzburg, Roentgenring 9, 97070 Würzburg, Germany
| | - Sören Doose
- 4 Department of Biotechnology and Biophysics, Biocenter, University of Würzburg, Am Hubland, 97074 Würzburg, Germany
| | - Andreas Weishaupt
- 2 Department of Neurology, University of Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany
| | - Holger Haselmann
- 1 Hans-Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
- 2 Department of Neurology, University of Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany
- 5 Center for Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - Benedikt Grünewald
- 1 Hans-Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
- 2 Department of Neurology, University of Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany
- 5 Center for Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - Markus Sauer
- 4 Department of Biotechnology and Biophysics, Biocenter, University of Würzburg, Am Hubland, 97074 Würzburg, Germany
| | - Manfred Heckmann
- 3 Department of Neurophysiology, Institute of Physiology, University of Würzburg, Roentgenring 9, 97070 Würzburg, Germany
| | - Klaus V. Toyka
- 2 Department of Neurology, University of Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany
| | - Esther Asan
- 6 Institute for Anatomy and Cell Biology, University of Würzburg, Koellikerstrasse 6, 97070 Würzburg, Germany
| | - Claudia Sommer
- 2 Department of Neurology, University of Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany
| | - Christian Geis
- 1 Hans-Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
- 2 Department of Neurology, University of Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany
- 5 Center for Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
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161
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Venkatesan A, Benavides DR. Autoimmune encephalitis and its relation to infection. Curr Neurol Neurosci Rep 2015; 15:3. [PMID: 25637289 DOI: 10.1007/s11910-015-0529-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Encephalitis, an inflammatory condition of the brain that results in substantial morbidity and mortality, has numerous causes. Over the past decade, it has become increasingly recognized that autoimmune conditions contribute significantly to the spectrum of encephalitis causes. Clinical suspicion and early diagnosis of autoimmune etiologies are of particular importance due to the need for early institution of immune suppressive therapies to improve outcome. Emerging clinical observations suggest that the most commonly recognized cause of antibody-mediated autoimmune encephalitis, anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, may in some cases be triggered by herpes virus infection. Other conditions such as Rasmussen's encephalitis (RE) and febrile infection-related epilepsy syndrome (FIRES) have also been posited to be autoimmune conditions triggered by infectious agents. This review focuses on emerging concepts in central nervous system autoimmunity and addresses clinical and mechanistic findings linking autoimmune encephalitis and infections. Particular consideration will be given to anti-NMDA receptor encephalitis and its relation to herpes simplex encephalitis.
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Affiliation(s)
- Arun Venkatesan
- Johns Hopkins Encephalitis Center, Department of Neurology, Johns Hopkins University School of Medicine, Meyer 6-113, 600 N. Wolfe Street, Baltimore, MD, 21287, USA,
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Day GS, Prüss H, Benseler SM, Paton TA, Paterson AD, Andrade DM. GRIN1 polymorphisms do not affect susceptibility or phenotype in NMDA receptor encephalitis. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2015; 2:e153. [PMID: 26443875 PMCID: PMC4582904 DOI: 10.1212/nxi.0000000000000153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 07/30/2015] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To determine whether distinct single nucleotide polymorphisms (SNPs) within the glutamate receptor ionotropic NMDA 1 gene (GRIN1) are associated with NMDA receptor (NMDAR) encephalitis and whether these same variants are associated with variability in the clinical presentation and course of affected patients. METHODS We performed clinical follow-up on 48 patients with NMDAR encephalitis and NMDAR autoantibodies detected in serum or CSF. All RefSeq GRIN1 coding exons were sequenced in 39 Caucasian-European patients, and the frequencies of SNPs were compared with those of an ethnically similar population using a case-control study design. Predetermined clinical variables were compared between patients with and without identified SNPs. RESULTS Two SNPs were identified in GRIN1: 24 (62%) Caucasian-European patients with NMDAR encephalitis had alternate alleles at both rs6293 (exon 6) and rs1126442 (exon 7; exon numbering according to NM_001185090). The SNPs were in complete linkage disequilibrium. The frequency of these variants did not differ between patients with NMDAR encephalitis and ethnically matched individuals in the general population. No differences in clinical presentation, measures of disease severity, clinical course, or outcomes were observed between patients with different genotypes at these SNPs. CONCLUSION Disease susceptibility or course in patients with NMDAR encephalitis was not strongly affected by SNPs in GRIN1. This study provides an estimate of the frequency of SNPs in GRIN1 in patients with NMDAR encephalitis and emphasizes the need for multisite collaborative studies enrolling larger numbers of patients to identify the genetic contributions to NMDAR encephalitis.
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Affiliation(s)
- Gregory S Day
- Department of Medicine (G.S.D., D.M.A.), Division of Neurology, and Dalla Lana School of Public Health (A.D.P.), University of Toronto, Ontario, Canada; Department of Neurology, Charité-Universitätsmedizin Berlin, and German Center for Neurodegenerative Diseases (DZNE) (H.P.), Berlin, Germany; Department of Rheumatology, Alberta Children's Hospital, and Research Institute (S.M.B.), University of Calgary, Alberta, Canada; The Centre for Applied Genomics (T.A.P., A.D.P.), The Hospital for Sick Children, Toronto, Ontario, Canada; and University Health Network (D.M.A.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - Harald Prüss
- Department of Medicine (G.S.D., D.M.A.), Division of Neurology, and Dalla Lana School of Public Health (A.D.P.), University of Toronto, Ontario, Canada; Department of Neurology, Charité-Universitätsmedizin Berlin, and German Center for Neurodegenerative Diseases (DZNE) (H.P.), Berlin, Germany; Department of Rheumatology, Alberta Children's Hospital, and Research Institute (S.M.B.), University of Calgary, Alberta, Canada; The Centre for Applied Genomics (T.A.P., A.D.P.), The Hospital for Sick Children, Toronto, Ontario, Canada; and University Health Network (D.M.A.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - Susanne M Benseler
- Department of Medicine (G.S.D., D.M.A.), Division of Neurology, and Dalla Lana School of Public Health (A.D.P.), University of Toronto, Ontario, Canada; Department of Neurology, Charité-Universitätsmedizin Berlin, and German Center for Neurodegenerative Diseases (DZNE) (H.P.), Berlin, Germany; Department of Rheumatology, Alberta Children's Hospital, and Research Institute (S.M.B.), University of Calgary, Alberta, Canada; The Centre for Applied Genomics (T.A.P., A.D.P.), The Hospital for Sick Children, Toronto, Ontario, Canada; and University Health Network (D.M.A.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - Tara A Paton
- Department of Medicine (G.S.D., D.M.A.), Division of Neurology, and Dalla Lana School of Public Health (A.D.P.), University of Toronto, Ontario, Canada; Department of Neurology, Charité-Universitätsmedizin Berlin, and German Center for Neurodegenerative Diseases (DZNE) (H.P.), Berlin, Germany; Department of Rheumatology, Alberta Children's Hospital, and Research Institute (S.M.B.), University of Calgary, Alberta, Canada; The Centre for Applied Genomics (T.A.P., A.D.P.), The Hospital for Sick Children, Toronto, Ontario, Canada; and University Health Network (D.M.A.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - Andrew D Paterson
- Department of Medicine (G.S.D., D.M.A.), Division of Neurology, and Dalla Lana School of Public Health (A.D.P.), University of Toronto, Ontario, Canada; Department of Neurology, Charité-Universitätsmedizin Berlin, and German Center for Neurodegenerative Diseases (DZNE) (H.P.), Berlin, Germany; Department of Rheumatology, Alberta Children's Hospital, and Research Institute (S.M.B.), University of Calgary, Alberta, Canada; The Centre for Applied Genomics (T.A.P., A.D.P.), The Hospital for Sick Children, Toronto, Ontario, Canada; and University Health Network (D.M.A.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - Danielle M Andrade
- Department of Medicine (G.S.D., D.M.A.), Division of Neurology, and Dalla Lana School of Public Health (A.D.P.), University of Toronto, Ontario, Canada; Department of Neurology, Charité-Universitätsmedizin Berlin, and German Center for Neurodegenerative Diseases (DZNE) (H.P.), Berlin, Germany; Department of Rheumatology, Alberta Children's Hospital, and Research Institute (S.M.B.), University of Calgary, Alberta, Canada; The Centre for Applied Genomics (T.A.P., A.D.P.), The Hospital for Sick Children, Toronto, Ontario, Canada; and University Health Network (D.M.A.), Toronto Western Hospital, Toronto, Ontario, Canada
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Prüss H, Leubner J, Wenke NK, Czirják GÁ, Szentiks CA, Greenwood AD. Anti-NMDA Receptor Encephalitis in the Polar Bear (Ursus maritimus) Knut. Sci Rep 2015; 5:12805. [PMID: 26313569 PMCID: PMC4551079 DOI: 10.1038/srep12805] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 07/06/2015] [Indexed: 12/31/2022] Open
Abstract
Knut the polar bear of the Berlin Zoological Garden drowned in 2011 following seizures and was diagnosed as having suffered encephalitis of unknown etiology after exhaustive pathogen screening. Using the diagnostic criteria applied to human patients, we demonstrate that Knut’s encephalitis is almost identical to anti-NMDA receptor encephalitis which is a severe autoimmune disease representing the most common non-infectious encephalitis in humans. High concentrations of antibodies specific against the NR1 subunit of the NMDA receptor were detected in Knut’s cerebrospinal fluid. Histological examination demonstrated very similar patterns of plasma cell infiltration and minimal neuronal loss in affected brain areas. We conclude that Knut suffered anti-NMDA receptor encephalitis making his the first reported non-human case of this treatable disease. The results suggest that anti-NMDA receptor encephalitis may be a disease of broad relevance to mammals that until now has remained undiagnosed.
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Affiliation(s)
- H Prüss
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - J Leubner
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Germany
| | - N K Wenke
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Germany
| | - G Á Czirják
- Department of Wildlife Diseases, Leibniz Institute for Zoo and Wildlife Research, Berlin, Germany
| | - C A Szentiks
- Department of Wildlife Diseases, Leibniz Institute for Zoo and Wildlife Research, Berlin, Germany
| | - A D Greenwood
- Department of Wildlife Diseases, Leibniz Institute for Zoo and Wildlife Research, Berlin, Germany
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164
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Melzer N, Budde T, Stork O, Meuth SG. Limbic Encephalitis: Potential Impact of Adaptive Autoimmune Inflammation on Neuronal Circuits of the Amygdala. Front Neurol 2015; 6:171. [PMID: 26284026 PMCID: PMC4522870 DOI: 10.3389/fneur.2015.00171] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 07/20/2015] [Indexed: 12/31/2022] Open
Abstract
Limbic encephalitis is characterized by adaptive autoimmune inflammation of the gray matter structures of the limbic system. It has recently been identified as a major cause of temporal lobe epilepsy accompanied by progressive declarative – mainly episodic – memory disturbance as well as a variety of rather poorly defined emotional and behavioral changes. While autoimmune inflammation of the hippocampus is likely to be responsible for declarative memory disturbance, consequences of autoimmune inflammation of the amygdala are largely unknown. The amygdala is central for the generation of adequate homoeostatic behavioral responses to emotionally significant external stimuli following processing in a variety of parallel neuronal circuits. Here, we hypothesize that adaptive cellular and humoral autoimmunity may target and modulate distinct inhibitory or excitatory neuronal networks within the amygdala, and thereby strongly impact processing of emotional stimuli and corresponding behavioral responses. This may explain some of the rather poorly understood neuropsychiatric symptoms in limbic encephalitis.
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Affiliation(s)
- Nico Melzer
- Department of Neurology, University of Münster , Münster , Germany
| | - Thomas Budde
- Institute of Physiology I, University of Münster , Münster , Germany
| | - Oliver Stork
- Department of Genetics and Molecular Neurobiology, Institute of Biology, Otto-von-Guericke University Magdeburg , Magdeburg , Germany
| | - Sven G Meuth
- Department of Neurology, University of Münster , Münster , Germany ; Department of Neuropathophysiology, Institute of Physiology I, University of Münster , Münster , Germany
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165
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Seebohm G, Piccini I, Strutz-Seebohm N. Paving the Way to Understand Autoantibody-Mediated Epilepsy on the Molecular Level. Front Neurol 2015. [PMID: 26217297 PMCID: PMC4491625 DOI: 10.3389/fneur.2015.00149] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Correct function of neuronal networks is enabled by a delicate interplay among neurons communicating with each other. One of the keys is the communication at chemical synapses where neurotransmitters like glutamate, GABA, and glycine enable signal transfer over the synaptic cleft. Thereby, the neurotransmitters are released from the presynapse and bind as ligands to specific receptors at the postsynaptic side to allow for modulation of the postsynaptic membrane potentials. The postsynaptic electrical signal, which is highly modulated by voltage-gated ion channels, spreads over the dendritic tree and is thus integrated to allow for generation of action potentials at the axon hillock. This concert of receptors and voltage-gated ion channels depends on correct function of all its components. Misfunction of receptors and/or voltage-gated potassium channels (VGKC) leads to diverse adverse effects in patients. Such malfunctions can be the result of inherited genetic alterations or pharmacological side effects by drugs. Recently, autoantibodies targeting receptor or channel complexes like NMDAR, AMPAR, GABA-receptors, glycine receptors, LGI1 or CASPR2 (previously termed as VGKC-complex antibodies) have been discovered. The presence of specific autoantibodies against these targets associates with severe forms of antibody-mediated encephalitis. Understanding the molecular details of autoantibody actions on receptor and VGKC complexes is highly desirable and may open the path to develop specific therapies to treat humoral autoimmune encephalitis. Here, we summarize the current knowledge and discuss technical approaches to fill the gap of knowledge. These techniques include electrophysiology, biochemical approaches for epitope mapping, and in silico modeling to simulate molecular interactions between autoantibody and its molecular target.
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Affiliation(s)
- Guiscard Seebohm
- Receptor Structure and Function Group, Department of Cardiovascular Medicine, Institute for Genetics of Heart Diseases (IfGH), University Hospital Münster , Münster , Germany
| | - Ilaria Piccini
- Receptor Structure and Function Group, Department of Cardiovascular Medicine, Institute for Genetics of Heart Diseases (IfGH), University Hospital Münster , Münster , Germany
| | - Nathalie Strutz-Seebohm
- Receptor Structure and Function Group, Department of Cardiovascular Medicine, Institute for Genetics of Heart Diseases (IfGH), University Hospital Münster , Münster , Germany
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Olsen AL, Lai Y, Dalmau J, Scherer SS, Lancaster E. Caspr2 autoantibodies target multiple epitopes. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2015; 2:e127. [PMID: 26185774 PMCID: PMC4496632 DOI: 10.1212/nxi.0000000000000127] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 05/22/2015] [Indexed: 01/17/2023]
Abstract
Objective: To better understand the mechanisms of autoantibodies to the axonal protein contactin-associated protein-like 2 (Caspr2) by studying their target epitopes. Methods: A plasmid for expressing Caspr2 was modified so that the various extracellular subdomains were deleted individually and in groups. Cultured cells were transfected to express these constructs and assayed by immunofluorescence staining with a commercial Caspr2 antibody and a panel of patient sera known to react with Caspr2. Western blotting was also performed. The role of glycosylation in immunogenicity was tested with tunicamycin and PNGase F treatment. Results: Patient antibodies bound to the extracellular domain of Caspr2. Neither native protein structure nor glycosylation was required for immunoreactivity. Caspr2 constructs with single or multidomain deletions were expressed on the plasma membrane. All deletion constructs were recognized by patients' sera, although reactivity was significantly reduced with deletion of the discoidin-like subdomain and strongly reduced or abolished with larger deletions of multiple N-terminal subdomains. Caspr2 with all subdomains deleted except the discoidin-like domain was still recognized by the antibodies. Conclusion: Caspr2 autoantibodies recognize multiple target epitopes in the extracellular domain of Caspr2, including one in the discoidin-like domain. Reactivity for some epitopes is not dependent on glycosylation or native protein structure.
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Affiliation(s)
- Abby L Olsen
- Department of Neurology (A.L.O., Y.L., J.D., S.S.S., E.L.), The University of Pennsylvania, Philadelphia; and ICREA-IDIBAPS (J.D.), Hospital Unit, University of Barcelona, Spain
| | - Yongjie Lai
- Department of Neurology (A.L.O., Y.L., J.D., S.S.S., E.L.), The University of Pennsylvania, Philadelphia; and ICREA-IDIBAPS (J.D.), Hospital Unit, University of Barcelona, Spain
| | - Josep Dalmau
- Department of Neurology (A.L.O., Y.L., J.D., S.S.S., E.L.), The University of Pennsylvania, Philadelphia; and ICREA-IDIBAPS (J.D.), Hospital Unit, University of Barcelona, Spain
| | - Steven S Scherer
- Department of Neurology (A.L.O., Y.L., J.D., S.S.S., E.L.), The University of Pennsylvania, Philadelphia; and ICREA-IDIBAPS (J.D.), Hospital Unit, University of Barcelona, Spain
| | - Eric Lancaster
- Department of Neurology (A.L.O., Y.L., J.D., S.S.S., E.L.), The University of Pennsylvania, Philadelphia; and ICREA-IDIBAPS (J.D.), Hospital Unit, University of Barcelona, Spain
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Sinmaz N, Amatoury M, Merheb V, Ramanathan S, Dale RC, Brilot F. Autoantibodies in movement and psychiatric disorders: updated concepts in detection methods, pathogenicity, and CNS entry. Ann N Y Acad Sci 2015; 1351:22-38. [DOI: 10.1111/nyas.12764] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Nese Sinmaz
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Mazen Amatoury
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Vera Merheb
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Sudarshini Ramanathan
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Russell C. Dale
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
- Discipline of Paediatrics and Child Health; Sydney Medical School, University of Sydney; Sydney Australia
| | - Fabienne Brilot
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
- Discipline of Paediatrics and Child Health; Sydney Medical School, University of Sydney; Sydney Australia
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Esposito S, Di Pietro GM, Madini B, Mastrolia MV, Rigante D. A spectrum of inflammation and demyelination in acute disseminated encephalomyelitis (ADEM) of children. Autoimmun Rev 2015; 14:923-9. [PMID: 26079482 PMCID: PMC7105213 DOI: 10.1016/j.autrev.2015.06.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 06/09/2015] [Indexed: 11/15/2022]
Abstract
Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disease of the central nervous system that involves multifocal areas of the white matter, rarely the gray matter and spinal cord, mainly affecting children and mostly occurring 1-2weeks after infections or more rarely after vaccinations. Though a specific etiologic agent is not constantly identified, to evaluate carefully patient's clinical history and obtain adequate samples for the search of a potential ADEM causal agent is crucial. In the case of a prompt diagnosis and adequate treatment, most children with ADEM have a favorable outcome with full recovery, but in the case of diagnostic delays or inappropriate treatment some patients might display neurological sequelae and persistent deficits or even show an evolution to multiple sclerosis. The suspicion of ADEM rises on a clinical basis and derives from systemic and neurologic signs combined with magnetic resonance imaging of the central nervous system. Other advanced imaging techniques may help an appropriate differential diagnosis and definition of exact disease extension. Although there is no standardized protocol or management for ADEM, corticosteroids, intravenous immunoglobulin, and plasmapheresis have been successfully used. There is no marker that permits to identify the subset of children with worse prognosis and future studies should try to detect any biological clue for prevision of neurologic damage as well as should optimize treatment strategies using an approach based on the effective risk of negative evolution.
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Affiliation(s)
- Susanna Esposito
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Giada Maria Di Pietro
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Barbara Madini
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Vincenza Mastrolia
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Donato Rigante
- Institute of Pediatrics, Università Cattolica Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
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Lichnerova K, Kaniakova M, Park SP, Skrenkova K, Wang YX, Petralia RS, Suh YH, Horak M. Two N-glycosylation Sites in the GluN1 Subunit Are Essential for Releasing N-methyl-d-aspartate (NMDA) Receptors from the Endoplasmic Reticulum. J Biol Chem 2015; 290:18379-90. [PMID: 26045554 DOI: 10.1074/jbc.m115.656546] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Indexed: 11/06/2022] Open
Abstract
NMDA receptors (NMDARs) comprise a subclass of neurotransmitter receptors whose surface expression is regulated at multiple levels, including processing in the endoplasmic reticulum (ER), intracellular trafficking via the Golgi apparatus, internalization, recycling, and degradation. With respect to early processing, NMDARs are regulated by the availability of GluN subunits within the ER, the presence of ER retention and export signals, and posttranslational modifications, including phosphorylation and palmitoylation. However, the role of N-glycosylation, one of the most common posttranslational modifications, in regulating NMDAR processing has not been studied in detail. Using biochemistry, confocal and electron microscopy, and electrophysiology in conjunction with a lentivirus-based molecular replacement strategy, we found that NMDARs are released from the ER only when two asparagine residues in the GluN1 subunit (Asn-203 and Asn-368) are N-glycosylated. Although the GluN2A and GluN2B subunits are also N-glycosylated, their N-glycosylation sites do not appear to be essential for surface delivery of NMDARs. Furthermore, we found that removing N-glycans from native NMDARs altered the receptor affinity for glutamate. Our results suggest a novel mechanism by which neurons ensure that postsynaptic membranes contain sufficient numbers of functional NMDARs.
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Affiliation(s)
- Katarina Lichnerova
- From the Institute of Physiology, Academy of Sciences of the Czech Republic v.v.i., Videnska 1083, 14220 Prague 4, Czech Republic, the Department of Physiology, Faculty of Science, Charles University in Prague, Albertov 6, 12843 Prague 2, Czech Republic
| | - Martina Kaniakova
- From the Institute of Physiology, Academy of Sciences of the Czech Republic v.v.i., Videnska 1083, 14220 Prague 4, Czech Republic
| | - Seung Pyo Park
- the Department of Biomedical Sciences, Neuroscience Research Institute, Seoul National University College of Medicine, Seoul 110-799, South Korea, and
| | - Kristyna Skrenkova
- From the Institute of Physiology, Academy of Sciences of the Czech Republic v.v.i., Videnska 1083, 14220 Prague 4, Czech Republic
| | - Ya-Xian Wang
- the Advanced Imaging Core, NIDCD/National Institutes of Health, Bethesda, Maryland 20892
| | - Ronald S Petralia
- the Advanced Imaging Core, NIDCD/National Institutes of Health, Bethesda, Maryland 20892
| | - Young Ho Suh
- the Department of Biomedical Sciences, Neuroscience Research Institute, Seoul National University College of Medicine, Seoul 110-799, South Korea, and
| | - Martin Horak
- From the Institute of Physiology, Academy of Sciences of the Czech Republic v.v.i., Videnska 1083, 14220 Prague 4, Czech Republic,
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Abstract
Anti-N-methyl-D-aspartate-receptor (NMDA-R) encephalitis is a new autoimmune, often paraneoplastic disorder that presents with complex neuropsychiatric symptoms. It was first described in 2007 by Dalmau et al. Our patient presented with headache, behavioral changes and then seizures with hallucinations. She was initially misdiagnosed to have schizophrenia and was prescribed antipsychotics. She deteriorated and developed further seizures with hypoventilation and choreoathetosis. Her blood investigations were positive for mycoplasma IGM. Her CSF studies showed high white cell counts, predominantly lymphocytes, and high anti-NMDA-R titre. Her brain MRI scans showed high tbl2 and FLAIR intensities in the grey and white matter of the left cerebellar hemisphere suggestive of acute disseminated encephalomyelitis. She responded to treatment with antibiotics, multiple antiepileptics, steroids and needed five sessions of plasmapheresis. There was no underlying malignancy on repeated scanning of the abdomen. She needed around one year for full recovery with intensive rehabilitation. The objective of this paper was to highlight the occurrence of this fairly new, challenging, easily missed, not-so-rare form of encephalitis often occurring in the absence of fever.
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Affiliation(s)
- Ahood Almuslamani
- Department of Clinical Neurosciences, Salmaniya Medical Complex, Manama, Bahrain
| | - Fatima Mahmood
- Department of Clinical Neurosciences, Salmaniya Medical Complex, Manama, Bahrain
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171
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Joubert B, Honnorat J. Autoimmune channelopathies in paraneoplastic neurological syndromes. BIOCHIMICA ET BIOPHYSICA ACTA-BIOMEMBRANES 2015; 1848:2665-76. [PMID: 25883091 DOI: 10.1016/j.bbamem.2015.04.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 03/10/2015] [Accepted: 04/03/2015] [Indexed: 01/17/2023]
Abstract
Paraneoplastic neurological syndromes and autoimmune encephalitides are immune neurological disorders occurring or not in association with a cancer. They are thought to be due to an autoimmune reaction against neuronal antigens ectopically expressed by the underlying tumour or by cross-reaction with an unknown infectious agent. In some instances, paraneoplastic neurological syndromes and autoimmune encephalitides are related to an antibody-induced dysfunction of ion channels, a situation that can be labelled as autoimmune channelopathies. Such functional alterations of ion channels are caused by the specific fixation of an autoantibody upon its target, implying that autoimmune channelopathies are usually highly responsive to immuno-modulatory treatments. Over the recent years, numerous autoantibodies corresponding to various neurological syndromes have been discovered and their mechanisms of action partially deciphered. Autoantibodies in neurological autoimmune channelopathies may target either directly ion channels or proteins associated to ion channels and induce channel dysfunction by various mechanisms generally leading to the reduction of synaptic expression of the considered channel. The discovery of those mechanisms of action has provided insights on the regulation of the synaptic expression of the altered channels as well as the putative roles of some of their functional subdomains. Interestingly, patients' autoantibodies themselves can be used as specific tools in order to study the functions of ion channels. This article is part of a Special Issue entitled: Membrane channels and transporters in cancers.
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Affiliation(s)
- Bastien Joubert
- University Lyon 1, University Lyon, Rue Guillaume Paradin, 69372 Lyon Cedex 08, France; INSERM, UMR-S1028, CNRS, UMR-5292, Lyon Neuroscience Research Center, Neuro-Oncology and Neuro-Inflammation Team, 7, Rue Guillaume Paradin, Lyon Cedex 08F-69372, France
| | - Jérôme Honnorat
- University Lyon 1, University Lyon, Rue Guillaume Paradin, 69372 Lyon Cedex 08, France; INSERM, UMR-S1028, CNRS, UMR-5292, Lyon Neuroscience Research Center, Neuro-Oncology and Neuro-Inflammation Team, 7, Rue Guillaume Paradin, Lyon Cedex 08F-69372, France; National Reference Centre for Paraneoplastic Neurological Diseases, hospices civils de Lyon, hôpital neurologique, 69677 Bron, France; Hospices Civils de Lyon, Neuro-oncology, Hôpital Neurologique, F-69677 Bron, France.
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172
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Ramberger M, Peschl P, Schanda K, Irschick R, Höftberger R, Deisenhammer F, Rostásy K, Berger T, Dalmau J, Reindl M. Comparison of diagnostic accuracy of microscopy and flow cytometry in evaluating N-methyl-D-aspartate receptor antibodies in serum using a live cell-based assay. PLoS One 2015; 10:e0122037. [PMID: 25815887 PMCID: PMC4376531 DOI: 10.1371/journal.pone.0122037] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 02/06/2015] [Indexed: 01/17/2023] Open
Abstract
N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune neurological disease, diagnosed by a specific autoantibody against NMDAR. Antibody testing using commercially available cell-based assays (CBA) or immunohistochemistry on rat brain tissue has proven high specificity and sensitivity. Here we compare an immunofluorescence live CBA to a flow cytometry (FACS) based assay to detect NMDAR antibodies by their binding to the surface of HEK293A cells functionally expressing NMDAR. Both assays were first established using a discovery group of 76 individuals and then validated in a group of 32 patients in a blinded manner. In the CBA, 23 of 23 patients with NMDAR encephalitis were positive for NMDAR antibodies and 0 of 85 controls (32 healthy controls and 53 patients with other neurological diseases), resulting in a sensitivity and specificity of 100% (95% confidence intervals (CI) 85.1-100.0 and 95.7-100.0, respectively). The FACS based assay detected NMDAR antibodies in 20 of 23 patients and in 0 of 85 controls. Therefore, with an equally high specificity (95% CI 95.7-100.0) the sensitivity of the FACS based assay was 87% (95% CI 66.4-97.2). Comparing antibody titers from CBA with delta median fluorescence intensities from FACS showed a high concordance (kappa = 0.943, p<0.0001) and correlation (r = 0.697, p<0.0001). In conclusion, evaluation of the FACS based assay revealed a lower sensitivity and high inter-assay variation, making the CBA a more reliable detection method.
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Affiliation(s)
- Melanie Ramberger
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Patrick Peschl
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Kathrin Schanda
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Regina Irschick
- Division of Neuroanatomy, Medical University of Innsbruck, Innsbruck, Austria
| | - Romana Höftberger
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
- Institució Catalana de Recerca i Estudis Avançats (ICREA), IDIBAPS, Hospital Clínic, Barcelona, Spain
| | - Florian Deisenhammer
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Kevin Rostásy
- Pediatric Neurology, Witten/Herdecke University, Children’s Hospital Datteln, Datteln, Germany
| | - Thomas Berger
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Josep Dalmau
- Institució Catalana de Recerca i Estudis Avançats (ICREA), IDIBAPS, Hospital Clínic, Barcelona, Spain
| | - Markus Reindl
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- * E-mail:
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173
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Iizuka T, Ishima D, Kaneko J, Nishiyama K. [Clinical spectrum and treatment strategy in anti-NMDA receptor encephalitis: current status and issues]. Rinsho Shinkeigaku 2015; 54:1098-102. [PMID: 25672719 DOI: 10.5692/clinicalneurol.54.1098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Anti-NMDA receptor encephalitis is a disorder caused by IgG antibodies to the extracellular conformal epitope of the NR1 subunits. This disorder predominantly affects young female with ovarian teratoma;however, any person of any age, unrelated to gender or the presence of tumor, can be affected. This disorder usually follows multistage beginning with prodromal symptoms, followed by psychiatric symptoms, unresponsive state accompanied by intractable dyskinesias, seizure and central hypoventilation. Diversity of clinical spectrum has recently been emphasized based on antibody detection in various disorders, including schizophrenia, epilepsy, CJD, neuromyelitis optica, and HSV encephalitis, but these data must be cautiously interpreted; low serum titers may be false positive or clinically not relevant. This disorder has been regarded as treatment-responsive; however, only a half of the patients respond to the first-line immunotherapy (corticosteroids, immunoglobulins or plasma exchange) or tumor removal, and 19 percent remain highly disabled at 24 months with an estimated morality rate of 7%. In refractory cases early initiation of the second-line immunotherapy (rituximab and/or cyclophosphamide) recommended; however, it is difficult to follow the recommendation due to many issues, among those, off-label use is the major reason that prevents initiation of the second-line immunotherapy in Japan.
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Affiliation(s)
- Takahiro Iizuka
- Department of Neurology, Kitasato University School of Medicine
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174
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Peng X, Hughes EG, Moscato EH, Parsons TD, Dalmau J, Balice-Gordon RJ. Cellular plasticity induced by anti-α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor encephalitis antibodies. Ann Neurol 2015; 77:381-98. [PMID: 25369168 PMCID: PMC4365686 DOI: 10.1002/ana.24293] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 09/19/2014] [Accepted: 10/22/2014] [Indexed: 02/06/2023]
Abstract
Objective Autoimmune-mediated anti–α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) encephalitis is a severe but treatment-responsive disorder with prominent short-term memory loss and seizures. The mechanisms by which patient antibodies affect synapses and neurons leading to symptoms are poorly understood. Methods The effects of patient antibodies on cultures of live rat hippocampal neurons were determined with immunostaining, Western blot, and electrophysiological analyses. Results We show that patient antibodies cause a selective decrease in the total surface amount and synaptic localization of GluA1- and GluA2-containing AMPARs, regardless of receptor subunit binding specificity, through increased internalization and degradation of surface AMPAR clusters. In contrast, patient antibodies do not alter the density of excitatory synapses, N-methyl-D-aspartate receptor (NMDAR) clusters, or cell viability. Commercially available AMPAR antibodies directed against extracellular epitopes do not result in a loss of surface and synaptic receptor clusters, suggesting specific effects of patient antibodies. Whole-cell patch clamp recordings of spontaneous miniature postsynaptic currents show that patient antibodies decrease AMPAR-mediated currents, but not NMDAR-mediated currents. Interestingly, several functional properties of neurons are also altered: inhibitory synaptic currents and vesicular γ-aminobutyric acid transporter (vGAT) staining intensity decrease, whereas the intrinsic excitability of neurons and short-interval firing increase. Interpretation These results establish that antibodies from patients with anti-AMPAR encephalitis selectively eliminate surface and synaptic AMPARs, resulting in a homeostatic decrease in inhibitory synaptic transmission and increased intrinsic excitability, which may contribute to the memory deficits and epilepsy that are prominent in patients with this disorder.
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Affiliation(s)
- Xiaoyu Peng
- Department of Neuroscience, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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175
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Lazar-Molnar E, Tebo AE. Autoimmune NMDA receptor encephalitis. Clin Chim Acta 2015; 438:90-7. [DOI: 10.1016/j.cca.2014.08.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 08/06/2014] [Accepted: 08/10/2014] [Indexed: 12/15/2022]
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176
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Tachibana N, Kinoshita M, Kametani F, Tanaka K, Une Y, Komatsu Y, Kobayashi Y, Ikeda SI. Expression of N-Methyl-D-Aspartate Receptor Subunits in the Bovine Ovum: Ova as a Potential Source of Autoantigens Causing Anti-NMDAR Encephalitis. TOHOKU J EXP MED 2015; 235:223-31. [DOI: 10.1620/tjem.235.223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | - Michiaki Kinoshita
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine
| | - Fuyuki Kametani
- Department of Dementia and Higher Brain Function, Tokyo Metropolitan Institute of Medical Science
| | - Keiko Tanaka
- Department of Neurology, Kanazawa Medical University
- Department of Life Science, Medical Research Institute, Kanazawa Medical University
| | - Yumi Une
- Laboratory of Veterinary Pathology, School of Veterinary Medicine, Azabu University
| | | | - Yukihiro Kobayashi
- Department of Laboratory Medicine, Shinshu University School of Medicine
| | - Shu-ichi Ikeda
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine
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177
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Geis C, Ritter C, Ruschil C, Weishaupt A, Grünewald B, Stoll G, Holmoy T, Misu T, Fujihara K, Hemmer B, Stadelmann C, Bennett JL, Sommer C, Toyka KV. The intrinsic pathogenic role of autoantibodies to aquaporin 4 mediating spinal cord disease in a rat passive-transfer model. Exp Neurol 2014; 265:8-21. [PMID: 25542977 DOI: 10.1016/j.expneurol.2014.12.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 12/15/2014] [Accepted: 12/17/2014] [Indexed: 12/16/2022]
Abstract
Neuromyelitis optica (NMO) is causally linked to autoantibodies (ABs) against aquaporin 4 (AQP4). Here, we focused on the pathogenic effects exclusively mediated by human ABs to AQP4 in vivo. We performed cell-free intrathecal (i.th.) passive transfer experiments in Lewis rats using purified patient NMO immunoglobulin G (IgG) and various recombinant human anti-AQP4 IgG-ABs via implanted i.th. catheters. Repetitive application of patient NMO IgG fractions and of recombinant human anti-AQP4 ABs induced signs of spinal cord disease. Magnetic resonance imaging (MRI) revealed longitudinal spinal cord lesions at the site of application of anti-AQP4 IgG. Somatosensory evoked potential amplitudes were reduced in symptomatic animals corroborating the observed functional impairment. Spinal cord histology showed specific IgG deposition in the grey and white matter in the affected areas. We did not find inflammatory cell infiltration nor activation of complement in spinal cord areas of immunoglobulin deposition. Moreover, destructive lesions showing axon or myelin damage and loss of astrocytes and oligodendrocytes were all absent. Immunoreactivity to AQP4 and to the excitatory amino acid transporter 2 (EAAT2) was markedly reduced whereas immunoreactivity to the astrocytic marker glial fibrillary acid protein (GFAP) was preserved. The expression of the NMDA-receptor NR1 subunit was downregulated in areas of IgG deposition possibly induced by sustained glutamatergic overexcitation. Disease signs and histopathology were reversible within weeks after stopping injections. We conclude that in vivo application of ABs directed at AQP 4 can induce a reversible spinal cord disease in recipient rats by inducing distinct histopathological abnormalities. These findings may be the experimental correlate of "penumbra-like" lesions recently reported in NMO patients adjacent to effector-mediated tissue damage.
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Affiliation(s)
- Christian Geis
- Department of Neurology and Clinical Research Group for Multiple Sclerosis and Neuroimmunology, University of Würzburg, 97080 Würzburg, Germany; Hans Berger Department of Neurology, Jena University Hospital, 07747 Jena, Germany; The Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, 07747 Jena, Germany.
| | - Christian Ritter
- Department of Neurology and Clinical Research Group for Multiple Sclerosis and Neuroimmunology, University of Würzburg, 97080 Würzburg, Germany
| | - Christoph Ruschil
- Department of Neurology and Clinical Research Group for Multiple Sclerosis and Neuroimmunology, University of Würzburg, 97080 Würzburg, Germany
| | - Andreas Weishaupt
- Department of Neurology and Clinical Research Group for Multiple Sclerosis and Neuroimmunology, University of Würzburg, 97080 Würzburg, Germany
| | - Benedikt Grünewald
- Department of Neurology and Clinical Research Group for Multiple Sclerosis and Neuroimmunology, University of Würzburg, 97080 Würzburg, Germany; Hans Berger Department of Neurology, Jena University Hospital, 07747 Jena, Germany; The Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, 07747 Jena, Germany
| | - Guido Stoll
- Department of Neurology and Clinical Research Group for Multiple Sclerosis and Neuroimmunology, University of Würzburg, 97080 Würzburg, Germany
| | - Trygve Holmoy
- Department of Neurology, Akershus University Hospital and Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
| | - Tatsuro Misu
- Department of Multiple Sclerosis Therapeutics and Neurology, Tohoku University Graduate School of Medicine, Sendai, 980-8577 Japan
| | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics and Neurology, Tohoku University Graduate School of Medicine, Sendai, 980-8577 Japan
| | - Bernhard Hemmer
- Klinikum rechts der Isar, Technische Universität, 81675 Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), 81675 Munich, Germany
| | - Christine Stadelmann
- Institute of Neuropathology, University Medical Center Göttingen, 37099 Göttingen, Germany
| | - Jeffrey L Bennett
- Departments of Neurology and Ophthalmology, University of Colorado Denver, Aurora, CO 80045, USA
| | - Claudia Sommer
- Department of Neurology and Clinical Research Group for Multiple Sclerosis and Neuroimmunology, University of Würzburg, 97080 Würzburg, Germany
| | - Klaus V Toyka
- Department of Neurology and Clinical Research Group for Multiple Sclerosis and Neuroimmunology, University of Würzburg, 97080 Würzburg, Germany
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178
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Planagumà J, Leypoldt F, Mannara F, Gutiérrez-Cuesta J, Martín-García E, Aguilar E, Titulaer MJ, Petit-Pedrol M, Jain A, Balice-Gordon R, Lakadamyali M, Graus F, Maldonado R, Dalmau J. Human N-methyl D-aspartate receptor antibodies alter memory and behaviour in mice. ACTA ACUST UNITED AC 2014; 138:94-109. [PMID: 25392198 DOI: 10.1093/brain/awu310] [Citation(s) in RCA: 322] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Anti-N-methyl D-aspartate receptor (NMDAR) encephalitis is a severe neuropsychiatric disorder that associates with prominent memory and behavioural deficits. Patients' antibodies react with the N-terminal domain of the GluN1 (previously known as NR1) subunit of NMDAR causing in cultured neurons a selective and reversible internalization of cell-surface receptors. These effects and the frequent response to immunotherapy have suggested an antibody-mediated pathogenesis, but to date there is no animal model showing that patients' antibodies cause memory and behavioural deficits. To develop such a model, C57BL6/J mice underwent placement of ventricular catheters connected to osmotic pumps that delivered a continuous infusion of patients' or control cerebrospinal fluid (flow rate 0.25 µl/h, 14 days). During and after the infusion period standardized tests were applied, including tasks to assess memory (novel object recognition in open field and V-maze paradigms), anhedonic behaviours (sucrose preference test), depressive-like behaviours (tail suspension, forced swimming tests), anxiety (black and white, elevated plus maze tests), aggressiveness (resident-intruder test), and locomotor activity (horizontal and vertical). Animals sacrificed at Days 5, 13, 18, 26 and 46 were examined for brain-bound antibodies and the antibody effects on total and synaptic NMDAR clusters and protein concentration using confocal microscopy and immunoblot analysis. These experiments showed that animals infused with patients' cerebrospinal fluid, but not control cerebrospinal fluid, developed progressive memory deficits, and anhedonic and depressive-like behaviours, without affecting other behavioural or locomotor tasks. Memory deficits gradually worsened until Day 18 (4 days after the infusion stopped) and all symptoms resolved over the next week. Accompanying brain tissue studies showed progressive increase of brain-bound human antibodies, predominantly in the hippocampus (maximal on Days 13-18), that after acid extraction and characterization with GluN1-expressing human embryonic kidney cells were confirmed to be against the NMDAR. Confocal microscopy and immunoblot analysis of the hippocampus showed progressive decrease of the density of total and synaptic NMDAR clusters and total NMDAR protein concentration (maximal on Day 18), without affecting the post-synaptic density protein 95 (PSD95) and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors. These effects occurred in parallel with memory and other behavioural deficits and gradually improved after Day 18, with reversibility of symptoms accompanied by a decrease of brain-bound antibodies and restoration of NMDAR levels. Overall, these findings establish a link between memory and behavioural deficits and antibody-mediated reduction of NMDAR, provide the biological basis by which removal of antibodies and antibody-producing cells improve neurological function, and offer a model for testing experimental therapies in this and similar disorders.
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Affiliation(s)
- Jesús Planagumà
- 1 Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain 2 ICFO-Institut de Ciències Fotòniques, Barcelona, Spain
| | - Frank Leypoldt
- 1 Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain 3 Institute of Clinical Chemistry, Neuroimmunology Unit, University Medical Centre Schleswig-Holstein Campus Lübeck, Germany
| | - Francesco Mannara
- 1 Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain 4 Laboratori de Neurofarmacologia, Facultat de Ciències de la Salut i de la Vida, Universitat Pompeu Fabra, Barcelona, Spain
| | - Javier Gutiérrez-Cuesta
- 4 Laboratori de Neurofarmacologia, Facultat de Ciències de la Salut i de la Vida, Universitat Pompeu Fabra, Barcelona, Spain
| | - Elena Martín-García
- 4 Laboratori de Neurofarmacologia, Facultat de Ciències de la Salut i de la Vida, Universitat Pompeu Fabra, Barcelona, Spain
| | - Esther Aguilar
- 1 Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Maarten J Titulaer
- 5 Department of Neurology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Mar Petit-Pedrol
- 1 Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Ankit Jain
- 6 Department of Neuroscience, University of Pennsylvania, PA, USA
| | | | | | - Francesc Graus
- 1 Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain 7 Servei de Neurologia, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Rafael Maldonado
- 4 Laboratori de Neurofarmacologia, Facultat de Ciències de la Salut i de la Vida, Universitat Pompeu Fabra, Barcelona, Spain
| | - Josep Dalmau
- 1 Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain 8 Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA 9 Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
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179
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Adang LA, Lynch DR, Panzer JA. Pediatric anti-NMDA receptor encephalitis is seasonal. Ann Clin Transl Neurol 2014; 1:921-5. [PMID: 25540806 PMCID: PMC4265063 DOI: 10.1002/acn3.100] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 08/07/2014] [Indexed: 11/09/2022] Open
Abstract
In the majority of pediatric anti-N-methyl-d-aspartate receptor encephalitis (NMDARe) cases, the underlying cause of antibody production and subsequent disease remains unknown. We aimed to characterize this poorly understood population, investigating epidemiological factors potentially related to disease etiology, particularly season of onset. In this retrospective case review study, we analyzed data from the 29 pediatric subjects with anti-NMDAR antibodies and found that symptoms were first reported in the warm months of April–September in 78% of non-tumor-related NMDARe (NT-NMDARe) cases. These findings support further investigation into a possible seasonal trigger of NT-NMDARe.
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Affiliation(s)
- Laura A Adang
- Departments of Pediatrics and Neurology, University of Pennsylvania Philadelphia, Pennsylvania, 19104
| | - David R Lynch
- Departments of Pediatrics and Neurology, University of Pennsylvania Philadelphia, Pennsylvania, 19104 ; Departments of Pediatrics and Child Psychiatry, The Children's Hospital of Philadelphia, University of Pennsylvania Philadelphia, Pennsylvania, 19104 ; Perelman School of Medicine, University of Pennsylvania Philadelphia, Pennsylvania, 19104
| | - Jessica A Panzer
- Departments of Pediatrics and Neurology, University of Pennsylvania Philadelphia, Pennsylvania, 19104
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180
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Doss S, Wandinger KP, Hyman BT, Panzer JA, Synofzik M, Dickerson B, Mollenhauer B, Scherzer CR, Ivinson AJ, Finke C, Schöls L, Müller Vom Hagen J, Trenkwalder C, Jahn H, Höltje M, Biswal BB, Harms L, Ruprecht K, Buchert R, Höglinger GU, Oertel WH, Unger MM, Körtvélyessy P, Bittner D, Priller J, Spruth EJ, Paul F, Meisel A, Lynch DR, Dirnagl U, Endres M, Teegen B, Probst C, Komorowski L, Stöcker W, Dalmau J, Prüss H. High prevalence of NMDA receptor IgA/IgM antibodies in different dementia types. Ann Clin Transl Neurol 2014; 1:822-32. [PMID: 25493273 PMCID: PMC4241809 DOI: 10.1002/acn3.120] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 08/24/2014] [Accepted: 08/25/2014] [Indexed: 11/11/2022] Open
Abstract
Objective To retrospectively determine the frequency of N-Methyl-D-Aspartate (NMDA) receptor (NMDAR) autoantibodies in patients with different forms of dementia. Methods Clinical characterization of 660 patients with dementia, neurodegenerative disease without dementia, other neurological disorders and age-matched healthy controls combined with retrospective analysis of serum or cerebrospinal fluid (CSF) for the presence of NMDAR antibodies. Antibody binding to receptor mutants and the effect of immunotherapy were determined in a subgroup of patients. Results Serum NMDAR antibodies of IgM, IgA, or IgG subtypes were detected in 16.1% of 286 dementia patients (9.5% IgM, 4.9% IgA, and 1.7% IgG) and in 2.8% of 217 cognitively healthy controls (1.9% IgM and 0.9% IgA). Antibodies were rarely found in CSF. The highest prevalence of serum antibodies was detected in patients with “unclassified dementia” followed by progressive supranuclear palsy, corticobasal syndrome, Parkinson’s disease-related dementia, and primary progressive aphasia. Among the unclassified dementia group, 60% of 20 patients had NMDAR antibodies, accompanied by higher frequency of CSF abnormalities, and subacute or fluctuating disease progression. Immunotherapy in selected prospective cases resulted in clinical stabilization, loss of antibodies, and improvement of functional imaging parameters. Epitope mapping showed varied determinants in patients with NMDAR IgA-associated cognitive decline. Interpretation Serum IgA/IgM NMDAR antibodies occur in a significant number of patients with dementia. Whether these antibodies result from or contribute to the neurodegenerative disorder remains unknown, but our findings reveal a subgroup of patients with high antibody levels who can potentially benefit from immunotherapy.
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Affiliation(s)
- Sarah Doss
- Department of Neurology, Charité - Universitätsmedizin Berlin Berlin, Germany ; Cluster of Excellence NeuroCure, Charité - Universitätsmedizin Berlin Berlin, Germany ; Experimental and Clinical Research Center, Charité - Universitätsmedizin Berlin and Max Delbrueck Center for Molecular Medicine Berlin, Germany
| | | | - Bradley T Hyman
- Massachusetts Alzheimer Disease Research Center Boston, Massachusetts
| | - Jessica A Panzer
- Division of Neurology, The Children's Hospital of Philadelphia Philadelphia, Pennsylvania
| | - Matthis Synofzik
- Centre for Neurology and Hertie-Institute for Clinical Brain Research Tübingen, Germany ; German Center for Neurodegenerative Diseases (DZNE) Tübingen Tübingen, Germany
| | | | - Brit Mollenhauer
- Paracelsus Elena Klinik Kassel, Germany ; Departments of Neurosurgery and Neuropathology, University Medical Center Goettingen Goettingen, Germany
| | | | | | - Carsten Finke
- Department of Neurology, Charité - Universitätsmedizin Berlin Berlin, Germany
| | - Ludger Schöls
- Centre for Neurology and Hertie-Institute for Clinical Brain Research Tübingen, Germany ; German Center for Neurodegenerative Diseases (DZNE) Tübingen Tübingen, Germany
| | - Jennifer Müller Vom Hagen
- Centre for Neurology and Hertie-Institute for Clinical Brain Research Tübingen, Germany ; German Center for Neurodegenerative Diseases (DZNE) Tübingen Tübingen, Germany
| | - Claudia Trenkwalder
- Paracelsus Elena Klinik Kassel, Germany ; Departments of Neurosurgery and Neuropathology, University Medical Center Goettingen Goettingen, Germany
| | - Holger Jahn
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Hamburg-Eppendorf Hamburg, Germany
| | - Markus Höltje
- Institute for Integrative Neuroanatomy, Charité - Universitätsmedizin Berlin Berlin, Germany
| | - Bharat B Biswal
- Department of Biomedical Engineering, New Jersey Institute of Technology Newark, New Jersey
| | - Lutz Harms
- Department of Neurology, Charité - Universitätsmedizin Berlin Berlin, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité - Universitätsmedizin Berlin Berlin, Germany
| | - Ralph Buchert
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin Berlin, Germany
| | - Günther U Höglinger
- Department of Neurology, Technische Universität München Munich, Germany ; German Center for Neurodegenerative Diseases (DZNE) Munich Munich, Germany ; Department of Neurology, Philipps-University Marburg, Germany
| | | | - Marcus M Unger
- Department of Neurology, Philipps-University Marburg, Germany ; Department of Neurology, Saarland University Homburg/Saar, Germany
| | - Peter Körtvélyessy
- Department of Neurology, Universitätsklinikum Magdeburg Magdeburg, Germany
| | - Daniel Bittner
- Department of Neurology, Universitätsklinikum Magdeburg Magdeburg, Germany ; German Center for Neurodegenerative Diseases (DZNE) Magdeburg Magdeburg, Germany
| | - Josef Priller
- Department of Neuropsychiatry, Charité - Universitätsmedizin Berlin Berlin, Germany ; Cluster of Excellence NeuroCure, Charité - Universitätsmedizin Berlin Berlin, Germany ; German Center for Neurodegenerative Diseases (DZNE) Berlin Berlin, Germany
| | - Eike J Spruth
- Department of Neuropsychiatry, Charité - Universitätsmedizin Berlin Berlin, Germany
| | - Friedemann Paul
- Department of Neurology, Charité - Universitätsmedizin Berlin Berlin, Germany ; Cluster of Excellence NeuroCure, Charité - Universitätsmedizin Berlin Berlin, Germany ; Experimental and Clinical Research Center, Charité - Universitätsmedizin Berlin and Max Delbrueck Center for Molecular Medicine Berlin, Germany
| | - Andreas Meisel
- Department of Neurology, Charité - Universitätsmedizin Berlin Berlin, Germany ; Cluster of Excellence NeuroCure, Charité - Universitätsmedizin Berlin Berlin, Germany
| | - David R Lynch
- Division of Neurology, The Children's Hospital of Philadelphia Philadelphia, Pennsylvania
| | - Ulrich Dirnagl
- Department of Neurology, Charité - Universitätsmedizin Berlin Berlin, Germany ; German Center for Neurodegenerative Diseases (DZNE) Berlin Berlin, Germany ; Center of Stroke Research Berlin, Germany
| | - Matthias Endres
- Department of Neurology, Charité - Universitätsmedizin Berlin Berlin, Germany ; Cluster of Excellence NeuroCure, Charité - Universitätsmedizin Berlin Berlin, Germany ; German Center for Neurodegenerative Diseases (DZNE) Berlin Berlin, Germany ; Center of Stroke Research Berlin, Germany
| | - Bianca Teegen
- Institute for Experimental Immunology, Affiliated to Euroimmun AG Lübeck, Germany
| | - Christian Probst
- Institute for Experimental Immunology, Affiliated to Euroimmun AG Lübeck, Germany
| | - Lars Komorowski
- Institute for Experimental Immunology, Affiliated to Euroimmun AG Lübeck, Germany
| | - Winfried Stöcker
- Institute for Experimental Immunology, Affiliated to Euroimmun AG Lübeck, Germany
| | - Josep Dalmau
- Service of Neurology, Hospital Clinic, University of Barcelona Barcelona, Spain
| | - Harald Prüss
- Department of Neurology, Charité - Universitätsmedizin Berlin Berlin, Germany ; German Center for Neurodegenerative Diseases (DZNE) Berlin Berlin, Germany
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181
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Abstract
Over the past 10 years, the continual discovery of novel forms of encephalitis associated with antibodies to cell-surface or synaptic proteins has changed the paradigms for diagnosing and treating disorders that were previously unknown or mischaracterized. We review here the process of discovery, the symptoms, and the target antigens of 11 autoimmune encephalitic disorders, grouped by syndromes and approached from a clinical perspective. Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis, several subtypes of limbic encephalitis, stiff-person spectrum disorders, and other autoimmune encephalitides that result in psychosis, seizures, or abnormal movements are described in detail. We include a novel encephalopathy with prominent sleep dysfunction that provides an intriguing link between chronic neurodegeneration and cell-surface autoimmunity (IgLON5). Some of the caveats of limited serum testing are outlined. In addition, we review the underlying cellular and synaptic mechanisms that for some disorders confirm the antibody pathogenicity. The multidisciplinary impact of autoimmune encephalitis has been expanded recently by the discovery that herpes simplex encephalitis is a robust trigger of synaptic autoimmunity, and that some patients may develop overlapping syndromes, including anti-NMDAR encephalitis and neuromyelitis optica or other demyelinating diseases.
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Affiliation(s)
- Frank Leypoldt
- Service of Neurology, Hospital Clinic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona, Barcelona, Spain; Institute of Clinical Chemistry, Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
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182
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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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183
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Meta-analysis of the association between N-methyl-d-aspartate receptor antibodies and schizophrenia, schizoaffective disorder, bipolar disorder, and major depressive disorder. Schizophr Res 2014; 157:249-58. [PMID: 24882425 DOI: 10.1016/j.schres.2014.05.001] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 04/30/2014] [Accepted: 05/01/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND N-methyl-d-aspartate receptor (NMDAR) antibodies have been documented in the serum of individuals with primary psychiatric disorders from several independent cohorts, but these findings have not been systematically assessed in aggregate or in relation to methodological covariates. METHODS We searched MEDLINE, EMBASE, and PsycINFO for studies in any language that provided data on NMDAR antibody seropositivity or absolute serum titers in schizophrenia or schizoaffective, bipolar, or major depressive disorders. We used a random effects model to pool estimates across studies. RESULTS Nine studies met the eligibility criteria. Five studies (3387 participants) provided data on NMDAR antibody seropositivity in psychiatric versus control groups based on high-specificity seropositivity thresholds (cell-based assays [CBAs]: 1:320 dilution, 1:200 dilution, visual score>1; enzyme-linked immunosorbent assay [ELISA]: 90(th) percentile of control titers). Meta-analysis showed significantly higher odds of NMDAR antibody seropositivity among those with schizophrenia or schizoaffective, bipolar, or major depressive disorders compared with healthy controls (odds ratio [OR], 3.10; 95% confidence interval [CI], 1.04-9.27; P=.043; I(2)=68%). Four studies (3194 participants) provided outcome data for these groups based on low-specificity seropositivity thresholds (CBAs 1:10 dilution; ELISA: 75(th) percentile of control titers). Meta-analysis showed greater heterogeneity and no significant between-group difference (OR, 2.31; 95% CI, 0.55-9.73; P=.25; I(2)=90%). Seropositive participants in psychiatric groups had various combinations of IgG, IgM, and IgA class antibodies against NR1, NR1/NR2B, and NR2A/NR2B subunits. Subgroup analysis revealed significantly higher odds of seropositivity among all participants based on 1:10 versus 1:320 dilution seropositivity thresholds (OR, 4.56; 95% CI, 2.41-8.62; P<.001; I(2)=0%; studies=2, n=2920), but no apparent difference between first-episode and chronic schizophrenia or schizoaffective disorder (OR, 1.15; 95% CI, 0.19-7.24; P=.88, I(2)=43%, studies=2, n=1108). Average NR2A/NR2B antibody titers determined by ELISA were significantly higher among participants with first-episode schizophrenia (P<.0001) and acute mania (P<.01) compared with healthy controls. Levels decreased by 58% at 8weeks in first-episode schizophrenia, and by about 13% at 4days in acute mania. CONCLUSIONS Individuals with schizophrenia or schizoaffective, bipolar, or major depressive disorders are collectively about three times more likely to have elevated NMDAR antibody titers compared with healthy controls based on high-specificity, but not low-specificity, seropositivity thresholds, though considerable methodological and statistical heterogeneity exists. Evidence concerning the effect of disease state and time of serum acquisition is varied and consistent, respectively. Adequately powered longitudinal studies employing standardized assay methods and seropositivity threshold definitions, and quantifying NMDAR antibodies in both sera and cerebrospinal fluid are needed to further elucidate the clinical and pathophysiological implications of this association.
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184
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Moscato EH, Peng X, Jain A, Parsons TD, Dalmau J, Balice-Gordon RJ. Acute mechanisms underlying antibody effects in anti-N-methyl-D-aspartate receptor encephalitis. Ann Neurol 2014; 76:108-19. [PMID: 24916964 PMCID: PMC4296347 DOI: 10.1002/ana.24195] [Citation(s) in RCA: 231] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 06/04/2014] [Accepted: 06/04/2014] [Indexed: 12/27/2022]
Abstract
Objective A severe but treatable form of immune-mediated encephalitis is associated with antibodies in serum and cerebrospinal fluid (CSF) against the GluN1 subunit of the N-methyl-D-aspartate receptor (NMDAR). Prolonged exposure of hippocampal neurons to antibodies from patients with anti-NMDAR encephalitis caused a reversible decrease in the synaptic localization and function of NMDARs. However, acute effects of the antibodies, fate of the internalized receptors, type of neurons affected, and whether neurons develop compensatory homeostatic mechanisms were unknown and are the focus of this study. Methods Dissociated hippocampal neuron cultures and rodent brain sections were used for immunocytochemical, physiological, and molecular studies. Results Patient antibodies bind to NMDARs throughout the rodent brain, and decrease NMDAR cluster density in both excitatory and inhibitory hippocampal neurons. They rapidly increase the internalization rate of surface NMDAR clusters, independent of receptor activity. This internalization likely accounts for the observed decrease in NMDAR-mediated currents, as no evidence of direct blockade was detected. Once internalized, antibody-bound NMDARs traffic through both recycling endosomes and lysosomes, similar to pharmacologically induced NMDAR endocytosis. The antibodies are responsible for receptor internalization, as their depletion from CSF abrogates these effects in hippocampal neurons. We find that although anti-NMDAR antibodies do not induce compensatory changes in glutamate receptor gene expression, they cause a decrease in inhibitory synapse density onto excitatory hippocampal neurons. Interpretation Our data support an antibody-mediated mechanism of disease pathogenesis driven by immunoglobulin-induced receptor internalization. Antibody-mediated downregulation of surface NMDARs engages homeostatic synaptic plasticity mechanisms, which may inadvertently contribute to disease progression. Ann Neurol 2014;76:108–119
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Affiliation(s)
- Emilia H Moscato
- Department of Neuroscience, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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185
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Anti–NMDA Receptor Encephalitis Associated With Transient Cerebral Dyschromatopsia, Prosopagnosia, and Lack of Stereopsis. J Neuroophthalmol 2014; 34:144-8. [DOI: 10.1097/wno.0000000000000117] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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186
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Tachibana N, Kinoshita M, Saito Y, Ikeda SI. Identification of the N-Methyl-D-aspartate receptor (NMDAR)-related epitope, NR2B, in the normal human ovary: implication for the pathogenesis of anti-NMDAR encephalitis. TOHOKU J EXP MED 2014; 230:13-6. [PMID: 23648631 DOI: 10.1620/tjem.230.13] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
N-methyl-D-aspartate receptors (NMDARs) are one type of ionotropic glutamate receptors (GluRs) and are heterotetrametric cation channels composed of NMDAR1 (NR1), NMDAR2 (NR2A, 2B, 2C or 2D) and NMDAR3 (NR3A or NR3B) subunits. The main subunits are NR1 and NR2 and their combinations are classified into several diverse forms including NR1/NR1/NR2A/NR2A, NR1/NR1/NR2B/NR2B and NR1/NR1/NR2A/NR2B. NMDARs are physiologically related to synapse development and synaptic plasticity in the central nervous system. Anti-NMDAR encephalitis is a form of autoimmune limbic encephalitis mainly affecting young women, with various manifestations including initial psychiatric symptoms, subsequent unresponsiveness, intractable generalized seizure, dysautonomia and orofacial dyskinesia. This disorder is often accompanied by ovarian teratoma that is originated from oocytes. Anti-neural antibody for the NR1/NR2 heteromer of NMDAR has been identified as a disease-specific hallmark. It has been emphasized that neural components in ovarian teratoma act as a trigger to produce anti-NMDAR antibodies, although about half of the patients with anti-NMDAR encephalitis are not associated with ovarian teratoma. To identify NMDAR-related epitopes located outside of the brain, we performed immunohistochemical examinations of normal human ovary and testis using specific antibodies against NR1, NR2A and NR2B, respectively, and found expression of the NR2B epitope in the cytoplasm of oocytes. In contrast, the testis showed no immunohistochemical reactivity. Therefore, oocytes contain NMDAR-related epitopes including NR2B. The NMDAR-related epitopes in normal oocytes may cause an antigen-antibody reaction in certain pathological conditions. The presence of NR2B immunoreactivity in oocytes may account for the fact that anti-NMDAR encephalitis predominantly affects young females.
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Affiliation(s)
- Naoko Tachibana
- Department of Neurology, Okaya City Hospital, Okaya, Nagano, Japan
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187
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Dupuis JP, Ladépêche L, Seth H, Bard L, Varela J, Mikasova L, Bouchet D, Rogemond V, Honnorat J, Hanse E, Groc L. Surface dynamics of GluN2B-NMDA receptors controls plasticity of maturing glutamate synapses. EMBO J 2014; 33:842-61. [PMID: 24591565 DOI: 10.1002/embj.201386356] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
NMDA-type glutamate receptors (NMDAR) are central actors in the plasticity of excitatory synapses. During adaptive processes, the number and composition of synaptic NMDAR can be rapidly modified, as in neonatal hippocampal synapses where a switch from predominant GluN2B- to GluN2A-containing receptors is observed after the induction of long-term potentiation (LTP). However, the cellular pathways by which surface NMDAR subtypes are dynamically regulated during activity-dependent synaptic adaptations remain poorly understood. Using a combination of high-resolution single nanoparticle imaging and electrophysiology, we show here that GluN2B-NMDAR are dynamically redistributed away from glutamate synapses through increased lateral diffusion during LTP in immature neurons. Strikingly, preventing this activity-dependent GluN2B-NMDAR surface redistribution through cross-linking, either with commercial or with autoimmune anti-NMDA antibodies from patient with neuropsychiatric symptoms, affects the dynamics and spine accumulation of CaMKII and impairs LTP. Interestingly, the same impairments are observed when expressing a mutant of GluN2B-NMDAR unable to bind CaMKII. We thus uncover a non-canonical mechanism by which GluN2B-NMDAR surface dynamics plays a critical role in the plasticity of maturing synapses through a direct interplay with CaMKII.
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Affiliation(s)
- Julien P Dupuis
- Interdisciplinary Institute for Neuroscience University de Bordeaux UMR 5297, Bordeaux, France
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188
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van Coevorden-Hameete MH, de Graaff E, Titulaer MJ, Hoogenraad CC, Sillevis Smitt PAE. Molecular and cellular mechanisms underlying anti-neuronal antibody mediated disorders of the central nervous system. Autoimmun Rev 2014; 13:299-312. [PMID: 24225076 DOI: 10.1016/j.autrev.2013.10.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 10/30/2013] [Indexed: 12/31/2022]
Abstract
Over the last decade multiple autoantigens located on the plasma membrane of neurons have been identified. Neuronal surface antigens include molecules directly involved in neurotransmission and excitability. Binding of the antibody to the antigen may directly alter the target protein's function, resulting in neurological disorders. The often striking reversibility of symptoms following early aggressive immunotherapy supports a pathogenic role for autoantibodies to neuronal surface antigens. In order to better understand and treat these neurologic disorders it is important to gain insight in the underlying mechanisms of antibody pathogenicity. In this review we discuss the clinical, circumstantial, in vitro and in vivo evidence for neuronal surface antibody pathogenicity and the possible underlying cellular and molecular mechanisms. This review shows that antibodies to neuronal surface antigens are often directed at conformational epitopes located in the extracellular domain of the antigen. The conformation of the epitope can be affected by specific posttranslational modifications. This may explain the distinct clinical phenotypes that are seen in patients with antibodies to antigens that are expressed throughout the brain. Furthermore, it is likely that there is a heterogeneous antibody population, consisting of different IgG subtypes and directed at multiple epitopes located in an immunogenic region. Binding of these antibodies may result in different pathophysiological mechanisms occurring in the same patient, together contributing to the clinical syndrome. Unraveling the predominant mechanism in each distinct antigen could provide clues for therapeutic interventions.
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Affiliation(s)
- M H van Coevorden-Hameete
- Department of Biology, Division of Cell Biology, Utrecht University, Padualaan 8, 3584 CH, Utrecht, The Netherlands.
| | - E de Graaff
- Department of Biology, Division of Cell Biology, Utrecht University, Padualaan 8, 3584 CH, Utrecht, The Netherlands.
| | - M J Titulaer
- Department of Neurology, Erasmus MC, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands.
| | - C C Hoogenraad
- Department of Biology, Division of Cell Biology, Utrecht University, Padualaan 8, 3584 CH, Utrecht, The Netherlands.
| | - P A E Sillevis Smitt
- Department of Neurology, Erasmus MC, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands.
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189
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Armangue T, Leypoldt F, Málaga I, Raspall-Chaure M, Marti I, Nichter C, Pugh J, Vicente-Rasoamalala M, Lafuente-Hidalgo M, Macaya A, Ke M, Titulaer MJ, Höftberger R, Sheriff H, Glaser C, Dalmau J. Herpes simplex virus encephalitis is a trigger of brain autoimmunity. Ann Neurol 2014; 75:317-23. [PMID: 24318406 DOI: 10.1002/ana.24083] [Citation(s) in RCA: 292] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 11/26/2013] [Accepted: 11/29/2013] [Indexed: 12/15/2022]
Abstract
In 5 prospectively diagnosed patients with relapsing post-herpes simplex encephalitis (HSE), N-methyl-D-aspartate receptor (NMDAR) antibodies were identified. Antibody synthesis started 1 to 4 weeks after HSE, preceding the neurological relapse. Three of 5 patients improved postimmunotherapy, 1 spontaneously, and 1 has started to improve. Two additional patients with NMDAR antibodies, 9 with unknown neuronal surface antibodies, and 1 with NMDAR and unknown antibodies, were identified during retrospective assessment of 34 HSE patients; the frequency of autoantibodies increased over time (serum, p=0.004; cerebrospinal fluid, p=0.04). The 3 retrospectively identified NMDAR antibody-positive patients also had evidence of relapsing post-HSE. Overall, these findings indicate that HSE triggers NMDAR antibodies and potentially other brain autoimmunity.
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Affiliation(s)
- Thaís Armangue
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Neurology Service, Hospital Clinic, University of Barcelona, Barcelona, Spain; Department of Pediatric Neurology, Materno-Infantil Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
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190
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Gleichman AJ, Panzer JA, Baumann BH, Dalmau J, Lynch DR. Antigenic and mechanistic characterization of anti-AMPA receptor encephalitis. Ann Clin Transl Neurol 2014; 1:180-189. [PMID: 24707504 PMCID: PMC3972064 DOI: 10.1002/acn3.43] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective Anti-AMPAR encephalitis is a recently discovered disorder characterized by the presence of antibodies in serum or cerebrospinal fluid against the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor. Here, we examine the antigenic specificity of anti-AMPAR antibodies, screen for new patients, and evaluate functional effects of antibody treatment of neurons. Methods We developed a fusion protein (FP)-based western blotting test for anti-AMPAR encephalitis antibodies. Antibody specificity was also evaluated using immunocytochemistry of HEK293 cells expressing deletion mutants of AMPAR subunits. Purified patient immunoglobulin G (IgG) or AMPAR antibody-depleted IgG was applied to live neuronal cultures; amplitude and frequency of miniature excitatory postsynaptic currents (mEPSCs) were measured to evaluate functional effects of antibodies. Results Using both immunocytochemistry and FP western blots, we defined an antigenic region of the receptor in the bottom lobe of the amino terminal domain. Additionally, we used FPs to screen 70 individuals with neurologic symptoms of unknown cause and 44 patients with no neurologic symptoms or symptoms of known neuroimmunological origin for anti-AMPAR antibodies. Fifteen of the 70 individuals had anti-AMPAR antibodies, with broader antigenic reactivity patterns. Using purified IgG from an individual of the original cohort of anti-AMPAR encephalitis patients and a newly discovered patient, we found that application of IgG from either patient cohort caused an AMPAR antibody-dependent decrease in the amplitude and frequency of mEPSCs in cultured neurons. Interpretation These results indicate that anti-AMPAR antibodies are widespread and functionally relevant; given the robust response of patients to immunomodulation, this represents a significant treatable patient population.
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Affiliation(s)
- Amy J Gleichman
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA ; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jessica A Panzer
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA ; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Bailey H Baumann
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA ; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Josep Dalmau
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA ; Institució Catalana de Recerca i Estudis Avançats (ICREA) at Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Service of Neurology, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - David R Lynch
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA ; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
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191
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Deakin J, Lennox BR, Zandi MS. Antibodies to the N-methyl-D-aspartate receptor and other synaptic proteins in psychosis. Biol Psychiatry 2014; 75:284-91. [PMID: 23988024 DOI: 10.1016/j.biopsych.2013.07.018] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 07/01/2013] [Accepted: 07/17/2013] [Indexed: 02/06/2023]
Abstract
This review concentrates on the evidence for autoantibodies to cell surface synaptic proteins in psychosis and schizophrenia. We and others have recently found antibodies to the N-methyl-D-aspartate receptor in first-episode psychosis. We describe the evidence for pathogenicity and disease-relevance of these antibodies, which builds on the novel field in neuroimmunology of cell surface antibody-associated central nervous system disorders. Relevant autoantibodies in psychosis and schizophrenia are likely to be those directed to cell surface proteins, in which the likelihood of pathogenicity is greater. We discuss the evidence for this from the field of paraneoplastic neurologic syndromes and the discovery of novel cell surface antigen central nervous system autoimmune syndromes.
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Affiliation(s)
- Julia Deakin
- Department of Psychiatry, University of Cambridge, Cambridge
| | | | - Michael S Zandi
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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192
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Glutamatergic autoencephalitides: an emerging field. J Neural Transm (Vienna) 2014; 121:957-68. [PMID: 24402576 DOI: 10.1007/s00702-013-1152-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 12/20/2013] [Indexed: 12/19/2022]
Abstract
Autoimmune responses targeting synaptic proteins are associated with a wide range of neurologic symptoms. Among these disorders are those associated with antibodies to ionotropic glutamate receptors, including the NMDAR (N-methyl-D-aspartate receptor) and AMPAR (α-amino-3-hydrozy-5-methyl-4-isoxazolepropionic acid receptor). Patients with anti-NMDAR encephalitis present with psychiatric symptoms, seizures, movement disorders, impaired consciousness, and autonomic derangements; half of patients have an associated ovarian teratoma, and most patients respond to immunosuppressive therapies. Patients' antibodies bind to the amino terminal domain of the NMDAR, and result in loss of NMDARs from synapses with subsequent NMDAR hypofunction. Anti-NMDAR antibodies have now been reported in other neuropsychiatric conditions, including psychosis, dementia, and HSV encephalitis. The pathophysiologic relevance of anti-NMDAR antibodies in these disorders is not yet clear, but their presence may indicate a role for immunotherapy in some patients. Although considerable work remains to be done, our understanding of disorders associated with anti-glutamate receptor antibodies has grown exponentially since they were first described just over 7 years ago, revolutionizing neurology. These antibodies, by interfering with synaptic function, readily link basic science and clinical medicine, and have revealed the impact of sudden but sustained loss of specific neurotransmitter receptors in humans. Improved understanding of their pathophysiology will lead to better treatments for these diseases while providing novel insights regarding the roles of glutamate receptors in learning, memory, and neuropsychiatric disease.
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Antibody titres at diagnosis and during follow-up of anti-NMDA receptor encephalitis: a retrospective study. Lancet Neurol 2013; 13:167-77. [PMID: 24360484 DOI: 10.1016/s1474-4422(13)70282-5] [Citation(s) in RCA: 618] [Impact Index Per Article: 56.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Anti-N-methyl-d-aspartate (NMDA) receptor encephalitis is a severe but treatable autoimmune disorder which diagnosis depends on sensitive and specific antibody testing. We aimed to assess the sensitivity and specificity of serum and CSF antibody testing in patients with anti-NMDA receptor encephalitis, and the relation between titres, relapses, outcome, and epitope repertoire. METHODS In this observational study, we used rat brain immunohistochemistry and cell-based assays (CBA) with fixed or live NMDA receptor-expressing cells to determine the sensitivity and specificity of antibody testing in paired serum and CSF samples. Samples were obtained at diagnosis from patients with anti-NMDA receptor encephalitis and from control participants worldwide. We deemed a patient to be antibody positive if their serum, their CSF, or both tested positive with both immunohistochemistry and CBA techniques; we determined titres with serial sample dilution using brain immunohistochemistry. We examined samples from 45 patients (25 with good outcome [modified Rankin Scale, mRS 0-2], ten with poor outcome [mRS 3-6], and ten with relapses) at three or more timepoints. We determined the epitope repertoire in the samples of 23 patients with CBA expressing GluN1-NMDA receptor mutants. FINDINGS We analysed samples from 250 patients with anti-NMDA receptor encephalitis and 100 control participants. All 250 patients had NMDA receptor antibodies in CSF but only 214 had antibodies in serum (sensitivity 100.0% [98.5-1000%] vs 85.6% [80.7-89.4%], p<0.0001). Serum immunohistochemistry testing was more often in agreement with CBA with fixed cells (77 [71%] of 108) than with CBA with live cells (63 [58%] of 108, p=0.0056). In multivariable analysis, CSF and serum titres were higher in patients with poor outcome than in those with good outcome (CSF dilution 340 vs 129, difference 211, [95% CI 1-421], p=0.049; serum dilution 7370 vs 1243, difference 6127 [2369-9885], p=0.0025), and in patients with teratoma than in those without teratoma (CSF 395 vs 110, difference 285 [134-437], p=0.0079; serum 5515 vs 1644, difference 3870 [548-7193], p=0.024). Over time there was a decrease of antibody titres in the 35 patients with good or poor outcome and samples followed at three timepoints regardless of outcome (from diagnosis to last follow-up: CSF 614 to 76, difference 538 [288-788]; serum 5460 to 1564, difference 3896 [2428-5362]; both p<0.0001). Relapses were associated with a change in titre more often in CSF than in serum (14 of 19 vs seven of 16, p=0.037). After recovery, 24 of 28 CSF samples and 17 of 23 serum samples from patients remained antibody positive. Patients' antibodies targeted a main epitope region at GluN1 aminoacid 369; the epitope repertoire did not differ between patients with different outcomes, and did not change during relapses. INTERPRETATION The sensitivity of NMDA receptor antibody testing is higher in CSF than in serum. Antibody titres in CSF and serum were higher in patients with poor outcome or teratoma than in patients with good outcome or no tumour. The titre change in CSF was more closely related with relapses than was that in serum. These findings emphasise the importance of including CSF in antibody studies, and that antibody titres can complement clinical assessments. FUNDING Dutch Cancer Society, National Institutes of Health, McKnight Neuroscience of Brain Disorders award, the Fondo de Investigaciones Sanitarias, ErasmusMC fellowship, and Fundació la Marató de TV3.
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194
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Autoimmune encephalitis: recent updates and emerging challenges. J Clin Neurosci 2013; 21:722-30. [PMID: 24246947 DOI: 10.1016/j.jocn.2013.07.017] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 07/03/2013] [Accepted: 07/04/2013] [Indexed: 12/12/2022]
Abstract
The knowledge of immune dysregulation and autoimmunity in neurological disorders has expanded considerably in recent times. Recognition of clinical syndromes, reliable methods of diagnosis, and early targeted immunotherapy can lead to a favourable outcome in acute and subacute neurological disorders that may be associated with significant morbidity and mortality if left untreated. This review focuses on the rapidly expanding field of autoimmune encephalitis. We describe the differences between limbic encephalitis associated with antibodies targeting intracellular antigens, and neuronal surface antibody syndromes (NSAS) where the antigens are primarily receptors or synaptic proteins located on the neuronal cell surface. We chronologically highlight important developments in NSAS by focusing on voltage gated potassium channel complex-associated antibody mediated encephalitis, anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis, and anti-dopamine 2 receptor antibody-associated basal ganglia encephalitis. Contentious issues such as the complexities of using serum antibodies as biomarkers, the initiation of central nervous system autoimmunity, and possible pathogenic mechanisms of these antibodies will be reviewed. The therapeutic challenges that clinicians face such as the timing of therapy and the role of second-line therapy will be discussed, with crucial concepts highlighted in the form of clinical vignettes. Future directions will involve the identification of novel antigens and methods to establish their pathogenicity, as well as evaluation of the most efficacious therapeutic strategies in patients with established NSAS.
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Pathmanandavel K, Starling J, Dale RC, Brilot F. Autoantibodies and the immune hypothesis in psychotic brain diseases: challenges and perspectives. Clin Dev Immunol 2013; 2013:257184. [PMID: 24062775 PMCID: PMC3766578 DOI: 10.1155/2013/257184] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 07/23/2013] [Accepted: 07/24/2013] [Indexed: 12/13/2022]
Abstract
The pathophysiology of psychosis is poorly understood, with both the cognitive and cellular changes of the disease process remaining mysterious. There is a growing body of evidence that points to dysfunction of the immune system in a subgroup of patients with psychosis. Recently, autoantibodies directed against neuronal cell surface targets have been identified in a range of syndromes that feature psychosis. Of interest is the detection of autoantibodies in patients whose presentations are purely psychiatric, such as those suffering from schizophrenia. Autoantibodies have been identified in a minority of patients, suggesting that antibody-associated mechanisms of psychiatric disease likely only account for a subgroup of cases. Recent work has been based on the application of cell-based assays-a paradigm whose strength lies in the expression of putative antigens in their natural conformation on the surface of live cells. The responsiveness of some of these newly described clinical syndromes to immune therapy supports the hypothesis that antibody-associated mechanisms play a role in the pathogenesis of psychotic disease. However, further investigation is required to establish the scope and significance of antibody pathology in psychosis. The identification of a subgroup of patients with antibody-mediated disease would promise more effective approaches to the treatment of these high-morbidity conditions.
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Affiliation(s)
- Karrnan Pathmanandavel
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, The Kids Research Institute at the Children's Hospital at Westmead, University of Sydney, Locked Bag 4001, Westmead, NSW 2145, Australia
- Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Westmead, NSW 2145, Australia
| | - Jean Starling
- The Walker Unit, Concord Centre for Mental Health, Concord West, NSW 2138, Australia
- Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia
| | - Russell C. Dale
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, The Kids Research Institute at the Children's Hospital at Westmead, University of Sydney, Locked Bag 4001, Westmead, NSW 2145, Australia
- Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Westmead, NSW 2145, Australia
| | - Fabienne Brilot
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, The Kids Research Institute at the Children's Hospital at Westmead, University of Sydney, Locked Bag 4001, Westmead, NSW 2145, Australia
- Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Westmead, NSW 2145, Australia
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Kalev-Zylinska ML, Symes W, Little KCE, Sun P, Wen D, Qiao L, Young D, During MJ, Barber PA. Stroke patients develop antibodies that react with components of N-methyl-D-aspartate receptor subunit 1 in proportion to lesion size. Stroke 2013; 44:2212-9. [PMID: 23723305 DOI: 10.1161/strokeaha.113.001235] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Antibodies against neuronal antigens develop in patients after stroke and some may serve as biomarkers of neuronal injury. We aimed to determine whether antibodies against subunit 1 (GluN1) of the N-methyl-D-aspartate receptor also develop after stroke and if so, whether they correlate with stroke characteristics. METHODS Forty-eight patients with ischemic stroke and 96 healthy controls were tested for the presence of serum antibodies targeting GluN1. Testing was conducted using 20-kDa recombinant GluN1-S2 peptide (by ELISA and Western blotting) and on rat brain tissue (by Western blotting and immunohistochemistry). Clinical examinations and computed tomographic brain scans were performed to assess clinical state and infarct size and location. RESULTS Of the 48 patients with ischemic stroke, 21 (44%) had antibodies that reacted with the recombinant GluN1-S2. There was no evidence of antibody binding to intact GluN1 in brain tissue. Western blot appearances suggested reactivity with GluN1 degradation products. Patients with anti-GluN1-S2 antibodies were more likely to have higher National Institutes of Health Stroke Scale scores, larger infarcts, and more frequent cortical involvement. Of the 96 controls, only 3 (3%), all aged>50 years, had antibodies that reacted with GluN1-S2 at low levels. CONCLUSIONS Antibodies that bind recombinant GluN1-S2 peptides (but not the intact GluN1 protein) develop transiently in patients after stroke in proportion to infarct size, suggesting that these antibodies are raised secondarily to neuronal damage. The anti-GluN1-S2 antibodies may provide useful information about the presence and severity of cerebral infarction. This will require confirmation in larger studies.
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Affiliation(s)
- Maggie L Kalev-Zylinska
- Department of Molecular Medicine and Pathology, The University of Auckland, Auckland, New Zealand.
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197
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Amrutkar SD, Trier NH, Hansen PR, Houen G. Fine mapping of a monoclonal antibody to the N-Methyl D-aspartate receptor reveals a short linear epitope. Biopolymers 2013. [PMID: 23203762 DOI: 10.1002/bip.22165] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Anti-N-Methyl D-aspartate receptor encephalitis is an autoimmune disease in which autoantibodies are produced against extracellular regions of the N-Methyl D-aspartate receptor (NMDAR). In this study, we used resin-bound peptides equipped with a base labile linker to map the epitope of a monoclonal NMDAR antibody against the NMDAR NR1 subunit. The antigenicity of the synthesized resin-bound peptides was determined by enzyme-linked immunosorbent assay. Distinct reactivity was found to two extracellular overlapping peptides (amino acids, 658-687). Using N- and C-terminally truncated resin-bound peptides, the minimum functional epitope was identified as the NPSDK sequence. The peptide sequence RNPSDK (amino acids, 673-678) was identified as the complete epitope, which was found to be located in the extracellular S2 domain of the NR1 subunit. Especially, the N-terminal arginine residue was found to be essential for reactivity, whereas the remaining amino acids could be replaced with amino acids of similar side-chain functionality, indicating the importance of backbone interaction in antibody reactivity.
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Affiliation(s)
- Surekha Dipak Amrutkar
- Department of Clinical Biochemistry, Immunology and Genetics, Statens Serum Institut, Copenhagen S 2300, Denmark
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198
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Armangue T, Titulaer MJ, Málaga I, Bataller L, Gabilondo I, Graus F, Dalmau J. Pediatric anti-N-methyl-D-aspartate receptor encephalitis-clinical analysis and novel findings in a series of 20 patients. J Pediatr 2013; 162:850-856.e2. [PMID: 23164315 PMCID: PMC3582718 DOI: 10.1016/j.jpeds.2012.10.011] [Citation(s) in RCA: 289] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 09/11/2012] [Accepted: 10/04/2012] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To report the clinical features of 20 pediatric patients with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. STUDY DESIGN Review of clinical data, long-term follow-up, and immunologic studies performed in a single center in Spain in the last 4 years. RESULTS The median age of the patients was 13 years (range, 8 months-18 years), 70% were female. In 12 patients (60%), the initial symptoms were neurologic, usually dyskinesias or seizures, and in the other 40% psychiatric. One month into the disease, all patients had involuntary movements and alterations of behavior and speech. All patients received steroids, intravenous immunoglobulin or plasma exchange, and 7 rituximab or cyclophosphamide. With a median follow up of 17.5 months, 85% had substantial recovery, 10% moderate or severe deficits, and 1 died. Three patients had previous episodes compatible with anti-NMDAR encephalitis, 2 of them with additional relapses after the diagnosis of the disorder. Ovarian teratoma was identified in 2 patients, 1 at onset of encephalitis and the other 1 year later. Two novel observations (1 patient each) include, the identification of an electroencephalographic pattern ("extreme delta brush") considered characteristic of this disorder, and the development of anti-NMDAR encephalitis as post herpes simplex encephalitis choreoathetosis. CONCLUSIONS The initial symptoms of pediatric anti-NMDAR encephalitis vary from those of the adults (more neurologic and less psychiatric in children), the development of a mono-symptomatic illness is extremely rare (except in relapses), and most patients respond to treatment. Our study suggests a link between post herpes simplex encephalitis choreoathetosis and anti-NMDAR encephalitis.
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Affiliation(s)
- Thaís Armangue
- Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Service of Neurology, Hospital Clínic, University of Barcelona, Barcelona (Spain),Service of Pediatric Neurology, Hospital Materno-Infantil Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona (Spain)
| | - Maarten J. Titulaer
- Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Service of Neurology, Hospital Clínic, University of Barcelona, Barcelona (Spain)
| | - Ignacio Málaga
- Child Neurology Unit, Pediatrics Department, Hospital Universitario Central de Asturias. Oviedo (Spain)
| | - Luis Bataller
- Service of Neurology, Hospital Universitari Politècnic La Fe, Valencia (Spain)
| | - Iñigo Gabilondo
- Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Service of Neurology, Hospital Clínic, University of Barcelona, Barcelona (Spain)
| | - Francesc Graus
- Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Service of Neurology, Hospital Clínic, University of Barcelona, Barcelona (Spain)
| | - Josep Dalmau
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Service of Neurology, Hospital Clínic, University of Barcelona, Barcelona (Spain),Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Service of Neurology, Hospital Clínic, University of Barcelona, Barcelona (Spain),Department of Neurology, University of Pennsylvania, Philadelphia, PA (USA)
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Abstract
The term autoimmune encephalitis is used to describe a group of disorders characterised by symptoms of limbic and extra-limbic dysfunction occurring in association with antibodies against synaptic antigens and proteins localised on the neuronal cell surface. In recent years there has been a rapidly expanding knowledge of these syndromes resulting in a shift in clinical paradigms and new insights into pathogenic mechanisms. Since many patients respond well to immunosuppressive treatment, the recognition of these disorders is of utmost importance. In general, there are no brain-imaging modalities or biomarkers specific of these disorders other than the demonstration of the neuronal antibodies. A disease classification based on these antibodies provides information on prognosis and paraneoplastic aetiology. This article focuses on recent clinical advances, newly characterised antibodies and treatment approaches to these disorders.
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Affiliation(s)
- Frank Leypoldt
- Post doctoral Research Fellow, Catalan Institution for Research and Advanced Studies (ICREA), August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Junior Attending Physician, Department of Neurology, University Medical Centre Hamburg-Eppendorf, Germany
| | - Klaus-Peter Wandinger
- Attending Physician, Institute of Clinical Chemistry, University Medical-Centre Schleswig-Holstein Campus Lübeck, Germany
- Attending Physician, Department of Neurology, University Medical-Centre Schleswig-Holstein Campus Lübeck, Germany
| | - Christian G Bien
- Head of Department, Epilepsy Centre Bethel, Mara-Clinic Bethel, Bielefeld, Germany
| | - Josep Dalmau
- Post doctoral Research Fellow, Catalan Institution for Research and Advanced Studies (ICREA), August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
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