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Sinmaz N, Nguyen T, Tea F, Dale RC, Brilot F. Mapping autoantigen epitopes: molecular insights into autoantibody-associated disorders of the nervous system. J Neuroinflammation 2016; 13:219. [PMID: 27577085 PMCID: PMC5006540 DOI: 10.1186/s12974-016-0678-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/17/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Our knowledge of autoantibody-associated diseases of the central (CNS) and peripheral (PNS) nervous systems has expanded greatly over the recent years. A number of extracellular and intracellular autoantigens have been identified, and there is no doubt that this field will continue to expand as more autoantigens are discovered as a result of improved clinical awareness and methodological practice. In recent years, interest has shifted to uncover the target epitopes of these autoantibodies. MAIN BODY The purpose of this review is to discuss the mapping of the epitope targets of autoantibodies in CNS and PNS antibody-mediated disorders, such as N-methyl-D-aspartate receptor (NMDAR), α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR), leucine-rich glioma-inactivated protein 1 (Lgi1), contactin-associated protein-like 2 (Caspr2), myelin oligodendrocyte glycoprotein (MOG), aquaporin-4 (AQP4), 65 kDa glutamic acid decarboxylase (GAD65), acetylcholine receptor (AChR), muscle-specific kinase (MuSK), voltage-gated calcium channel (VGCC), neurofascin (NF), and contactin. We also address the methods used to analyze these epitopes, the relevance of their determination, and how this knowledge can inform studies on autoantibody pathogenicity. Furthermore, we discuss triggers of autoimmunity, such as molecular mimicry, ectopic antigen expression, epitope spreading, and potential mechanisms for the rising number of double autoantibody-positive patients. CONCLUSIONS Molecular insights into specificity and role of autoantibodies will likely improve diagnosis and treatment of CNS and PNS neuroimmune diseases.
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Affiliation(s)
- Nese Sinmaz
- Brain Autoimmunity 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
| | - Tina Nguyen
- Brain Autoimmunity 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
| | - Fiona Tea
- Brain Autoimmunity 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
| | - Russell C Dale
- Brain Autoimmunity 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 Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Fabienne Brilot
- Brain Autoimmunity 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 Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia.
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202
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Utility of CSF Cytokine/Chemokines as Markers of Active Intrathecal Inflammation: Comparison of Demyelinating, Anti-NMDAR and Enteroviral Encephalitis. PLoS One 2016; 11:e0161656. [PMID: 27575749 PMCID: PMC5004915 DOI: 10.1371/journal.pone.0161656] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 08/09/2016] [Indexed: 12/11/2022] Open
Abstract
Background Despite the discovery of CSF and serum diagnostic autoantibodies in autoimmune encephalitis, there are still very limited CSF biomarkers for diagnostic and monitoring purposes in children with inflammatory or autoimmune brain disease. The cause of encephalitis is unknown in up to a third of encephalitis cohorts, and it is important to differentiate infective from autoimmune encephalitis given the therapeutic implications. Aim To study CSF cytokines and chemokines as diagnostic biomarkers of active neuroinflammation, and assess their role in differentiating demyelinating, autoimmune, and viral encephalitis. Methods We measured and compared 32 cytokine/chemokines using multiplex immunoassay and APRIL and BAFF using ELISA in CSF collected prior to commencing treatment from paediatric patients with confirmed acute disseminated encephalomyelitis (ADEM, n = 16), anti-NMDAR encephalitis (anti-NMDAR E, n = 11), and enteroviral encephalitis (EVE, n = 16). We generated normative data using CSF from 20 non-inflammatory neurological controls. The sensitivity of CSF cytokine/chemokines to diagnose encephalitis cases was calculated using 95th centile of control values as cut off. We correlated CSF cytokine/chemokines with disease severity and follow up outcome based on modified Rankin scale. One-way hierarchical correlational cluster analysis of molecules was performed in different encephalitis and outcome groups. Results In descending order, CSF TNF-α, IL-10, IFN-α, IL-6, CXCL13 and CXCL10 had the best sensitivity (>79.1%) when all encephalitis patients were included. The combination of IL-6 and IFN-α was most predictive of inflammation on multiple logistic regression with area under the ROC curve 0.99 (CI 0.97–1.00). There were no differences in CSF cytokine concentrations between EVE and anti-NMDAR E, whereas ADEM showed more pronounced elevation of Th17 related (IL-17, IL-21) and Th2 (IL-4, CCL17) related cytokine/chemokines. Unlike EVE, heat map analysis showed similar clustering of cytokine/chemokine molecules in immune mediated encephalitis (ADEM and anti-NMDAR E). Th1 and B cell (CXCL13 and CXCL10) molecules clustered together in patients with severe encephalopathy at admission and worse disability at follow up in all encephalitis. There was no correlation between CSF neopterin and IFN-γ or IFN-α. Conclusion A combination panel of cytokine/chemokines consisting of CSF TNF-α, IL-10, IFN-α, IL-6, CXCL13 and CXCL10 measured using multiplex immunoassay may be used to diagnose and monitor intrathecal inflammation in the brain. Given their association with worse outcome, certain key chemokines (CXCL13, CXCL10) could represent potential therapeutic targets in encephalitis.
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Fraune J, Gerlach S, Rentzsch K, Teegen B, Lederer S, Affeldt K, Fechner K, Danckwardt M, Voigt J, Probst C, Komorowski L, Stöcker W. Multiparametric serological testing in autoimmune encephalitis using computer-aided immunofluorescence microscopy (CAIFM). Autoimmun Rev 2016; 15:937-42. [PMID: 27490202 DOI: 10.1016/j.autrev.2016.07.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 07/05/2016] [Indexed: 12/30/2022]
Abstract
Autoantibodies against neuronal cell surface antigens are tightly associated with immunotherapy-responsive autoimmune encephalitis, and a considerable number of corresponding autoantigens has been identified in recent years. Most patients initially present with overlapping symptoms, and a broad range of autoantibodies has to be considered to establish the correct diagnosis and initiate treatment as soon as possible to prevent irreversible and sometimes even life-threatening damage to the brain. Recombinant cell-based immunofluorescence allows to authentically present fragile membrane-associated surface antigens and, in combination with multiparametric analysis in the form of biochip mosaics, has turned out to be highly beneficial for parallel and prompt determination of anti-neuronal autoantibodies and comprehensive differential diagnostics. For the evaluation of recombinant cell-based IIFT, a semi-automated novel function was introduced into an established platform for computer-aided immunofluorescence microscopy. The system facilitates the microscopic analysis of the tests and supports the laboratory personnel in the rapid issuance of diagnostic findings, which is of major importance for autoimmune encephalitis patients since timely initiation of treatment may lead to their full recovery.
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Affiliation(s)
- Johanna Fraune
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Stefan Gerlach
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Kristin Rentzsch
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Bianca Teegen
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Sabine Lederer
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Kai Affeldt
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Kai Fechner
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Maick Danckwardt
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Jörn Voigt
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Christian Probst
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Lars Komorowski
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany
| | - Winfried Stöcker
- Institute for Experimental Immunology, Euroimmun AG, Seekamp 31, 23560 Lübeck, Germany.
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Abstract
PURPOSE OF REVIEW To provide an update on paraneoplastic neurologic syndromes (PNS), the involved tumors, and types of immune responses. RECENT FINDINGS PNS are a diverse group of syndromes that may present as a relatively isolated syndrome such as predominant cerebellar degeneration or limbic encephalitis, or with more complex phenotypes such as diffuse encephalomyelitis that affects different levels of the neuraxis producing a variety of clinical manifestations. The detection of specific antineuronal antibodies can confirm or strongly support the paraneoplastic cause of the syndrome and direct the search for the associated cancer. Previously thought to be unresponsive to therapy, it has recently been shown that there are some antibody-associated PNS that are highly responsive to treatment, including tumor-directed therapies and immunotherapy. SUMMARY The recognition of PNS is important for the early detection of an underlying malignancy and prompt initiation of therapies, which offers the best opportunity to stabilize or improve the neurological deficits and for those syndromes associated with cell surface antibodies usually results in substantial improvement or full recovery.
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Brenton JN, Goodkin HP. Antibody-Mediated Autoimmune Encephalitis in Childhood. Pediatr Neurol 2016; 60:13-23. [PMID: 27343023 DOI: 10.1016/j.pediatrneurol.2016.04.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 03/31/2016] [Accepted: 04/05/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND The differential diagnosis of encephalitis in childhood is vast, and evaluation for an etiology is often unrevealing. Encephalitis by way of autoimmunity has long been suspected, as in cases of acute disseminated encephalomyelitis; however, researchers have only recently reported evidence of antibody-mediated immune dysregulation resulting in clinical encephalitis. MAIN FINDINGS These pathologic autoantibodies, aimed at specific neuronal targets, can result in a broad spectrum of symptoms including psychosis, catatonia, behavioral changes, memory loss, autonomic dysregulation, seizures, and abnormal movements. Autoimmune encephalitis in childhood is often quite different from adult-onset autoimmune encephalitis in clinical presentation, frequency of tumor association, and ultimate prognosis. As many of the autoimmune encephalitides are sensitive to immunotherapy, prompt diagnosis and initiation of appropriate treatment are paramount. CONCLUSIONS Here we review the currently recognized antibody-mediated encephalitides of childhood and will provide a framework for diagnosis and treatment considerations.
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Affiliation(s)
- J Nicholas Brenton
- Division of Pediatric Neurology, Department of Neurology, University of Virginia, Charlottesville, Virginia.
| | - Howard P Goodkin
- Division of Pediatric Neurology, Department of Neurology, University of Virginia, Charlottesville, Virginia
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Li Z, Cui T, Shi W, Wang Q. Clinical analysis of leucine-rich glioma inactivated-1 protein antibody associated with limbic encephalitis onset with seizures. Medicine (Baltimore) 2016; 95:e4244. [PMID: 27428233 PMCID: PMC4956827 DOI: 10.1097/md.0000000000004244] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
We summarized the clinical characteristics of patients presenting with seizures and limbic encephalitis (LE) associated with leucine-rich glioma inactivated-1 protein antibody (LGI1) in order help recognize and treat this condition at its onset.We analyzed clinical, video electroencephalogram (VEEG), magnetic resonance imaging (MRI), and laboratory data of 10 patients who presented with LGI1-LE and followed up their outcomes from 2 to 16 (9.4 ± 4.2) months.All patients presented with seizures onset, including faciobrachial dystonic seizure (FBDS), partial seizure (PS), and generalized tonic-clonic seizure (GTCS). Four patients (Cases 3, 5, 7, and 8) had mild cognitive deficits. Interictal VEEG showed normal patterns, focal slowing, or sharp waves in the temporal or frontotemporal lobes. Ictal VEEG of Cases 4, 5, and 7 showed diffuse voltage depression preceding FBDS, a left frontal/temporal origin, and a bilateral temporal origin, respectively. Ictal foci could not be localized in other cases. MRI scan revealed T2/fluid-attenuated inversion recovery (FLAIR) hyperintensity and evidence of edema in the right medial temporal lobe in Case 3, left hippocampal atrophy in Case 5, hyperintensities in the bilateral medial temporal lobes in Case 7, and hyperintensities in the basal ganglia and frontal cortex in Case 10. All 10 serum samples were positive for LGI1 antibody, but it was only detected in the cerebrospinal fluid (CSF) of 7 patients. Five patients (Cases 2, 4, 6, 7, and 8) presented with hyponatremia. One patient (Case 2) was diagnosed with small cell lung cancer. While responses to antiepileptic drugs (AEDs) were poor, most patients (except Case 2) responded favorably to immunotherapy.LGI1-LE may initially manifest with various types of seizures, particularly FBDS and complex partial seizures (CPS) of mesial temporal origin, and slowly progressive cognitive involvement. Clinical follow-up, VEEG monitoring, and MRI scan are helpful in early diagnosis. Immunotherapy is effective for the treatment of both seizure and LE associated with LGI1 antibody. Although mostly nonparaneoplastic, tumor screening is recommended in some cases.
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Affiliation(s)
| | | | | | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, China
- Correspondence: Qun Wang, No.6 Tiantanxili, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing,China (e-mail: )
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di Biase L, Assenza G, Iorio R, Melgari JM, Salomone G, Marano M, Muda AO, Di Lazzaro V. Efficacy of oral corticosteroids therapy in anti-glutamic acid decarboxylase antibodies cerebellar ataxia. Parkinsonism Relat Disord 2016; 30:78-80. [PMID: 27236207 DOI: 10.1016/j.parkreldis.2016.05.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 05/16/2016] [Accepted: 05/20/2016] [Indexed: 12/20/2022]
Affiliation(s)
- Lazzaro di Biase
- Institute of Neurology, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, 00128 Rome, Italy; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Medical Research Council Brain Network Dynamics Unit, Department of Pharmacology, University of Oxford, Oxford, UK; Sobell Department of Motor Neuroscience and Movement Disorders, Unit of Functional Neurosurgery, University College London, London, UK.
| | - Giovanni Assenza
- Institute of Neurology, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Raffaele Iorio
- Institute of Neurology, Department of Geriatrics, Neuroscience and Orthopedics, Catholic University, Rome, Italy
| | - Jean-Marc Melgari
- Institute of Neurology, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, 00128 Rome, Italy; Institute of Neurology, Caravaggio Treviglio Hospital, Treviglio BG, Italy
| | - Gaetano Salomone
- Institute of Neurology, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Massimo Marano
- Institute of Neurology, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Andrea Onetti Muda
- Department of Pathology, Pathology Unit, Campus Bio-Medico University, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Vincenzo Di Lazzaro
- Institute of Neurology, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, 00128 Rome, Italy
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Golombeck KS, Bönte K, Mönig C, van Loo KM, Hartwig M, Schwindt W, Widman G, Lindenau M, Becker AJ, Glatzel M, Elger CE, Wiendl H, Meuth SG, Lohmann H, Gross CC, Melzer N. Evidence of a pathogenic role for CD8(+) T cells in anti-GABAB receptor limbic encephalitis. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2016; 3:e232. [PMID: 27213174 PMCID: PMC4853055 DOI: 10.1212/nxi.0000000000000232] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 03/17/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To characterize the cellular autoimmune response in patients with γ-aminobutyric acid (GABA)B receptor antibody-associated limbic encephalitis (GABAB-R LE). METHODS Patients underwent MRI, extensive neuropsychological assessment, and multiparameter flow cytometry of peripheral blood and CSF. RESULTS We identified a series of 3 cases of nonparaneoplastic GABAB-R LE and one case of paraneoplastic GABAB-R LE associated with small cell lung cancer. All patients exhibited temporal lobe epilepsy, neuropsychological deficits, and MRI findings typical of LE. Absolute numbers of CD19(+) B cells, CD138(+) CD19(+) plasma cells, CD4(+) T cells, activated HLADR(+) CD4(+) T cells, as well as CD8(+) T cells and HLADR(+) CD8(+) T cells did not differ in peripheral blood but were elevated in CSF of patients with GABAB-R LE compared to controls. Augmented absolute numbers of CD138(+) CD19(+) plasma cells and activated HLADR(+) CD8(+) T cells in CSF corresponded to higher overall neuropsychological and memory deficits in patients with GABAB-R LE. A histologic specimen of one patient following selective amygdalohippocampectomy revealed perivascular infiltrates of CD138(+) plasma cells and CD4(+) T cells, whereas cytotoxic CD8(+) T cells were detected within the brain parenchyma in close contact to neurons. CONCLUSION Our data suggest a pathogenic role for CD8(+) T cells in addition to the established role of plasma cell-derived autoantibodies in GABAB-R LE.
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Affiliation(s)
- Kristin S Golombeck
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Kathrin Bönte
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Constanze Mönig
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Karen M van Loo
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Marvin Hartwig
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Wolfram Schwindt
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Guido Widman
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Matthias Lindenau
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Albert J Becker
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Markus Glatzel
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Christian E Elger
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Heinz Wiendl
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Sven G Meuth
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Hubertus Lohmann
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Catharina C Gross
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Nico Melzer
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
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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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210
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Rubinstein TB, Putterman C, Goilav B. Biomarkers for CNS involvement in pediatric lupus. Biomark Med 2016; 9:545-58. [PMID: 26079959 DOI: 10.2217/bmm.15.26] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
CNS disease, or central neuropsychiatric lupus erythematosus (cNPSLE), occurs frequently in pediatric lupus, leading to significant morbidity and poor long-term outcomes. Diagnosing cNPSLE is especially difficult in pediatrics; many current diagnostic tools are invasive and/or costly, and there are no current accepted screening mechanisms. The most complicated aspect of diagnosis is differentiating primary disease from other etiologies; research to discover new biomarkers is attempting to address this dilemma. With many mechanisms involved in the pathogenesis of cNPSLE, biomarker profiles across several modalities (molecular, psychometric and neuroimaging) will need to be used. For the care of children with lupus, the challenge will be to develop biomarkers that are accessible by noninvasive measures and reliable in a pediatric population.
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Affiliation(s)
- Tamar B Rubinstein
- Department of Pediatrics, Division of Rheumatology, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Avenue, Bronx, NY 10467, USA
| | - Chaim Putterman
- Department of Medicine, Division of Rheumatology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA
| | - Beatrice Goilav
- Department of Pediatrics, Division of Nephrology, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Avenue, Bronx, NY 10467, USA
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211
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Affiliation(s)
- Pan-Pan Zhao
- Department of Neurology, First Hospital of Jilin University, Xinmin Street 71#, Changchun, 130021, China
- Department of Neurology, First Hospital of Xinxiang Medical University, Weihui, China
| | - Ying Zhang
- Department of Neurology, First Hospital of Jilin University, Xinmin Street 71#, Changchun, 130021, China
| | - Lan Gao
- Department of Neurology, First Hospital of Jilin University, Xinmin Street 71#, Changchun, 130021, China
| | - Li Sun
- Department of Neurology, First Hospital of Jilin University, Xinmin Street 71#, Changchun, 130021, China.
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212
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Britton PN, Eastwood K, Paterson B, Durrheim DN, Dale RC, Cheng AC, Kenedi C, Brew BJ, Burrow J, Nagree Y, Leman P, Smith DW, Read K, Booy R, Jones CA. Consensus guidelines for the investigation and management of encephalitis in adults and children in Australia and New Zealand. Intern Med J 2016; 45:563-76. [PMID: 25955462 DOI: 10.1111/imj.12749] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 02/17/2015] [Indexed: 02/06/2023]
Abstract
Encephalitis is a complex neurological syndrome caused by inflammation of the brain parenchyma. The management of encephalitis is challenging because: the differential diagnosis of encephalopathy is broad; there is often rapid disease progression; it often requires intensive supportive management; and there are many aetiologic agents for which there is no definitive treatment. Patients with possible meningoencephalitis are often encountered in the emergency care environment where clinicians must consider differential diagnoses, perform appropriate investigations and initiate empiric antimicrobials. For patients who require admission to hospital and in whom encephalitis is likely, a staged approach to investigation and management is preferred with the potential involvement of multiple medical specialties. Key considerations in the investigation and management of patients with encephalitis addressed in this guideline include: Which first-line investigations should be performed?; Which aetiologies should be considered possible based on clinical features, risk factors and radiological features?; What tests should be arranged in order to diagnose the common causes of encephalitis?; When to consider empiric antimicrobials and immune modulatory therapies?; and What is the role of brain biopsy?
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Affiliation(s)
- P N Britton
- Discipline of Paediatrics and Child Health and Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Infectious Diseases and Microbiology, The Children's Hospital at Westmead, Sydney, Australia
| | - K Eastwood
- Health Protection, Hunter New England Population Health, Newcastle, New South Wales, Australia.,Biopreparedness, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - B Paterson
- Biopreparedness, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - D N Durrheim
- Biopreparedness, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - R C Dale
- Discipline of Paediatrics and Child Health and Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Neurology, The Children's Hospital at Westmead, Sydney, Australia
| | - A C Cheng
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - C Kenedi
- Departments of, General Medicine, Auckland City Hospital, Auckland, New Zealand, USA.,Liaison Psychiatry, Auckland City Hospital, Auckland, New Zealand, USA.,Department of Medicine and Department of Psychiatry, Duke University Medical Center, Durham, North Carolina, USA
| | - B J Brew
- St Vincent's Centre for applied medical research, University of New South Wales, Sydney, Australia.,Department of Neurology, St Vincent's Hospital, Sydney, Australia
| | - J Burrow
- Department of Neurology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Y Nagree
- Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, Australia.,Emergency Department, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - P Leman
- Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, Australia.,Emergency Department, Royal Perth Hospital, Perth, Australia
| | - D W Smith
- Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, Australia
| | - K Read
- Department of Infectious Diseases, North Shore Hospital, Auckland, New Zealand, USA
| | - R Booy
- Discipline of Paediatrics and Child Health and Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Infectious Diseases and Microbiology, The Children's Hospital at Westmead, Sydney, Australia.,National Centre for Immunisation Research and Surveillance, The Children's Hospital at Westmead, Sydney, Australia
| | - C A Jones
- Discipline of Paediatrics and Child Health and Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Infectious Diseases and Microbiology, The Children's Hospital at Westmead, Sydney, Australia
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213
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Dogan Onugoren M, Golombeck KS, Bien C, Abu-Tair M, Brand M, Bulla-Hellwig M, Lohmann H, Münstermann D, Pavenstädt H, Thölking G, Valentin R, Wiendl H, Melzer N, Bien CG. Immunoadsorption therapy in autoimmune encephalitides. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2016; 3:e207. [PMID: 26977423 PMCID: PMC4772911 DOI: 10.1212/nxi.0000000000000207] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 12/15/2015] [Indexed: 12/19/2022]
Abstract
Objective: It was hypothesized that in encephalitides with autoantibodies directed to CNS surface antigens an antibody-removing intervention might speed up recovery. Methods: The outcome of autoimmune encephalitis in 19 patients with antibodies against surface antigens (leucine-rich, glioma inactivated 1 [LGI1], n = 3; contactin-associated protein-2 [CASPR2], n = 4; NMDA receptor [NMDAR], n = 7) and intracellular antigens (glutamic acid decarboxylase [GAD], n = 5) after immunoadsorption in addition to corticosteroid therapy was evaluated retrospectively. Modified Rankin scale (mRS) scores and data on seizures, memory, and antibody titers directly after immunoadsorption (early follow-up) and after a median of 4 months (late follow-up) were compiled. Results: Immediately after immunoadsorption, 9 of 14 patients with antibodies against LGI1, CASPR2, or NMDAR (64%), but none with GAD antibodies, had improved by at least one mRS point. Five of the 7 patients with LGI1 or CASRP2 antibodies had become seizure-free, and 2 patients with NMDAR antibodies had a memory improvement of more than 1 SD of a normal control population. At late follow-up, 12 of 14 patients with surface antibodies had improved (86%), and none of the patients with GAD antibodies. Conclusions: It is suggested that addition of immunoadsorption to immunosuppression therapy in patients with surface antibodies may accelerate recovery. This supports the pathogenic role of surface antibodies. Classification of evidence: This study provides Class IV evidence that immunoadsorption combined with immunosuppression therapy is effective in patients with autoimmune encephalitis with surface antibodies.
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Affiliation(s)
- Müjgan Dogan Onugoren
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Kristin S Golombeck
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Corinna Bien
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Mariam Abu-Tair
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Marcus Brand
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Michael Bulla-Hellwig
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Hubertus Lohmann
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Dieter Münstermann
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Hermann Pavenstädt
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Gerold Thölking
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Rainer Valentin
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Heinz Wiendl
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Nico Melzer
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Christian G Bien
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
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214
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Newman MP, Blum S, Wong RCW, Scott JG, Prain K, Wilson RJ, Gillis D. Autoimmune encephalitis. Intern Med J 2016; 46:148-57. [DOI: 10.1111/imj.12974] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 10/12/2015] [Accepted: 11/19/2015] [Indexed: 12/31/2022]
Affiliation(s)
- M. P. Newman
- Department of Immunology; Princess Alexandra Hospital; Queensland Australia
| | - S. Blum
- Department of Neurology; Princess Alexandra Hospital; Woolloongabba Queensland Australia
- Mater Centre for Neurosciences; Queensland Australia
| | - R. C. W. Wong
- Department of Immunology; Princess Alexandra Hospital; Queensland Australia
- Division of Immunology, Central Laboratory, HSSA Pathology Queensland; Royal Brisbane and Women's Hospital; Herston Queensland Australia
| | - J. G. Scott
- Discipline of Psychiatry; The University of Queensland Centre for Clinical Research; Herston Queensland Australia
- Metro North Mental Health; Royal Brisbane and Women's Hospital; Herston Queensland Australia
| | - K. Prain
- Division of Immunology, Central Laboratory, HSSA Pathology Queensland; Royal Brisbane and Women's Hospital; Herston Queensland Australia
| | - R. J. Wilson
- Division of Immunology, Central Laboratory, HSSA Pathology Queensland; Royal Brisbane and Women's Hospital; Herston Queensland Australia
| | - D. Gillis
- Department of Immunology; Princess Alexandra Hospital; Queensland Australia
- Division of Immunology, Central Laboratory, HSSA Pathology Queensland; Royal Brisbane and Women's Hospital; Herston Queensland Australia
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215
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Bai HX, Zou Y, Lee AM, Lancaster E, Yang L. Diagnostic Value and Safety of Brain Biopsy in Patients With Cryptogenic Neurological Disease: A Systematic Review and Meta-analysis of 831 Cases. Neurosurgery 2016; 77:283-95; discussion 295. [PMID: 25856111 DOI: 10.1227/neu.0000000000000756] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The role of brain biopsy in patients with cryptogenic neurological disease is uncertain. OBJECTIVE To determine the risks and benefits of diagnostic brain biopsy for nonneoplastic indications in immunocompetent patients. METHODS Appropriate studies were identified by searching electronic databases. RESULTS We screened 3645 abstracts and included 20 studies with a total of 831 patients. Indications for biopsy were: (1a) severe neurological disease of unknown etiology in adults (n = 7) and (1b) in children (n = 2); (2) suspected primary angiitis of the central nervous system (PACNS) (n = 3); (3) chronic meningitis of unknown cause (n = 3); (4) atypical dementia (n = 4); and (5) nonneoplastic disease (n = 1). Diagnostic success rates calculated for subgroups were 51.3% (34.5-68.1) for 1a, 53.8% (42.9-64.5) for 1b, 74.7% (64.0-84.1) for 2, 30.3% (17.2-45.4) for 3, and 60.8% (41.2-78.8) for 4. Clinical impact rates were 30.5% (13.6-50.6) for 1a (n = 6), 67.1% (42.8-87.3) for 1b (n = 2), 8.3% (2.3-20.0) for 3 (n = 1), and 14.2% (6.5-24.3) for 4 (n = 2). Lymphoma (n = 32) and Creutzfeldt-Jakob disease (n = 30) were the most common diagnoses on the final histopathology reports of positive brain biopsies in 1a. In 1b, encephalitis (n = 7), PACNS (n = 6), and demyelination (n = 6) were the most common. The odds ratio for achieving a diagnostic biopsy when there was a radiological target was 3.70 (P = .014, 95% confidence interval, 1.31-10.42). CONCLUSION Brain biopsy in cryptogenic neurological disease was associated with the highest diagnostic yield in patients with suspected PACNS. The greatest clinical impact was seen in children with cryptogenic neurological disease. The presence of a radiological target was associated with a higher diagnostic yield.
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Affiliation(s)
- Harrison Xiao Bai
- ‡Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China; §Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia; ¶Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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216
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Wang KKW, Yang Z, Yue JK, Zhang Z, Winkler EA, Puccio AM, Diaz-Arrastia R, Lingsma HF, Yuh EL, Mukherjee P, Valadka AB, Gordon WA, Okonkwo DO, Manley GT, Cooper SR, Dams-O'Connor K, Hricik AJ, Inoue T, Maas AIR, Menon DK, Schnyer DM, Sinha TK, Vassar MJ. Plasma Anti-Glial Fibrillary Acidic Protein Autoantibody Levels during the Acute and Chronic Phases of Traumatic Brain Injury: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot Study. J Neurotrauma 2016; 33:1270-7. [PMID: 26560343 DOI: 10.1089/neu.2015.3881] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
We described recently a subacute serum autoantibody response toward glial fibrillary acidic protein (GFAP) and its breakdown products 5-10 days after severe traumatic brain injury (TBI). Here, we expanded our anti-GFAP autoantibody (AutoAb[GFAP]) investigation to the multicenter observational study Transforming Research and Clinical Knowledge in TBI Pilot (TRACK-TBI Pilot) to cover the full spectrum of TBI (Glasgow Coma Scale 3-15) by using acute (<24 h) plasma samples from 196 patients with acute TBI admitted to three Level I trauma centers, and a second cohort of 21 participants with chronic TBI admitted to inpatient TBI rehabilitation. We find that acute patients self-reporting previous TBI with loss of consciousness (LOC) (n = 43) had higher day 1 AutoAb[GFAP] (mean ± standard error: 9.11 ± 1.42; n = 43) than healthy controls (2.90 ± 0.92; n = 16; p = 0.032) and acute patients reporting no previous TBI (2.97 ± 0.37; n = 106; p < 0.001), but not acute patients reporting previous TBI without LOC (8.01 ± 1.80; n = 47; p = 0.906). These data suggest that while exposure to TBI may trigger the AutoAb[GFAP] response, circulating antibodies are elevated specifically in acute TBI patients with a history of TBI. AutoAb[GFAP] levels for participants with chronic TBI (average post-TBI time 176 days or 6.21 months) were also significantly higher (15.08 ± 2.82; n = 21) than healthy controls (p < 0.001). These data suggest a persistent upregulation of the autoimmune response to specific brain antigen(s) in the subacute to chronic phase after TBI, as well as after repeated TBI insults. Hence, AutoAb[GFAP] may be a sensitive assay to study the dynamic interactions between post-injury brain and patient-specific autoimmune responses across acute and chronic settings after TBI.
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Affiliation(s)
- Kevin K W Wang
- 1 Departments of Psychiatry and Neuroscience, University of Florida , Gainesville, Florida
| | - Zhihui Yang
- 1 Departments of Psychiatry and Neuroscience, University of Florida , Gainesville, Florida
| | - John K Yue
- 2 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California.,3 Department of Neurological Surgery, University of California , San Francisco, San Francisco, California
| | - Zhiqun Zhang
- 1 Departments of Psychiatry and Neuroscience, University of Florida , Gainesville, Florida
| | - Ethan A Winkler
- 2 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California.,3 Department of Neurological Surgery, University of California , San Francisco, San Francisco, California
| | - Ava M Puccio
- 4 Department of Neurological Surgery, University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania
| | - Ramon Diaz-Arrastia
- 5 Department of Neurology, Uniformed Services University of the Health Sciences , and Center for Neuroscience and Regenerative Medicine, Bethesda, Maryland
| | - Hester F Lingsma
- 6 Department of Public Health, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Esther L Yuh
- 2 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California.,7 Department of Radiology, University of California , San Francisco, San Francisco, California
| | - Pratik Mukherjee
- 2 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California.,7 Department of Radiology, University of California , San Francisco, San Francisco, California
| | | | - Wayne A Gordon
- 9 Department of Rehabilitation Medicine, Mount Sinai School of Medicine , New York, New York
| | - David O Okonkwo
- 4 Department of Neurological Surgery, University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania
| | - Geoffrey T Manley
- 2 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California.,3 Department of Neurological Surgery, University of California , San Francisco, San Francisco, California
| | - Shelly R Cooper
- 2 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California.,3 Department of Neurological Surgery, University of California , San Francisco, San Francisco, California.,6 Department of Public Health, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Kristen Dams-O'Connor
- 9 Department of Rehabilitation Medicine, Mount Sinai School of Medicine , New York, New York
| | - Allison J Hricik
- 4 Department of Neurological Surgery, University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania
| | - Tomoo Inoue
- 2 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California.,3 Department of Neurological Surgery, University of California , San Francisco, San Francisco, California
| | - Andrew I R Maas
- 10 Department of Neurosurgery, Antwerp University Hospital , Edegem, Belgium
| | - David K Menon
- 11 Division of Anaesthesia, University of Cambridge and Addenbrooke's Hospital , Cambridge, United Kingdom
| | - David M Schnyer
- 12 Department of Psychology, University of Texas , Austin, Texas
| | - Tuhin K Sinha
- 7 Department of Radiology, University of California , San Francisco, San Francisco, California
| | - Mary J Vassar
- 2 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California.,3 Department of Neurological Surgery, University of California , San Francisco, San Francisco, California
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217
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Abstract
In recent years a large number of antibody-associated or antibody-defined encephalitides have been discovered. These conditions are often referred to as autoimmune encephalitides. The clinical features include prominent epileptic seizures, cognitive and psychiatric disturbance. These encephalitides can be divided in those with antibodies against intracellular antigens and those with antibodies against surface antigens. The discovery of new antibodies against targets on the surface of neurons is especially interesting since patients with such antibodies can be successfully treated immunologically. This chapter focuses on the pathology and the pathogenetic mechanisms involved in these encephalitides and discusses some of the questions that are raised in this exciting new field. It is important to realise, however, that because of the use of antibodies to diagnose the patients, and their improvement with treatment, there are relatively few biopsy or postmortem reports, limiting the neuropathological data and conclusions that can be drawn. For this reason we especially focus on the most frequent autoimmune encephalitides, those with antibodies to the NMDA receptor and with antibodies to the known protein components of the VGKC complex. Analysis of these encephalitides show completely different pathogenic mechanisms. In VGKC complex encephalitis, antibodies seem to bind to their target and activate complement, leading to destruction and loss of neurons. On the other hand, in NMDAR encephalitis, complement activation and neuronal degeneration seems to be largely absent. Instead, binding of antibodies leads to a decrease of NMDA receptors resulting in a hypofunction. This hypofunction offers an explanation for some of the clinical features such as psychosis and episodic memory impairment, but not for the frequent seizures. Thus, additional analysis of the few human brain specimens present and the use of specific animal models are needed to further understand the effects of these antibodies in autoimmune encephalitides.
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Affiliation(s)
- Jan Bauer
- Center for Brain Research, Medical University Vienna, Vienna, Austria.
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218
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Abstract
Over the last 15 years it has become clear that rare but highly recognizable diseases of the central nervous system (CNS), including newly identified forms of limbic encephalitis and other encephalopathies, are likely to be mediated by antibodies (Abs) to CNS proteins. The Abs are directed against membrane receptors and ion channel-associated proteins that are expressed on the surface of neurons in the CNS, such as N-methyl D-aspartate receptors and leucine-rich, glioma inactivated 1 protein and contactin-associated protein like 2, that are associated with voltage-gated potassium channels. The diseases are not invariably cancer-related and are therefore different from the classical paraneoplastic neurological diseases that are associated with, but not caused by, Abs to intracellular proteins. Most importantly, the new antibody-associated diseases almost invariably respond to immunotherapies with considerable and sometimes complete recovery, and there is convincing evidence of their pathogenicity in the relatively limited studies performed so far. Treatments include first-line steroids, intravenous immunoglobulins, and plasma exchange, and second-line rituximab and cyclophosphamide, followed in many cases by steroid-sparing agents in the long-term. This review focuses mainly on N-methyl D-aspartate receptor- and voltage-gated potassium channel complex-related Abs in adults, the clinical phenotypes, and treatment responses. Pediatric cases are referred to but not reviewed in detail. As there have been very few prospective studies, the conclusions regarding immunotherapies are based on retrospective studies.
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Affiliation(s)
- Matteo Gastaldi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
- University of Pavia, Pavia, Italy.
| | - Anaïs Thouin
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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219
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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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220
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Abstract
Autoimmune neurologic diseases are of major clinical importance in children. Antibody-mediated diseases of the central nervous system are now increasingly recognized in childhood, where the antibodies bind to cell surface epitopes on neuronal or glial proteins, and the patients demonstrate either focal or more generalized clinical signs depending on the extent of brain regions targeted by the antibodies. The antibodies are directed towards ion channels, receptors, and membrane proteins; and the diseases include limbic encephalitis and N-methyl-d-aspartate receptor-antibody encephalitis, among many others. Additionally there are conditions where the wider immune system is implicated. Neurologic features like seizures, movement disorders, autonomic dysfunction, and sleep disorders, with neuroimaging and electrophysiologic features, may indicate a specific antibody-mediated or immune disorder. Often, phenotypic overlap is observed between these conditions, and phenotypic variation seen in children with the same condition. Nevertheless, many patients benefit from immunotherapy with substantial improvement, although huge efforts are still required to optimize the outcome for many patients. In many patients no antibodies have yet been identified, even though they respond to immunotherapies. Here we describe the known antibodies and associated diseases, discuss conditions that are thought to be immune-mediated but have no known immunologic biomarker, and provide guidelines for the investigation and classification of these disorders.
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221
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Kothur K, Wienholt L, Brilot F, Dale RC. CSF cytokines/chemokines as biomarkers in neuroinflammatory CNS disorders: A systematic review. Cytokine 2016; 77:227-37. [DOI: 10.1016/j.cyto.2015.10.001] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 08/19/2015] [Accepted: 10/01/2015] [Indexed: 11/25/2022]
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222
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Bradl M, Lassmann H. Neurologic autoimmunity: mechanisms revealed by animal models. HANDBOOK OF CLINICAL NEUROLOGY 2016; 133:121-43. [PMID: 27112675 DOI: 10.1016/b978-0-444-63432-0.00008-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Over the last decade, neurologic autoimmunity has become a major consideration in the diagnosis and management of patients with many neurologic presentations. The nature of the associated antibodies and their targets has led to appreciation of the importance of the accessibility of the target antigen to antibodies, and a partial understanding of the different mechanisms that can follow antibody binding. This chapter will first describe the basic principles of autoimmune inflammation and tissue damage in the central and peripheral nervous system, and will then demonstrate what has been learnt about neurologic autoimmunity from circumstantial clinical evidence and from passive, active, and occasionally spontaneous or genetic animal models. It will cover neurologic autoimmune diseases ranging from disorders of neuromuscular transmission, peripheral and ganglionic neuropathy, to diseases of the central nervous system, where autoantibodies are either pathogenic and cause destruction or changes in function of their targets, where they are harmless bystanders of T-cell-mediated tissue damage, or are not involved at all. Finally, this chapter will summarize the relevance of current animal models for studying the different neurologic autoimmune diseases, and it will identify aspects where future animal models need to be improved to better reflect the disease reality experienced by affected patients, e.g., the chronicity or the relapsing/remitting nature of their disease.
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Affiliation(s)
- Monika Bradl
- Department of Neuroimmunology, Center for Brain Research, Medical University Vienna, Vienna, Austria.
| | - Hans Lassmann
- Department of Neuroimmunology, Center for Brain Research, Medical University Vienna, Vienna, Austria
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223
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[Encephalitis associated with anti-NMDA antibodies]. Med Clin (Barc) 2015; 145:504-5. [PMID: 25724249 DOI: 10.1016/j.medcli.2015.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 01/14/2015] [Accepted: 01/15/2015] [Indexed: 11/21/2022]
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224
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Nosadini M, Mohammad SS, Ramanathan S, Brilot F, Dale RC. Immune therapy in autoimmune encephalitis: a systematic review. Expert Rev Neurother 2015; 15:1391-419. [DOI: 10.1586/14737175.2015.1115720] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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225
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Affiliation(s)
- Kelly Graham Gwathmey
- Department of Neurology; University of Virginia; P.O. Box 800394 Charlottesville Virginia 22908 USA
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226
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Maat P, de Beukelaar JW, Jansen C, Schuur M, van Duijn CM, van Coevorden MH, de Graaff E, Titulaer M, Rozemuller AJ, Sillevis Smitt P. Pathologically confirmed autoimmune encephalitis in suspected Creutzfeldt-Jakob disease. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2015; 2:e178. [PMID: 26601117 PMCID: PMC4645173 DOI: 10.1212/nxi.0000000000000178] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 09/23/2015] [Indexed: 01/17/2023]
Abstract
Objective: To determine the clinical features and presence in CSF of antineuronal antibodies in patients with pathologically proven autoimmune encephalitis derived from a cohort of patients with suspected Creutzfeldt-Jakob disease (CJD). Methods: The Dutch Surveillance Centre for Prion Diseases performed 384 autopsies on patients with suspected CJD over a 14-year period (1998–2011). Clinical information was collected from treating physicians. Antineuronal antibodies were tested in CSF obtained postmortem by immunohistochemistry on fresh frozen rat brain sections, by Luminex assay for the presence of well-characterized onconeural antibodies, and by cell-based assays for antibodies against NMDAR, GABABR1/2, GABAAR GLUR1/2, LGI1, Caspr2, and DPPX. Results: In 203 patients, a diagnosis of definite CJD was made, while in 181 a variety of other conditions were diagnosed, mainly neurodegenerative. In 22 of these 181, the neuropathologist diagnosed autoimmune encephalitis. One patient was excluded because of lack of clinical information. Inflammatory infiltrates were predominantly perivascular and consisted mainly of T cells. The predominant locations were basal ganglia and thalamus (90%) and temporal lobes and hippocampus (81%). In 6 patients (29%), antineuronal antibodies were detected in postmortem CSF, directed against Hu, NMDAR, GABABR1/2, Caspr2, and an unidentified synaptic antigen in 2. The most frequent symptoms were dementia (90%), gait disturbance (86%), cerebellar signs (67%), and neuropsychiatric symptoms (67%). Immunopathologic and clinical findings did not differ between autoantibody-negative patients and patients with antineuronal antibodies. Conclusions: It is important to consider immune-mediated disorders in the differential diagnosis of rapidly progressive neurologic deficits.
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Affiliation(s)
- Peter Maat
- Departments of Neurology (P.M., J.W.d.B., M.H.v.C., M.T., P.S.S.) and Epidemiology (M.S., C.M.v.D.), Erasmus MC, Rotterdam; Dutch Surveillance Centre for Prion Diseases (C.J., A.J.R.), Department of Pathology, University Medical Center Utrecht; Department of Biology (M.H.v.G., E.d.G.), Division of Cell Biology, Utrecht University; and Department of Neurology (J.W.d.B.), Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | - Janet W de Beukelaar
- Departments of Neurology (P.M., J.W.d.B., M.H.v.C., M.T., P.S.S.) and Epidemiology (M.S., C.M.v.D.), Erasmus MC, Rotterdam; Dutch Surveillance Centre for Prion Diseases (C.J., A.J.R.), Department of Pathology, University Medical Center Utrecht; Department of Biology (M.H.v.G., E.d.G.), Division of Cell Biology, Utrecht University; and Department of Neurology (J.W.d.B.), Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | - Casper Jansen
- Departments of Neurology (P.M., J.W.d.B., M.H.v.C., M.T., P.S.S.) and Epidemiology (M.S., C.M.v.D.), Erasmus MC, Rotterdam; Dutch Surveillance Centre for Prion Diseases (C.J., A.J.R.), Department of Pathology, University Medical Center Utrecht; Department of Biology (M.H.v.G., E.d.G.), Division of Cell Biology, Utrecht University; and Department of Neurology (J.W.d.B.), Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | - Maaike Schuur
- Departments of Neurology (P.M., J.W.d.B., M.H.v.C., M.T., P.S.S.) and Epidemiology (M.S., C.M.v.D.), Erasmus MC, Rotterdam; Dutch Surveillance Centre for Prion Diseases (C.J., A.J.R.), Department of Pathology, University Medical Center Utrecht; Department of Biology (M.H.v.G., E.d.G.), Division of Cell Biology, Utrecht University; and Department of Neurology (J.W.d.B.), Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | - Cornelia M van Duijn
- Departments of Neurology (P.M., J.W.d.B., M.H.v.C., M.T., P.S.S.) and Epidemiology (M.S., C.M.v.D.), Erasmus MC, Rotterdam; Dutch Surveillance Centre for Prion Diseases (C.J., A.J.R.), Department of Pathology, University Medical Center Utrecht; Department of Biology (M.H.v.G., E.d.G.), Division of Cell Biology, Utrecht University; and Department of Neurology (J.W.d.B.), Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | - Marleen H van Coevorden
- Departments of Neurology (P.M., J.W.d.B., M.H.v.C., M.T., P.S.S.) and Epidemiology (M.S., C.M.v.D.), Erasmus MC, Rotterdam; Dutch Surveillance Centre for Prion Diseases (C.J., A.J.R.), Department of Pathology, University Medical Center Utrecht; Department of Biology (M.H.v.G., E.d.G.), Division of Cell Biology, Utrecht University; and Department of Neurology (J.W.d.B.), Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | - Esther de Graaff
- Departments of Neurology (P.M., J.W.d.B., M.H.v.C., M.T., P.S.S.) and Epidemiology (M.S., C.M.v.D.), Erasmus MC, Rotterdam; Dutch Surveillance Centre for Prion Diseases (C.J., A.J.R.), Department of Pathology, University Medical Center Utrecht; Department of Biology (M.H.v.G., E.d.G.), Division of Cell Biology, Utrecht University; and Department of Neurology (J.W.d.B.), Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | - Maarten Titulaer
- Departments of Neurology (P.M., J.W.d.B., M.H.v.C., M.T., P.S.S.) and Epidemiology (M.S., C.M.v.D.), Erasmus MC, Rotterdam; Dutch Surveillance Centre for Prion Diseases (C.J., A.J.R.), Department of Pathology, University Medical Center Utrecht; Department of Biology (M.H.v.G., E.d.G.), Division of Cell Biology, Utrecht University; and Department of Neurology (J.W.d.B.), Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | - Annemieke J Rozemuller
- Departments of Neurology (P.M., J.W.d.B., M.H.v.C., M.T., P.S.S.) and Epidemiology (M.S., C.M.v.D.), Erasmus MC, Rotterdam; Dutch Surveillance Centre for Prion Diseases (C.J., A.J.R.), Department of Pathology, University Medical Center Utrecht; Department of Biology (M.H.v.G., E.d.G.), Division of Cell Biology, Utrecht University; and Department of Neurology (J.W.d.B.), Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | - Peter Sillevis Smitt
- Departments of Neurology (P.M., J.W.d.B., M.H.v.C., M.T., P.S.S.) and Epidemiology (M.S., C.M.v.D.), Erasmus MC, Rotterdam; Dutch Surveillance Centre for Prion Diseases (C.J., A.J.R.), Department of Pathology, University Medical Center Utrecht; Department of Biology (M.H.v.G., E.d.G.), Division of Cell Biology, Utrecht University; and Department of Neurology (J.W.d.B.), Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
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227
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Abstract
Common somatic conditions are bound to occur by chance in individuals with neurological disorders as prevalent as epilepsy, but when biological links underlying the comorbidity can be uncovered, the relationship may provide clues into the origin and mechanisms of both. The expanding list of monogenic epilepsies and their associated clinical features offer a remarkable opportunity to mine the epilepsy genome for coordinate neurodevelopmental phenotypes and examine their pathogenic mechanisms. Defined single-gene-linked epilepsy syndromes identified to date include all of the most frequently cited comorbidities, such as cognitive disorders, autism, migraine, mood disorders, late-onset dementia, and even premature lethality. Gene-linked comorbidities may be aggravated by, or independent of, seizure history. Mutations in these genes establish clear biological links between abnormal neuronal synchronization and a variety of neurobehavioral disorders, and critically substantiate the definition of epilepsy as a complex spectrum disorder. Mapping the neural circuitry of epilepsy comorbidities and understanding their single-gene risk should substantially clarify this challenging aspect of clinical epilepsy management.
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Affiliation(s)
- Jeffrey L Noebels
- Developmental Neurogenetics Laboratory, Departments of Neurology, Neuroscience, and Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas 77030
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228
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Heine J, Prüss H, Bartsch T, Ploner C, Paul F, Finke C. Imaging of autoimmune encephalitis – Relevance for clinical practice and hippocampal function. Neuroscience 2015; 309:68-83. [DOI: 10.1016/j.neuroscience.2015.05.037] [Citation(s) in RCA: 165] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 05/04/2015] [Accepted: 05/15/2015] [Indexed: 12/25/2022]
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229
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Fauser S, Uttner I, Ariño H, Scherbaum WA, Saiz A, Lewerenz J. Long latency between GAD-antibody detection and development of limbic encephalitis--a case report. BMC Neurol 2015; 15:177. [PMID: 26420440 PMCID: PMC4589124 DOI: 10.1186/s12883-015-0435-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 09/21/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In the pathogenesis of limbic encephalitis other promoting factors besides the pure existence of autoantibodies are increasingly discussed to play a significant role. This is to our knowledge the first described patient in whom the presence of autoantibodies precedes the manifestation of limbic encephalitis for many years. CASE PRESENTATION At the age of 38 years, in the serum of a patient with polyendocrine autoimmunity high titers of cytoplasmic islet cell antibodies and of anti-glutamate decarboxylase (GAD) 65 antibodies were observed as an incidential finding, GAD67 antibodies were negative at that time. After a latency of 18 years, she manifested with refractory temporal lobe epilepsy most likely due to autoimmune limbic encephalitis. After epilepsy onset, the patient underwent magnetic resonance imaging (MRI), electroencephalography, cerebrospinal fluid (CSF), serum and neuropsychological investigations during a follow-up period of 8 years. A pharmacoresistent epilepsy with seizure onset from the right temporal lobe and declarative memory deficits were observed affecting primarily the recall of verbal informations. MRI showed a slightly increased signal in the right amygdala without progression. GAD antibodies could be detected in serum (titre 1: 1000) and CSF (titre 1:1) by immunofluorescence. Both, GAD65 and GAD67 antibodies were observed in cell-based assays. CONCLUSIONS It can be assumed that in addition to a pre-existing systemic T-cell response associated with the longstanding polyendocrine autoimmunity, a delayed intrathecal autoimmunity developed leading to limbic encephalitis. This change might be reflected by the development of GAD67 antibodies in our patient. Besides the contribution of this case report to a better understandig of the pathomechanisms for the development of central nervous system (CNS) autoimmunity, it also has a clinical impact as early treatment of GAD antibody-associated CNS disorders has a better prognosis. Therefore, vigilance for symptoms indicating GAD antibody-associated CNS autoimmunity is mandatory in patients with GAD antibody-associated endocrine dysfunction.
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Affiliation(s)
- Susanne Fauser
- Department of Neurology, University Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany. .,Epilepsiezentrum Bethel, Maraweg, 2133617, Bielefeld, Germany.
| | - Ingo Uttner
- Department of Neurology, University Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany.
| | - Helena Ariño
- Service of Neurology, Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Hospital Clínic, Villarroel 170, Barcelona, 08036, Spain.
| | - Werner A Scherbaum
- Heinrich-Heine University, University Hospital, Moorenstrasse 5, 40225, Duesseldorf, Germany.
| | - Albert Saiz
- Service of Neurology, Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Hospital Clínic, Villarroel 170, Barcelona, 08036, Spain.
| | - Jan Lewerenz
- Department of Neurology, University Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany.
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230
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Abstract
Autoimmune encephalitis (AE) is increasingly recognized as a nonparaneoplastic disorder with autoantibodies to neuronal proteins. Although MRI is frequently unremarkable, PET imaging might contribute to identification of affected brain regions in distinct AE. We report on serial FDG PET in a 72-year-old man with particular AE subtype, with potassium channel complex antibodies and prodromal stage with dystonic seizures. Serial FDG PET/CT revealed that besides limbic structures, basal ganglia are centrally involved and presumably play a key role in the generation of dystonic seizures.
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231
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Abstract
The variety of physiological functions controlled by dopamine in the brain and periphery is mediated by the D1, D2, D3, D4 and D5 dopamine GPCRs. Drugs acting on dopamine receptors are significant tools for the management of several neuropsychiatric disorders including schizophrenia, bipolar disorder, depression and Parkinson's disease. Recent investigations of dopamine receptor signalling have shown that dopamine receptors, apart from their canonical action on cAMP-mediated signalling, can regulate a myriad of cellular responses to fine-tune the expression of dopamine-associated behaviours and functions. Such signalling mechanisms may involve alternate G protein coupling or non-G protein mechanisms involving ion channels, receptor tyrosine kinases or proteins such as β-arrestins that are classically involved in GPCR desensitization. Another level of complexity is the growing appreciation of the physiological roles played by dopamine receptor heteromers. Applications of new in vivo techniques have significantly furthered the understanding of the physiological functions played by dopamine receptors. Here we provide an update of the current knowledge regarding the complex biology, signalling, physiology and pharmacology of dopamine receptors.
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232
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Bergink V, Armangue T, Titulaer MJ, Markx S, Dalmau J, Kushner SA. Autoimmune Encephalitis in Postpartum Psychosis. Am J Psychiatry 2015; 172:901-8. [PMID: 26183699 PMCID: PMC4854531 DOI: 10.1176/appi.ajp.2015.14101332] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Significant immunological alterations have been observed in women with first-onset affective psychosis during the postpartum period. Recent studies have highlighted the possibility that a subset of patients with first-onset severe psychiatric episodes might suffer from undiagnosed autoimmune encephalitis. Therefore, the authors performed a three-step immunohistochemistry-based screening for CNS autoantibodies in a large cohort of patients with postpartum psychosis and matched postpartum comparison subjects. METHOD Ninety-six consecutive patients with postpartum psychosis and 64 healthy postpartum women were included. Screening for antibodies in patient serum was performed using immunohistochemistry. Samples showing any staining were further examined by immunocytochemistry using live hippocampal neurons and cell-based assays to test for anti-N-methyl-d-aspartate (NMDA) receptor antibodies. Cell-based assays for all other known CNS antigens were performed in those samples with immunocytochemistry labeling but negative for NMDA receptor antibodies. RESULTS Four patients (4%) with neuropil labeling suggestive for extracellular antigen reactivity were identified. Serum samples from all four patients showed clear extracellular labeling of live hippocampal neurons. Two women had the specific staining pattern characteristic for anti-NMDA receptor antibody positivity, which was confirmed by cell-based assays. Neither patient with anti-NMDA receptor antibody positivity had evidence of an ovarian teratoma. The other two patients tested negative by cell-based assays for all known CNS antigens. None of the matched postpartum comparison subjects had confirmed neuronal surface antibodies. The two patients with anti-NMDA receptor antibodies both showed extrapyramidal symptoms following initiation of treatment with low-dose haloperidol. CONCLUSIONS In patients with acute psychosis during the postpartum period, systematic screening for anti-NMDA receptor autoantibodies should be considered. The acute onset of severe atypical psychiatric symptoms in young female patients should raise the index of suspicion for anti-NMDA receptor encephalitis, particularly in the setting of neurological symptoms, including extrapyramidal side effects of antipsychotic treatment.
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233
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The spectrum of autoimmune encephalopathies. J Neuroimmunol 2015; 287:93-7. [PMID: 26439968 DOI: 10.1016/j.jneuroim.2015.08.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 08/04/2015] [Accepted: 08/19/2015] [Indexed: 01/31/2023]
Abstract
Despite being a potentially reversible neurological condition, no clear guidelines for diagnosis or management of autoimmune encephalitis exist. In this study we analyzed clinical presentation, laboratory and imaging characteristics, and outcome of autoimmune encephalitis from three teaching hospitals. Non-paraneoplastic autoimmune encephalitis associated with antibodies against membrane antigens was the most common syndrome, especially in the pediatric population. Clinical outcome was better for patients with shorter latency from symptom onset to diagnosis and initiation of immunomodulation. Patients with underlying malignancy were less likely to respond well to immunomodulatory therapy. The clinical spectrum of autoimmune encephalitis is fairly broad, but prompt recognition and treatment often leads to excellent outcome.
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234
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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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Menezes R, Pantelyat A, Izbudak I, Birnbaum J. Movement and Other Neurodegenerative Syndromes in Patients with Systemic Rheumatic Diseases: A Case Series of 8 Patients and Review of the Literature. Medicine (Baltimore) 2015; 94:e0971. [PMID: 26252269 PMCID: PMC4616569 DOI: 10.1097/md.0000000000000971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Patients with rheumatic diseases can present with movement and other neurodegenerative disorders. It may be underappreciated that movement and other neurodegenerative disorders can encompass a wide variety of disease entities. Such disorders are strikingly heterogeneous and lead to a wider spectrum of clinical injury than seen in Parkinson's disease. Therefore, we sought to stringently phenotype movement and other neurodegenerative disorders presenting in a case series of rheumatic disease patients. We integrated our findings with a review of the literature to understand mechanisms which may account for such a ubiquitous pattern of clinical injury.Seven rheumatic disease patients (5 Sjögren's syndrome patients, 2 undifferentiated connective tissue disease patients) were referred and could be misdiagnosed as having Parkinson's disease. However, all of these patients were ultimately diagnosed as having other movement or neurodegenerative disorders. Findings inconsistent with and more expansive than Parkinson's disease included cerebellar degeneration, dystonia with an alien-limb phenomenon, and nonfluent aphasias.A notable finding was that individual patients could be affected by cooccurring movement and other neurodegenerative disorders, each of which could be exceptionally rare (ie, prevalence of ∼1:1000), and therefore with the collective probability that such disorders were merely coincidental and causally unrelated being as low as ∼1-per-billion. Whereas our review of the literature revealed that ubiquitous patterns of clinical injury were frequently associated with magnetic resonance imaging (MRI) findings suggestive of a widespread vasculopathy, our patients did not have such neuroimaging findings. Instead, our patients could have syndromes which phenotypically resembled paraneoplastic and other inflammatory disorders which are known to be associated with antineuronal antibodies. We similarly identified immune-mediated and inflammatory markers of injury in a psoriatic arthritis patient who developed an amyotrophic lateral sclerosis (ALS)-plus syndrome after tumor necrosis factor (TNF)-inhibitor therapy.We have described a diverse spectrum of movement and other neurodegenerative disorders in our rheumatic disease patients. The widespread pattern of clinical injury, the propensity of our patients to present with co-occurring movement disorders, and the lack of MRI neuroimaging findings suggestive of a vasculopathy collectively suggest unique patterns of immune-mediated injury.
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Affiliation(s)
- Rikitha Menezes
- From the Division of Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (RM); Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (AP); Division of Neuroradiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (II); and Division of Rheumatology and Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (JB)
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Zandi MS, Paterson RW, Ellul MA, Jacobson L, Al-Diwani A, Jones JL, Cox AL, Lennox B, Stamelou M, Bhatia KP, Schott JM, Coles AJ, Kullmann DM, Vincent A. Clinical relevance of serum antibodies to extracellular N-methyl-D-aspartate receptor epitopes. J Neurol Neurosurg Psychiatry 2015; 86:708-13. [PMID: 25246644 PMCID: PMC6055984 DOI: 10.1136/jnnp-2014-308736] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 08/25/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVE There are now a large number of requests for N-methyl-D-aspartate receptor autoantibody (NMDAR-Ab) tests, and it is important to assess the clinical relevance of all results, particularly when they are reported as 'Low Positive'. METHODS The clinical data of 56 patients found Positive or Low Positive by the Oxford live cell-based assay were reviewed. An autoimmune basis for the condition was assigned as 'Definite', 'Possible' or 'Unlikely'. The number of core features (encephalopathy, psychiatric, cognitive, epileptic, extrapyramidal and inflammatory cerebrospinal fluid (CSF)) was tabulated. RESULTS Twenty-five (44.6%) patients had a Definite NMDAR-Ab encephalitis (eight ovarian teratomas, one Hodgkin's lymphoma), 18 (32.1%) a Possible NMDAR-Ab encephalitis and 13 (23.2%) an Unlikely autoimmune syndrome. Serum NMDAR-Ab levels were higher in patients with tumours. Positive NMDAR-Abs were found not only in patients with three or more core features and a Definite syndrome, but also in five patients classified as Possible. Conversely, Low Positive NMDAR-Abs were present in 7 Definite cases as well as in 13 Possible cases. Unlikely patients had mainly Low Positive antibodies and fewer core features. CSF NMDAR-Abs, only available in 11 pairs and at varying time points, broadly related to serum levels and were Positive in 3/3 patients with tumours but in only 2/5 Definite patients, and none of the Possible or Unlikely cases. INTERPRETATION Using live cell-based assays, Positive and Low Positive antibodies can be of clinical significance. The number of core clinical features should help to select those patients in whom an immunotherapy intervention might be considered, irrespective of the antibody level.
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Affiliation(s)
- Michael S Zandi
- Department of Clinical Neurosciences, Addenbrooke's Hospital, Cambridge, UK National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK
| | - Ross W Paterson
- National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK
| | - Mark A Ellul
- Department of Clinical Neurosciences, Addenbrooke's Hospital, Cambridge, UK
| | - Leslie Jacobson
- Neurosciences Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Adam Al-Diwani
- Neurosciences Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Joanne L Jones
- Department of Clinical Neurosciences, Addenbrooke's Hospital, Cambridge, UK
| | - Amanda L Cox
- Department of Clinical Neurosciences, Addenbrooke's Hospital, Cambridge, UK
| | - Belinda Lennox
- Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Maria Stamelou
- National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK
| | - Kailash P Bhatia
- National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK
| | - Jonathan M Schott
- National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK
| | - Alasdair J Coles
- Department of Clinical Neurosciences, Addenbrooke's Hospital, Cambridge, UK
| | - Dimitri M Kullmann
- National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK
| | - Angela Vincent
- National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK Neurosciences Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
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237
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Ding H, Jian Z, Stary CM, Yi W, Xiong X. Molecular Pathogenesis of Anti-NMDAR Encephalitis. BIOMED RESEARCH INTERNATIONAL 2015; 2015:643409. [PMID: 26221602 PMCID: PMC4499418 DOI: 10.1155/2015/643409] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Accepted: 04/20/2015] [Indexed: 01/17/2023]
Abstract
Anti-NMDAR encephalitis is a recently identified autoimmune disease, described by an immune-mediated loss of NMDA glutamate receptors, resulting in progressive mental deterioration. To date, literature on anti-NMDAR encephalitis has been largely clinically oriented, including descriptions of the clinical presentation and course, diagnostic methods, and potential clinical treatments. However, the underlying molecular mechanisms contributing to the complex immunological cellular transformation that is associated with the progression of anti-NMDAR encephalitis remain to be adequately explored. This review will provide a summary of the current literature on anti-NMDAR encephalitis, including the immunologic molecular mechanisms contributing to disease progression. In particular this review will focus on the effect of anti-NMDAR on GluN2-NMDAR expression and the molecular transformation of B and T leukocytes in the loss of self-tolerance. Further research on the immunologic mechanisms contributing to anti-NMDAR encephalitis may provide an avenue for future novel diagnostic approaches, such as immunologic surveillance, as well as new therapeutic strategies for this recently identified autoimmune disease.
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Affiliation(s)
- Hao Ding
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, China
| | - Zhihong Jian
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, China
| | - Creed M. Stary
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Wei Yi
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, China
| | - Xiaoxing Xiong
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, China
- Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, China
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Spatola M, Novy J, Du Pasquier R, Dalmau J, Rossetti AO. Status epilepticus of inflammatory etiology: a cohort study. Neurology 2015; 85:464-70. [PMID: 26092915 DOI: 10.1212/wnl.0000000000001717] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 04/01/2015] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Inflammation-related epilepsy is increasingly recognized; however, studies on status epilepticus (SE) are very infrequent. We therefore aimed to determine the frequency of inflammatory etiologies in adult SE, and to assess related demographic features and outcomes. METHODS This was a retrospective analysis of a prospective registry of adult patients with SE treated in our center, from January 2008 to June 2014, excluding postanoxic causes. We classified SE episodes into 3 etiologic categories: infectious, autoimmune, and noninflammatory. Demographic and clinical variables were analyzed regarding their relationship to etiologies and functional outcome. RESULTS Among the 570 SE consecutive episodes, 33 (6%) were inflammatory (2.5% autoimmune; 3.3% infectious), without any change in frequency over the study period. Inflammatory SE episodes involved younger patients (mean age 53 vs 61 years, p = 0.015) and were more often refractory to initial antiepileptic treatment (58% vs 38%, odds ratio = 2.19, 95% confidence interval = 1.07-4.47, p = 0.041), despite similar clinical outcome. Subgroup analysis showed that, compared with infectious SE episodes, autoimmune SE involved younger adults (mean age 44 vs 60 years, p = 0.017) and was associated with lower morbidity (return to baseline conditions in 71% vs 32%, odds ratio = 5.41, 95% confidence interval = 1.19-24.52, p = 0.043) without any difference in mortality. CONCLUSIONS Despite increasing awareness, inflammatory SE etiologies were relatively rare; their occurrence in younger individuals and higher refractoriness to treatment did not have any effect on outcome. Autoimmune SE episodes also occurred in younger patients, but tended to have better outcomes in survivors than infectious SE.
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Affiliation(s)
- Marianna Spatola
- From the Service of Neurology (M.S., J.N., R.D.P., A.O.R.), Department of Clinical Neurosciences, CHUV and University of Lausanne, Switzerland; IDIBAPS and Service of Neurology (J.D.), Hospital Clinic, University of Barcelona, Spain; and Department of Neurology (J.D.), University of Pennsylvania, Philadelphia
| | - Jan Novy
- From the Service of Neurology (M.S., J.N., R.D.P., A.O.R.), Department of Clinical Neurosciences, CHUV and University of Lausanne, Switzerland; IDIBAPS and Service of Neurology (J.D.), Hospital Clinic, University of Barcelona, Spain; and Department of Neurology (J.D.), University of Pennsylvania, Philadelphia
| | - Renaud Du Pasquier
- From the Service of Neurology (M.S., J.N., R.D.P., A.O.R.), Department of Clinical Neurosciences, CHUV and University of Lausanne, Switzerland; IDIBAPS and Service of Neurology (J.D.), Hospital Clinic, University of Barcelona, Spain; and Department of Neurology (J.D.), University of Pennsylvania, Philadelphia
| | - Josep Dalmau
- From the Service of Neurology (M.S., J.N., R.D.P., A.O.R.), Department of Clinical Neurosciences, CHUV and University of Lausanne, Switzerland; IDIBAPS and Service of Neurology (J.D.), Hospital Clinic, University of Barcelona, Spain; and Department of Neurology (J.D.), University of Pennsylvania, Philadelphia
| | - Andrea O Rossetti
- From the Service of Neurology (M.S., J.N., R.D.P., A.O.R.), Department of Clinical Neurosciences, CHUV and University of Lausanne, Switzerland; IDIBAPS and Service of Neurology (J.D.), Hospital Clinic, University of Barcelona, Spain; and Department of Neurology (J.D.), University of Pennsylvania, Philadelphia.
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239
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Sinmaz N, Amatoury M, Merheb V, Ramanathan S, Dale RC, Brilot F. Autoantibodies in movement and psychiatric disorders: updated concepts in detection methods, pathogenicity, and CNS entry. Ann N Y Acad Sci 2015; 1351:22-38. [DOI: 10.1111/nyas.12764] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Nese Sinmaz
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Mazen Amatoury
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Vera Merheb
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Sudarshini Ramanathan
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Russell C. Dale
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
- Discipline of Paediatrics and Child Health; Sydney Medical School, University of Sydney; Sydney Australia
| | - Fabienne Brilot
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
- Discipline of Paediatrics and Child Health; Sydney Medical School, University of Sydney; Sydney Australia
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Abstract
PURPOSE OF REVIEW This article provides an approach to the recognition and management of paraneoplastic neuropathies. RECENT FINDINGS Paraneoplastic neuropathies may have unique phenotypic presentations, such as sensory neuronopathy, autonomic enteric neuropathy, demyelinating neuropathy, and, rarely, motor neuropathy. Paraneoplastic sensorimotor neuropathy, on the other hand, may be indistinguishable from other common types of axonal polyneuropathy. Certain patterns of neuropathies are commonly seen with different types of cancers, but this relationship is not exclusive and not all patients whose pattern of neuropathy suggests a paraneoplastic disorder have an underlying cancer. In addition to definitive therapy for malignancy, immunomodulatory therapy, such as corticosteroids, IV immunoglobulin (IVIg), or immunosuppressants, may benefit some patients, but there are very few published treatment data for paraneoplastic neuropathies. SUMMARY Prompt recognition of paraneoplastic neuropathies may lead to identification and treatment of an occult cancer. Treatment can potentially arrest the progression of neuropathy.
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241
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Abstract
Antibody-mediated diseases of the central nervous system are a relatively new and challenging field in autoimmune neurologic disease and of major clinical importance in children and adults. The antibodies bind to cell-surface epitopes on neuronal or glial proteins, and the patients demonstrate either focal or more generalized clinical signs depending on the extent of brain regions targeted by the antibodies. The presence of seizures, movement disorders, autonomic dysfunction and sleep disorders, alongside neuroimaging and electrophysiological features may indicate a specific antibody-mediated disorder. However, phenotypic variation may be observed in children with the same antibody. Regardless, many patients benefit from immunotherapy with substantial improvement.
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Affiliation(s)
- Ming Lim
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Level 6, West Wing, Oxford 3 9DU, UK; Children's Neurosciences, Evelina Children's Hospital @ Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, Lambeth Palace Road, London SE1 7EH, UK.
| | - Yael Hacohen
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Level 6, West Wing, Oxford 3 9DU, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Level 6, West Wing, Oxford 3 9DU, UK.
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242
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Affiliation(s)
- Maxwell Greene
- Department of Neurology, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric Lancaster
- Department of Neurology, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
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243
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Wright S, Hacohen Y, Jacobson L, Agrawal S, Gupta R, Philip S, Smith M, Lim M, Wassmer E, Vincent A. N-methyl-D-aspartate receptor antibody-mediated neurological disease: results of a UK-based surveillance study in children. Arch Dis Child 2015; 100:521-6. [PMID: 25637141 PMCID: PMC4453622 DOI: 10.1136/archdischild-2014-306795] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 10/31/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE N-methyl-D-aspartate receptor antibody (NMDAR-Ab) encephalitis is a well-recognised clinico-immunological syndrome that presents with neuropsychiatric symptoms cognitive decline, movement disorder and seizures. This study reports the clinical features, management and neurological outcomes of paediatric NMDAR-Ab-mediated neurological disease in the UK. DESIGN A prospective surveillance study. Children with NMDAR-Ab-mediated neurological diseases were voluntarily reported to the British Neurological Surveillance Unit (BPNSU) from November 2010 to December 2011. Initial and follow-up questionnaires were sent out to physicians. RESULTS Thirty-one children fulfilled the criteria for the study. Eight presented during the study period giving an incidence of 0.85 per million children per year (95% CI 0.64 to 1.06); 23 cases were historical. Behavioural change and neuropsychiatric features were present in 90% of patients, and seizures and movement disorders both in 67%. Typical NMDAR-Ab encephalitis was reported in 24 children and partial phenotype without encephalopathy in seven, including predominantly psychiatric (four) and movement disorder (three). All patients received steroids, 22 (71%) received intravenous immunoglobulin, 9 (29%) received plasma exchange,and 10 (32%) received second-line immunotherapy. Of the 23 patients who were diagnosed early, 18 (78%) made a full recovery compared with only 1 of 8 (13%) of the late diagnosed patients (p=0.002, Fisher's exact test). Seven patients relapsed, with four needing additional second-line immunotherapy. CONCLUSIONS Paediatric NMDAR-Ab-mediated neurological disease appears to be similar to adult NMDAR-Ab encephalitis, but some presented with a partial phenotype. Early treatment was associated with a quick and often full recovery.
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Affiliation(s)
- Sukhvir Wright
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK,Department of Paediatric Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Yael Hacohen
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Leslie Jacobson
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Shakti Agrawal
- Department of Paediatric Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Rajat Gupta
- Department of Paediatric Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Sunny Philip
- Department of Paediatric Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Martin Smith
- Department of Paediatric Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Ming Lim
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK,Children's Neurosciences, Evelina Children's Hospital @ Guy's and St Thomas’ NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - Evangeline Wassmer
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
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244
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Rossi M, Mead S, Collinge J, Rudge P, Vincent A. Neuronal antibodies in patients with suspected or confirmed sporadic Creutzfeldt-Jakob disease. J Neurol Neurosurg Psychiatry 2015; 86:692-4. [PMID: 25246643 PMCID: PMC4453627 DOI: 10.1136/jnnp-2014-308695] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 08/14/2014] [Accepted: 08/31/2014] [Indexed: 01/28/2023]
Abstract
OBJECTIVES There have been reports of patients with antibodies to neuronal antigens misdiagnosed as sporadic Creutzfeldt-Jakob disease (sCJD). Conversely, low levels of antibodies to neuronal proteins have been reported in patients with sCJD. However, the frequency of misdiagnoses, or of antibodies in patients with subsequently confirmed sCJD, is not clear. METHODS We reviewed 256 consecutive cases of sCJD seen in the National Prion Clinic, of whom 150 had sera previously referred for selected antibody tests. Eighty-two available samples were retested for antibodies to N-methyl-d-aspartate receptor (NMDAR), the glycine receptor (GlyR), voltage-gated potassium channel (VGKC)-complex and the associated proteins, leucine-rich glioma inactivated 1 (LGI1) and contactin-associated protein 2 (CASPR2). RESULTS Four of the initial 150 sera referred were positive; two had antibodies to NMDAR, and two to the VGKC-complex, one of which was also positive for GlyR antibodies. Of the 82 sCJD sera retested, one had VGKC-complex antibodies confirming the previous result, two had CASPR2 and GlyR antibodies and one had CASPR2 and NMDAR antibodies; all antibodies were at low levels. Over the same period three patients with autoimmune encephalitis and high VGKC-complex antibodies were initially referred as sCJD. CONCLUSIONS This study indicates that <5% patients with sCJD develop serum antibodies to these neuronal antigens and, when positive, only at low titres. By contrast, three patients referred with possible prion disease had a clinical picture in keeping with autoimmune encephalitis and very high VGKC-complex/LGI1 antibodies. Low titres of neuronal antibodies occur only rarely in suspected patients with sCJD and when present should be interpreted with caution.
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Affiliation(s)
- Meghan Rossi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Simon Mead
- NHS National Prion Clinic, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, London, UK
- MRC Prion Unit, Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
| | - John Collinge
- NHS National Prion Clinic, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, London, UK
- MRC Prion Unit, Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
| | - Peter Rudge
- NHS National Prion Clinic, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, London, UK
- MRC Prion Unit, Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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245
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Segovia-Miranda F, Serrano F, Dyrda A, Ampuero E, Retamal C, Bravo-Zehnder M, Parodi J, Zamorano P, Valenzuela D, Massardo L, van Zundert B, Inestrosa NC, González A. Pathogenicity of Lupus Anti-Ribosomal P Antibodies: Role of Cross-Reacting Neuronal Surface P Antigen in Glutamatergic Transmission and Plasticity in a Mouse Model. Arthritis Rheumatol 2015; 67:1598-610. [DOI: 10.1002/art.39081] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 02/12/2015] [Indexed: 12/25/2022]
Affiliation(s)
| | - Felipe Serrano
- Pontificia Universidad Católica de Chile; Santiago Chile
| | | | | | | | | | | | - Pedro Zamorano
- Pontificia Universidad Católica de Chile; Santiago Chile
| | | | | | | | - Nibaldo C. Inestrosa
- Pontificia Universidad Católica de Chile, Santiago, Chile, and Universidad de Magallanes; Punta Arenas Chile
| | - Alfonso González
- Pontificia Universidad Católica de Chile, Santiago, Chile, and Universidad de Magallanes; Punta Arenas Chile
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246
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Zekeridou A, Karantoni E, Viaccoz A, Ducray F, Gitiaux C, Villega F, Deiva K, Rogemond V, Mathias E, Picard G, Tardieu M, Antoine JC, Delattre JY, Honnorat J. Treatment and outcome of children and adolescents with N-methyl-d-aspartate receptor encephalitis. J Neurol 2015; 262:1859-66. [DOI: 10.1007/s00415-015-7781-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 05/06/2015] [Accepted: 05/08/2015] [Indexed: 01/03/2023]
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247
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Suleiman J, Dale RC. The recognition and treatment of autoimmune epilepsy in children. Dev Med Child Neurol 2015; 57:431-40. [PMID: 25483277 DOI: 10.1111/dmcn.12647] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2014] [Indexed: 01/07/2023]
Abstract
There is emerging interest in autoimmune epilepsy, which represents a small but potentially treatable form of epilepsy. Most insights into autoimmune epilepsy derive from the recent descriptions of autoimmune encephalitis that takes two general forms: a focal encephalitis (such as limbic) or a diffuse encephalitis (such as anti-N-methyl-D-aspartate receptor [NMDAR] encephalitis). The features of autoimmune epilepsy include acute or subacute onset of seizures, usually in the context of encephalopathy, and inflammation of the central nervous system on testing cerebrospinal fluid or magnetic resonance imaging. Neuronal antibodies associated with autoimmune encephalitis and seizures in children include NMDAR, voltage-gated potassium channel complex, glycine receptor, γ-Aminobutyric acid type A receptor (GABA(A)R), γ-Aminobutyric acid type B receptor (GABA(B)R), and glutamic acid decarboxylase antibodies. These antibodies support the diagnosis of autoimmune epilepsy, but are not essential for diagnosis. When autoimmune epilepsy is suspected, first-line immune therapy with corticosteroids in addition to intravenous immunoglobulin or plasma exchange should be considered. Second-line therapy with rituximab or cyclophosphamide can be considered if the syndrome is severe. A response to immune therapy supports the diagnosis of autoimmune epilepsy. Neuronal antibodies are increasingly found in patients with focal epilepsy of unknown cause who do not have 'encephalitis'. Recent epidemiological studies support the link between epilepsy and autoimmune diseases. Future studies need to define the spectrum of autoimmune epilepsy and focus on early identification and treatment.
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Affiliation(s)
- Jehan Suleiman
- Department of Paediatrics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates; Paediatrics and Child Health Discipline, Clinical School, The Children's Hospital at Westmead, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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248
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Abstract
Paraneoplastic disorders of the nervous system (PNDs) are rare and unique disorders, where a specific pattern of neural damage occurs as a side effect of the interaction between the neoplasm and the host immune response. Clinical recognition of PNDs may be challenging but can lead to early detection of an occult neoplasm. Their study may lead to a better understanding of nervous system autoimmunity and even to devising novel immunotherapies against certain tumor types. Familiarity with the clinical syndromes, neuroradiological findings, autoantibodies, and tissue responses associated with PND may help arrive at a correct diagnosis in most cases.
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Affiliation(s)
- S Humayun Gultekin
- Department of Pathology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
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249
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Honnorat J. Early-onset immunotherapy by intravenous immunoglobulin and corticosteroids in well characterized onconeural-antibody-positive paraneoplastic neurological syndrome. Clin Exp Immunol 2015; 178 Suppl 1:127-9. [PMID: 25546790 DOI: 10.1111/cei.12539] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- J Honnorat
- Neuro-Oncologie, Hôpital Neurologique Pierre Wertheimer, Lyon, France
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250
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Rosenfeld MR. Antibody-mediated central nervous system diseases: disease recognition and treatment challenges. Clin Exp Immunol 2015; 178 Suppl 1:30-2. [PMID: 25546752 DOI: 10.1111/cei.12501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- M R Rosenfeld
- IDIBAPS/Hospital Clinic, Barcelona, Spain; University of Pennsylvania, Philadelphia, PA, USA
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