1
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Kapoor M, Khoo A, Lunn MPT, Reddel S, Carr AS. Immunoglobulin use in neurology: a practical approach. Pract Neurol 2024:pn-2022-003655. [PMID: 39097408 DOI: 10.1136/pn-2022-003655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2024] [Indexed: 08/05/2024]
Abstract
Human immunoglobulin, delivered either intravenously (IVIg) or subcutaneously, is used to treat a range of immune-mediated neurological disorders. It has a role in acute or subacute inflammatory disease control and as a maintenance therapy in chronic disease management. This review considers mechanisms of IVIg action and the evidence for IVIg in neurological conditions. We use Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) as frameworks to demonstrate an approach to IVIg use in acute and chronic dysimmune neurological conditions across two different healthcare systems: the UK and Australia. We highlight the benefits and limitations of IVIg and focus on practical considerations such as informed consent, managing risks and adverse effects, optimal dosing and monitoring response. We use these basic clinical practice principles to discuss the judicious use of an expensive and scarce blood product with international relevance.
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Affiliation(s)
- Mahima Kapoor
- Neuroscience / FMNHS / School of Translational Medicine, Monash University, Melbourne, Victoria, Australia
| | - Anthony Khoo
- Flinders University College of Medicine and Public Health, Adelaide, South Australia, Australia
- Department of Neurology, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Michael P T Lunn
- Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
- UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Stephen Reddel
- ANZAC Research Institute, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Aisling S Carr
- UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
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2
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El-Abassi RN, Soliman M, Levy MH, England JD. Treatment and Management of Autoimmune Neuropathies. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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3
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Ishida H, Unagami K, Omoto K, Kanzawa T, Tanabe K. Desensitization Regimen Consisting of High-Dose Intravenous Immunoglobulin, Plasmapheresis, and Rituximab (an Anti-CD20 Antibody), Without Eculizumab and/or Bortezomib, in 41 Highly Sensitized Kidney Transplant Recipients. EXP CLIN TRANSPLANT 2021; 19:1032-1040. [PMID: 34498551 DOI: 10.6002/ect.2021.0234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Antibody-mediated rejection in patients with positive crossmatches can be severe and result in sudden onset of oliguria, leading to graft loss. In an attempt to prevent posttransplant oliguria, we adopted a preoperative desensitization protocol involving the use of high-dose intravenous immunoglobulin/plasmapheresis and the anti-CD20 antibody, rituximab, in 41 transplant recipients with positive crossmatch test results. MATERIALS AND METHODS We retrospectively examined the clinical courses of the 41 kidney transplant recipients, paying special attention to renal graft function, urine volume, and changes in the titers of donor-specific antibodies. RESULTS Four grafts were lost during an average of 4.5-year follow-up. Average graft function was excellent, with a serum creatinine level of 1.3 ± 0.4 mg/dL. Sufficient urine output, with no oliguria or anuria, was achieved postoperatively in 40 of the 41 patients. However, among the 34 patients who underwent graft biopsies, the biopsies revealed acute antibody-mediated rejection in 21 patients (62%), and chronic antibodymediated rejection in 10 patients (30%). CONCLUSIONS The high-dose intravenous immunoglobulin treatment included in our desensitization protocol was shown to be safe and effective for achieving successful transplant outcomes and allowed the avoidance of more aggressive B-cell-targeted treatments, such as C5 inhibitors and/or proteosome inhibitors, for preventing posttransplant oliguria and anuria.
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Affiliation(s)
- Hideki Ishida
- From the Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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4
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Baksmeier C, Blundell P, Steckel J, Schultz V, Gu Q, Da Silva Filipe A, Kohl A, Linnington C, Lu D, Dell A, Haslam S, Wang J, Czajkowsky D, Goebels N, Pleass RJ. Modified recombinant human IgG1-Fc is superior to natural intravenous immunoglobulin at inhibiting immune-mediated demyelination. Immunology 2021; 164:90-105. [PMID: 33880776 PMCID: PMC8358725 DOI: 10.1111/imm.13341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/23/2021] [Accepted: 03/31/2021] [Indexed: 12/13/2022] Open
Abstract
Intravenous immunoglobulin (IVIG) is an established treatment for numerous autoimmune conditions. Although Fc fragments derived from IVIG have shown efficacy in controlling immune thrombocytopenia in children, the mechanisms of action are unclear and controversial. The aim of this study was to dissect IVIG effector mechanisms using further adapted Fc fragments on demyelination in an ex vivo model of the central nervous system-immune interface. Using organotypic cerebellar slice cultures (OSCs) from transgenic mice, we induced extensive immune-mediated demyelination and oligodendrocyte loss with an antibody specific for myelin oligodendrocyte glycoprotein (MOG) and complement. Protective effects of adapted Fc fragments were assessed by live imaging of green fluorescent protein expression, immunohistochemistry and confocal microscopy. Cysteine- and glycan-adapted Fc fragments protected OSC from demyelination in a dose-dependent manner where equimolar concentrations of either IVIG or control Fc were ineffective. The protective effects of the adapted Fc fragments are partly attributed to interference with complement-mediated oligodendroglia damage. Transcriptome analysis ruled out signatures associated with inflammatory or innate immune responses. Taken together, our findings show that recombinant biomimetics can be made that are at least two hundred-fold more effective than IVIG in controlling demyelination by anti-MOG antibodies.
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Affiliation(s)
- Christine Baksmeier
- Department of NeurologyMedical FacultyHeinrich‐Heine‐University DuesseldorfDuesseldorfGermany
| | - Pat Blundell
- Department of Tropical Disease BiologyLiverpool School of Tropical MedicineLiverpoolUK
| | - Julia Steckel
- Department of NeurologyMedical FacultyHeinrich‐Heine‐University DuesseldorfDuesseldorfGermany
| | - Verena Schultz
- Institute of Infection, Immunity and InflammationCollege of Medical Veterinary and Life SciencesUniversity of GlasgowGlasgowUK
| | - Quan Gu
- Institute of Infection, Immunity and InflammationCollege of Medical Veterinary and Life SciencesUniversity of GlasgowGlasgowUK
| | - Ana Da Silva Filipe
- Institute of Infection, Immunity and InflammationCollege of Medical Veterinary and Life SciencesUniversity of GlasgowGlasgowUK
| | - Alain Kohl
- Institute of Infection, Immunity and InflammationCollege of Medical Veterinary and Life SciencesUniversity of GlasgowGlasgowUK
| | - Chris Linnington
- Institute of Infection, Immunity and InflammationCollege of Medical Veterinary and Life SciencesUniversity of GlasgowGlasgowUK
| | - Dongli Lu
- Department of Life SciencesImperial College LondonLondonUK
| | - Anne Dell
- Department of Life SciencesImperial College LondonLondonUK
| | - Stuart Haslam
- Department of Life SciencesImperial College LondonLondonUK
| | - Jiabin Wang
- Shanghai Center for Systems BiomedicineKey Laboratory of Systems Biomedicine (Ministry of Education)Shanghai Jiao Tong UniversityShanghaiChina
| | - Dan Czajkowsky
- State Key Laboratory for Oncogenes and Related Genes and Bio‐ID CenterSchool of Biomedical EngineeringShanghai Jiao Tong UniversityShanghaiChina
| | - Norbert Goebels
- Department of NeurologyMedical FacultyHeinrich‐Heine‐University DuesseldorfDuesseldorfGermany
| | - Richard J. Pleass
- Department of Tropical Disease BiologyLiverpool School of Tropical MedicineLiverpoolUK
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5
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Kalampokini S, Artemiadis A, Zis P, Hadjihannas L, Parpas G, Kyrri A, Hadjigeorgiou GM. Osmotic demyelination syndrome improving after immune-modulating treatment: Case report and literature review. Clin Neurol Neurosurg 2021; 208:106811. [PMID: 34358802 DOI: 10.1016/j.clineuro.2021.106811] [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: 03/17/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Osmotic demyelination syndrome (ODS), which embraces central pontine and extrapontine myelinolysis, is an uncommon neurological disorder that occurs due to plasma osmotic changes. CASE PRESENTATION We present the case of a 55-year-old man, who presented with severe hyponatremia due to repeated vomiting, antidepressant treatment and consumption of large amounts of water. Fifteen days after sodium correction, the patient showed fluctuation of vigilance, dysarthria and dysphagia, tremor, cogwheel rigidity, bilateral facial palsy, ophthalmoplegia and tetraparesis. A brain MRI scan revealed extrapontine and later on pontine myelinolysis. He received intravenous steroids and subsequently immunoglobulin. His status began to improve gradually after completion of immunoglobulin and at three month-follow-up had no neurological deficit. LITERATURE REVIEW A comprehensive literature search of all reported ODS cases that received immunoglobulin, steroids or plasmapheresis was conducted in the electronic databases PubMed and Web of science. CONCLUSIONS Improvement was seen in most cases that received immunoglobulin either during treatment or in the first days after treatment. With regard to steroids, although most cases reported improvement in the following months their effect on the outcome is unclear. Most cases treated with plasmapheresis reported favorable outcome at variable follow-up time. Immunoglobulin and steroids have immunomodulatory effects, which could contribute to promotion of myelin repair in ODS. Plasmapheresis has effects on the immune system beyond removing myelinotoxins from the circulation. More evidence is required to support their use in ODS. However, in view of the disease severity, these therapeutic choices should be considered in the clinical management of ODS.
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Affiliation(s)
- Stefania Kalampokini
- Medical School, University of Cyprus, Nicosia, Cyprus; Department of Neurology, Nicosia General Hospital, Nicosia, Cyprus.
| | - Artemios Artemiadis
- Medical School, University of Cyprus, Nicosia, Cyprus; Department of Neurology, Nicosia General Hospital, Nicosia, Cyprus
| | - Panagiotis Zis
- Medical School, University of Cyprus, Nicosia, Cyprus; Department of Neurology, Nicosia General Hospital, Nicosia, Cyprus
| | - Linos Hadjihannas
- Department of Internal medicine, Nicosia General Hospital, Nicosia, Cyprus
| | - Giorgos Parpas
- Department of Internal medicine, Nicosia General Hospital, Nicosia, Cyprus
| | - Artemis Kyrri
- Department of Internal medicine, Nicosia General Hospital, Nicosia, Cyprus
| | - Georgios M Hadjigeorgiou
- Medical School, University of Cyprus, Nicosia, Cyprus; Department of Neurology, Nicosia General Hospital, Nicosia, Cyprus
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Abdel-Wahed L, Cho TA. Immune-Mediated Myelopathies: A Review of Etiologies, Diagnostic Approach, and Therapeutic Management. Semin Neurol 2021; 41:269-279. [PMID: 34030191 DOI: 10.1055/s-0041-1725152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Myelopathy is a broad term used to describe a heterogeneous group of disorders that affects the spinal cord; the focus of this article will be a subgroup of these disorders with an autoimmune and inflammatory-based pathology. Symptoms typically develop over hours or days and then worsen over a matter of days to weeks, but sometimes can have a more insidious or subacute presentation, which can make the diagnosis more puzzling. Despite relatively low incidence rates, almost a third of affected patients are left with severely disabling symptoms. Prompt recognition of the underlying etiology is essential so that a specific targeted therapy can be implemented for optimal outcomes. The authors discuss a systematic approach to immune-mediated myelopathies, with a focus on the unique characteristics of each that may aid in diagnosis.
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Affiliation(s)
- Lama Abdel-Wahed
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Tracey A Cho
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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7
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Immunoglobulins reduced oxidative stress in human microglial cells induced by high dose of acetoacetate. Brain Res 2020; 1748:147054. [PMID: 32818529 DOI: 10.1016/j.brainres.2020.147054] [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: 02/21/2020] [Revised: 07/12/2020] [Accepted: 08/08/2020] [Indexed: 11/23/2022]
Abstract
Diabetic ketoacidosis (DKA) has been associated with cognitive impairment and structural alterations in the brain. There is increased evidence supporting the role of neuroinflammation in causing these alterations. In the present study, using human microglial cell line (CHME-5), we aimed to investigate the effect of immunoglobulins (IG) on survival, activation, reactive oxygen species (ROS) and cytokine production of microglia exposed to ketone bodies. We demonstrated that high and low dose of ketone bodies induced a significant increase in ROS within 1 h after exposure to CHME-5 cells with upregulation in mitochondrial superoxide level 5 min after exposure suggestive of early and selective impairment of mitochondrial function. A significant and delayed increase of apoptosis of CHME-5 cells was observed 4 days after ketone bodies exposure. Cytokine expression reached a peak within 1 h and persisted for 3 days after exposure to ketone bodies. IG significantly reduced ROS and transiently suppressed cytokine expression of CHME-5 cells after exposure to ketone bodies. However, no effect of IG on apoptosis was observed. Overall, these results supported that ketone bodies induced microglia activation with early and selective impairment of mitochondrial function, increased cytokines expression and delayed increase in apoptosis. IG suppressed microglia activation and transiently inhibited cytokines expression without affecting apoptosis. These results warrant further experimental work on the role of microglia and potential benefit of IG in brain structural changes induced by DKA.
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8
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Dalakas MC, Alexopoulos H, Spaeth PJ. Complement in neurological disorders and emerging complement-targeted therapeutics. Nat Rev Neurol 2020; 16:601-617. [PMID: 33005040 PMCID: PMC7528717 DOI: 10.1038/s41582-020-0400-0] [Citation(s) in RCA: 164] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2020] [Indexed: 12/30/2022]
Abstract
The complement system consists of a network of plasma and membrane proteins that modulate tissue homeostasis and contribute to immune surveillance by interacting with the innate and adaptive immune systems. Dysregulation, impairment or inadvertent activation of complement components contribute to the pathogenesis of some autoimmune neurological disorders and could even contribute to neurodegenerative diseases. In this Review, we summarize current knowledge about the main functions of the complement pathways and the involvement of complement in neurological disorders. We describe the complex network of complement proteins that target muscle, the neuromuscular junction, peripheral nerves, the spinal cord or the brain and discuss the autoimmune mechanisms of complement-mediated myopathies, myasthenia, peripheral neuropathies, neuromyelitis and other CNS disorders. We also consider the emerging role of complement in some neurodegenerative diseases, such as Alzheimer disease, amyotrophic lateral sclerosis and even schizophrenia. Finally, we provide an overview of the latest complement-targeted immunotherapies including monoclonal antibodies, fusion proteins and peptidomimetics that have been approved, that are undergoing phase I–III clinical trials or that show promise for the treatment of neurological conditions that respond poorly to existing immunotherapies. In this Review, Dalakas et al. discuss the complement system, the role it plays in autoimmune neurological disease and neurodegenerative disease, and provide an overview of the latest therapeutics that target complement and that can be used for or have potential in neurological disorders. Complement has an important physiological role in host immune defences and tissue remodelling. The physiological role of complement extends to the regulation of synaptic development. Complement has a key pathophysiological role in autoimmune neurological diseases and mediates the actions of pathogenic autoantibodies, such as acetylcholine receptor antibodies and aquaporin 4 antibodies. For some autoimmune neurological diseases, such as myasthenia gravis and neuromyelitis optica spectrum disorders, approved complement-targeted treatments are now available. Complement also seems to be of pathogenic relevance in neurodegenerative diseases such as Alzheimer disease, in which innate immune-driven inflammation is receiving increasing attention. The field of complement-targeted therapeutics is rapidly expanding, with several FDA-approved agents and others currently in phase II and phase III clinical trials.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA. .,Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter J Spaeth
- Institute of Pharmacology, University of Bern, Bern, Switzerland
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9
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Beneficial effects of intravenous immunoglobulin as an add-on therapy to azathioprine for NMO-IgG-seropositive neuromyelitis optica spectrum disorders. Mult Scler Relat Disord 2020; 42:102109. [DOI: 10.1016/j.msard.2020.102109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/01/2020] [Accepted: 04/06/2020] [Indexed: 02/08/2023]
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10
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Otallah S. Acute disseminated encephalomyelitis in children and adults: A focused review emphasizing new developments. Mult Scler 2020; 27:1153-1160. [PMID: 32552256 DOI: 10.1177/1352458520929627] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Acute disseminated encephalomyelitis (ADEM) was originally described in the medical literature more than 200 years ago. However, consensus clinical diagnostic criteria are less than 15 years old. Accurate diagnostic testing for myelin oligodendrocyte glycoprotein (MOG) autoantibodies has only become clinically available in the last 3-5 years and has facilitated a rapidly evolving understanding of patients with recurrent demyelination following ADEM. The field is working to optimize treatment for these patients with hopes of prospective treatment studies in the not too distant future. New imaging data suggest that even monophasic demyelination may have long-term impacts that were previously unrecognized. Recent developments in the literature are described in order to guide practice for providers who treat both adults and children with monophasic and recurrent forms of ADEM with and without MOG antibodies.
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Affiliation(s)
- Scott Otallah
- Wake Forest Baptist Health, Winston-Salem, NC, USA/Pediatric Multiple Sclerosis and Demyelinating Disorders Clinic, Wake Forest University, Winston-Salem, NC, USA
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11
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Long-term outcome of a group of Japanese children with myelin-oligodendrocyte glycoprotein encephalomyelitis without preventive immunosuppressive therapy. Brain Dev 2019; 41:790-795. [PMID: 31281008 DOI: 10.1016/j.braindev.2019.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 06/15/2019] [Accepted: 06/17/2019] [Indexed: 11/22/2022]
Abstract
INTRODUCTION There is increasing evidence that immunosuppressive therapy is essential for reducing disease activity and avoiding further attacks in patients positive for anti-myelin-oligodendrocyte glycoprotein (MOG) antibodies. However, to date, no placebo-controlled trial has been published. OBJECTIVE We aimed to evaluate the long-term outcome and anti-MOG antibody titers of seropositive Japanese pediatric patients without long-term immunosuppressive therapy. METHODS Of 11 consecutive patients positive for anti-MOG antibodies seen at Tohoku University Hospital from 1992 to 2013, 5 patients did not receive preventive long-term immunosuppressive treatment and had been followed up longitudinally (more than 60 months). RESULTS The follow-up periods were 68-322 months (median, 150 months). The expanded disability status scale scores of all patients were 0 at the last observation. Three patients were negative for the antibody at the last follow-up, and the titers of the two patients whose anti-MOG antibodies were positive at the last follow-up were lower than at the first examinations. The interval to the second attack in three patients was 1-124 months (median, 33 months). Acute attacks were treated with methylprednisolone pulse therapy (four patients) or intravenous immunoglobulin (one patient). All patients achieved full recovery after acute therapy. Oral corticosteroid was tapered over a period of 6-26 weeks (median, 17 weeks). CONCLUSIONS We reported our experience with very long-term follow-up of 5 Japanese pediatric patients with anti-MOG antibody-positive disease who did not receive long-term immunosuppressive therapy. Persistent positivity to anti-MOG antibody in some patients suggests the necessity for long-term follow up despite infrequent relapse.
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12
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Hacohen Y, Wong YY, Lechner C, Jurynczyk M, Wright S, Konuskan B, Kalser J, Poulat AL, Maurey H, Ganelin-Cohen E, Wassmer E, Hemingway C, Forsyth R, Hennes EM, Leite MI, Ciccarelli O, Anlar B, Hintzen R, Marignier R, Palace J, Baumann M, Rostásy K, Neuteboom R, Deiva K, Lim M. Disease Course and Treatment Responses in Children With Relapsing Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease. JAMA Neurol 2019; 75:478-487. [PMID: 29305608 DOI: 10.1001/jamaneurol.2017.4601] [Citation(s) in RCA: 273] [Impact Index Per Article: 54.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Importance Myelin oligodendrocyte glycoprotein antibodies (MOG-Abs) are consistently identified in a range of demyelinating disorders in adults and children. Current therapeutic strategies are largely center specific, and no treatments have been formally evaluated. Objective To examine the clinical phenotypes, treatment responses, and outcomes of children with relapsing MOG-Ab-associated disease. Design, Setting, and Participants This study prospectively collected demographic, clinical, and radiologic data from 102 patients from 8 countries of the EU Paediatric Demyelinating Disease Consortium from January 1, 2014, through December 31, 2016. Patients were treated according to local protocols. Main Outcomes and Measures Annualized relapse rates (ARRs) and Expanded Disability Status Scale (EDSS) scores before and during treatment with disease-modifying drugs (DMDs). Results A total of 102 children were identified (median [range] age, 7.0 [1.5-7.9] years; male to female ratio, 1.0:1.8; white to other race/ethnicity ratio, 3.6:1.0). Original diagnoses were neuromyelitis optica spectrum disorder (44 patients [43.1%]), acute disseminated encephalomyelitis followed by optic neuritis (20 [19.6%]), multiphasic disseminated encephalomyelitis (20 [19.6%]), and relapsing optic neuritis (18 [17.6%]). In all, 464 demyelinating events were reported. Treated patients had more relapses (median, 3.0; range, 1.0-17.0) than untreated patients (median, 1.0; range 1.0-7.0) (P = .009) and higher EDSS scores (median, 1.5; interquartile range, 0-2.5) than untreated patients (median, 1.0; interquartile range, 0-1.5) (P < .001). Fifty-two children (51.0%) received DMDs: 28 (53.8%) were treated with 1 DMD, 17 (32.7%) with 2, and 7 (13.5%) with 3 or more sequential DMDs. Patients relapsed during all treatments, with a total of 127 relapses on treatment reported. No changes in median ARR and EDSS score were observed between the preinitiation and postinitiation phases of interferon beta and glatiramer acetate treatment (n = 11). The median ARR was reduced from 1.84 to 1.0 with azathioprine (n = 20, P < .001), 1.79 to 0.52 with mycophenolate mofetil (n = 15, P = .003), and 2.12 to 0.67 with rituximab (n = 9, P < .001), although the median EDSS score remained unchanged. An improvement in ARR (from 2.16 to 0.51, P < .001) and EDSS score (from 2.2 to 1.2, P = .01) was observed in the 12 patients treated with regular intravenous immunoglobulins. Conclusions and Relevance Although commonly used to treat patients with multiple sclerosis, DMDs were not associated with clinical improvement in children with MOG-Ab-associated disease, whereas azathioprine, mycophenolate mofetil, rituximab, and particularly intravenous immunoglobulins were associated with a reduction in relapse frequency. A correct diagnosis of relapsing MOG-Ab-associated disorders is therefore important to optimize immune treatment.
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Affiliation(s)
- Yael Hacohen
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, University College London Institute of Neurology, London, United Kingdom.,Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Yu Yi Wong
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Christian Lechner
- Division of Paediatric Neurology, Department of Paediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Maciej Jurynczyk
- Neurology Department, John Radcliffe Hospital, Oxford, United Kingdom
| | - Sukhvir Wright
- Department of Paediatric Neurology, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Bahadir Konuskan
- Division of Pediatric Neurology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Judith Kalser
- Centre Hospitalier, Universitaire Vaudois of Lausanne, Lausanne, Switzerland
| | - Anne Lise Poulat
- Department of Pediatric Neurology, Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France
| | - Helene Maurey
- National Referral Center for Neuro-Inflammatory Diseases and Pediatric Neurology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,Service de Neuropédiatrie, University Paris Sud, Le Kremlin-Bicêtre, France
| | - Esther Ganelin-Cohen
- Pediatric Neurology Unit, Schneider Children's Medical Center, Tel-Aviv, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Evangeline Wassmer
- Department of Paediatric Neurology, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Chery Hemingway
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Rob Forsyth
- Institute of Neuroscience, Newcastle University, Newcastle, United Kingdom
| | | | - M Isabel Leite
- Neurology Department, John Radcliffe Hospital, Oxford, United Kingdom
| | - Olga Ciccarelli
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, University College London Institute of Neurology, London, United Kingdom
| | - Banu Anlar
- Division of Pediatric Neurology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Rogier Hintzen
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Romain Marignier
- Service de Neurologie A and Eugène Devic Foundation Against Multiple Sclerosis, Observatoire Français de la Sclérose en Plaques, Hôpital Neurologique Pierre Wertheimer-Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France.,Lyon's Neuroscience Research Center, INSERM U 1028/Centre National de la Recherche Scientifique 5292, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Jacqueline Palace
- Neurology Department, John Radcliffe Hospital, Oxford, United Kingdom
| | - Matthias Baumann
- Division of Paediatric Neurology, Department of Paediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Kevin Rostásy
- Department of Pediatric Neurology, Children's Hospital Datteln, University Witten/Herdecke, Witten, Germany
| | - Rinze Neuteboom
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Kumaran Deiva
- National Referral Center for Neuro-Inflammatory Diseases and Pediatric Neurology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' National Health Service Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom.,Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
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13
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The immunological response to traumatic brain injury. J Neuroimmunol 2019; 332:112-125. [DOI: 10.1016/j.jneuroim.2019.04.005] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 04/09/2019] [Accepted: 04/09/2019] [Indexed: 12/30/2022]
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14
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Keller CW, Quast I, Dalakas MC, Lünemann JD. IVIG efficacy in CIDP patients is not associated with terminal complement inhibition. J Neuroimmunol 2019; 330:23-27. [PMID: 30772754 DOI: 10.1016/j.jneuroim.2019.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/05/2019] [Accepted: 02/07/2019] [Indexed: 01/17/2023]
Abstract
Patients with acute and chronic inflammatory demyelinating neuropathies exhibit elevated serum and cerebrospinal fluid (CSF) levels of terminal complement activation products and therapeutic inhibition of complement activation is currently tested for its safety and efficacy in patients with Guillain-Barré syndrome (GBS). Here, we determined serum levels of the complement activation products C3a, C5a and the soluble terminal complement complex (sTCC) in 39 individuals with chronic inflammatory demyelinating polyneuropathy (CIDP) who participated in one of the largest ever conducted clinical trial in patients with CIDP (ICE trial) and received Intravenous Immunoglobulin (IVIG) or placebo (albumin) in 3 week intervals for up to 24 weeks. In placebo-treated patients with spontaneous disease remission, serum sTCC levels moderately decreased over time. Levels of complement activation products were, however, not modulated by IVIG and remained unchanged in patients with a beneficial response to IVIG therapy as compared to those with steady or worsened disease. These results suggest that the therapeutic efficacy of IVIG in CIDP is based on immunomodulatory mechanisms different from complement inhibition. Terminal complement activation merits further investigation as a surrogate marker for disease progression and therapeutic target in patients with CIDP.
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Affiliation(s)
- Christian W Keller
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster 48149, Germany; Institute of Experimental Immunology, Department of Neuroinflammation, University of Zurich, Zürich 8057, Switzerland
| | - Isaak Quast
- Department of Immunology and Pathology, Central Clinical School, Monash University, Melbourne, Australia
| | - Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, USA; Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Jan D Lünemann
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster 48149, Germany; Institute of Experimental Immunology, Department of Neuroinflammation, University of Zurich, Zürich 8057, Switzerland.
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Abstract
Purpose of review The purpose of this review is to summarize current understanding regarding the treatment of myelin oligodendrocyte glycoprotein antibody (MOG-Ab)-associated demyelination in children. Emphasis is placed on the unique obstacles we face when predicting the risk of relapse and the important implications of such challenges when planning treatment protocols. Recent findings MOG-Abs are consistently identified in a range of acquired demyelinating syndromes (ADS) in adults and children with a clinical phenotype distinct of MS and AQP4-Ab neuromyelitis optica spectrum disorder. Although initially thought to be associated with a benign disease, recent reports of children who are treatment-resistant and developed progressive disability over time raise important questions about how children with relapsing MOG-Ab disease should be managed. Summary MOG-Abs are common in children with ADS with both monophasic and relapsing disease courses. Treatment of patients with MOG-Ab-associated demyelination includes management of acute relapses and chronic immunotherapy for those with relapsing disease. Emerging consensus supports distinction of treatment strategies from those typically used for relapsing remitting MS, and several groups debate whether to follow treatment protocols akin to those for AQP4-Ab NMOSD. A key challenge remains predicting the severity of the disease at onset. Collaborative international consensus to derive shared clinical evaluative platforms standardized biological and neuroimaging protocols which can be used clinically, and partnered research programs are required to advance personalized treatment for children with MOG-Ab-associated demyelination.
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