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Mikkelsen AW, Nilsson AC, Tenstad HB, Lillevang ST, Asgari N. Initial screening for neuronal autoantibodies and their putative impact on survival in patients with small-cell lung cancer. Thorac Cancer 2024; 15:1350-1356. [PMID: 38703039 PMCID: PMC11168912 DOI: 10.1111/1759-7714.15318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/11/2024] [Accepted: 04/16/2024] [Indexed: 05/06/2024] Open
Abstract
INTRODUCTION Small-cell lung cancer (SCLC) may be associated with neuronal autoantibodies and paraneoplastic neurological syndromes. It has been suggested that neuronal autoantibodies, especially antineuronal nuclear antibody type 1 (Hu) autoantibodies, are associated with longer survival of patients with SCLC. The objective of this study was to determine the frequency and distribution of neuronal autoantibodies at the time of diagnosis of SCLC patients and assess survival rates in relation to autoimmunity. METHODS In this retrospective study, serum from 40 patients with biopsy-proven SCLC at the time of diagnosis was studied prior to treatment. The sera originated from a cancer registry at the Oncology Department, Vejle Hospital from 2007 to 2010. The sera were analyzed blindly to clinical status for the presence of neuronal autoantibodies. Medical records were reviewed for neurological symptoms. RESULTS Neuronal autoantibodies were detected in 22/40 (55%) of the SCLC patients. A broad range of neurological symptoms was recorded in 28/40 (70%) patients, of which 14/28 (50%) were positive for neuronal autoantibodies. The most frequently detected autoantibodies were Hu (7/40, 17.5%) followed by GAD65 (6/22, 15.0%). Striational and P/Q- or N-type voltage-gated calcium channel antibodies were less common, with each found in five patients (12.5%). Eight patients (20%) had coexisting autoantibodies. Autoantibody-positivity was not associated with survival. CONCLUSION Neuronal autoantibodies were at time of diagnosis found in approximately half of the treatment-naïve SCLC patients. Neither autoantibody positivity at diagnosis nor neurological manifestations correlated with survival and their clinical importance requires further studies in larger, prospective cohorts.
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Affiliation(s)
| | - Anna Christine Nilsson
- Department of Clinical ImmunologyOdense University HospitalOdenseDenmark
- Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Helene Broch Tenstad
- Department of Clinical ImmunologyOdense University HospitalOdenseDenmark
- Department of RheumatologyOdense University HospitalOdenseDenmark
| | | | - Nasrin Asgari
- Department of NeurologySlagelse HospitalSlagelseDenmark
- Institute of Regional Health ResearchUniversity of Southern DenmarkOdenseDenmark
- Department of NeurobiologyInstitute of Molecular Medicine, University of Southern DenmarkOdenseDenmark
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2
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Pena C, Moustafa A, Mohamed AR, Grubb B. Autoimmunity in Syndromes of Orthostatic Intolerance: An Updated Review. J Pers Med 2024; 14:435. [PMID: 38673062 PMCID: PMC11051445 DOI: 10.3390/jpm14040435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
Orthostatic intolerance is a broad term that represents a spectrum of dysautonomic disorders, including postural orthostatic tachycardia syndrome (POTS) and orthostatic hypotension (OH), as manifestations of severe autonomic failure. While the etiology of orthostatic intolerance has not yet fully been uncovered, it has been associated with multiple underlying pathological processes, including peripheral neuropathy, altered renin-aldosterone levels, hypovolemia, and autoimmune processes. Studies have implicated adrenergic, cholinergic, and angiotensin II type I autoantibodies in the pathogenesis of orthostatic intolerance. Several case series have demonstrated that immunomodulation therapy resulted in favorable outcomes, improving autonomic symptoms in POTS and OH. In this review, we highlight the contemporary literature detailing the association of autoimmunity with POTS and OH.
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Affiliation(s)
- Clarissa Pena
- Department of Internal Medicine, University of Toledo, Toledo, OH 43614, USA;
| | - Abdelmoniem Moustafa
- Division of Cardiovascular Medicine, University of Toledo, Toledo, OH 43614, USA; (A.M.); (B.G.)
| | - Abdel-Rhman Mohamed
- Department of Internal Medicine, University of Toledo, Toledo, OH 43614, USA;
| | - Blair Grubb
- Division of Cardiovascular Medicine, University of Toledo, Toledo, OH 43614, USA; (A.M.); (B.G.)
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3
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Shelly S, Dubey D, Mills JR, Klein CJ. Paraneoplastic neuropathies and peripheral nerve hyperexcitability disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:239-273. [PMID: 38494281 DOI: 10.1016/b978-0-12-823912-4.00020-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Peripheral neuropathy is a common referral for patients to the neurologic clinics. Paraneoplastic neuropathies account for a small but high morbidity and mortality subgroup. Symptoms include weakness, sensory loss, sweating irregularity, blood pressure instability, severe constipation, and neuropathic pain. Neuropathy is the first presenting symptom of malignancy among many patients. The molecular and cellular oncogenic immune targets reside within cell bodies, axons, cytoplasms, or surface membranes of neural tissues. A more favorable immune treatment outcome occurs in those where the targets reside on the cell surface. Patients with antibodies binding cell surface antigens commonly have neural hyperexcitability with pain, cramps, fasciculations, and hyperhidrotic attacks (CASPR2, LGI1, and others). The antigenic targets are also commonly expressed in the central nervous system, with presenting symptoms being myelopathy, encephalopathy, and seizures with neuropathy, often masked. Pain and autonomic components typically relate to small nerve fiber involvement (nociceptive, adrenergic, enteric, and sudomotor), sometimes without nerve fiber loss but rather hyperexcitability. The specific antibodies discovered help direct cancer investigations. Among the primary axonal paraneoplastic neuropathies, pathognomonic clinical features do not exist, and testing for multiple antibodies simultaneously provides the best sensitivity in testing (AGNA1-SOX1; amphiphysin; ANNA-1-HU; ANNA-3-DACH1; CASPR2; CRMP5; LGI1; PCA2-MAP1B, and others). Performing confirmatory antibody testing using adjunct methods improves specificity. Antibody-mediated demyelinating paraneoplastic neuropathies are limited to MAG-IgM (IgM-MGUS, Waldenström's, and myeloma), with the others associated with cytokine elevations (VEGF, IL6) caused by osteosclerotic myeloma, plasmacytoma (POEMS), and rarely angiofollicular lymphoma (Castleman's). Paraneoplastic disorders have clinical overlap with other idiopathic antibody disorders, including IgG4 demyelinating nodopathies (NF155 and Contactin-1). This review summarizes the paraneoplastic neuropathies, including those with peripheral nerve hyperexcitability.
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Affiliation(s)
- Shahar Shelly
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Neurology, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Christopher J Klein
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
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4
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Kadish R, Clardy SL. Epidemiology of paraneoplastic neurologic syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:57-77. [PMID: 38494297 DOI: 10.1016/b978-0-12-823912-4.00011-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes (PNS), initially depicted as seemingly cryptic remote manifestations of malignancy, were first described clinically in the early 20th century, with pathophysiologic correlates becoming better elucidated in the latter half of the century. There remain many questions not only about the pathophysiology but also regarding the epidemiology of these conditions. The continuous discovery of novel autoantigens and related neurologic disease has broadened the association in classical PNS to include conditions such as paraneoplastic cerebellar degeneration. It has also brought into focus several other neurologic syndromes with a putative neoplastic association. These conditions are overall rare, making it difficult to capture large numbers of patients to study, and raising the question of whether incidence is increasing over time or improved identification is driving the increased numbers of cases. With the rise and increasing use of immunotherapy for cancer treatment, the incidence of these conditions is additionally expected to rise and may present with various clinical symptoms. As we enter an era of clinical trial intervention in these conditions, much work is needed to capture more granular data on population groups defined by socioeconomic characteristics such as age, ethnicity, economic resources, and gender to optimize care and clinical trial planning.
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Affiliation(s)
- Robert Kadish
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Stacey L Clardy
- Department of Neurology, University of Utah, Salt Lake City, UT, United States; George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States.
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5
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Golden EP, Vernino S. Paraneoplastic autonomic neuropathies and GI dysmotility. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:275-282. [PMID: 38494282 DOI: 10.1016/b978-0-12-823912-4.00005-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
A number of the well-recognized autoimmune and paraneoplastic neurologic syndromes commonly involve the autonomic nervous system. In some cases, the autonomic nerves or ganglia are primary targets of neurologic autoimmunity, as in immune-mediated autonomic ganglionopathies. In other disorders such as encephalitis, autonomic centers in the brain may be affected. The presence of autonomic dysfunction (especially gastrointestinal dysmotility) is sometimes overlooked even though this may contribute significantly to the symptom burden in these paraneoplastic disorders. Additionally, recognition of autonomic features as part of the clinical syndrome can help point the diagnostic evaluation toward autoimmune and paraneoplastic etiologies. As with other paraneoplastic disorders, the clinical syndrome and the presence and type of neurologic autoantibodies help to secure the diagnosis and direct the most appropriate investigation for malignancy. Optimal management for these conditions typically includes aggressive treatment of the neoplasm, immunomodulatory therapy, and symptomatic treatments for orthostatic hypotension and gastrointestinal dysmotility.
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Affiliation(s)
- Elisabeth P Golden
- Department of Medicine, Neurology Section, UT Health Science Center at Tyler, Tyler, TX, United States
| | - Steven Vernino
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, United States.
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Chiu D, Rhee J, Gonzalez Castro LN. Diagnosis and Treatment of Paraneoplastic Neurologic Syndromes. Antibodies (Basel) 2023; 12:50. [PMID: 37606434 PMCID: PMC10443237 DOI: 10.3390/antib12030050] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 08/23/2023] Open
Abstract
Paraneoplastic antibody syndromes result from the anti-tumor antibody response against normal antigens ectopically expressed by tumor cells. Although this antibody response plays an important role in helping clear a nascent or established tumor, the engagement of antigens expressed in healthy tissues can lead to complex clinical syndromes with challenging diagnosis and management. The majority of known paraneoplastic antibody syndromes have been found to affect the central and peripheral nervous system. The present review provides an update on the pathophysiology of paraneoplastic neurologic syndromes, as well as recommendations for their diagnosis and treatment.
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Affiliation(s)
- Daniel Chiu
- Department of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Boston, MA 02114, USA
| | - John Rhee
- Department of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Boston, MA 02114, USA
| | - L. Nicolas Gonzalez Castro
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
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7
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Pechlivanidou M, Ninou E, Karagiorgou K, Tsantila A, Mantegazza R, Francesca A, Furlan R, Dudeck L, Steiner J, Tzartos J, Tzartos S. Autoimmunity to Neuronal Nicotinic Acetylcholine Receptors. Pharmacol Res 2023; 192:106790. [PMID: 37164280 DOI: 10.1016/j.phrs.2023.106790] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 04/30/2023] [Accepted: 05/05/2023] [Indexed: 05/12/2023]
Abstract
Nicotinic acetylcholine receptors (nAChRs) are widely expressed in many and diverse cell types, participating in various functions of cells, tissues and systems. In this review, we focus on the autoimmunity against neuronal nAChRs, the specific autoantibodies and their mechanisms of pathological action in selected autoimmune diseases. We summarize the current relevant knowledge from human diseases as well as from experimental models of autoimmune neurological disorders related to antibodies against neuronal nAChR subunits. Despite the well-studied high immunogenicity of the muscle nAChRs where autoantibodies are the main pathogen of myasthenia gravis, autoimmunity to neuronal nAChRs seems infrequent, except for the autoantibodies to the ganglionic receptor, the α3 subunit containing nAChR (α3-nAChR), which are detected and are likely pathogenic in Autoimmune Autonomic Ganglionopathy (AAG). We describe the detection, presence and function of these antibodies and especially the recent development of a cell-based assay (CBA) which, contrary to until recently available assays, is highly specific for AAG. Rare reports of autoantibodies to the other neuronal nAChR subtypes include a few cases of antibodies to α7 and/or α4β2 nAChRs in Rasmussen encephalitis, schizophrenia, autoimmune meningoencephalomyelitis, and in some myasthenia gravis patients with concurrent CNS symptoms. Neuronal-type nAChRs are also present in several non-excitable tissues, however the presence and possible role of antibodies against them needs further verification. It is likely that the future development of more sensitive and disease-specific assays would reveal that neuronal nAChR autoantibodies are much more frequent and may explain the mechanisms of some seronegative autoimmune diseases.
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Affiliation(s)
| | | | - Katerina Karagiorgou
- Tzartos NeuroDiagnostics, Athens, Greece; Department of Biochemistry and Biotechnology, University of Thessaly, Larissa, Greece
| | | | - Renato Mantegazza
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Andreetta Francesca
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Raffaello Furlan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Rozzano, Milan, Italy; Clinical and Research Center - IRCCS, Humanitas University, Rozzano, Milan, Italy
| | - Leon Dudeck
- Department of Psychiatry and Psychotherapy, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany; Laboratory of Translational Psychiatry, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Johann Steiner
- Department of Psychiatry and Psychotherapy, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany; Laboratory of Translational Psychiatry, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany; Center for Behavioral Brain Sciences (CBBS), Magdeburg, Germany; Center for Health and Medical Prevention (CHaMP), Magdeburg, Germany; German Center for Mental Health DZPG, Center for Intervention and Research on Adaptive and Maladaptive Brain Circuits Underlying Mental Health C-I-R-C, Halle-Jena-Magdeburg, Germany
| | - John Tzartos
- 2(nd) Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece.
| | - Socrates Tzartos
- Tzartos NeuroDiagnostics, Athens, Greece; Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece; Department of Pharmacy, University of Patras, Patras, Greece.
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8
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Nagata R, Matsuura E, Nozuma S, Dozono M, Noguchi Y, Ando M, Hiramatsu Y, Kodama D, Tanaka M, Kubota R, Yamakuchi M, Higuchi Y, Sakiyama Y, Arata H, Higashi K, Hashiguchi T, Nakane S, Takashima H. Anti-ganglionic acetylcholine receptor antibodies in functional neurological symptom disorder/conversion disorder. Front Neurol 2023; 14:1137958. [PMID: 36860574 PMCID: PMC9968745 DOI: 10.3389/fneur.2023.1137958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 01/23/2023] [Indexed: 02/17/2023] Open
Abstract
Objective Autoimmune autonomic ganglionopathy (AAG) is a rare disorder characterized by autonomic failure associated with the presence of anti-ganglionic acetylcholine receptor (gAChR) antibodies; however, several studies have reported that individuals with anti-gAChR antibodies present with central nervous system (CNS) symptoms such as impaired consciousness and seizures. In the present study, we investigated whether the presence of serum anti-gAChR antibodies correlated with autonomic symptoms in patients with functional neurological symptom disorder/conversion disorder (FNSD/CD). Methods Clinical data were collected for 59 patients presenting with neurologically unexplained motor and sensory symptoms at the Department of Neurology and Geriatrics between January 2013 and October 2017 and who were ultimately diagnosed with FNSD/CD according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Correlations between serum anti-gAChR antibodies and clinical symptoms and laboratory data were analyzed. Data analysis was conducted in 2021. Results Of the 59 patients with FNSD/CD, 52 (88.1%) exhibited autonomic disturbances and 16 (27.1%) were positive for serum anti-gAChR antibodies. Cardiovascular autonomic dysfunction, including orthostatic hypotension, was significantly more prevalent (75.0 vs. 34.9%, P = 0.008), whereas involuntary movements were significantly less prevalent (31.3 vs. 69.8%, P = 0.007), among anti-gAChR antibody-positive compared with -negative patients. Anti-gAChR antibody serostatus did not correlate significantly with the frequency of other autonomic, sensory, or motor symptoms analyzed. Conclusions An autoimmune mechanism mediated by anti-gAChR antibodies may be involved in disease etiology in a subgroup of FNSD/CD patients.
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Affiliation(s)
- Ryusei Nagata
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Eiji Matsuura
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Satoshi Nozuma
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Mika Dozono
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Yutaka Noguchi
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Masahiro Ando
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Yu Hiramatsu
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Daisuke Kodama
- Division of Neuroimmunology, Joint Research Center for Human Retrovirus Infection, Kagoshima University, Kagoshima, Japan
| | - Masakazu Tanaka
- Division of Neuroimmunology, Joint Research Center for Human Retrovirus Infection, Kagoshima University, Kagoshima, Japan
| | - Ryuji Kubota
- Division of Neuroimmunology, Joint Research Center for Human Retrovirus Infection, Kagoshima University, Kagoshima, Japan
| | - Munekazu Yamakuchi
- Department of Laboratory and Vascular Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Yujiro Higuchi
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Yusuke Sakiyama
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Hitoshi Arata
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Keiko Higashi
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Teruto Hashiguchi
- Department of Laboratory and Vascular Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Shunya Nakane
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Hiroshi Takashima
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan,*Correspondence: Hiroshi Takashima ✉
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Stamm B, DiBiase R, Harris GR, Kaprielian H, Brahmbhatt N, Wu AD, Baker J, Liotta EM. Clinical Reasoning: A Young Adult Man With Cognitive Changes, Gait Difficulty, and Renal Insufficiency. Neurology 2023; 100:206-212. [PMID: 36323524 DOI: 10.1212/wnl.0000000000201500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 09/16/2022] [Indexed: 01/22/2023] Open
Abstract
A 22-year-old right-handed man with recently diagnosed gout and renal insufficiency presented with 3 months of progressive gait instability and cognitive changes. He initially presented to an outside institution and underwent a broad workup, but an etiology for his symptoms was not found. On subsequent presentation to our institution, his examination revealed multidomain cognitive dysfunction, spasticity, hyperreflexia, and clonus. A broad workup was again pursued and was notable for an MRI of the brain, revealing cortical atrophy advanced for his age, bland CSF, and a weakly positive serum acetylcholine receptor ganglionic neuronal antibody of unclear significance. The history of gout and inadequately explained renal insufficiency led to a workup for inborn errors of metabolism, including urine amino acid analysis, which revealed a homocysteine peak. This finding prompted further evaluation, revealing markedly elevated serum homocysteine and methylmalonic acid and low methionine. He ultimately developed superficial venous thromboses, a segmental pulmonary embolism, and clinical and electrographic seizures. He was initiated on appropriate treatment, and his symptoms markedly improved. The case serves as a reminder to include late-onset inborn errors of metabolism in the differential for young adult patients with onset of neurologic, psychiatric, renal, and thromboembolic symptoms.
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Affiliation(s)
- Brian Stamm
- From the Ken & Ruth Davee Department of Neurology (B.S., R.D., G.R.H., H.K., N.B., A.D.W., E.M.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Pediatrics (J.B.), Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Rebecca DiBiase
- From the Ken & Ruth Davee Department of Neurology (B.S., R.D., G.R.H., H.K., N.B., A.D.W., E.M.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Pediatrics (J.B.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Glenn Ryan Harris
- From the Ken & Ruth Davee Department of Neurology (B.S., R.D., G.R.H., H.K., N.B., A.D.W., E.M.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Pediatrics (J.B.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Hagop Kaprielian
- From the Ken & Ruth Davee Department of Neurology (B.S., R.D., G.R.H., H.K., N.B., A.D.W., E.M.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Pediatrics (J.B.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Nupur Brahmbhatt
- From the Ken & Ruth Davee Department of Neurology (B.S., R.D., G.R.H., H.K., N.B., A.D.W., E.M.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Pediatrics (J.B.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Allan D Wu
- From the Ken & Ruth Davee Department of Neurology (B.S., R.D., G.R.H., H.K., N.B., A.D.W., E.M.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Pediatrics (J.B.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Joshua Baker
- From the Ken & Ruth Davee Department of Neurology (B.S., R.D., G.R.H., H.K., N.B., A.D.W., E.M.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Pediatrics (J.B.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Eric M Liotta
- From the Ken & Ruth Davee Department of Neurology (B.S., R.D., G.R.H., H.K., N.B., A.D.W., E.M.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Pediatrics (J.B.), Northwestern University Feinberg School of Medicine, Chicago, IL
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10
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Younger DS. Autonomic failure: Clinicopathologic, physiologic, and genetic aspects. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:55-102. [PMID: 37562886 DOI: 10.1016/b978-0-323-98818-6.00020-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Over the past century, generations of neuroscientists, pathologists, and clinicians have elucidated the underlying causes of autonomic failure found in neurodegenerative, inherited, and antibody-mediated autoimmune disorders, each with pathognomonic clinicopathologic features. Autonomic failure affects central autonomic nervous system components in the α-synucleinopathy, multiple system atrophy, characterized clinically by levodopa-unresponsive parkinsonism or cerebellar ataxia, and pathologically by argyrophilic glial cytoplasmic inclusions (GCIs). Two other central neurodegenerative disorders, pure autonomic failure characterized clinically by deficits in norepinephrine synthesis and release from peripheral sympathetic nerve terminals; and Parkinson's disease, with early and widespread autonomic deficits independent of the loss of striatal dopamine terminals, both express Lewy pathology. The rare congenital disorder, hereditary sensory, and autonomic neuropathy type III (or Riley-Day, familial dysautonomia) causes life-threatening autonomic failure due to a genetic mutation that results in loss of functioning baroreceptors, effectively separating afferent mechanosensing neurons from the brain. Autoimmune autonomic ganglionopathy caused by autoantibodies targeting ganglionic α3-acetylcholine receptors instead presents with subacute isolated autonomic failure affecting sympathetic, parasympathetic, and enteric nervous system function in various combinations. This chapter is an overview of these major autonomic disorders with an emphasis on their historical background, neuropathological features, etiopathogenesis, diagnosis, and treatment.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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11
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de Rojas Leal C, Lage-Sánchez JM, Pinel-Ríos J, León Plaza O, Hamad-Cueto O, Dawid de Vera MT, Dawid-Milner MS. Paraneoplastic autoimmune autonomic ganglionopathy as the first symptom of bladder cancer: a case report and review of literature. Neurol Sci 2022; 43:4841-4845. [DOI: 10.1007/s10072-022-06075-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/10/2022] [Indexed: 10/18/2022]
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12
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Eldokla AM, Numan MT. Postural orthostatic tachycardia syndrome after mRNA COVID-19 vaccine. Clin Auton Res 2022; 32:307-311. [PMID: 35870086 PMCID: PMC9308031 DOI: 10.1007/s10286-022-00880-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 07/11/2022] [Indexed: 12/19/2022]
Affiliation(s)
- Ahmed M Eldokla
- Department of Neurology, State University of New York, Upstate Medical University, Syracuse, NY, 13210, USA.
- Department of Pathology, State University of New York, Upstate Medical University, Syracuse, NY, 13210, USA.
| | - Mohammed T Numan
- Pediatric Cardiology, Children's Heart Institute, McGovern Medical School, UT Health Science Center, Houston, TX, 77030, USA
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Montalvo M, Nallapaneni P, Hassan S, Nurko S, Pittock SJ, Khlevner J. Autoimmune gastrointestinal dysmotility following SARS-CoV-2 infection successfully treated with intravenous immunoglobulin. Neurogastroenterol Motil 2022; 34:e14314. [PMID: 34984765 PMCID: PMC9257846 DOI: 10.1111/nmo.14314] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 09/24/2021] [Accepted: 12/10/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Autoimmune gastrointestinal dysmotility (AGID) is a limited form of dysautonomia that can be paraneoplastic or idiopathic. Some presentations can be preceded by a viral infection. METHODS We report a case of a 17-year-old girl that developed intractable nausea and early satiety after SARS-CoV-2 infection. KEY RESULTS Over ten months, she required nasogastric and nasoduodenal tube feedings and finally was advanced to total parenteral nutrition to meet her caloric needs. Her α3 nicotinic ganglionic acetylcholine and anti-striational antibodies were mildly elevated. Gastrointestinal transit scintigraphy studies showed delayed gastric emptying and slowed small bowel transit. Thermoregulatory sweat test showed areas of anhidrosis consistent with autonomic sudomotor impairment. After IVIG treatment the patient's symptoms improved dramatically and she was able to tolerate full oral diet. This was reflected by improvement of her baseline transit studies and the thermoregulatory sweat test. CONCLUSIONS AND INFERENCES This is the first report of AGID occurring after SARS-CoV-2 infection. The dramatic response to IVIG emphasizes the importance of early recognition and the reversible and treatable nature of this condition.
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Affiliation(s)
- Mayra Montalvo
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Padmini Nallapaneni
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Sara Hassan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Sean J. Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Julie Khlevner
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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Karagiorgou K, Dandoulaki M, Mantegazza R, Andreetta F, Furlan R, Lindstrom J, Zisimopoulou P, Chroni E, Kokotis P, Anagnostou E, Tzanetakos D, Breza M, Katsarou Z, Amoiridis G, Mastorodemos V, Bregianni M, Bonakis A, Tsivgoulis G, Voumvourakis K, Tzartos S, Tzartos J. Novel Cell-Based Assay for Alpha-3 Nicotinic Receptor Antibodies Detects Antibodies Exclusively in Autoimmune Autonomic Ganglionopathy. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2022; 9:9/3/e1162. [PMID: 35351814 PMCID: PMC8969289 DOI: 10.1212/nxi.0000000000001162] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 02/10/2022] [Indexed: 11/30/2022]
Abstract
Background and Objectives Autoantibodies against α3-subunit–containing nicotinic acetylcholine receptors (α3-nAChRs), usually measured by radioimmunoprecipitation assay (RIPA), are detected in patients with autoimmune autonomic ganglionopathy (AAG). However, low α3-nAChR antibody levels are frequently detected in other neurologic diseases with questionable significance. Our objective was to develop a method for the selective detection of the potentially pathogenic α3-nAChR antibodies, seemingly present only in patients with AAG. Methods The study involved sera from 55 patients from Greece, suspected for autonomic failure, and 13 patients from Italy diagnosed with autonomic failure, positive for α3-nAChR antibodies by RIPA. In addition, sera from 52 patients with Ca2+ channel or Hu antibodies and from 2,628 controls with various neuroimmune diseases were included. A sensitive live cell-based assay (CBA) with α3-nAChR–transfected cells was developed to detect antibodies against the cell-exposed α3-nAChR domain. Results Twenty-five patients were found α3-nAChR antibody positive by RIPA. Fifteen of 25 patients were also CBA positive. Of interest, all 15 CBA-positive patients had AAG, whereas all 10 CBA-negative patients had other neurologic diseases. RIPA antibody levels of the CBA-negative sera were low, although our CBA could detect dilutions of AAG sera corresponding to equally low RIPA antibody levels. No serum bound to control-transfected cells, and none of the 2,628 controls was α3-CBA positive. Discussion This study showed that in contrast to the established RIPA for α3-nAChR antibodies, which at low levels is of moderate disease specificity, our CBA seems AAG specific, while at least equally sensitive with the RIPA. This study provides Class II evidence that α3-nAChR CBA is a specific assay for AAG. Classification of Evidence This study provides Class II evidence that an α3-nAChR cell-based assay is a more specific assay for AAG than the standard RIPA.
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Affiliation(s)
- Katerina Karagiorgou
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Maria Dandoulaki
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Renato Mantegazza
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Francesca Andreetta
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Raffaello Furlan
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Jon Lindstrom
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Paraskevi Zisimopoulou
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Elisabeth Chroni
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Panagiotis Kokotis
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Evangelos Anagnostou
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Dimitrios Tzanetakos
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Marianthi Breza
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Zoe Katsarou
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Georgios Amoiridis
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Vasileios Mastorodemos
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Marianna Bregianni
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Anastasios Bonakis
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Georgios Tsivgoulis
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Konstantinos Voumvourakis
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - Socrates Tzartos
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
| | - John Tzartos
- From the Tzartos NeuroDiagnostics (K.K., M.D., S.T., J.T.), Athens; Department of Biochemistry and Biotechnology (K.K.), University of Thessaly, Larissa, Greece; Neuroimmunology and Neuromuscular Diseases Unit (R.M., F.A.), Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Biomedical Sciences Humanitas University (R.F.), Milan, Italy; Department of Neuroscience (J.L.), Medical School, University of Pennsylvania, Philadelphia, PA; Department of Neurobiology (P.Z., S.T.), Hellenic Pasteur Institute, Athens, Greece; Department of Neurology (E.C.), School of Medicine, University of Patras; 1st Department of Neurology (P.K., E.A., D.T., M. Breza), School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens (NKUA), Athens; Department of Neurology (Z.K.), Hippokration Hospital, Thessaloniki; Neurology Department (G.A., V.M.), University Hospital of Crete, Heraklion, Crete; and 2nd Department of Neurology (M. Bregianni, A.B., G.T., K.V., J.T.), Attikon University Hospital, School of Medicine, NKUA, Athens, Greece
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15
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Gotera N, Schultheis CP. A Case of a Splitting Headache: Paraneoplastic Rhombencephalitis. Cureus 2022; 14:e24302. [PMID: 35602787 PMCID: PMC9121404 DOI: 10.7759/cureus.24302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 11/29/2022] Open
Abstract
Paraneoplastic neurologic syndromes are a set of rare neurological conditions with a wide variety of presentations, ranging from headache to gait imbalance. These conditions are often underreported and underdiagnosed. Paraneoplastic rhombencephalitis is a subtype that involves inflammation of the hindbrain. This case involves a 67-year-old female with metastatic small-cell lung cancer who acutely developed neurological symptoms with magnetic resonance imaging findings consistent with rhombencephalitis. Our case discusses the updated diagnostic criteria for paraneoplastic neurologic syndrome released in July 2021 compared with the prior criteria in 2004. In addition, it illustrates the importance of increasing awareness of this condition for early diagnosis and prompt treatment, which can potentially influence morbidity outcomes.
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16
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Fedorowski A, Ricci F, Hamrefors V, Sandau KE, Chung TH, Muldowney JAS, Gopinathannair R, Olshansky B. Orthostatic Hypotension: Management of a Complex, But Common, Medical Problem. Circ Arrhythm Electrophysiol 2022; 15:e010573. [PMID: 35212554 PMCID: PMC9049902 DOI: 10.1161/circep.121.010573] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Orthostatic hypotension (OH), a common, often overlooked, disorder with many causes, is associated with debilitating symptoms, falls, syncope, cognitive impairment, and risk of death. Chronic OH, a cardinal sign of autonomic dysfunction, increases with advancing age and is commonly associated with neurodegenerative and autoimmune diseases, diabetes, hypertension, heart failure, and kidney failure. Management typically involves a multidisciplinary, patient-centered, approach to arrive at an appropriate underlying diagnosis that is causing OH, treating accompanying conditions, and providing individually tailored pharmacological and nonpharmacological treatment. We propose a novel streamlined pathophysiological classification of OH; review the relationship between the cardiovascular disease continuum and OH; discuss OH-mediated end-organ damage; provide diagnostic and therapeutic algorithms to guide clinical decision making and patient care; identify current gaps in knowledge and try to define future research directions. Using a case-based learning approach, specific clinical scenarios are presented highlighting various presentations of OH to provide a practical guide to evaluate and manage patients who have OH.
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Affiliation(s)
- Artur Fedorowski
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Neuroscience, Imaging & Clinical Sciences, “G.d’Annunzio” University, Chieti-Pescara
- Casa di Cura Villa Serena, Città Sant’Angelo, Italy
| | - Viktor Hamrefors
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | | | - Tae Hwan Chung
- Dept of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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17
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Autoimmune autonomic ganglionopathy: Ganglionic acetylcholine receptor autoantibodies. Autoimmun Rev 2021; 21:102988. [PMID: 34728435 DOI: 10.1016/j.autrev.2021.102988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/28/2021] [Indexed: 11/24/2022]
Abstract
Autoimmune Autonomic Ganglionopathy (AAG) is a rare immune-mediated disease of the autonomic nervous system. The incidence of AAG is unknown and diagnosis is often difficult due to the multicompartmental nature of the autonomic nervous system - sympathetic, parasympathetic and enteric components - with variable severity and number of components affected. Diagnostic confidence is increased when ganglionic acetylcholine receptor (gnACHR) autoantibodies are detected. Three gnACHR autoantibody diagnostic assays have been described (two binding assays, one receptor immunomodulation assay), but cross-validation between assays is limited. The prevalence of gnACHR autoantibodies in AAG is not known, with application of different clinical and laboratory criteria in the few studies of AAG cohorts and large retrospective laboratory studies of positive gnACHR autoantibodies lacking adequate clinical characterisation. Furthermore, the rate of unexpected gnACHR autoantibody positivity in conditions without overt autonomic dysfunction (false positive results) adds to the complexity of their interpretation. We review the pathophysiology of gnACHR autoantibodies and assays for their detection, with immunomodulation and high titer radioimmunoprecipitation results likely offering better AAG disease identification.
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18
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Bryarly M, Raj SR, Phillips L, Hynan LS, Okamoto LE, Arnold AC, Paranjape SY, Vernino M, Black BK, Vernino S. Ganglionic Acetylcholine Receptor Antibodies in Postural Tachycardia Syndrome. Neurol Clin Pract 2021; 11:e397-e401. [PMID: 34484936 DOI: 10.1212/cpj.0000000000001047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/10/2020] [Indexed: 01/21/2023]
Abstract
Objective Postural tachycardia syndrome (POTS), the most common form of dysautonomia, may be associated with autoimmunity in some cases. Autoantibodies against the ganglionic acetylcholine receptor (gAChR) have been reported in a minority of patients with POTS, but the prevalence and clinical relevance is unclear. Methods Clinical information and serum samples were systematically collected from participants with POTS and healthy control volunteers (n = 294). The level of positive gAChR antibodies was classified as very low (0.02-0.05 nmol/L), low (0.05-0.2 nmol/L), and high (>0.2 nmol/L). Results Fifteen of 217 patients with POTS (7%) had gAChR antibodies (8 very low and 7 low). Six of the 77 healthy controls (8%) were positive (3 very low and 3 low). There were no clinical differences between seropositive and seronegative patients with POTS. Conclusions Prevalence of gAChR antibody did not differ between POTS and healthy controls, and none had high antibody levels. Patients with POTS were not clinically different based on seropositivity. Low levels of gAChR antibodies are not clinically important in POTS.
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Affiliation(s)
- Meredith Bryarly
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Satish R Raj
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Lauren Phillips
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Linda S Hynan
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Luis E Okamoto
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Amy C Arnold
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Sachin Y Paranjape
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Megan Vernino
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Bonnie K Black
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Steven Vernino
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
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19
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Kanuri SH, Shivamurthy P, Albadareen R, Elbey MA, Gopinathannair R, Lakkireddy D. Autoimmune dysautonomia secondary to chronic organophosphate exposure. HeartRhythm Case Rep 2021; 7:522-524. [PMID: 34434699 PMCID: PMC8377226 DOI: 10.1016/j.hrcr.2021.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
| | | | - Rawan Albadareen
- Department of Neurology, Overland Park Regional Medical Center, Overland Park, Kansas
| | - Mehmet Ali Elbey
- Kansas City Heart Rhythm Institute (KCHRI), Overland Park, Kansas
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20
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Antibody Testing for Suspected Autoimmune Autonomic Dysfunction and Small Fiber Neuropathies. J Clin Neurophysiol 2021; 38:274-278. [PMID: 34009850 DOI: 10.1097/wnp.0000000000000627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
SUMMARY Autonomic dysfunction and small fiber neuropathies are heterogeneous disorders with a wide array of potential etiologies. As with other neurologic diseases, autoantibodies specific to neural tissue, either in the setting of cancer or systemic autoimmunity, may cause autonomic abnormalities. Given the complex and varied functions of the autonomic nervous system, however, the presentation of these conditions may be quite variable. This, in addition to pitfalls of autonomic testing especially for the novice, can lead to inaccuracies in recognizing and characterizing these conditions. We now have a large number of autoantibodies available for testing with more in the pipeline thanks to unprecedented developments in the field of neuroimmunology. Those have been very helpful in uncovering potentially treatable mechanisms of autonomic disease, but also pose a challenge to the clinician given their multiplicity and variable specificity. Growing knowledge regarding autoimmune autonomic implications and the autonomic specificities of each antibody, in addition to the increasing attention to the relevance of antibody titers are of utmost importance for clinicians concerned with autonomic neurology. This review attempts to shed a light on the frequently encountered antibodies in relation to autonomic dysfunction.
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21
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Urriola N, Spies JM, Blazek K, Lang B, Adelstein S. A Flow Cytometric Assay to Detect Functional Ganglionic Acetylcholine Receptor Antibodies by Immunomodulation in Autoimmune Autonomic Ganglionopathy. Front Immunol 2021; 12:705292. [PMID: 34249013 PMCID: PMC8261233 DOI: 10.3389/fimmu.2021.705292] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/07/2021] [Indexed: 12/13/2022] Open
Abstract
Autoimmune Autonomic Ganglionopathy (AAG) is an uncommon immune-mediated neurological disease that results in failure of autonomic function and is associated with autoantibodies directed against the ganglionic acetylcholine receptor (gnACHR). The antibodies are routinely detected by immunoprecipitation assays, such as radioimmunoassays (RIA), although these assays do not detect all patients with AAG and may yield false positive results. Autoantibodies against the gnACHR exert pathology by receptor modulation. Flow cytometric analysis is able to determine if this has occurred, in contrast to the assays in current use that rely on immunoprecipitation. Here, we describe the first high-throughput, non-radioactive flow cytometric assay to determine autoantibody mediated gnACHR immunomodulation. Previously identified gnACHR antibody seronegative and seropositive sera samples (RIA confirmed) were blinded and obtained from the Oxford Neuroimmunology group along with samples collected locally from patients with or without AAG. All samples were assessed for the ability to cause gnACHR immunomodulation utilizing the prototypical gnACHR expressing cell line, IMR-32. Decision limits were calculated from healthy controls, and Receiver Operating Characteristic (ROC) curves were constructed after unblinding all samples. One hundred and ninety serum samples were analyzed; all 182 expected negative samples (from healthy controls, autonomic disorders not thought to be AAG, other neurological disorders without autonomic dysfunction and patients with Systemic Lupus Erythematosus) were negative for immunomodulation (<18%), as were the RIA negative AAG and unconfirmed AAG samples. All RIA positive samples displayed significant immunomodulation. There were no false positive or negative samples. There was perfect qualitative concordance as compared to RIA, with an Area Under ROC of 1. Detection of Immunomodulation by flow cytometry for the identification of gnACHR autoantibodies offers excellent concordance with the gnACHR antibody RIA, and overcomes many of the shortcomings of immunoprecipitation assays by directly measuring the pathological effects of these autoantibodies at the cellular level. Further work is needed to determine the correlation between the degree of immunomodulation and disease severity.
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Affiliation(s)
- Nicolás Urriola
- Department of Clinical Immunology and Allergy, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Judith M Spies
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Katrina Blazek
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Bethan Lang
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Stephen Adelstein
- Department of Clinical Immunology and Allergy, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Central Sydney Immunopathology Laboratory, NSW Health Pathology, Sydney, NSW, Australia
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22
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Abbatemarco JR, Rodenbeck SJ, Day GS, Titulaer MJ, Yeshokumar AK, Clardy SL. Autoimmune Neurology: The Need for Comprehensive Care. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/5/e1033. [PMID: 34131068 PMCID: PMC8207636 DOI: 10.1212/nxi.0000000000001033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/03/2021] [Indexed: 12/23/2022]
Abstract
Autoimmune neurology is a rapidly developing specialty driven by an increasing recognition of autoimmunity as the cause for a broad set of neurologic disorders and ongoing discovery of new neural autoantibodies associated with recognizable clinical syndromes. The diversity of clinical presentations, unique pathophysiology, and the complexity of available treatments requires a dedicated multidisciplinary team to diagnose and manage patients. In this article, we focus on antibody-associated autoimmune encephalitis (AE) to illustrate broader themes applicable to the specialty. We discuss common diagnostic challenges including the utilization of clinical assessment tools along with the determination of the prognostic significance of certain autoantibodies, with a focus on implications for long-term management. A growing body of literature demonstrates the long-term cognitive, behavioral, and physical sequelae of AE. Dedicated resources are needed to effectively manage these patients. These resources may be best provided by experienced neurology clinics in partnership with other neurologic subspecialists, as well as psychiatrists, neuropsychologists, and physical medicine and rehabilitation providers.
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Affiliation(s)
- Justin R Abbatemarco
- From the Department of Neurology (J.R.A., S.J.R., S.L.C.), University of Utah, Salt Lake City; Department of Neurology (G.S.D.), Mayo Clinic in Florida, Jacksonville; Department of Neurology (M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (A.K.Y.), Icahn School of Medicine at Mount Sinai, New York; and George E. Wahlen Veterans Affairs Medical Center (S.L.C.), Salt Lake City, UT
| | - Stefanie J Rodenbeck
- From the Department of Neurology (J.R.A., S.J.R., S.L.C.), University of Utah, Salt Lake City; Department of Neurology (G.S.D.), Mayo Clinic in Florida, Jacksonville; Department of Neurology (M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (A.K.Y.), Icahn School of Medicine at Mount Sinai, New York; and George E. Wahlen Veterans Affairs Medical Center (S.L.C.), Salt Lake City, UT
| | - Gregory S Day
- From the Department of Neurology (J.R.A., S.J.R., S.L.C.), University of Utah, Salt Lake City; Department of Neurology (G.S.D.), Mayo Clinic in Florida, Jacksonville; Department of Neurology (M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (A.K.Y.), Icahn School of Medicine at Mount Sinai, New York; and George E. Wahlen Veterans Affairs Medical Center (S.L.C.), Salt Lake City, UT
| | - Maarten J Titulaer
- From the Department of Neurology (J.R.A., S.J.R., S.L.C.), University of Utah, Salt Lake City; Department of Neurology (G.S.D.), Mayo Clinic in Florida, Jacksonville; Department of Neurology (M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (A.K.Y.), Icahn School of Medicine at Mount Sinai, New York; and George E. Wahlen Veterans Affairs Medical Center (S.L.C.), Salt Lake City, UT
| | - Anusha K Yeshokumar
- From the Department of Neurology (J.R.A., S.J.R., S.L.C.), University of Utah, Salt Lake City; Department of Neurology (G.S.D.), Mayo Clinic in Florida, Jacksonville; Department of Neurology (M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (A.K.Y.), Icahn School of Medicine at Mount Sinai, New York; and George E. Wahlen Veterans Affairs Medical Center (S.L.C.), Salt Lake City, UT
| | - Stacey L Clardy
- From the Department of Neurology (J.R.A., S.J.R., S.L.C.), University of Utah, Salt Lake City; Department of Neurology (G.S.D.), Mayo Clinic in Florida, Jacksonville; Department of Neurology (M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (A.K.Y.), Icahn School of Medicine at Mount Sinai, New York; and George E. Wahlen Veterans Affairs Medical Center (S.L.C.), Salt Lake City, UT.
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23
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Stauffer C, Llano DA, Kitten S. Nicotinic ganglionic acetylcholine receptor autoantibodies associated with paraneoplastic disease in a neuropsychiatric patient. BMJ Case Rep 2021; 14:14/5/e240824. [PMID: 34045196 DOI: 10.1136/bcr-2020-240824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Nicotinic ganglionic acetylcholine receptor autoantibodies (alpha-3-AChR Ab) are associated with paraneoplastic syndromes when present in low elevations. These antibodies can be tested for as part of an autoimmune encephalopathy panel in neuropsychiatric patients; a mildly elevated titre of alpha-3-AChR Ab that may start as an incidental finding can lead to the diagnosis of a previously undetected cancer. While alpha-3-AChR Ab are most typically associated with thymomas and small cell lung cancer, the presence of these antibodies can suggest a diverse range of other cancers. This case presents a patient with longstanding neuropsychiatric symptoms and possible functional hypothyroidism for whom a low elevation in alpha-3-AChR Ab led to the finding of papillary thyroid carcinoma.
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Affiliation(s)
- Catherine Stauffer
- Carle Foundation Hospital, Urbana, Illinois, USA .,Carle Illinois College of Medicine, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
| | - Daniel A Llano
- Carle Neuroscience Institute, Carle Foundation Hospital, Urbana, Illinois, USA
| | - Suzanna Kitten
- Psychiatry, Carle Foundation Hospital, Urbana, Illinois, USA
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24
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Jitprapaikulsan J, Paul P, Thakolwiboon S, Mittal SO, Pittock SJ, Dubey D. Paraneoplastic neurological syndrome: an evolving story. Neurooncol Pract 2021; 8:362-374. [PMID: 34277016 DOI: 10.1093/nop/npab002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Paraneoplastic neurological syndrome (PNS) comprises a group of neurological disorders that result from a misguided immune response to the nervous system triggered by a distant tumor. These disorders frequently manifest before the diagnosis of the underlying neoplasm. Since the first reported case in 1888 by Oppenheim, the knowledge in this area has evolved rapidly. Several classic PNS have been described, such as limbic encephalitis, paraneoplastic cerebellar degeneration, encephalomyelitis, opsoclonus-myoclonus, sensory neuronopathy, Lambert-Eaton Myasthenic syndrome, and chronic gastrointestinal dysmotility. It is now recognized that PNS can have varied nonclassical manifestations that extend beyond the traditional syndromic descriptions. Multiple onconeural antibodies with high specificity for certain tumor types and neurological phenotypes have been discovered over the past 3 decades. Increasing use of immune checkpoint inhibitors (ICIs) has led to increased recognition of neurologic ICI-related adverse events. Some of these resemble PNS. In this article, we review the clinical, oncologic, and immunopathogenic associations of PNS.
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Affiliation(s)
- Jiraporn Jitprapaikulsan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota.,Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pritikanta Paul
- Department of Neurology, Mayo Clinic, Rochester, Minnesota.,Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, Illinois
| | - Smathorn Thakolwiboon
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Department of Neurology, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Shivam Om Mittal
- Department of Neurology, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.,Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, Minnesota.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.,Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota
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25
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Amin M, Li Y, Daly TM, Marquardt RJ. Evaluating the frequency of positive paraneoplastic antibodies and associated malignancy risk. J Neurol Sci 2021; 423:117347. [PMID: 33640579 DOI: 10.1016/j.jns.2021.117347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/10/2021] [Accepted: 02/11/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the association between malignancy and frequently positive paraneoplastic antibodies. METHODS A retrospective cohort study was carried out for all patients who received paraneoplastic antibody testing in 2013-2014 at a tertiary referral center. Available medical records on included patients were reviewed through July 2020. Patients were divided into antibody positive and negative subgroups. Focused analysis was performed on the subgroup of patients who received testing via a commonly used antibody panel. RESULTS A total of 1860 patients (the full cohort) received 19,323 antibody testing via panel or individual antibody testing, and were followed-up for a mean period of 36.2 months (range 0-83 months). Altogether 229 antibodies in 196 patients were positive, and 9 (3.9%) in 7 patients were against onconeuronal antigens. The remaining 220 (96.1%) were positive for mostly antibodies against cell surface or synaptic antigens. A total of 1161 patients received Mayo Clinic paraneoplastic antibody panel tests (the panel cohort), and 14.9% (173) of these patients possessed one or more positive antibodies. For the panel cohort, no difference was found between antibody positive and negative groups with respect to the prevalence of previously existing malignancy (15.6% versus 16.6%, p = 0.745) or incidence of new malignancy (4.0% vs. 3.7%, p = 0.848) during the follow-up period. No difference was observed in the incidence of new malignancy during follow-up between the antibody positive and negative groups for the 7 most frequently positive antibodies. CONCLUSIONS The presence of frequently positive antibodies, mostly to cell surface or synaptic antigens, is not clearly associated with the development of malignancy in the subsequent three years.
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Affiliation(s)
- Moein Amin
- Neurological Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Yuebing Li
- Neurological Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Thomas M Daly
- Neurological Institute, Cleveland Clinic, Cleveland, OH, United States of America; Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Robert J Marquardt
- Neurological Institute, Cleveland Clinic, Cleveland, OH, United States of America.
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Kaur D, Tiwana H, Stino A, Sandroni P. Autonomic neuropathies. Muscle Nerve 2020; 63:10-21. [PMID: 32926436 DOI: 10.1002/mus.27048] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 12/17/2022]
Abstract
Autonomic neuropathies represent a complex group of disorders that preferentially target autonomic fibers and can be classified as either acute/subacute or chronic in onset. Acute-onset autonomic neuropathies manifest with such conditions as paraneoplastic syndromes, Guillain-Barre syndrome, Sjögren syndrome, infection, or toxins/chemotherapy. When the presentation is acute, immune-mediated, and without a secondary cause, autoimmune autonomic ganglionopathy is likely, and should be considered for immunotherapy. Of the chronic-onset forms, diabetes is the most widespread and disabling, with autonomic impairment portending increased mortality and cardiac wall remodeling risk. Acquired light chain (AL) and transthyretin (TTR) amyloidosis represent two other key etiologies, with TTR amyloidosis now amenable to newly-approved gene-modifying therapies. The COMPASS-31 questionnaire is a validated outcome measure that can be used to monitor autonomic severity and track treatment response. Symptomatic treatments targeting orthostatic hypotension, among other symptoms, should be individualized and complement disease-modifying therapy, when possible.
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Affiliation(s)
- Divpreet Kaur
- Department of Neurology, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Harmanpreet Tiwana
- Department of Neurology, Dartmouth-Hitchcok Medical Center, Lebanon, New Hampshire, USA
| | - Amro Stino
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Paola Sandroni
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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Muccioli L, Nicodemo M, Cortelli P, Guarino M. Subacute-onset paraneoplastic autonomic neuropathy associated with prostate cancer. Clin Auton Res 2020; 30:579-580. [PMID: 32816184 PMCID: PMC7439798 DOI: 10.1007/s10286-020-00719-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 08/13/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Lorenzo Muccioli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Marianna Nicodemo
- Neurology Unit, S. Orsola-Malpighi University Hospital, Via Giuseppe Massarenti 9, 40139, Bologna, IT, Italy.,IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Pietro Cortelli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Maria Guarino
- Neurology Unit, S. Orsola-Malpighi University Hospital, Via Giuseppe Massarenti 9, 40139, Bologna, IT, Italy. .,IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy.
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28
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Sanchez JMS, McNally JS, Cortez MM, Hemp J, Pace LA, Clardy SL. Neuroimmunogastroenterology: At the Interface of Neuroimmunology and Gastroenterology. Front Neurol 2020; 11:787. [PMID: 32849234 PMCID: PMC7412790 DOI: 10.3389/fneur.2020.00787] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 06/25/2020] [Indexed: 12/11/2022] Open
Abstract
The central nervous system (CNS) is an important regulator of the gastrointestinal tract, and CNS dysfunction can result in significant and disabling gastrointestinal symptom manifestation. For patients with neuroimmunologic and neuroinflammatory conditions, the recognition of gastrointestinal symptoms is under-appreciated, yet the gastrointestinal manifestations have a dramatic impact on quality of life. The current treatment strategies, often employed independently by the neurologist and gastroenterologist, raise the question of whether such patients are being treated optimally when siloed in one specialty. Neuroimmunogastroenterology lies at the borderlands of medical specialties, and there are few resources to guide neurologists in this area. Here, we provide an overview highlighting the potential mechanisms of crosstalk between immune-mediated neurological disorders and gastrointestinal dysfunction.
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Affiliation(s)
- John Michael S. Sanchez
- Division of Microbiology and Immunology, Department of Pathology, University of Utah, Salt Lake City, UT, United States
| | - J. Scott McNally
- Department of Radiology, Utah Center for Advanced Imaging Research, University of Utah, Salt Lake City, UT, United States
| | - Melissa M. Cortez
- Department of Neurology, Imaging and Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - James Hemp
- Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States
| | - Laura A. Pace
- Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States
| | - Stacey L. Clardy
- Department of Neurology, Imaging and Neurosciences Center, University of Utah, Salt Lake City, UT, United States
- George E. Whalen Veterans Affairs Medical Center, Salt Lake City, UT, United States
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Nakane S. [Autoimmune autonomic ganglionopathy]. Rinsho Shinkeigaku 2019; 59:783-790. [PMID: 31761837 DOI: 10.5692/clinicalneurol.cn-001354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Autoimmune autonomic ganglionopathy (AAG) is an acquired immune-mediated disorder of widespread autonomic failure. Approximately half of the patients with AAG have the autoantibodies against the neuronal nicotinic acetylcholine receptor (AChR) in autonomic ganglia. These ganglionic AChR antibodies have the potential to mediate the synaptic transmission in sympathetic, parasympathetic, and enteric ganglia. Therefore, seropositive AAG patients exhibit various autonomic symptoms. Extra-autonomic manifestations (coexistence with brain involvement, sensory disturbance, endocrine disorders, autoimmune diseases and tumors) are present in many patients with AAG. The nicotinic AChRs comprise a family of abundantly expressed ligand-gated cation channels found throughout the central and peripheral nervous systems. Moreover, limited manifestations of autoimmune dysautonomia including autoimmune gastrointestinal dysmotility are newly recognized clinical entity. Although combined immunomodulatory therapy is beneficial for almost all patients with AAG, several case reports of some AAG patients with small benefit exist. This review focuses on the recent progress in the clinical approaches of AAG and its related disorders involving the role of autoantibodies and clinical practice.
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Affiliation(s)
- Shunya Nakane
- Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital
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30
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Lapides DA. Shared Decision-making in Autoimmune Neurology: Making Decisions in the Face of Uncertainty. Neurol Clin Pract 2019; 11:141-146. [PMID: 33842067 DOI: 10.1212/cpj.0000000000000796] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 11/18/2019] [Indexed: 11/15/2022]
Abstract
Purpose of review In this article, the author explores the use of shared decision making (SDM) in the management of the preference-sensitive condition, neural autoantibody-mediated syndromes. Recent findings The field of autoimmune neurology lacks trials and often data to support therapeutic decisions. Treatment choices need to be made acutely, lacking crucial laboratory information and with uncertainty regarding treatment response and prognosis. This lack of data does not necessitate indecision in a population where delayed treatment may lead to poor outcomes. Over the past several decades, SDM has emerged as a model of communication enabling clinicians and their patients to explore current knowledge in the context of a patient's values and goals to arrive at joint decision, even when data are lacking. Summary SDM is a tool autoimmune neurologists should use to develop individualized treatment plans based on the patient's clinical presentation contextualized within specific values and preferences.
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Affiliation(s)
- David A Lapides
- Department of Neurology, University of Virginia, Charlottesville, VA
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31
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Pittock SJ, Mills JR, McKeon A. Reader response: Unintended consequences of Mayo paraneoplastic evaluations. Neurology 2019; 93:606. [PMID: 31551274 DOI: 10.1212/wnl.0000000000008179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Zekeridou A, Lennon VA. Neurologic Autoimmunity in the Era of Checkpoint Inhibitor Cancer Immunotherapy. Mayo Clin Proc 2019; 94:1865-1878. [PMID: 31358366 DOI: 10.1016/j.mayocp.2019.02.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 01/30/2019] [Accepted: 02/20/2019] [Indexed: 01/21/2023]
Abstract
Neurologic autoimmune disorders in the context of systemic cancer reflect antitumor immune responses against onconeural proteins that are autoantigens in the nervous system. These responses observe basic principles of cancer immunity and are highly pertinent to oncological practice since the introduction of immune checkpoint inhibitor cancer therapy. The patient's autoantibody profile is consistent with the antigenic composition of the underlying malignancy. A major determinant of the pathogenic outcome is the anatomic and subcellular location of the autoantigen. IgGs targeting plasma membrane proteins (eg, muscle acetylcholine receptor -IgG in patients with paraneoplastic myasthenia gravis) have pathogenic potential. However, IgGs specific for intracellular antigens (eg, antineuronal nuclear antibody 1 [anti-Hu] associated with sensory neuronopathy and small cell lung cancer) are surrogate markers for CD8+ T lymphocytes targeting peptides derived from nuclear or cytoplasmic proteins. In an inflammatory milieu, those peptides translocate to neural plasma membranes as major histocompatibility complex class I protein complexes. Paraneoplastic neurologic autoimmunity can affect any level of the neuraxis and may be mistaken for cancer progression. Importantly, these disorders generally respond favorably to early-initiated immunotherapy and cancer treatment. Small cell lung cancer and thymoma are commonly associated with neurologic autoimmunity, but in the context of checkpoint inhibitor therapy, other malignancy associations are increasingly recognized.
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Affiliation(s)
- Anastasia Zekeridou
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN; Department of Neurology, Mayo Clinic, Rochester, MN.
| | - Vanda A Lennon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN; Department of Neurology, Mayo Clinic, Rochester, MN; Department of Immunology, Mayo Clinic, Rochester, MN
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34
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Golden EP, Vernino S. Autoimmune autonomic neuropathies and ganglionopathies: epidemiology, pathophysiology, and therapeutic advances. Clin Auton Res 2019; 29:277-288. [DOI: 10.1007/s10286-019-00611-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 05/03/2019] [Indexed: 12/12/2022]
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35
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Autoimmune autonomic ganglionopathy associated with monoclonal gammopathy of undetermined significance: a case report. Neurol Sci 2019; 40:1481-1483. [PMID: 30685800 DOI: 10.1007/s10072-019-3731-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
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36
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Rafanelli M, Walsh K, Hamdan MH, Buyan-Dent L. Autonomic dysfunction: Diagnosis and management. HANDBOOK OF CLINICAL NEUROLOGY 2019; 167:123-137. [PMID: 31753129 DOI: 10.1016/b978-0-12-804766-8.00008-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The autonomic nervous system is designed to maintain physiologic homeostasis. Its widespread connections make it vulnerable to disruption by many disease processes including primary etiologies such as Parkinson's disease, multiple system atrophy, dementia with Lewy bodies, and pure autonomic failure and secondary etiologies such as diabetes mellitus, amyloidosis, and immune-mediated illnesses. The result is numerous symptoms involving the cardiovascular, gastrointestinal, and urogenital systems. Patients with autonomic dysfunction (AUD) often have peripheral and/or cardiac denervation leading to impairment of the baroreflex, which is known to play a major role in determining hemodynamic outcome during orthostatic stress and low cardiac output states. Heart rate and plasma norepinephrine responses to orthostatic stress are helpful in diagnosing impairment of the baroreflex in patients with orthostatic hypotension (OH) and suspected AUD. Similarly, cardiac sympathetic denervation diagnosed with MIBG scintigraphy or 18F-DA PET scanning has also been shown to be helpful in distinguishing preganglionic from postganglionic involvement and in diagnosing early stages of neurodegenerative diseases. In this chapter, we review the causes of AUD, the pathophysiology and resulting cardiovascular manifestations with emphasis on the diagnosis and treatment of OH.
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Affiliation(s)
- Martina Rafanelli
- Division of Geriatric Cardiology and Medicine, University of Florence, Florence, Italy
| | - Kathleen Walsh
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Mohamed H Hamdan
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Laura Buyan-Dent
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States.
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37
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Autoimmunity in postural orthostatic tachycardia syndrome: Current understanding. Auton Neurosci 2018; 215:78-82. [DOI: 10.1016/j.autneu.2018.04.005] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 04/25/2018] [Accepted: 04/25/2018] [Indexed: 01/01/2023]
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Fealey RD. Thermoregulation in neuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2018; 157:777-787. [PMID: 30459040 DOI: 10.1016/b978-0-444-64074-1.00048-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
Peripheral neuropathy affecting autonomic and small sensory fibers can cause abnormalities of both autonomic and behavioral thermoregulation. Quantitative autonomic and sensory neurophysiologic tests and quantification of the linear density of intraepidermal nerve fibers potentially can stratify those at risk of impaired thermoregulation during cold and heat challenges. New data relating to thermoregulatory sweating impairment in neuropathy are presented in this chapter. Of 516 neuropathy patients analyzed, 345 were found to have thermoregulatory sweat test (TST) abnormalities with a mean percentage of anterior body surface anhidrosis (TST%) of 12% and a significant reduction in total body sweat rate, although the rate of core temperature rise with heating (slope) was not significantly different from that of patients with a normal TST. However a subset of abnormal TST patients having 25% or greater TST% showed a significantly more rapid rise in core temperature (lower slope) than age- and sex-matched neuropathy patients with a normal TST. Etiologies of neuropathy in this more severe group included diabetes, erythromelalgia, immune-mediated autonomic neuropathy, primary systemic amyloidosis, and neuropathy associated with postganglionic-autonomic degenerative disorders.
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Affiliation(s)
- Robert D Fealey
- Department of Neurology, Mayo Clinic, Rochester, MN, United States.
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39
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Ueno T, Hasegawa Y, Hagiwara R, Kon T, Nunomura JI, Tomiyama M. Integrated treatment for autonomic paraneoplastic syndrome improves performance status in a patient with small lung cell carcinoma: a case report. BMC Neurol 2018; 18:189. [PMID: 30414621 PMCID: PMC6230283 DOI: 10.1186/s12883-018-1192-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 10/28/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Paraneoplastic neurological syndromes (PNS) are rare disorders associated with cancer and are believed to be immune mediated. Patients with autonomic PNS suffer from variable combinations of parasympathetic and sympathetic failure. Autonomic PNS are usually associated with other PNS, such as encephalomyelitis and sensory neuropathy; however, autonomic symptoms may rarely manifest as PNS symptoms. Autonomic symptoms, therefore, may be overlooked in patients with cancer. CASE PRESENTATION We described a 65-year-old Japanese man who was diagnosed with autonomic PNS due to small-cell lung carcinoma (SCLC) with Eastern Cooperative Oncology Group (ECOG) performance status 3, who suffered from orthostatic hypotension, and urinary retention needing a urethral balloon. Laboratory studies showed decreased levels of noradrenaline, and were positive for anti-ganglionic acetylcholine receptor antibody, type 1 antineuronal nuclear antibody, and sry-like high mobility group box 1 antibody. Nerve conduction evaluations and 123I-metaiodobenzylguanidine myocardial scintigraphy showed no abnormalities. Abdominal contrast-enhanced computed tomography revealed marked colonic distention. The patient's autonomic symptoms resolved following integrated treatment (symptomatic treatment, immunotherapy, and additional chemotherapy) enabling the patient to walk, remove the urethral balloon, and endure further chemotherapy. ECOG performance status remained at 1, 10 months after admission. CONCLUSIONS Integrated treatment for autonomic PNS may improve autonomic symptoms and ECOG performance status of patients with cancer.
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Affiliation(s)
- Tatsuya Ueno
- Department of Neurology, Aomori Prefectural Central Hospital, 2-1-1 Higashi-Tsukurimichi, Aomori, 030-8551, Japan.
| | - Yukihiro Hasegawa
- Department of Respiratory Medicine, Aomori Prefectural Central Hospital, 2-1-1 Higashi-Tsukurimichi, Aomori, 030-8551, Japan
| | - Rie Hagiwara
- Department of Neurology, Aomori Prefectural Central Hospital, 2-1-1 Higashi-Tsukurimichi, Aomori, 030-8551, Japan
| | - Tomoya Kon
- Department of Neurology, Aomori Prefectural Central Hospital, 2-1-1 Higashi-Tsukurimichi, Aomori, 030-8551, Japan
| | - Jin-Ichi Nunomura
- Department of Neurology, Aomori Prefectural Central Hospital, 2-1-1 Higashi-Tsukurimichi, Aomori, 030-8551, Japan
| | - Masahiko Tomiyama
- Department of Neurology, Aomori Prefectural Central Hospital, 2-1-1 Higashi-Tsukurimichi, Aomori, 030-8551, Japan
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Nakane S, Mukaino A, Higuchi O, Watari M, Maeda Y, Yamakawa M, Nakahara K, Takamatsu K, Matsuo H, Ando Y. Autoimmune autonomic ganglionopathy: an update on diagnosis and treatment. Expert Rev Neurother 2018; 18:953-965. [PMID: 30352532 DOI: 10.1080/14737175.2018.1540304] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Autoimmune autonomic ganglionopathy (AAG) is an acquired immune-mediated disorder that leads to autonomic failure. The disorder is associated with autoantibodies to the ganglionic nicotinic acetylcholine receptor (gAChR). We subsequently reported that AAG is associated with an overrepresentation of psychiatric symptoms, sensory disturbance, autoimmune diseases, and endocrine disorders. Area covered: The aim of this review was to describe AAG and highlight its pivotal pathophysiological aspects, clinical features, laboratory examinations, and therapeutic options. Expert commentary: AAG is a complex neuroimmunological disease, these days considered as an autonomic failure with extra-autonomic manifestations (and various limited forms). Further comprehension of the pathophysiology of this disease is required, especially the mechanisms of the extra-autonomic manifestations should be elucidated. There is the possibility that the co-presence of antibodies that were directed against the other subunits in both the central and peripheral nAChRs in the serum of the AAG patients. Some patients improve with immunotherapies such as IVIg and/or corticosteroid and/or plasma exchange. 123I-MIBG myocardial scintigraphy may be a useful tool to monitor the therapeutic effects of immunotherapies.
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Affiliation(s)
- Shunya Nakane
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan.,b Department of Molecular Neurology and Therapeutics , Kumamoto University Hospital , Kumamoto , Japan
| | - Akihiro Mukaino
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan.,b Department of Molecular Neurology and Therapeutics , Kumamoto University Hospital , Kumamoto , Japan
| | - Osamu Higuchi
- c Department of Neurology and Clinical Research , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | - Mari Watari
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
| | - Yasuhiro Maeda
- c Department of Neurology and Clinical Research , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | - Makoto Yamakawa
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
| | - Keiichi Nakahara
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
| | - Koutaro Takamatsu
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
| | - Hidenori Matsuo
- c Department of Neurology and Clinical Research , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | - Yukio Ando
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
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Ebright MJ, Li SH, Reynolds E, Burke JF, Claytor BR, Grisold A, Banerjee M, Callaghan BC. Unintended consequences of Mayo paraneoplastic evaluations. Neurology 2018; 91:e2057-e2066. [PMID: 30366974 DOI: 10.1212/wnl.0000000000006577] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 08/14/2018] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To determine the proportion of true and false positives from paraneoplastic panels and effects on downstream testing/treatment. METHODS Using a retrospective cohort study design, we identified 500 consecutive patients with Mayo paraneoplastic autoantibody testing and performed chart abstraction. Paraneoplastic presentation types were categorized into probable, possible, and other by consensus. True positives were defined as a positive antibody titer with no other explanation found in addition to one of the following: syndrome known to be associated with the antibody, clinical improvement with treatment, and new malignancy. Comparisons of diagnostic testing and treatments between false and true positives were performed. Multivariable logistic regression was used to evaluate associations between patient-level factors and true positives. RESULTS The mean (SD) age of the population was 55.4 (17.1) years, and 55.4% were female, with 1.3 (1.2) years of follow-up. Of the 500 tests, 87 (17.4%, 95% confidence interval [CI] 14.1%-20.7%) were positive and 62 (71.3%, 95% CI 61.8%-80.8%) of these were false positives. Of those with a possible/other presentation (n = 369), 2 (0.5%, 95% CI 0.0%-1.0%) were true positives. CT of the chest (30.7% vs 11.8%, p ≤ 0.01) was performed more often in false positives than true negatives. Probable presentation type (odds ratio [OR] 57.9, 95% CI 12.5-268.0) and outpatient setting (OR 8.7, 95% CI 2.4-31.8) were associated with true-positive results. CONCLUSION Paraneoplastic tests result in a large proportion of false positives, particularly in those with clinical presentations that are not well established as paraneoplastic diseases. Future work should construct panels targeted to specific clinical presentations and ensure that tests are ordered in the appropriate clinical context.
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Affiliation(s)
- Matthew J Ebright
- From the Health Services Research Program (M.J.E., J.F.B., B.R.C., B.C.C.), Department of Neurology, Department of Pathology (S.-H.L.), and Department of Biostatistics (E.R., M.B.), School of Public Health, University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; and Department of Neurology (A.G.), Medical University of Vienna, Austria
| | - Shih-Hon Li
- From the Health Services Research Program (M.J.E., J.F.B., B.R.C., B.C.C.), Department of Neurology, Department of Pathology (S.-H.L.), and Department of Biostatistics (E.R., M.B.), School of Public Health, University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; and Department of Neurology (A.G.), Medical University of Vienna, Austria
| | - Evan Reynolds
- From the Health Services Research Program (M.J.E., J.F.B., B.R.C., B.C.C.), Department of Neurology, Department of Pathology (S.-H.L.), and Department of Biostatistics (E.R., M.B.), School of Public Health, University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; and Department of Neurology (A.G.), Medical University of Vienna, Austria
| | - James F Burke
- From the Health Services Research Program (M.J.E., J.F.B., B.R.C., B.C.C.), Department of Neurology, Department of Pathology (S.-H.L.), and Department of Biostatistics (E.R., M.B.), School of Public Health, University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; and Department of Neurology (A.G.), Medical University of Vienna, Austria
| | - Ben R Claytor
- From the Health Services Research Program (M.J.E., J.F.B., B.R.C., B.C.C.), Department of Neurology, Department of Pathology (S.-H.L.), and Department of Biostatistics (E.R., M.B.), School of Public Health, University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; and Department of Neurology (A.G.), Medical University of Vienna, Austria
| | - Anna Grisold
- From the Health Services Research Program (M.J.E., J.F.B., B.R.C., B.C.C.), Department of Neurology, Department of Pathology (S.-H.L.), and Department of Biostatistics (E.R., M.B.), School of Public Health, University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; and Department of Neurology (A.G.), Medical University of Vienna, Austria
| | - Mousumi Banerjee
- From the Health Services Research Program (M.J.E., J.F.B., B.R.C., B.C.C.), Department of Neurology, Department of Pathology (S.-H.L.), and Department of Biostatistics (E.R., M.B.), School of Public Health, University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; and Department of Neurology (A.G.), Medical University of Vienna, Austria
| | - Brian C Callaghan
- From the Health Services Research Program (M.J.E., J.F.B., B.R.C., B.C.C.), Department of Neurology, Department of Pathology (S.-H.L.), and Department of Biostatistics (E.R., M.B.), School of Public Health, University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; and Department of Neurology (A.G.), Medical University of Vienna, Austria.
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Naides SJ. The role of the laboratory in the expanding field of neuroimmunology: Autoantibodies to neural targets. J Immunol Methods 2018; 463:1-20. [PMID: 30300607 DOI: 10.1016/j.jim.2018.04.003] [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: 12/15/2017] [Accepted: 04/12/2018] [Indexed: 12/15/2022]
Abstract
Accelerated identification of autoantibodies associated with previously idiopathic neurological disease has provided insights into disease mechanisms, enhanced understanding of neurological function, and opportunities for improved therapeutic interventions. The role of the laboratory in the expanding field of neuroimmunology is critical as specific autoantibody identification provides guidance to clinicians in diagnosis, prognosis, tumor search strategies, and therapeutic interventions. The number of specific autoantibodies identified continues to increase and newer testing strategies increase efficiencies in the laboratory and availability to clinicians. The need for broadly targeted efficient testing is underscored by the variability in clinical presentation and tumor associations attributable to a specific autoantibody, and conversely the various autoantibody specificities that can be the cause of a given clinical presentation. While many of the antineural antibodies were first recognized in the setting of neoplastic disease, idiopathic autoimmune neurological disease in the absence of underlying tumor is increasingly recognized. Appropriation of therapeutic modalities used to treat autoimmune disease to treat these autoantibody mediated neurological diseases has improved patient outcomes. Interaction between clinicians and laboratorians is critical to our understanding of these diseases and optimization of the clinical benefits of our increasing knowledge in neuroimmunology.
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Affiliation(s)
- Stanley J Naides
- Immunology R&D, Quest Diagnostics Nichols Institute, 33608 Ortega Highway, San Juan Capistrano, CA 92675, USA.
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Cutsforth-Gregory JK, McKeon A, Coon EA, Sletten DM, Suarez M, Sandroni P, Singer W, Benarroch EE, Fealey RD, Low PA. Ganglionic Antibody Level as a Predictor of Severity of Autonomic Failure. Mayo Clin Proc 2018; 93:1440-1447. [PMID: 30170741 PMCID: PMC6173625 DOI: 10.1016/j.mayocp.2018.05.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 04/30/2018] [Accepted: 05/07/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess antibody level as a test of autonomic failure (AF) associated with ganglionic nicotinic acetylcholine receptor antibody (AChR-Ab) autoimmunity. PATIENTS AND METHODS We searched the Mayo Clinic laboratory database of 926 ganglionic AChR-Ab-seropositive patients seen at our institution between October 1, 1997, and April 1, 2015, for initial level of 0.05 nmol/L or higher and contemporaneous autonomic reflex screen (standardized evaluation of adrenergic, cardiovagal, and sudomotor functions) from which Composite Autonomic Scoring Scale (CASS) scores could be calculated. RESULTS Of 289 patients who met inclusion criteria, 163 (56.4%) were women, median age was 54 years (range, 10-87 years), median antibody level was 0.11 nmol/L (range, 0.05-22.10 nmol/L), and median CASS total score was 2.0 (range, 0-10). Using receiver operating characteristic curve analysis, a level above 0.40 nmol/L predicted severe AF (CASS score, ≥7) with 92% specificity and 56% sensitivity. For at least moderate AF (CASS score ≥4 and anhidrosis ≥25%), a level of at least 0.20 nmol/L had 80% specificity and 59% sensitivity. Levels below 0.20 nmol/L were not predictive of the presence or absence of AF. For predicting orthostatic hypotension, ganglionic AChR-Ab level had excellent specificity above 0.4 nmol/L but lacked sensitivity. Autoantibodies to additional targets were present in 61 patients (21.1%). CONCLUSION Ganglionic AChR-Ab level of at least 0.40 nmol/L is a moderately sensitive and highly specific marker for severe AF, as is a level of at least 0.20 nmol/L for moderate AF if CASS score is coupled with anhidrosis of 25% or more, among patients with suspected ganglionic AChR-Ab autoimmune autonomic ganglionopathy. Antibody levels of less than 0.20 nmol/L have little clinical importance in the absence of clinical AF.
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Affiliation(s)
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | | | - Phillip A Low
- Department of Neurology, Mayo Clinic, Rochester, MN.
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45
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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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Osuagwu FC, Mohiuddin SS, Malas N. Autoimmune Encephalopathy Beyond Anti-NMDAR Encephalitis: The Case of an Adolescent Male with AntiAcetylcholine Receptor Ganglionic Neuronal Antibody Encephalitis. PSYCHOSOMATICS 2018; 60:416-420. [PMID: 30093243 DOI: 10.1016/j.psym.2018.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 07/09/2018] [Accepted: 07/13/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Ferdnand C Osuagwu
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Michigan Medical School, MI.
| | - Sarah S Mohiuddin
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Michigan Medical School, MI
| | - Nasuh Malas
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Michigan Medical School, MI; Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, MI
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Joseph A, Wanono R, Flamant M, Vidal-Petiot E. Orthostatic hypotension: A review. Nephrol Ther 2018; 13 Suppl 1:S55-S67. [PMID: 28577744 DOI: 10.1016/j.nephro.2017.01.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 01/08/2017] [Indexed: 11/27/2022]
Abstract
Orthostatic hypotension, defined by a drop in blood pressure of at least 20mmHg for systolic blood pressure and at least 10mmHg for diastolic blood pressure within 3minutes of standing up, is a frequent finding, particularly in elderly patients. It is associated with a significant increase in morbidity and mortality. Although it is often multifactorial, the first favoring factor is medications. Other etiologies are divided in neurogenic orthostatic hypotension, characterized by autonomic failure due to central or peripheral nervous system disorders, and non-neurogenic orthostatic hypotension, mainly favoured by hypovolemia. Treatment always requires education of the patient regarding triggering situations and physiological countermanoeuvers. Pharmacological treatment may sometimes be necessary and mainly relies on volume expansion by fludrocortisone and/or a vasopressor agents such as midodrine. There is no predefined blood pressure target, the goal of therapy being the relief of symptoms and fall prevention.
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Affiliation(s)
- Adrien Joseph
- Service de physiologie, DHU Fire, hôpital Bichat, 46, rue Henri-Huchard, 75018 Paris, France
| | - Ruben Wanono
- Service de physiologie, DHU Fire, hôpital Bichat, 46, rue Henri-Huchard, 75018 Paris, France; Université Paris Diderot, Sorbonne Paris-Cité, 46, rue Henri-Huchard, 75018 Paris, France
| | - Martin Flamant
- Service de physiologie, DHU Fire, hôpital Bichat, 46, rue Henri-Huchard, 75018 Paris, France; Université Paris Diderot, Sorbonne Paris-Cité, 46, rue Henri-Huchard, 75018 Paris, France; Inserm U1149, 46, rue Henri-Huchard, 75018 Paris, France
| | - Emmanuelle Vidal-Petiot
- Service de physiologie, DHU Fire, hôpital Bichat, 46, rue Henri-Huchard, 75018 Paris, France; Université Paris Diderot, Sorbonne Paris-Cité, 46, rue Henri-Huchard, 75018 Paris, France; Inserm U1149, 46, rue Henri-Huchard, 75018 Paris, France.
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Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martín A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018; 39:1883-1948. [PMID: 29562304 DOI: 10.1093/eurheartj/ehy037] [Citation(s) in RCA: 976] [Impact Index Per Article: 162.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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49
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Vogrig A, Pauletto G, Belgrado E, Pegolo E, Di Loreto C, Rogemond V, Honnorat J, Eleopra R. Effect of thymectomy on refractory autoimmune status epilepticus. J Neuroimmunol 2018; 317:90-94. [PMID: 29336839 DOI: 10.1016/j.jneuroim.2018.01.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 01/06/2018] [Accepted: 01/08/2018] [Indexed: 12/14/2022]
Abstract
Refractory status epilepticus (RSE) is an increasingly recognized manifestation of autoimmune encephalitis, which can occur either as a paraneoplastic or non-paraneoplastic disorder. The effect of tumor removal in paraneoplastic status epilepticus has never been explored systematically, although early tumor treatment is usually recommended. In this study, we report clinical, pathological and EEG findings of a patient who developed RSE as one of multiple paraneoplastic manifestations of thymoma and the effect of thymectomy on seizure outcome. To our knowledge, this is the first report of successful treatment of RSE with tumor removal in paraneoplastic encephalitis.
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Affiliation(s)
- Alberto Vogrig
- Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy.
| | - Giada Pauletto
- Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Enrico Belgrado
- Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Enrico Pegolo
- Department of Medical and Biological Sciences, Institution of Anatomic Pathology, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Carla Di Loreto
- Department of Medical and Biological Sciences, Institution of Anatomic Pathology, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Veronique Rogemond
- French Reference Center of Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Synatac Team, NeuroMyoGene Institut, INSERM U1217/CNRS UMR5310, University Claude Bernard Lyon 1, Lyon, France
| | - Jerome Honnorat
- French Reference Center of Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Synatac Team, NeuroMyoGene Institut, INSERM U1217/CNRS UMR5310, University Claude Bernard Lyon 1, Lyon, France
| | - Roberto Eleopra
- Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
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50
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Autoimmune paraneoplastic syndromes associated to lung cancer: A systematic review of the literature: Part 5: Neurological auto-antibodies, discussion, flow chart, conclusions. Lung Cancer 2017; 111:164-175. [DOI: 10.1016/j.lungcan.2017.07.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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