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Abstract
PURPOSE OF REVIEW To describe the clinical, laboratory, and MRI features that characterize cognitive decline in the setting of central nervous system (CNS) autoimmunity, and provide an overview of current treatment modalities. RECENT FINDINGS The field of autoimmune neurology is rapidly expanding due to the increasing number of newly discovered autoantibodies directed against specific CNS targets. The clinical syndromes associated with these autoantibodies are heterogeneous but frequently share common, recognizable clinical, and MRI characteristics. While the detection of certain autoantibodies strongly suggest the presence of an underlying malignancy (onconeural autoantibodies), a large proportion of cases remain idiopathic. Cognitive decline and encephalopathy are common manifestations of CNS autoimmunity, and can mimic neurodegenerative disorders. Recent findings suggest that the frequency of autoimmune encephalitis in the population is higher than previously thought, and potentially rivals that of infectious encephalitis. Moreover, emerging clinical scenarios that may predispose to CNS autoimmunity are increasingly been recognized. These include autoimmune dementia/encephalitis post-herpes simplex virus encephalitis, post-transplant and in association with immune checkpoint inhibitor treatment of cancer. Early recognition of autoimmune cognitive impairment is important given the potential for reversibility and disability prevention with appropriate treatment. Autoimmune cognitive impairment is treatable and may arise in a number of different clinical settings, with important treatment implications. Several clinical and para-clinical clues may help to differentiate these disorders from dementia of other etiologies.
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Affiliation(s)
- Elia Sechi
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. .,Department Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
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302
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Dash D, Pandey S. Movement disorders associated with neuronal antibodies. Acta Neurol Scand 2019; 139:106-117. [PMID: 30338517 DOI: 10.1111/ane.13039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 10/12/2018] [Accepted: 10/13/2018] [Indexed: 12/28/2022]
Abstract
Movement disorders are one of the common clinical features of neurological disease associated with neuronal antibodies which is a group of potentially reversible disorder. They can present with hypokinetic or hyperkinetic types of involuntary movements and may have other associated neurological symptoms. The spectrum of abnormal movements associated with neuronal antibodies is widening. Some specific phenomenology of movement disorders are likely to give clue about the type of antibody, for instance, presence of paroxysmal dystonia (facio-brachial dystonic seizures) are a pointer toward presence of LGI-1 antibodies, and orofacial lingual dyskinesia is associated with NMDAR associated encephalitis. The presence of specific type of movement disorder allows high suspicion of testing of certain specific type of antibodies. In this review, we have discussed the various antibodies and the spectrum of movement disorder associated with them, highlighting if any distinct movement disorder allows the clinician to suspect type of antibody in a certain clinical context. We have also reviewed the treatment of the movement disorder associated with the neuronal antibodies. Physicians should have high index of suspicion of these disorders, as early institution of treatment options can lead to better outcome.
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Affiliation(s)
- Deepa Dash
- Department of Neurology; All India Institute of Medical Sciences; New Delhi India
| | - Sanjay Pandey
- Department of Neurology; Govind Ballabh Pant Postgraduate Institute of Medical Education and Research; New Delhi India
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303
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Magnetic resonance imaging in immune-mediated myelopathies. J Neurol 2019; 267:1233-1244. [PMID: 30694379 DOI: 10.1007/s00415-019-09206-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 01/15/2019] [Accepted: 01/18/2019] [Indexed: 10/27/2022]
Abstract
Immune-mediated myelopathies are a heterogeneous group of inflammatory spinal cord disorders including autoimmune disorders with known antibodies, e.g. aquaporin-4 IgG channelopathy or anti-myelin oligodendrocyte glycoprotein-associated myelitis, myelopathies in the context of multiple sclerosis and systemic autoimmune disorders with myelopathy, as well as post-infectious and paraneoplastic myelopathies. Although magnetic resonance imaging of the spinal cord is still challenging due to the small dimension of the cord cross-section and frequent movement and susceptibility artifacts, recent methodological advances have led to improved diagnostic evaluation and characterization of immune-mediated myelopathies. Topography, length and width of the lesion, gadolinium enhancement pattern, and changes in morphology over time help in narrowing the broad differential diagnosis. In this review, we give an overview of recent advances in magnetic resonance imaging of immune-mediated myelopathies and its role in the differential diagnosis and monitoring of this heterogeneous group of disorders.
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304
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Affiliation(s)
- Elia Sechi
- Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA/Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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305
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Ciron J, Sourdrille F, Biotti D, Tchoumi T, Ruiz A, Bernard-Valnet R, Maubeuge N, Marignier R. Area postrema syndrome: Another feature of anti-GFAP encephalomyelitis. Mult Scler 2019; 26:253-255. [DOI: 10.1177/1352458518817992] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Anti–Glial fibrillary acidic protein (GFAP) encephalomyelitis is a recently described entity and while the spectrum of this disease has been explored, further research is needed to fully describe its phenotype. Area postrema syndrome (APS) is usually associated with neuromyelitis optica spectrum disorders (NMOSDs), whereas no case of APS has been previously reported with anti-GFAP encephalomyelitis. In this article, we report a case of APS in a 41-year-old woman in the context of anti-GFAP encephalomyelitis. This case was not associated with additional anti-AQP4 IgG and therefore extends the clinico-radiological spectrum of anti-GFAP encephalomyelitis.
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Affiliation(s)
- Jonathan Ciron
- Department of Neurology, University Hospital of Toulouse, Toulouse, France
- Department of Neurology, University Hospital of Poitiers, Poitiers, France
| | - Fanny Sourdrille
- Department of Neurology, University Hospital of Poitiers, Poitiers, France
| | - Damien Biotti
- Department of Neurology, University Hospital of Toulouse, Toulouse, France
| | - Thierry Tchoumi
- Department of Neurology, Hospital of Saintonge, Saintes, France
| | - Anne Ruiz
- Lyon Neuroscience Research Center, Lyon, France
| | | | - Nicolas Maubeuge
- Department of Neurology, University Hospital of Poitiers, Poitiers, France
| | - Romain Marignier
- Lyon Neuroscience Research Center, Lyon, France
- Department of Neurology, University Hospital of Lyon, Lyon, France
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306
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Xie L, Liu T, Yao H, Wu L, Qiu W, Chen B, Liu S, Huang Q, Yang H, Xu H, Long Y, Gao C. Autoimmune inflammatory meningoencephalitis in a patient negative for glial fibrillary acidic protein-specific immunoglobulin G. Mult Scler Relat Disord 2018; 28:167-171. [PMID: 30605794 DOI: 10.1016/j.msard.2018.12.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 11/08/2018] [Accepted: 12/28/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND In this study, we describe clinical findings in a patient with autoimmune inflammatory meningoencephalitis who was negative for antibodies against glial fibrillary acidic protein (GFAP-IgG). METHODS Serum and cerebral spinal fluid (CSF) samples were collected from the patient as part of a study of 520 patients with neurological syndromes. Antibodies against GFAP and other proteins associated with neurological disorders were measured by rat brain- and cell-based indirect immunofluorescence assays. RESULTS A 42-year-old female was diagnosed with autoimmune inflammatory meningoencephalitis. She experienced a subacute and relapsing course with decreased vision, fever, headache, ataxia, hemiplegia, and disturbance of consciousness. Brain magnetic resonance imaging showed extensive lesions in the white matter along the ventricle, brainstem, right internal capsule, and meninges. The patient responded well to steroid treatment. Examination of CSF revealed a normal white blood cell count and protein level. Serum and CSF were negative for GFAP-specific antibodies and all other autoantibodies tested. Immunohistochemical staining of a brain biopsy collected during relapse revealed chronic inflammation and severe edema. Extensive and strong staining of CD163+ macrophages were evident throughout the lesions; however, CD3+ cells were rare and CD138+ and CD20+ cells were absent. CONCLUSION We describe a case of subacute corticosteroid-responsive nonvasculitic autoimmune inflammatory meningoencephalitis in the absence of GFAP-IgG. The pathological features were distinct from those of patients with GFAP-IgG-positive meningoencephalitis, suggesting that nonvasculitic autoimmune inflammatory meningoencephalitis is a heterogeneous neurological syndrome.
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Affiliation(s)
- Longchang Xie
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
| | - Tianni Liu
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
| | - Haiyan Yao
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
| | - Linzhan Wu
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Guangzhou Medical University, 63# Duobao Road, Guangzhou 510150, China
| | - Baikeng Chen
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
| | - Si Liu
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
| | - Qingmei Huang
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
| | - Huacai Yang
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
| | - Huiming Xu
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
| | - Youming Long
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China.
| | - Cong Gao
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
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Bradshaw MJ, Lisak RP, Meltzer E, Melamed E, Lucas A, Freeman L, Frohman TC, Costello K, Balcer L, Galetta S, Chitnis T, Zamvil SS, Frohman EM. A young man in "double-trouble": Hallucinations and cranial nerve palsies: From the National Multiple Sclerosis Society Case Conference Proceedings. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2018; 6:e526. [PMID: 30637300 PMCID: PMC6310360 DOI: 10.1212/nxi.0000000000000526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 10/23/2018] [Indexed: 01/17/2023]
Affiliation(s)
- Michael J Bradshaw
- Partners Multiple Sclerosis Center (M.J.B., T.C.), Brigham and Women's Hospital; Massachusetts General Hospital (M.J.B., T.C.); Harvard Medical School (M.J.B., T.C.), Boston, MA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E. Meltzer, E. Melamed, A.L.), Dell Medical School at the University of Texas at Austin; Department of Neurology (L.F.), McGovern Medical School at UT Health, Houston; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; Departments of Neurology (L.B., S.G.), Population Health and Ophthalmology, New York University School of Medicine; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Robert P Lisak
- Partners Multiple Sclerosis Center (M.J.B., T.C.), Brigham and Women's Hospital; Massachusetts General Hospital (M.J.B., T.C.); Harvard Medical School (M.J.B., T.C.), Boston, MA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E. Meltzer, E. Melamed, A.L.), Dell Medical School at the University of Texas at Austin; Department of Neurology (L.F.), McGovern Medical School at UT Health, Houston; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; Departments of Neurology (L.B., S.G.), Population Health and Ophthalmology, New York University School of Medicine; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Ethan Meltzer
- Partners Multiple Sclerosis Center (M.J.B., T.C.), Brigham and Women's Hospital; Massachusetts General Hospital (M.J.B., T.C.); Harvard Medical School (M.J.B., T.C.), Boston, MA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E. Meltzer, E. Melamed, A.L.), Dell Medical School at the University of Texas at Austin; Department of Neurology (L.F.), McGovern Medical School at UT Health, Houston; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; Departments of Neurology (L.B., S.G.), Population Health and Ophthalmology, New York University School of Medicine; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Esther Melamed
- Partners Multiple Sclerosis Center (M.J.B., T.C.), Brigham and Women's Hospital; Massachusetts General Hospital (M.J.B., T.C.); Harvard Medical School (M.J.B., T.C.), Boston, MA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E. Meltzer, E. Melamed, A.L.), Dell Medical School at the University of Texas at Austin; Department of Neurology (L.F.), McGovern Medical School at UT Health, Houston; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; Departments of Neurology (L.B., S.G.), Population Health and Ophthalmology, New York University School of Medicine; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Ashlea Lucas
- Partners Multiple Sclerosis Center (M.J.B., T.C.), Brigham and Women's Hospital; Massachusetts General Hospital (M.J.B., T.C.); Harvard Medical School (M.J.B., T.C.), Boston, MA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E. Meltzer, E. Melamed, A.L.), Dell Medical School at the University of Texas at Austin; Department of Neurology (L.F.), McGovern Medical School at UT Health, Houston; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; Departments of Neurology (L.B., S.G.), Population Health and Ophthalmology, New York University School of Medicine; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Leorah Freeman
- Partners Multiple Sclerosis Center (M.J.B., T.C.), Brigham and Women's Hospital; Massachusetts General Hospital (M.J.B., T.C.); Harvard Medical School (M.J.B., T.C.), Boston, MA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E. Meltzer, E. Melamed, A.L.), Dell Medical School at the University of Texas at Austin; Department of Neurology (L.F.), McGovern Medical School at UT Health, Houston; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; Departments of Neurology (L.B., S.G.), Population Health and Ophthalmology, New York University School of Medicine; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Teresa C Frohman
- Partners Multiple Sclerosis Center (M.J.B., T.C.), Brigham and Women's Hospital; Massachusetts General Hospital (M.J.B., T.C.); Harvard Medical School (M.J.B., T.C.), Boston, MA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E. Meltzer, E. Melamed, A.L.), Dell Medical School at the University of Texas at Austin; Department of Neurology (L.F.), McGovern Medical School at UT Health, Houston; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; Departments of Neurology (L.B., S.G.), Population Health and Ophthalmology, New York University School of Medicine; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Kathleen Costello
- Partners Multiple Sclerosis Center (M.J.B., T.C.), Brigham and Women's Hospital; Massachusetts General Hospital (M.J.B., T.C.); Harvard Medical School (M.J.B., T.C.), Boston, MA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E. Meltzer, E. Melamed, A.L.), Dell Medical School at the University of Texas at Austin; Department of Neurology (L.F.), McGovern Medical School at UT Health, Houston; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; Departments of Neurology (L.B., S.G.), Population Health and Ophthalmology, New York University School of Medicine; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Laura Balcer
- Partners Multiple Sclerosis Center (M.J.B., T.C.), Brigham and Women's Hospital; Massachusetts General Hospital (M.J.B., T.C.); Harvard Medical School (M.J.B., T.C.), Boston, MA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E. Meltzer, E. Melamed, A.L.), Dell Medical School at the University of Texas at Austin; Department of Neurology (L.F.), McGovern Medical School at UT Health, Houston; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; Departments of Neurology (L.B., S.G.), Population Health and Ophthalmology, New York University School of Medicine; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Steven Galetta
- Partners Multiple Sclerosis Center (M.J.B., T.C.), Brigham and Women's Hospital; Massachusetts General Hospital (M.J.B., T.C.); Harvard Medical School (M.J.B., T.C.), Boston, MA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E. Meltzer, E. Melamed, A.L.), Dell Medical School at the University of Texas at Austin; Department of Neurology (L.F.), McGovern Medical School at UT Health, Houston; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; Departments of Neurology (L.B., S.G.), Population Health and Ophthalmology, New York University School of Medicine; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Tanuja Chitnis
- Partners Multiple Sclerosis Center (M.J.B., T.C.), Brigham and Women's Hospital; Massachusetts General Hospital (M.J.B., T.C.); Harvard Medical School (M.J.B., T.C.), Boston, MA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E. Meltzer, E. Melamed, A.L.), Dell Medical School at the University of Texas at Austin; Department of Neurology (L.F.), McGovern Medical School at UT Health, Houston; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; Departments of Neurology (L.B., S.G.), Population Health and Ophthalmology, New York University School of Medicine; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Scott S Zamvil
- Partners Multiple Sclerosis Center (M.J.B., T.C.), Brigham and Women's Hospital; Massachusetts General Hospital (M.J.B., T.C.); Harvard Medical School (M.J.B., T.C.), Boston, MA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E. Meltzer, E. Melamed, A.L.), Dell Medical School at the University of Texas at Austin; Department of Neurology (L.F.), McGovern Medical School at UT Health, Houston; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; Departments of Neurology (L.B., S.G.), Population Health and Ophthalmology, New York University School of Medicine; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Elliot M Frohman
- Partners Multiple Sclerosis Center (M.J.B., T.C.), Brigham and Women's Hospital; Massachusetts General Hospital (M.J.B., T.C.); Harvard Medical School (M.J.B., T.C.), Boston, MA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E. Meltzer, E. Melamed, A.L.), Dell Medical School at the University of Texas at Austin; Department of Neurology (L.F.), McGovern Medical School at UT Health, Houston; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; Departments of Neurology (L.B., S.G.), Population Health and Ophthalmology, New York University School of Medicine; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
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308
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Shan F, Long Y, Qiu W. Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy: A Review of the Literature. Front Immunol 2018; 9:2802. [PMID: 30568655 PMCID: PMC6290896 DOI: 10.3389/fimmu.2018.02802] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/13/2018] [Indexed: 11/13/2022] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is an autoimmune disease of the nervous system first defined in 2016. GFAP autoantibody, especially IgG that binds to GFAPα, has been reported in the cerebrospinal fluid (CSF) and serum of patients with GFAP astrocytopathy. The positive predictive value of GFAP antibody in the CSF is higher than in the serum. Tissue-based assay (TBA) and cell-based assay (CBA) are both recommended methods for the detection of GFAP antibody. GFAP astrocytopathy is accompanied by neoplasms, but the relationship between virus infection and GFAP astrocytopathy is unclear. GFAP antibody itself does not induce pathological changes; it is only a biomarker for the process of immune inflammation. The pathology of GFAP astrocytopathy in humans is heterogeneous. GFAP astrocytopathy is commonly diagnosed in individuals over 40 years old and most patients have an acute or subacute onset. Clinical manifestations include fever, headache, encephalopathy, involuntary movement, myelitis, and abnormal vision. Lesions involve the subcortical white matter, basal ganglia, hypothalamus, brainstem, cerebellum, and spinal cord. The characteristic MRI feature is brain linear perivascular radial gadolinium enhancement in the white matter perpendicular to the ventricle. Currently, there are no uniform diagnostic criteria or consensus for GFAP astrocytopathy and coexisting neural autoantibodies detected in the same patient make the diagnosis difficult. A standard treatment regimen is yet to be developed. Most GFAP astrocytopathy patients respond well to steroid therapy although some patients are prone to relapse or even die.
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Affiliation(s)
- Fulan Shan
- Department of Neurology, Zengcheng District People's Hospital of Guangzhou, Guangzhou, China
| | - Youming Long
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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309
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Levy M, Giovannoni G, Hawkes C, Waubant E. Refining the Nosology of Antigen-Specific Diseases Within the Spectrum of Neuromyelitis Optica. Mult Scler Relat Disord 2018; 25:A1-A2. [PMID: 30384960 DOI: 10.1016/j.msard.2018.09.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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310
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Borisow N, Mori M, Kuwabara S, Scheel M, Paul F. Diagnosis and Treatment of NMO Spectrum Disorder and MOG-Encephalomyelitis. Front Neurol 2018; 9:888. [PMID: 30405519 PMCID: PMC6206299 DOI: 10.3389/fneur.2018.00888] [Citation(s) in RCA: 164] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 10/01/2018] [Indexed: 12/21/2022] Open
Abstract
Neuromyelitis optica spectrum disorders (NMOSD) are autoantibody mediated chronic inflammatory diseases. Serum antibodies (Abs) against the aquaporin-4 water channel lead to recurrent attacks of optic neuritis, myelitis and/or brainstem syndromes. In some patients with symptoms of NMOSD, no AQP4-Abs but Abs against myelin-oligodendrocyte-glycoprotein (MOG) are detectable. These clinical syndromes are now frequently referred to as "MOG-encephalomyelitis" (MOG-EM). Here we give an overview on current recommendations concerning diagnosis of NMOSD and MOG-EM. These include antibody and further laboratory testing, MR imaging and optical coherence tomography. We discuss therapeutic options of acute attacks as well as longterm immunosuppressive treatment, including azathioprine, rituximab, and immunoglobulins.
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Affiliation(s)
- Nadja Borisow
- NeuroCure Clinical Research Center, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Masahiro Mori
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Michael Scheel
- NeuroCure Clinical Research Center, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neuroradiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Friedemann Paul
- NeuroCure Clinical Research Center, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité – Universitätsmedizin Berlin, Berlin, Germany
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Ricken G, Schwaiger C, De Simoni D, Pichler V, Lang J, Glatter S, Macher S, Rommer PS, Scholze P, Kubista H, Koneczny I, Höftberger R. Detection Methods for Autoantibodies in Suspected Autoimmune Encephalitis. Front Neurol 2018; 9:841. [PMID: 30364136 PMCID: PMC6191500 DOI: 10.3389/fneur.2018.00841] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 09/18/2018] [Indexed: 12/11/2022] Open
Abstract
This review provides an overview on different antibody test methods that can be applied in cases of suspected paraneoplastic neurological syndromes (PNS) and anti-neuronal autoimmune encephalitis (AIE) in order to explain their diagnostic value, describe potential pitfalls and limitations, and discuss novel approaches aimed at discovering further autoantibodies. Onconeuronal antibodies are well-established biomarkers for PNS and may serve as specific tumor markers. The recommended procedure to detect onconeuronal antibodies is a combination of indirect immunohistochemistry on fixed rodent cerebellum and confirmation of the specificity by line assays. Simplification of this approach by only using line assays with recombinant proteins bears the risk to miss antibody-positive samples. Anti-neuronal surface antibodies are sensitive and specific biomarkers for AIE. Their identification requires the use of test methods that allow the recognition of conformation dependent epitopes. These commonly include cell-based assays and tissue based assays with unfixed rodent brain tissue. Tissue based assays can detect most of the currently known neuronal surface antibodies and thus enable broad screening of biological samples. A complementary testing on live neuronal cell cultures may confirm that the antibody recognizes a surface epitope. In patients with peripheral neuropathy, the screening may be expanded to teased nerve fibers to identify antibodies against the node of Ranvier. This method helps to identify a novel subgroup of peripheral autoimmune neuropathies, resulting in improved immunotherapy of these patients. Tissue based assays are useful to discover additional autoantibody targets that play a role in diverse autoimmune neurological syndromes. Antibody screening assays represent promising avenues of research to improve the diagnostic yield of current assays for antibody-associated autoimmune encephalitis.
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Affiliation(s)
- Gerda Ricken
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Carmen Schwaiger
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Desiree De Simoni
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Valerie Pichler
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Julia Lang
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Sarah Glatter
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Stefan Macher
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paulus S Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Petra Scholze
- Department of Pathobiology of the Nervous System, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Helmut Kubista
- Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Inga Koneczny
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
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312
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Basal E, Zalewski N, Kryzer TJ, Hinson SR, Guo Y, Dubey D, Benarroch EE, Lucchinetti CF, Pittock SJ, Lennon VA, McKeon A. Paraneoplastic neuronal intermediate filament autoimmunity. Neurology 2018; 91:e1677-e1689. [PMID: 30282771 PMCID: PMC6207411 DOI: 10.1212/wnl.0000000000006435] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 07/23/2018] [Indexed: 12/13/2022] Open
Abstract
Objective To describe paraneoplastic neuronal intermediate filament (NIF) autoimmunity. Methods Archived patient and control serum and CSF specimens were evaluated by tissue-based indirect immunofluorescence assay (IFA). Autoantigens were identified by Western blot and mass spectrometry. NIF specificity was confirmed by dual tissue section staining and 5 recombinant NIF-specific HEK293 cell-based assays (CBAs, for α-internexin, neurofilament light [NfL], neurofilament medium, or neurofilament heavy chain, and peripherin). NIF–immunoglobulin Gs (IgGs) were correlated with neurologic syndromes and cancers. Results Among 65 patients, NIF-IgG-positive by IFA and CBAs, 33 were female (51%). Median symptom onset age was 62 years (range 18–88). Patients fell into 2 groups, defined by the presence of NfL-IgG (21 patients, who mostly had ≥4 NIF-IgGs detected) or its absence (44 patients, who mostly had ≤2 NIF-IgGs detected). Among NfL-IgG-positive patients, 19/21 had ≥1 subacute onset CNS disorders: cerebellar ataxia (11), encephalopathy (11), or myelopathy (2). Cancers were detected in 16 of 21 patients (77%): carcinomas of neuroendocrine lineage (10) being most common (small cell [5], Merkel cell [3], other neuroendocrine [2]). Two of 257 controls (0.8%, both with small cell carcinoma) were positive by both IFA and CBA. Five of 7 patients with immunotherapy data improved. By comparison, the 44 NfL-IgG-negative patients had findings of unclear significance: diverse nervous system disorders (p = 0.006), as well as limited (p = 0.003) and more diverse (p < 0.0001) cancer accompaniments. Conclusions NIF-IgG detection by IFA, with confirmatory CBA testing that yields a profile including NfL-IgG, defines a paraneoplastic CNS disorder (usually ataxia or encephalopathy) accompanying neuroendocrine lineage neoplasia.
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Affiliation(s)
- Eati Basal
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Nicholas Zalewski
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Thomas J Kryzer
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Shannon R Hinson
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Yong Guo
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Divyanshu Dubey
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Eduardo E Benarroch
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Claudia F Lucchinetti
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Sean J Pittock
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Vanda A Lennon
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Andrew McKeon
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN.
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Theroux LM, Goodkin HP, Heinan KC, Quigg M, Brenton JN. Extreme delta brush and distinctive imaging in a pediatric patient with autoimmune GFAP astrocytopathy. Mult Scler Relat Disord 2018; 26:121-123. [PMID: 30245384 DOI: 10.1016/j.msard.2018.09.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/19/2018] [Accepted: 09/12/2018] [Indexed: 11/17/2022]
Abstract
Autoimmune encephalitis has been increasingly recognized within the pediatric population, and the number of implicated autoantibodies continues to grow. The identification of characteristic clinical and paraclinical features helps direct the evaluation and increases the likelihood of making a definitive diagnosis of a specific antibody-mediated encephalitis. The finding of extreme delta brush on electroencephalogram (EEG) has been suggested to serve as a clinical clue to the diagnosis of anti-NMDA-R encephalitis. Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a recently described antibody-mediated meningoencephalomyelitis, reported almost exclusively in adult patients. We report a case of autoimmune GFAP astrocytopathy in a pediatric patient with extreme delta brush pattern on EEG, negative anti-NMDA-R antibodies, and distinctive MRI findings. The findings reported herein should prompt clinicians to consider the diagnosis of autoimmune GFAP astrocytopathy in patients with suspected autoimmune encephalitis.
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Affiliation(s)
- Liana M Theroux
- Division of Pediatric Neurology, Department of Neurology, University of Virginia, 1221 Lee St., Charlottesville, VA, USA.
| | - Howard P Goodkin
- Division of Pediatric Neurology, Department of Neurology, University of Virginia, 1221 Lee St., Charlottesville, VA, USA.
| | - Kristen C Heinan
- Division of Pediatric Neurology, Department of Neurology, University of Virginia, 1221 Lee St., Charlottesville, VA, USA.
| | - Mark Quigg
- Department of Neurology, University of Virginia, Charlottesville, VA, USA.
| | - J Nicholas Brenton
- Division of Pediatric Neurology, Department of Neurology, University of Virginia, 1221 Lee St., Charlottesville, VA, USA.
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314
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Glial Fibrillary Acidic Protein Antibody: Another Antibody in the Multiple Sclerosis Diagnostic Mix. J Neuroophthalmol 2018; 38:281-284. [PMID: 29923872 DOI: 10.1097/wno.0000000000000689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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315
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Autoimmune GFAP astrocytopathy: Prospective evaluation of 90 patients in 1 year. J Neuroimmunol 2018; 321:157-163. [DOI: 10.1016/j.jneuroim.2018.04.016] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 04/26/2018] [Accepted: 04/26/2018] [Indexed: 12/17/2022]
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316
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Predictors of neural-specific autoantibodies and immunotherapy response in patients with cognitive dysfunction. J Neuroimmunol 2018; 323:62-72. [PMID: 30196836 DOI: 10.1016/j.jneuroim.2018.07.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/07/2018] [Accepted: 07/16/2018] [Indexed: 01/08/2023]
Abstract
Recognition of autoimmunity as a cause of encephalopathy has increased. Recent studies have validated the use of Antibody-Prevalence-in-Epilepsy (APE) and Responsive-to-immunotherapy-in-Epilepsy (RITE) scores in the evaluation and management of autoimmune-epilepsy. We aim to assess the utility of these models for patients with cognitive dysfunction. Among the evaluated patients, 17% had antibodies universally associated with autoimmune-encephalopathy. NMDA-R-IgG and LGI1-IgG were the most common antibody specificities. Antibody-Prevalence-in-Epilepsy-and-Encephalopathy (APE2) score ≥ 4 was 99% sensitive and 93% specific for neural-specific-antibodies. Responsive-to-immunotherapy-in-Epilepsy-and-Encephalopathy (RITE2) score ≥ 7 had 96% sensitivity and 86% specificity for favorable initial immunotherapy response. Application of these models may optimize autoantibody evaluations and immunotherapeutic trials.
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317
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Luessi F, Engel S, Spreer A, Bittner S, Zipp F. GFAPα IgG-associated encephalitis upon daclizumab treatment of MS. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2018; 5:e481. [PMID: 30027106 PMCID: PMC6047833 DOI: 10.1212/nxi.0000000000000481] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 05/31/2018] [Indexed: 11/15/2022]
Abstract
Objective To describe a case of glial fibrillary acidic protein (GFAP)α immunoglobulin G (IgG)-associated encephalitis in a patient referred to us with MS on daclizumab treatment and to summarize characteristics of 5 additional recent German MS cases of serious encephalitis along with a previously published American case of CNS vasculitis associated with daclizumab. Methods Evaluation of cause, clinical symptoms, and treatment response. Results The 6 patients included 4 women and 2 men. The median age at onset was 38 years (range 32–51 years). Clinical presentation was marked by progressing neuropsychologic and/or neurologic deficits. Additional drug rash with eosinophilia was seen in 3 patients, whereas 2 patients showed a highly active demyelinating process. Examination of CSF samples detected pleocytosis, elevated total protein levels, and GFAPα IgG antibodies, which were not found in serum. In our case, we discovered autoimmune GFAP astrocytopathy associated with encephalitis as secondary autoimmunity, which was steroid responsive. Clinical outcome of other cases was marked by partial recovery in 4 patients and persistent foster care in 1 patient. Conclusions Our case of GFAPα IgG-associated encephalitis along with 12 other cases of serious inflammatory brain disorders following daclizumab treatment so far indicates that interfering with NK cells and Tregs by anti-CD25 antibody therapy can result in severe secondary CNS autoimmunity in man.
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Affiliation(s)
- Felix Luessi
- Department of Neurology and Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Sinah Engel
- Department of Neurology and Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Annette Spreer
- Department of Neurology and Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Stefan Bittner
- Department of Neurology and Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Frauke Zipp
- Department of Neurology and Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Germany
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318
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Ovarian Teratoma Associated with Coexisting Anti-N-Methyl-D-Aspartate Receptor and Glial Fibrillary Acidic Protein Autoimmune Meningoencephalitis in an Adolescent Girl: A Case Report. J Pediatr Adolesc Gynecol 2018; 31:321-324. [PMID: 29294378 DOI: 10.1016/j.jpag.2017.12.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 12/21/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Ovarian teratomas are rarely associated with paraneoplastic autoimmune meningoencephalitis. In addition to the well known N-methyl-D-aspartate receptor (NMDA-R) antibody, the glial fibrillary acidic protein (GFAP) antibody is a novel biomarker of autoimmune meningoencephalitis that might be seen in patients with ovarian teratoma. CASE A 13-year-old girl with acute-onset meningoencephalitis and incidental finding of ovarian teratoma was found to have coexisting anti-NMDA-R and GFAP antibodies present in her cerebrospinal fluid. SUMMARY AND CONCLUSION NMDA-R and GFAP autoimmune encephalitis should be considered in adolescent patients with neurologic or psychiatric symptoms and an ovarian teratoma. Prompt diagnosis and surgical resection increase the likelihood of full neurologic recovery.
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319
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Trau SP, Gallentine WB. Autoimmune GFAP-Associated Meningoencephalomyelitis: A Report of a Pediatric Patient. Pediatr Neurol 2018; 82:50. [PMID: 29622490 DOI: 10.1016/j.pediatrneurol.2018.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 02/03/2018] [Indexed: 11/20/2022]
Affiliation(s)
- Steven P Trau
- Division of Neurology, Department of Pediatrics, Duke University Children's Hospital and Duke University School of Medicine, DUMC Box 3936, Durham, North Carolina 27710.
| | - William B Gallentine
- Division of Neurology, Department of Pediatrics, Duke University Children's Hospital and Duke University School of Medicine, DUMC Box 3936, Durham, North Carolina 27710
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320
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Yang X, Xu H, Ding M, Huang Q, Chen B, Yang H, Liu T, Long Y, Gao C. Overlapping Autoimmune Syndromes in Patients With Glial Fibrillary Acidic Protein Antibodies. Front Neurol 2018; 9:251. [PMID: 29755396 PMCID: PMC5932346 DOI: 10.3389/fneur.2018.00251] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 03/29/2018] [Indexed: 12/22/2022] Open
Abstract
Background Glial fibrillary acidic protein (GFAP) astrocytopathy, an autoimmune central nervous system disorder with a specific GFAP-IgG, often coexists with other antibodies. Objective The aim of this article was to study overlapping syndromes in autoimmune GFAP astrocytopathy. Methods Antibody was detected by indirect immunofluorescence assay. Patient data were analyzed retrospectively. Results Thirty patients with positive GFAP-IgG were included, of whom 10 were defined as overlapping syndrome. Four patients with positive aquaporin-4 (AQP4)-IgG, two with N-methyl-d-aspartate receptor-IgG, three with unknown neuronal antibodies, and one with double AQP4 and myelin oligodendrocyte glycoprotein-IgG were identified. GFAP-IgG and other specific antibodies occurred simultaneously at the initial attack in eight patients. The main symptoms included fever, headache, ataxia, psychosis, hypersomnia, dyskinesia, dementia, seizure, myelitis, and optical symptoms. Brain magnetic resonance imaging in four patients revealed characteristic radial enhancing patterns in the white matter. Cortical abnormalities were found in four patients. Other brain abnormalities occurred in the hypothalamus, midbrain, pons, medulla, cerebellum, and meninges. Six patients exhibited lesions in the spinal cord. In a subgroup study, patients with overlapping syndrome were younger at onset than those with non-overlapping syndrome. Conclusion Overlapping antibodies are common in GFAP astrocytopathy.
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Affiliation(s)
- Xinguang Yang
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Guangzhou, China
| | - Huiming Xu
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Guangzhou, China
| | - Meilin Ding
- Department of Geriatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qingmei Huang
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Guangzhou, China
| | - Baikeng Chen
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Guangzhou, China
| | - Huacai Yang
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Guangzhou, China
| | - Tianni Liu
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Guangzhou, China
| | - Youming Long
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Guangzhou, China
| | - Cong Gao
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Guangzhou, China
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321
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McKeon A, Benarroch EE. Glial fibrillary acid protein: Functions and involvement in disease. Neurology 2018; 90:925-930. [PMID: 29653988 DOI: 10.1212/wnl.0000000000005534] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Andrew McKeon
- From the Department of Neurology, Mayo Clinic, Rochester, MN
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322
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323
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Autoimmune GFAP astrocytopathy after viral encephalitis: A case report. Mult Scler Relat Disord 2018; 21:84-87. [DOI: 10.1016/j.msard.2018.02.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 02/11/2018] [Accepted: 02/13/2018] [Indexed: 11/24/2022]
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324
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Zarkali A, Cousins O, Athauda D, Moses S, Moran N, Harikrishnan S. Glial fibrillary acidic protein antibody-positive meningoencephalomyelitis. Pract Neurol 2018; 18:315-319. [PMID: 29440316 DOI: 10.1136/practneurol-2017-001863] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2018] [Indexed: 11/04/2022]
Abstract
Glial fibrillary acidic protein antibody-positive meningoencephalomyelitis is a newly described, possibly under-recognised, severe inflammatory condition of the nervous system. The clinical presentation is variable but most commonly is a combination of meningitis, encephalitis and myelitis; other manifestations may include seizures, psychiatric symptoms and tremor. There is a significant association with malignancies, often occult, and with other autoimmune conditions. Although the disease responds well to corticosteroids acutely, it typically relapses when these are tapered, and so patients need long-term immunosuppression. We report a young man presenting with subacute meningoencephalitis and subsequent myelitis, and discuss the typical presentation and management of this severe but treatable condition.
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Affiliation(s)
- Angeliki Zarkali
- East Kent Neurology Unit, East Kent University Hospitals NHS Foundation Trust, Canterbury, UK
| | - Oliver Cousins
- East Kent Neurology Unit, East Kent University Hospitals NHS Foundation Trust, Canterbury, UK
| | - Dilan Athauda
- East Kent Neurology Unit, East Kent University Hospitals NHS Foundation Trust, Canterbury, UK.,University College London, London, UK
| | - Samuel Moses
- East Kent Microbiology and Virology, East Kent University Hospitals NHS Foundation Trust, Canterbury, UK
| | - Nicholas Moran
- East Kent Neurology Unit, East Kent University Hospitals NHS Foundation Trust, Canterbury, UK.,King's College London, London, UK
| | - Sreedharan Harikrishnan
- East Kent Neurology Unit, East Kent University Hospitals NHS Foundation Trust, Canterbury, UK.,King's College London, London, UK
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325
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Iorio R, Damato V, Evoli A, Gessi M, Gaudino S, Di Lazzaro V, Spagni G, Sluijs JA, Hol EM. Clinical and immunological characteristics of the spectrum of GFAP autoimmunity: a case series of 22 patients. J Neurol Neurosurg Psychiatry 2018; 89:138-146. [PMID: 28951498 DOI: 10.1136/jnnp-2017-316583] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 09/04/2017] [Accepted: 09/05/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To report the clinical and immunological characteristics of 22 new patients with glial fibrillar acidic protein (GFAP) autoantibodies. METHODS From January 2012 to March 2017, we recruited 451 patients with suspected neurological autoimmune disease at the Catholic University of Rome. Patients' serum and cerebrospinal fluid (CSF) samples were tested for neural autoantibodies by immunohistochemistry on mouse and rat brain sections, by cell-based assays (CBA) and immunoblot. GFAP autoantibodies were detected by immunohistochemistry and their specificity confirmed by CBA using cells expressing human GFAPα and GFAPδ proteins, by immunoblot and immunohistochemistry on GFAP-/- mouse brain sections. RESULTS Serum and/or CSF IgG of 22/451 (5%) patients bound to human GFAP, of which 22/22 bound to GFAPα, 14/22 to both GFAPα and GFAPδ and none to the GFAPδ isoform only. The neurological presentation was: meningoencephalomyelitis or encephalitis in 10, movement disorder (choreoathetosis or myoclonus) in 3, anti-epileptic drugs (AED)-resistant epilepsy in 3, cerebellar ataxia in 3, myelitis in 2, optic neuritis in 1 patient. Coexisting neural autoantibodies were detected in five patients. Six patients had other autoimmune diseases. Tumours were found in 3/22 patients (breast carcinoma, 1; ovarian carcinoma, 1; thymoma, 1). Nineteen patients were treated with immunotherapy and 16 patients (84%) improved. Histopathology analysis of the leptomeningeal biopsy specimen from one patient revealed a mononuclear infiltrate with macrophages and CD8+ T cells. CONCLUSIONS GFAP autoimmunity is not rare. The clinical spectrum encompasses meningoencephalitis, myelitis, movement disorders, epilepsy and cerebellar ataxia. Coexisting neurological and systemic autoimmunity are relatively common. Immunotherapy is beneficial in most cases.
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Affiliation(s)
- Raffaele Iorio
- Department of Neuroscience, Istituto di Neurologia, Fondazione Policlinico Universitario 'Agostino Gemelli', Università Cattolica del Sacro Cuore, Rome, Italy
| | - Valentina Damato
- Department of Neuroscience, Istituto di Neurologia, Fondazione Policlinico Universitario 'Agostino Gemelli', Università Cattolica del Sacro Cuore, Rome, Italy
| | - Amelia Evoli
- Department of Neuroscience, Istituto di Neurologia, Fondazione Policlinico Universitario 'Agostino Gemelli', Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marco Gessi
- Institute of Pathology, Fondazione Policlinico Universitario 'Agostino Gemelli', Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simona Gaudino
- Department of Radiological Sciences, Institute of Radiology, Fondazione Policlinico Universitario 'Agostino Gemelli', Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio.Medico di Roma, Rome, Italy
| | - Gregorio Spagni
- Department of Neuroscience, Istituto di Neurologia, Fondazione Policlinico Universitario 'Agostino Gemelli', Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jacqueline A Sluijs
- Department of Translational Neuroscience, Brain Center Rudolf Magnus, University Medical Center, Utrecht, The Netherlands
| | - Elly M Hol
- Department of Translational Neuroscience, Brain Center Rudolf Magnus, University Medical Center, Utrecht, The Netherlands.,Institute for Neuroscience, An Institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
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326
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Long Y, Liang J, Xu H, Huang Q, Yang J, Gao C, Qiu W, Lin S, Chen X. Autoimmune glial fibrillary acidic protein astrocytopathy in Chinese patients: a retrospective study. Eur J Neurol 2018; 25:477-483. [PMID: 29193473 DOI: 10.1111/ene.13531] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 11/02/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Y. Long
- Department of Neurology Second Affiliated Hospital of Guangzhou Medical University Guangzhou China
- Institute of Neuroscience Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province Ministry of Education of China Collaborative Innovation Center for Neurogenetics and Channelopathies Second Affiliated Hospital of Guangzhou Medical University Guangzhou China
| | - J. Liang
- Department of Neurology Second Affiliated Hospital of Guangzhou Medical University Guangzhou China
- Institute of Neuroscience Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province Ministry of Education of China Collaborative Innovation Center for Neurogenetics and Channelopathies Second Affiliated Hospital of Guangzhou Medical University Guangzhou China
| | - H. Xu
- Department of Neurology Second Affiliated Hospital of Guangzhou Medical University Guangzhou China
- Institute of Neuroscience Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province Ministry of Education of China Collaborative Innovation Center for Neurogenetics and Channelopathies Second Affiliated Hospital of Guangzhou Medical University Guangzhou China
| | - Q. Huang
- Department of Neurology Second Affiliated Hospital of Guangzhou Medical University Guangzhou China
- Institute of Neuroscience Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province Ministry of Education of China Collaborative Innovation Center for Neurogenetics and Channelopathies Second Affiliated Hospital of Guangzhou Medical University Guangzhou China
| | - J. Yang
- Department of Neurology Second Affiliated Hospital of Guangzhou Medical University Guangzhou China
- Institute of Neuroscience Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province Ministry of Education of China Collaborative Innovation Center for Neurogenetics and Channelopathies Second Affiliated Hospital of Guangzhou Medical University Guangzhou China
| | - C. Gao
- Department of Neurology Second Affiliated Hospital of Guangzhou Medical University Guangzhou China
- Institute of Neuroscience Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province Ministry of Education of China Collaborative Innovation Center for Neurogenetics and Channelopathies Second Affiliated Hospital of Guangzhou Medical University Guangzhou China
| | - W. Qiu
- Department of Neurology Third Affiliated Hospital of Sun Yat‐Sen University Guangzhou China
| | - S. Lin
- Department of Emergency Second Affiliated Hospital of Guangzhou Medical University Guangzhou China
| | - X. Chen
- Department of Emergency Second Affiliated Hospital of Guangzhou Medical University Guangzhou China
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327
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Bruscolini A, Sacchetti M, La Cava M, Gharbiya M, Ralli M, Lambiase A, De Virgilio A, Greco A. Diagnosis and management of neuromyelitis optica spectrum disorders - An update. Autoimmun Rev 2018; 17:195-200. [PMID: 29339316 DOI: 10.1016/j.autrev.2018.01.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/08/2017] [Indexed: 12/14/2022]
Abstract
Neuromyelitis optica (NMO) and Neuromyelitis optica spectrum disorders (NMOSD) are a group of autoimmune conditions characterized by inflammatory involvement of the optic nerve, spinal cord and central nervous system. Novel evidence showed a key role of autoantibodies against aquaporin-4 immunoglobulin G (AQP4 IgG) in the pathogenesis of NMOSD and, recently, new classification and diagnostic criteria have been adopted to facilitate an earlier identification and improve the management of these conditions. Diagnosis of NMOSD is currently based on clinical, neuroimaging and laboratory features. Standard treatment is based on the use of steroids and immunosuppressive drugs and aims to control the severity of acute attacks and to prevent relapses of the disease. This review gives an update of latest knowledge of NMOSD and NMO, emphasizing the novel diagnostic criteria and both current and future therapeutic approaches.
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Affiliation(s)
- Alice Bruscolini
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Marta Sacchetti
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Maurizio La Cava
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Magda Gharbiya
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Massimo Ralli
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Alessandro Lambiase
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Armando De Virgilio
- Otorhinolaryngology Unit, Humanitas Clinical and Research Center, Via Alessandro Manzoni, 56, 20089 Rozzano (MI), Italy.
| | - Antonio Greco
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
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328
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Shu Y, Long Y, Chang Y, Li R, Sun X, Wang Y, Huang Y, Li J, Chen J, Yang Y, Lu Z, Hu X, Kermode AG, Qiu W. Brain Immunohistopathology in a Patient with Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy. Neuroimmunomodulation 2018; 25:1-6. [PMID: 29788018 DOI: 10.1159/000488879] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/23/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a novel meningoencephalomyelitis. However, the pathogenesis of this disease is unclear. We therefore examined a brain biopsy from a patient with autoimmune GFAP astrocytopathy by immunohistopathology. METHODS We examined brain biopsy sections from a patient with autoimmune GFAP astrocytopathy using hematoxylin and eosin (HE) and Luxol fast blue (LFB) staining, and immunostaining with antibodies for CD4, CD8, CD3, CD20, CD68, CD138, Neu-N, GFAP, myelin oligodendrocyte glycoprotein (MOG), and aquaporin-4 (AQP4). RESULTS HE staining revealed extensive inflammatory cells (marked lymphocytes) around brain vessels, and LFB showed no signs of demyelination or axon loss. Immunohistochemical analysis showed CD3+ and CD4+ T cells cuffing around brain vessels, accompanied by CD8+ T cells, CD20+ B cells, and CD138+ plasma cells, while some macrophages (CD68+) were scattered throughout the brain parenchyma. There was no loss of AQP4 or MOG expression in this patient, while GFAP was abundantly expressed. CONCLUSIONS These findings suggest that inflammatory cells, including T cells, B cells, plasma cells, and macrophages, are involved in autoimmune GFAP astrocytopathy. Demyelination and astrocyte loss may not necessarily occur in this disease.
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Affiliation(s)
- Yaqing Shu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Youming Long
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yanyu Chang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Rui Li
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiaobo Sun
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yuge Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yinong Huang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jing Li
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jianning Chen
- Department of Pathology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yu Yang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhengqi Lu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xueqiang Hu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Allan G Kermode
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Centre for Neuromuscular and Neurological Disorders, Department of Neurology, Sir Charles Gairdner Hospital, University of Western Australia, Queen Elizabeth II Medical Centre, Perth, Washington, Australia
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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329
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Balint B, Vincent A, Meinck HM, Irani SR, Bhatia KP. Movement disorders with neuronal antibodies: syndromic approach, genetic parallels and pathophysiology. Brain 2018; 141:13-36. [PMID: 29053777 PMCID: PMC5888977 DOI: 10.1093/brain/awx189] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/10/2017] [Accepted: 06/13/2017] [Indexed: 01/17/2023] Open
Abstract
Movement disorders are a prominent and common feature in many autoantibody-associated neurological diseases, a group of potentially treatable conditions that can mimic infectious, metabolic or neurodegenerative disease. Certain movement disorders are likely to associate with certain autoantibodies; for example, the characteristic dyskinesias, chorea and dystonia associated with NMDAR antibodies, stiff person spectrum disorders with GAD, glycine receptor, amphiphysin or DPPX antibodies, specific paroxysmal dystonias with LGI1 antibodies, and cerebellar ataxia with various anti-neuronal antibodies. There are also less-recognized movement disorder presentations of antibody-related disease, and a considerable overlap between the clinical phenotypes and the associated antibody spectra. In this review, we first describe the antibodies associated with each syndrome, highlight distinctive clinical or radiological 'red flags', and suggest a syndromic approach based on the predominant movement disorder presentation, age, and associated features. We then examine the underlying immunopathophysiology, which may guide treatment decisions in these neuroimmunological disorders, and highlight the exceptional interface between neuronal antibodies and neurodegeneration, such as the tauopathy associated with IgLON5 antibodies. Moreover, we elaborate the emerging pathophysiological parallels between genetic movement disorders and immunological conditions, with proteins being either affected by mutations or targeted by autoantibodies. Hereditary hyperekplexia, for example, is caused by mutations of the alpha subunit of the glycine receptor leading to an infantile-onset disorder with exaggerated startle and stiffness, whereas antibodies targeting glycine receptors can induce acquired hyperekplexia. The spectrum of such immunological and genetic analogies also includes cerebellar ataxias and some encephalopathies. Lastly, we discuss how these pathophysiological considerations could reflect on possible future directions regarding antigen-specific immunotherapies or targeting the pathophysiological cascades downstream of the antibody effects.
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Affiliation(s)
- Bettina Balint
- Sobell Department of Motor Neuroscience and Movement Disorders UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
- Department of Neurology, University Hospital, Heidelberg, Germany
- Neuroimmunology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Angela Vincent
- Neuroimmunology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | | | - Sarosh R Irani
- Neuroimmunology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Kailash P Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
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330
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Dubey D, Pittock SJ, Kelly CR, McKeon A, Lopez-Chiriboga AS, Lennon V, Gadoth A, Smith CY, Bryant SC, Klein CJ, Aksamit AJ, Toledano M, Boeve BF, Tilemma JM, Flanagan EP. Autoimmune encephalitis epidemiology and a comparison to infectious encephalitis. Ann Neurol 2018; 83:166-177. [PMID: 29293273 PMCID: PMC6011827 DOI: 10.1002/ana.25131] [Citation(s) in RCA: 412] [Impact Index Per Article: 68.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 12/10/2017] [Accepted: 12/28/2017] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To evaluate the incidence and prevalence of autoimmune encephalitis and compare it to that of infectious encephalitis. METHODS We performed a population-based comparative study of the incidence and prevalence of autoimmune and infectious encephalitis in Olmsted County, Minnesota. Autoimmune encephalitis diagnosis and subgroups were defined by 2016 diagnostic criteria, and infectious encephalitis diagnosis required a confirmed infectious pathogen. Age- and sex-adjusted prevalence and incidence rates were calculated. Patients with encephalitis of uncertain etiology were excluded. RESULTS The prevalence of autoimmune encephalitis on January 1, 2014 of 13.7/100,000 was not significantly different from that of all infectious encephalitides (11.6/100,000; p = 0.63) or the viral subcategory (8.3/100,000; p = 0.17). The incidence rates (1995-2015) of autoimmune and infectious encephalitis were 0.8/100,000 and 1.0/100,000 person-years, respectively (p = 0.58). The number of relapses or recurrent hospitalizations was higher for autoimmune than infectious encephalitis (p = 0.03). The incidence of autoimmune encephalitis increased over time from 0.4/100,000 person-years (1995-2005) to 1.2/100,000 person-years (2006-2015; p = 0.02), attributable to increased detection of autoantibody-positive cases. The incidence (2.8 vs 0.7/100,000 person-years, p = 0.01) and prevalence (38.3 vs 13.7/100,000, p = 0.04) of autoimmune encephalitis was higher among African Americans than Caucasians. The prevalence of specific neural autoantibodies was as follows: myelin oligodendrocyte glycoprotein, 1.9/100,000; glutamic acid decarboxylase 65, 1.9/100,000; unclassified neural autoantibody, 1.4/100,000; leucine-rich glioma-inactivated protein 1, 0.7/100,000; collapsin response-mediator protein 5, 0.7/100,000; N-methyl-D-aspartate receptor, 0.6/100,000; antineuronal nuclear antibody type 2, 0.6/100,000; and glial fibrillary acidic protein α, 0.6/100,000. INTERPRETATION This study shows that the prevalence and incidence of autoimmune encephalitis are comparable to infectious encephalitis, and its detection is increasing over time. Ann Neurol 2018;83:166-177.
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Affiliation(s)
| | - Sean J. Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Vanda Lennon
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Department of Immunology, Mayo Clinic, Rochester, MN, USA
| | - Avi Gadoth
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Carin Y. Smith
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Sandra C. Bryant
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Christopher J. Klein
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | | | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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331
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Zekeridou A, McKeon A, Flanagan EP. A path to understanding autoimmune GFAP astrocytopathy. Eur J Neurol 2017; 25:421-422. [PMID: 29193488 DOI: 10.1111/ene.13527] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- A Zekeridou
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, MN, USA.,Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - A McKeon
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, MN, USA.,Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - E P Flanagan
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, MN, USA.,Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN, USA
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332
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Sarnat HB, Scantlebury MH. Novel Inflammatory Neuropathology in Immature Brain: (1) Fetal Tuberous Sclerosis, (2) Febrile Seizures, (3) α-B-crystallin, and (4) Role of Astrocytes. Semin Pediatr Neurol 2017; 24:152-160. [PMID: 29103422 DOI: 10.1016/j.spen.2017.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Though the term "inflammation" is traditionally defined as proliferation or infiltration of lymphatic cells of the lymphatic immune system and macrophages or as immunoreactive proteins including cytokines, interleukins and major histocompatibility complexes, recently recognized reactions to tissue injury also are inflammation, often occurring in the central nervous system in conditions where they previously were not anticipated and where they may play a role in both pathogenesis and repair. We highlight 4 such novel inflammatory conditions revealed by neuropathologic studies: (1) inflammatory markers and cells in the brain of human fetuses with tuberous sclerosis complex and perhaps other disorders of the mechanistic target of rapamycin genetic or metabolic pathway, (2) inflammatory markers in the brain related to febrile seizures of infancy and early childhood, (3) heat-shock protein upregulation in glial cells and neurons at sites of chronic epileptic foci, and (4) the emerging role of astrocytes in the presence of and participation in inflammation. Novel evidence shows that cerebral inflammation plays a role in some genetic diseases as early as midgestation and thus is not always acquired postnatally or in adult life.
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Affiliation(s)
- Harvey B Sarnat
- Department of Pediatrics, University of Calgary Cumming School of Medicine and Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada; Department of Pathology and Laboratory Medicine (Neuropathology), University of Calgary Cumming School of Medicine and Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine and Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada.
| | - Morris H Scantlebury
- Department of Pediatrics, University of Calgary Cumming School of Medicine and Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine and Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
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333
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Dubey D, Singh J, Britton JW, Pittock SJ, Flanagan EP, Lennon VA, Tillema JM, Wirrell E, Shin C, So E, Cascino GD, Wingerchuk DM, Hoerth MT, Shih JJ, Nickels KC, McKeon A. Predictive models in the diagnosis and treatment of autoimmune epilepsy. Epilepsia 2017; 58:1181-1189. [DOI: 10.1111/epi.13797] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2017] [Indexed: 12/22/2022]
Affiliation(s)
- Divyanshu Dubey
- Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
| | - Jaysingh Singh
- Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
| | | | - Sean J. Pittock
- Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Rochester Minnesota U.S.A
| | - Eoin P. Flanagan
- Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Rochester Minnesota U.S.A
| | - Vanda A. Lennon
- Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Rochester Minnesota U.S.A
- Department of Immunology; Mayo Clinic; Rochester Minnesota U.S.A
| | | | - Elaine Wirrell
- Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
| | - Cheolsu Shin
- Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
| | - Elson So
- Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
| | | | | | | | - Jerry J. Shih
- Department of Neurology; Mayo Clinic; Jacksonville Florida U.S.A
| | | | - Andrew McKeon
- Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Rochester Minnesota U.S.A
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