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Melzer N, Weber K, Räuber S, Rosenow F. [(Auto)immunity in focal epilepsy: mechanisms of (auto‑)immune-inflammatory epileptogenic neurodegeneration]. DER NERVENARZT 2024:10.1007/s00115-024-01695-5. [PMID: 38953922 DOI: 10.1007/s00115-024-01695-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/07/2024] [Indexed: 07/04/2024]
Abstract
OBJECTIVE While the neuronal mechanisms of epileptic hyperexcitability (HE) have been studied in detail, recent findings suggest that extraneuronal, mainly immune-mediated inflammatory and vascular mechanisms play an important role in the development and progression of HE in epilepsy and the cognitive and behavioral comorbidities. MATERIAL AND METHODS Narrative review. RESULTS As in autoimmune (limbic) encephalitis (ALE/AIE) or Rasmussen's encephalitis (RE), the primary adaptive and innate immune responses and associated changes in the blood-brain barrier (BBB) and neurovascular unit (NVU) can cause acute cortical hyperexcitability (HE) and the development of hippocampal sclerosis (HS) and other structural cortical lesions with chronic HE. Cortical HE, which is associated with malformation of cortical development (MCD) and low-grade epilepsy-associated tumors (LEAT), for example, can be accompanied by secondary adaptive and innate immune responses and alterations in the BBB and NVU, potentially modulating the ictogenicity and epileptogenicity. These associations illustrate the influence of adaptive and innate immune mechanisms and associated changes in the BBB and NVU on cortical excitability and vice versa, suggesting a dynamic and complex interplay of these factors in the development and progression of epilepsy in general. DISCUSSION The described concept of a neuro-immune-vascular interaction in focal epilepsy opens up new possibilities for the pathogenetic understanding and thus also for the selective therapeutic intervention.
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Affiliation(s)
- Nico Melzer
- Klinik für Neurologie, Medizinische Fakultät und Universitätsklinikum, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
| | - Katharina Weber
- Neurologisches Institut (Edinger Institut), Universitätsklinikum Frankfurt, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
- Frankfurt Cancer Institute (FCI), Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
- Partnerstätte Frankfurt, Frankfurt am Main und Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Deutsches Konsortium für Translationale Krebsforschung (DKTK), Heidelberg, Deutschland
- Universitäres Centrum für Tumorerkrankungen Frankfurt (UCT), Universitätsklinikum Frankfurt, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
| | - Saskia Räuber
- Klinik für Neurologie, Medizinische Fakultät und Universitätsklinikum, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - Felix Rosenow
- Epilepsiezentrum Frankfurt Rhein-Main, Klinik für Neurologie, Zentrum für Neurologie und Neurochirurgie, Universitätsklinikum Frankfurt, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland.
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland.
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2
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Guillén N, Pérez-Millan A, Falgàs N, Lledó-Ibáñez GM, Rami L, Sarto J, Botí MA, Arnaldos-Pérez C, Ruiz-García R, Naranjo L, Segura B, Balasa M, Sala-Llonch R, Lladó A, Gray SM, Johannesen JK, Pantoni MM, Rutledge GA, Sawant R, Wang Y, Watson LS, Dalmau J, Sanchez-Valle R. Cognitive profile, neuroimaging and fluid biomarkers in post-acute COVID-19 syndrome. Sci Rep 2024; 14:12927. [PMID: 38839833 PMCID: PMC11153491 DOI: 10.1038/s41598-024-63071-2] [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: 11/16/2023] [Accepted: 05/24/2024] [Indexed: 06/07/2024] Open
Abstract
We aimed to characterize the cognitive profile of post-acute COVID-19 syndrome (PACS) patients with cognitive complaints, exploring the influence of biological and psychological factors. Participants with confirmed SARS-CoV-2 infection and cognitive complaints ≥ 8 weeks post-acute phase were included. A comprehensive neuropsychological battery (NPS) and health questionnaires were administered at inclusion and at 1, 3 and 6 months. Blood samples were collected at each visit, MRI scan at baseline and at 6 months, and, optionally, cerebrospinal fluid. Cognitive features were analyzed in relation to clinical, neuroimaging, and biochemical markers at inclusion and follow-up. Forty-nine participants, with a mean time from symptom onset of 10.4 months, showed attention-executive function (69%) and verbal memory (39%) impairment. Apathy (64%), moderate-severe anxiety (57%), and severe fatigue (35%) were prevalent. Visual memory (8%) correlated with total gray matter (GM) and subcortical GM volume. Neuronal damage and inflammation markers were within normal limits. Over time, cognitive test scores, depression, apathy, anxiety scores, MRI indexes, and fluid biomarkers remained stable, although fewer participants (50% vs. 75.5%; p = 0.012) exhibited abnormal cognitive evaluations at follow-up. Altered attention/executive and verbal memory, common in PACS, persisted in most subjects without association with structural abnormalities, elevated cytokines, or neuronal damage markers.
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Affiliation(s)
- Núria Guillén
- Alzheimer's Disease and Other Cognitive Disorders Unit, Service of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
| | - Agnès Pérez-Millan
- Alzheimer's Disease and Other Cognitive Disorders Unit, Service of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
- Institut de Neurociències, Faculty of Medicine and Medical Sciences, University of Barcelona, Barcelona, Spain
- Department of Biomedicine, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Neus Falgàs
- Alzheimer's Disease and Other Cognitive Disorders Unit, Service of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
| | | | - Lorena Rami
- Alzheimer's Disease and Other Cognitive Disorders Unit, Service of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
| | - Jordi Sarto
- Alzheimer's Disease and Other Cognitive Disorders Unit, Service of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
| | - Maria A Botí
- Alzheimer's Disease and Other Cognitive Disorders Unit, Service of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
| | - Cristina Arnaldos-Pérez
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
- Immunology Service, Biomedical Diagnostic Center, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Raquel Ruiz-García
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
- Immunology Service, Biomedical Diagnostic Center, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Laura Naranjo
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
- Immunology Service, Biomedical Diagnostic Center, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Bàrbara Segura
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
- Institut de Neurociències, Faculty of Medicine and Medical Sciences, University of Barcelona, Barcelona, Spain
- Medical Psychology Unit, Department of Medicine, University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain
| | - Mircea Balasa
- Alzheimer's Disease and Other Cognitive Disorders Unit, Service of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
| | - Roser Sala-Llonch
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
- Institut de Neurociències, Faculty of Medicine and Medical Sciences, University of Barcelona, Barcelona, Spain
- Department of Biomedicine, Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Barcelona, Spain
| | - Albert Lladó
- Alzheimer's Disease and Other Cognitive Disorders Unit, Service of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
- Institut de Neurociències, Faculty of Medicine and Medical Sciences, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | - Yi Wang
- Sage Therapeutics, Cambridge, USA
| | | | - Josep Dalmau
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
- Institut de Neurociències, Faculty of Medicine and Medical Sciences, University of Barcelona, Barcelona, Spain
- Department of Neurology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
- Enfermedades Raras, Centro de Investigación Biomédica en Red, Madrid, Spain
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Catalan Institute for Research and Advanced Studies (ICREA), Barcelona, Spain
| | - Raquel Sanchez-Valle
- Alzheimer's Disease and Other Cognitive Disorders Unit, Service of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain.
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain.
- Institut de Neurociències, Faculty of Medicine and Medical Sciences, University of Barcelona, Barcelona, Spain.
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Tan S, Frade H, Abdul-Baki KS, De Gannes S, Singh P, Lopez Valencia E, Kumar A, Esechie A, Patel C. Anti-α-Amino-3-Hydroxy-5-Methyl-4-Isoxazolepropionic Acid (AMPA) Receptor Antibody Encephalitis in an Immunosuppressed Patient With Myasthenia Gravis Post-thymoma Treatment. Cureus 2024; 16:e63239. [PMID: 39070428 PMCID: PMC11281858 DOI: 10.7759/cureus.63239] [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] [Accepted: 06/26/2024] [Indexed: 07/30/2024] Open
Abstract
Anti-α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor encephalitis is a rare form of autoimmune encephalitis. We report a case of a patient with myasthenia gravis post-thymoma treatment who presented with deteriorating mental status. She was found to have positive AMPA receptor titers in her cerebrospinal fluid and subsequently attained full recovery. Of the limited number of cases that were documented, we report the only case of a patient who was previously immunocompromised to develop the condition. Even though autoimmune encephalitis is an emerging condition, its early differentiation from other causes of encephalitis is crucial in the prognosis of the patient.
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Affiliation(s)
- Suyuan Tan
- Internal Medicine, The University of Texas Medical Branch, Galveston, USA
| | - Heitor Frade
- Neurology, The University of Texas Medical Branch, Galveston, USA
| | - Kian S Abdul-Baki
- Internal Medicine, The University of Texas Medical Branch, Galveston, USA
| | | | - Puneet Singh
- Critical Care Medicine, The University of Texas Medical Branch, Galveston, USA
| | - Ernesto Lopez Valencia
- Anesthesiology and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Anand Kumar
- Internal Medicine, The University of Texas Medical Branch, Galveston, USA
| | - Aimalohi Esechie
- Neurology, The University of Texas Medical Branch, Galveston, USA
| | - Chilvana Patel
- Neurology, The University of Texas Medical Branch, Galveston, USA
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Papi C, Milano C, Spatola M. Mechanisms of autoimmune encephalitis. Curr Opin Neurol 2024; 37:305-315. [PMID: 38667756 DOI: 10.1097/wco.0000000000001270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2024]
Abstract
PURPOSE OF REVIEW To provide an overview of the pathogenic mechanisms involved in autoimmune encephalitides mediated by antibodies against neuronal surface antigens, with a focus on NMDAR and LGI1 encephalitis. RECENT FINDINGS In antibody-mediated encephalitides, binding of IgG antibodies to neuronal surface antigens results in different pathogenic effects depending on the type of antibody, IgG subclass and epitope specificity. NMDAR IgG1 antibodies cause crosslinking and internalization of the target, synaptic and brain circuitry alterations, as well as alterations of NMDAR expressing oligodendrocytes, suggesting a link with white matter lesions observed in MRI studies. LGI1 IgG4 antibodies, instead, induce neuronal dysfunction by disrupting the interaction with cognate proteins and altering AMPAR-mediated signaling. In-vitro findings have been corroborated by memory and behavioral changes in animal models obtained by passive transfer of patients' antibodies or active immunization. These models have been fundamental to identify targets for innovative therapeutic strategies, aimed at counteracting or preventing antibody effects, such as the use of soluble ephrin-B2, NMDAR modulators (e.g., pregnenolone, SGE-301) or chimeric autoantibody receptor T cells (CAART) in models of NMDAR encephalitis. SUMMARY A deep understanding of the pathogenic mechanisms underlying antibody-mediated encephalitides is crucial for the development of new therapeutic approaches targeting brain autoimmunity.
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Affiliation(s)
- Claudia Papi
- Department of Neuroscience, Catholic University of the Sacred Heart, Rome, Italy
- Fundació Recerca Biomedica Clinic - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRBC-IDIBAPS), Barcelona, Spain
| | - Chiara Milano
- Fundació Recerca Biomedica Clinic - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRBC-IDIBAPS), Barcelona, Spain
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Marianna Spatola
- Fundació Recerca Biomedica Clinic - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRBC-IDIBAPS), Barcelona, Spain
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Italia M, Salvadè M, La Greca F, Zianni E, Pelucchi S, Spinola A, Ferrari E, Archetti S, Alberici A, Benussi A, Solje E, Haapasalo A, Hoffmann D, Katisko K, Krüger J, Facchinetti R, Scuderi C, Padovani A, DiLuca M, Scheggia D, Borroni B, Gardoni F. Anti-GluA3 autoantibodies define a new sub-population of frontotemporal lobar degeneration patients with distinct neuropathological features. Brain Behav Immun 2024; 118:380-397. [PMID: 38485064 DOI: 10.1016/j.bbi.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 03/07/2024] [Accepted: 03/11/2024] [Indexed: 03/19/2024] Open
Abstract
Autoantibodies directed against the GluA3 subunit (anti-GluA3 hIgGs) of AMPA receptors have been identified in 20%-25% of patients with frontotemporal lobar degeneration (FTLD). Data from patients and in vitro/ex vivo pre-clinical studies indicate that anti-GluA3 hIgGs negatively affect glutamatergic neurotransmission. However, whether and how the chronic presence of anti-GluA3 hIgGs triggers synaptic dysfunctions and the appearance of FTLD-related neuropathological and behavioural signature has not been clarified yet. To address this question, we developed and characterized a pre-clinical mouse model of passive immunization with anti-GluA3 hIgGs purified from patients. In parallel, we clinically compared FTLD patients who were positive for anti-GluA3 hIgGs to negative ones. Clinical data showed that the presence of anti-GluA3 hIgGs defined a subgroup of patients with distinct clinical features. In the preclinical model, anti-GluA3 hIgGs administration led to accumulation of phospho-tau in the postsynaptic fraction and dendritic spine loss in the prefrontal cortex. Remarkably, the preclinical model exhibited behavioural disturbances that mostly reflected the deficits proper of patients positive for anti-GluA3 hIgGs. Of note, anti-GluA3 hIgGs-mediated alterations were rescued in the animal model by enhancing glutamatergic neurotransmission with a positive allosteric modulator of AMPA receptors. Overall, our study clarified the contribution of anti-GluA3 autoantibodies to central nervous system symptoms and pathology and identified a specific subgroup of FTLD patients. Our findings will be instrumental in the development of a therapeutic personalised medicine strategy for patients positive for anti-GluA3 hIgGs.
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Affiliation(s)
- Maria Italia
- Department of Pharmacological and Biomolecular Sciences (DiSFeB), University of Milan, Milan, Italy
| | - Michela Salvadè
- Department of Pharmacological and Biomolecular Sciences (DiSFeB), University of Milan, Milan, Italy
| | - Filippo La Greca
- Department of Pharmacological and Biomolecular Sciences (DiSFeB), University of Milan, Milan, Italy
| | - Elisa Zianni
- Department of Pharmacological and Biomolecular Sciences (DiSFeB), University of Milan, Milan, Italy
| | - Silvia Pelucchi
- Department of Pharmacological and Biomolecular Sciences (DiSFeB), University of Milan, Milan, Italy
| | - Alessio Spinola
- Department of Pharmacological and Biomolecular Sciences (DiSFeB), University of Milan, Milan, Italy
| | - Elena Ferrari
- Department of Pharmacological and Biomolecular Sciences (DiSFeB), University of Milan, Milan, Italy
| | - Silvana Archetti
- Department of Laboratories, Central Laboratory of Clinical Chemistry Analysis. ASST Spedali Civili, Brescia, Italy
| | - Antonella Alberici
- Neurology Unit, Centre for Neurodegenerative Disorders, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Alberto Benussi
- Neurology Unit, Centre for Neurodegenerative Disorders, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Eino Solje
- Institute of Clinical Medicine - Neurology, University of Eastern Finland, Kuopio, Finland; Neuro Center, Neurology, Kuopio University Hospital, Kuopio, Finland
| | - Annakaisa Haapasalo
- A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Dorit Hoffmann
- A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Kasper Katisko
- Institute of Clinical Medicine - Neurology, University of Eastern Finland, Kuopio, Finland; Neuro Center, Neurology, Kuopio University Hospital, Kuopio, Finland
| | - Johanna Krüger
- Research Unit of Clinical Medicine, Neurology, University of Oulu, Oulu, Finland; Neurocenter, Neurology, Oulu University Hospital, Oulu, Finland; Medical Research Center, Oulu University Hospital, Oulu, Finland
| | - Roberta Facchinetti
- Department of Physiology and Pharmacology "Vittorio Erspamer", Sapienza University of Rome, Rome, Italy
| | - Caterina Scuderi
- Department of Physiology and Pharmacology "Vittorio Erspamer", Sapienza University of Rome, Rome, Italy
| | - Alessandro Padovani
- Neurology Unit, Centre for Neurodegenerative Disorders, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Monica DiLuca
- Department of Pharmacological and Biomolecular Sciences (DiSFeB), University of Milan, Milan, Italy
| | - Diego Scheggia
- Department of Pharmacological and Biomolecular Sciences (DiSFeB), University of Milan, Milan, Italy
| | - Barbara Borroni
- Neurology Unit, Centre for Neurodegenerative Disorders, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Fabrizio Gardoni
- Department of Pharmacological and Biomolecular Sciences (DiSFeB), University of Milan, Milan, Italy.
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Iizuka M, Nagata N, Kanazawa N, Iwami T, Nagashima M, Nakamura M, Kaneko J, Kitamura E, Nishiyama K, Mamorita N, Iizuka T. H-intensity scale score to estimate CSF GluN1 antibody titers with one-time immunostaining using a commercial assay. Front Immunol 2024; 15:1350837. [PMID: 38745654 PMCID: PMC11091310 DOI: 10.3389/fimmu.2024.1350837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/25/2024] [Indexed: 05/16/2024] Open
Abstract
Introduction Anti-NMDA receptor encephalitis is an autoimmune disorder caused by autoantibodies (abs) against the conformational epitope on GluN1 subunits. GluN1-abs have been determined with cell-based assay (CBA) co-expressing GluN1/GluN2 subunits. However, commercial fixed CBA expressing only GluN1 subunit has increasingly been used in clinical practice. The ab titers can be determined with serial dilutions, but its clinical significance remains unclear. We aimed to develop an H-intensity scale (HIS) score to estimate GluN1-ab titers in cerebrospinal fluid (CSF) with one-time immunostaining using both commercial CBA and immunohistochemistry and report its usefulness. "H" is the initial of a patient with high CSF GluN1-ab titers (1:2,048). Methods We first determined the reliability of CBA in 370 patients with suspected autoimmune encephalitis by comparing the results between commercial CBA and established assay in Dalmau's Lab. Then, we made positive control panels using the patient H's CSF diluted in a fourfold serial dilution method (1:2, 1:8, 1:32, 1:128, 1:512, and 1:2,048). Based on the panels, we scored the intensity of ab reactivity of 79 GluN1-ab-positive patients' CSF (diluted at 1:2) on a scale from 0 to 6 (with ≥1 considered positive). To assess inter-assay reliability, we performed immunostaining twice in 21 patients' CSF. We investigated an association between the score of CSF obtained at diagnosis and the clinical/paraclinical features. Results The sensitivity and specificity of CBA were 93.7% (95% CI: 86.0-97.3) and 98.6% (95% CI: 96.5-99.5), respectively. Linear regression analysis showed a good agreement between the scores of the first and second assays. Patients with a typical spectrum, need for mechanical ventilation support, autonomic symptoms/central hypoventilation, dyskinesias, speech dysfunction, decreased level of consciousness, preceding headache, ovarian teratoma, and CSF leukocyte count >20 cells/µL had a higher median HIS score than those without, but HIS score was not associated with sex, age at onset, or seizure. HIS score at diagnosis had a significant effect on 1-year functional status. Discussion The severity of disease and four of the six core symptoms were associated with higher GluN1-ab titers in CSF at diagnosis, which may play a role in poor 1-year functional status. An incomplete phenotype can be attributed to low CSF GluN1-ab titers.
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Affiliation(s)
- Masaki Iizuka
- Department of Neurology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Naomi Nagata
- Department of Neurology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Naomi Kanazawa
- Department of Neurology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tomomi Iwami
- Department of Neurology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Makoto Nagashima
- Department of Neurology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Masaaki Nakamura
- Department of Neurology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Juntaro Kaneko
- Department of Neurology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Eiji Kitamura
- Department of Neurology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kazutoshi Nishiyama
- Department of Neurology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Noritaka Mamorita
- Department of Medical Informatics, Kitasato University School of Allied Health Sciences, Sagamihara, Japan
| | - Takahiro Iizuka
- Department of Neurology, Kitasato University School of Medicine, Sagamihara, Japan
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He J, Li J, Wei Y, He Z, Liu J, Yuan N, Zhou R, He X, Ren H, Gu L, Liao Y, Chen X, Tang J. Multiple serum anti-glutamate receptor antibody levels in clozapine-treated/naïve patients with treatment-resistant schizophrenia. BMC Psychiatry 2024; 24:248. [PMID: 38566016 PMCID: PMC10985978 DOI: 10.1186/s12888-024-05689-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 03/14/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Glutamatergic function abnormalities have been implicated in the etiology of treatment-resistant schizophrenia (TRS), and the efficacy of clozapine may be attributed to its impact on the glutamate system. Recently, evidence has emerged suggesting the involvement of immune processes and increased prevalence of antineuronal antibodies in TRS. This current study aimed to investigate the levels of multiple anti-glutamate receptor antibodies in TRS and explore the effects of clozapine on these antibody levels. METHODS Enzyme linked immunosorbent assay (ELISA) was used to measure and compare the levels of anti-glutamate receptor antibodies (NMDAR, AMPAR, mGlur3, mGluR5) in clozapine-treated TRS patients (TRS-C, n = 37), clozapine-naïve TRS patients (TRS-NC, n = 39), and non-TRS patients (nTRS, n = 35). Clinical symptom severity was assessed using the Positive and Negative Symptom Scale (PANSS), while cognitive function was evaluated using the MATRICS Consensus Cognitive Battery (MCCB). RESULT The levels of all four glutamate receptor antibodies in TRS-NC were significantly higher than those in nTRS (p < 0.001) and in TRS-C (p < 0.001), and the antibody levels in TRS-C were comparable to those in nTRS. However, no significant associations were observed between antibody levels and symptom severity or cognitive function across all three groups after FDR correction. CONCLUSION Our findings suggest that TRS may related to increased anti-glutamate receptor antibody levels and provide further evidence that glutamatergic dysfunction and immune processes may contribute to the pathogenesis of TRS. The impact of clozapine on anti-glutamate receptor antibody levels may be a pharmacological mechanism underlying its therapeutic effects.
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Affiliation(s)
- Jingqi He
- Department of Psychiatry, Sir Run-Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jinguang Li
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, China
- Affiliated Wuhan Mental Health Center, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yisen Wei
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, China
- Department of Psychiatry, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Zhangyin He
- Department of Psychiatry, Sir Run-Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- School of Mental Health, Wenzhou Medical University, Wenzhou, China
| | - Junyu Liu
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, China
- Xiangya Nursing School of Central South University, Changsha, China
| | - Ning Yuan
- Hunan Provincial Brain Hospital (The second people's Hospital of Hunan Province), Changsha, China
| | | | - Xingtao He
- The Ninth Hospital of Changsha, Changsha, China
| | - Honghong Ren
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, China
- Department of Psychiatry, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Lin Gu
- RIKEN Center for Advanced Intelligence Project, Tokyo, Japan
- Research Center for Advanced Science and Technology (RCAST), University of Tokyo, Tokyo, Japan
| | - Yanhui Liao
- Department of Psychiatry, Sir Run-Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaogang Chen
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, China.
| | - Jinsong Tang
- Department of Psychiatry, Sir Run-Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
- Hunan Provincial Brain Hospital (The second people's Hospital of Hunan Province), Changsha, China.
- Zigong Mental Health Center, Zigong, China.
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8
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Norrito RL, Puleo MG, Pintus C, Basso MG, Rizzo G, Di Chiara T, Di Raimondo D, Parrinello G, Tuttolomondo A. Paraneoplastic Cerebellar Degeneration Associated with Breast Cancer: A Case Report and a Narrative Review. Brain Sci 2024; 14:176. [PMID: 38391750 PMCID: PMC10887192 DOI: 10.3390/brainsci14020176] [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: 12/27/2023] [Revised: 01/23/2024] [Accepted: 02/07/2024] [Indexed: 02/24/2024] Open
Abstract
Paraneoplastic neurological syndromes (PNSs) are an uncommon complication of cancer, affecting nearby 1/10,000 subjects with a tumour. PNSs can involve all the central and peripheral nervous systems, the muscular system, and the neuromuscular junction, causing extremely variable symptomatology. The diagnosis of the paraneoplastic disease usually precedes the clinical manifestations of cancer, making an immediate recognition of the pathology crucial to obtain a better prognosis. PNSs are autoimmune diseases caused by the expression of common antigens by the tumour and the nervous system. Specific antibodies can help clinicians diagnose them, but unfortunately, they are not always detectable. Immunosuppressive therapy and the treatment of cancer are the cornerstones of therapy for PNSs. This paper reports a case of PNSs associated with breast tumours and focuses on the most common paraneoplastic neurological syndromes. We report a case of a young female with a clinical syndrome of the occurrence of rigidity in the right lower limb with postural instability with walking supported and diplopia, with a final diagnosis of paraneoplastic cerebellar degeneration and seronegative rigid human syndrome associated with infiltrating ductal carcinoma of the breast.
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Affiliation(s)
- Rosario Luca Norrito
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Maria Grazia Puleo
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Chiara Pintus
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Maria Grazia Basso
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Giuliana Rizzo
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Tiziana Di Chiara
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Domenico Di Raimondo
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Gaspare Parrinello
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Antonino Tuttolomondo
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
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9
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Su M, Luo Q, Wu Z, Feng H, Zhou H. Thymoma-associated autoimmune encephalitis with myasthenia gravis: Case series and literature review. CNS Neurosci Ther 2024; 30:e14568. [PMID: 38421083 PMCID: PMC10850820 DOI: 10.1111/cns.14568] [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] [Received: 03/31/2023] [Revised: 11/20/2023] [Accepted: 12/02/2023] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVES This comprehensive review aimed to compile cases of patients with thymoma diagnosed with both autoimmune encephalitis (AE) and myasthenia gravis (MG), and describe their clinical characteristics. METHODS Clinical records of 3 AE patients in the first affiliated hospital of Sun Yat-sen University were reviewed. All of them were diagnosed with AE between 1 November 2021 and 1 March 2022, and clinical evidence about thymoma and MG was found. All published case reports were searched for comprehensive literature from January 1990 to June 2022. RESULTS A total of 18 cases diagnosed with thymoma-associated autoimmune encephalitis (TAAE) and thymoma-associated myasthenia gravis (TAMG) were included in this complication, wherein 3 cases were in the first affiliated hospital of Sun Yat-sen University and the other 15 were published case reports. 5/18 patients had alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor antibody (AMPAR-Ab) in their serum and cerebrospinal fluid (CSF). All of them had positive anti-acetylcholine receptor antibody (AChR-Ab). And 12/18 patients showed a positive response to thymectomy and immunotherapy. Besides, thymoma recurrences were detected because of AE onset. And the shortest interval between operation and AE onset was 2 years in patients with thymoma recurrence. CONCLUSIONS There was no significant difference in the clinical manifestations between these patients and others with only TAMG or TAAE. TAAE was commonly associated with AMPAR2-Ab. Significantly, AE more commonly heralded thymoma recurrences than MG onset. And the intervals of thymectomy and MG or AE onset had different meanings for thymoma recurrence and prognoses of patients.
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Affiliation(s)
- Miao Su
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Qiuyan Luo
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
- Department of NeurologyGuangzhou Women and Children's Medical CenterGuangzhouChina
| | - Zichao Wu
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Huiyu Feng
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Hongyan Zhou
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
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10
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Scott RC, Moshé SL, Holmes GL. Do vaccines cause epilepsy? Review of cases in the National Vaccine Injury Compensation Program. Epilepsia 2024; 65:293-321. [PMID: 37914395 DOI: 10.1111/epi.17794] [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] [Received: 06/05/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE The National Childhood Vaccine Injury Act of 1986 created the National Vaccine Injury Compensation Program (VICP), a no-fault alternative to the traditional tort system. Since 1988, the total compensation paid exceeds $5 billion. Although epilepsy is one of the leading reasons for filing a claim, there has been no review of the process and validity of the legal outcomes given current medical information. The objectives were to review the evolution of the VICP program in regard to vaccine-related epilepsy and assess the rationale behind decisions made by the court. METHODS Publicly available cases involving epilepsy claims in the VICP were searched through Westlaw and the US Court of Federal Claims websites. All published reports were reviewed for petitioner's theories supporting vaccine-induced epilepsy, respondent's counterarguments, the final decision regarding compensation, and the rationale underlying these decisions. The primary goal was to determine which factors went into decisions regarding whether vaccines caused epilepsy. RESULTS Since the first epilepsy case in 1989, there have been many changes in the program, including the removal of residual seizure disorder as a vaccine-related injury, publication of the Althen prongs, release of the acellular form of pertussis, and recognition that in genetic conditions the underlying genetic abnormality rather than the immunization causes epilepsy. We identified 532 unique cases with epilepsy: 105 with infantile spasms and 427 with epilepsy without infantile spasms. The petitioners' experts often espoused outdated, erroneous causation theories that lacked an acceptable medical or scientific foundation and were frequently criticized by the court. SIGNIFICANCE Despite the lack of epidemiological or mechanistic evidence indicating that childhood vaccines covered by the VICP result in or aggravate epilepsy, these cases continue to be adjudicated. After 35 years of intense litigation, it is time to reconsider whether epilepsy should continue to be a compensable vaccine-induced injury.
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Affiliation(s)
- Rodney C Scott
- Nemours Children's Hospital-Delaware, Wilmington, Delaware, USA
| | - Solomon L Moshé
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Gregory L Holmes
- Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
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11
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Alkhayat D, Khawaji ZY, Sunyur AM, Sanyour OA, Badawi AS. Overview of Paraneoplastic Autoantibody-Mediated Cognitive Impairment and Behavioral Changes: A Narrative Review. Cureus 2024; 16:e51787. [PMID: 38322089 PMCID: PMC10846349 DOI: 10.7759/cureus.51787] [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: 01/06/2024] [Indexed: 02/08/2024] Open
Abstract
Cognitive dysfunction and behavioral change can be some of the manifestations of cancer, occurring as a part of paraneoplastic neurological syndrome, most commonly in small cell lung cancer. Paraneoplastic limbic encephalitis is the leading cause of cognitive disturbance and abnormal behavior in paraneoplastic syndromes, which is usually autoantibody-mediated. Autoantibodies are the main contributors to the development of cognitive dysfunction and behavioral change in cancer patients, with studies suggesting a higher liability for antibody-positive cancer patients to be affected. Anti-NMDAR and anti-AMPAR are antibodies targeted against surface antigens, manifesting predominantly as memory disturbance, abnormal behavior, psychiatric symptoms, and seizures. Other surface antigen-targeted antibodies include anti-GABA, anti-CASPR2, and anti-LGI1, which were shown to have cognitive function impairment and abnormal behavior as some of the main presentations, predominantly affecting memory. Cognitive deterioration and changes in behavior were also relatively common with some of the intracellular antigen-targeted antibodies, including anti-Hu, anti-SOX1, anti-PCA2, and anti-Zic2. Affected behavior and cognition, however, were reported less commonly in other paraneoplastic antibodies against intracellular antigens (anti-Yo, anti-GAD, anti-Ma2, anti-Ri, anti-CV2, and anti-KLHL11). Our article will provide a comprehensive review of the clinical manifestations of cognitive impairment and behavioral changes among cancer patients who develop paraneoplastic syndrome. Additionally, this review will discuss the role of specific paraneoplastic autoantibodies and the clinical spectrum linked to each separately.
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Affiliation(s)
| | | | - Amal M Sunyur
- Medicine and Surgery, Taibah University, Medina, SAU
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12
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Wagner B, Irani S. Autoimmune and paraneoplastic seizures. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:151-172. [PMID: 38494275 DOI: 10.1016/b978-0-12-823912-4.00009-8] [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
Seizures are a common feature of autoimmune encephalitis and are especially prevalent in patients with the commonest autoantibodies, against LGI1, CASPR2 and the NMDA, GABAB, and GABAA receptors. In this chapter, we discuss the classification, clinical, investigation, and treatment aspects of patients with these, and other autoantibody-mediated and -associated, illnesses. We highlight distinctive and common seizure semiologies which, often alongside other features we outline, can help the clinical diagnosis of an autoantibody-associated syndrome. Next, we classify these syndromes by either focusing on whether they represent underlying causative autoantibodies or T-cell-mediated syndromes and on the distinction between acute symptomatic seizures and a more enduring tendency to autoimmune-associated epilepsy, a practical and valuable distinction for both patients and clinicians which relates to the pathogenesis. We emphasize the more effective immunotherapy response in patients with causative autoantibodies, and discuss the emerging evidence for various first-, second-, and third-line immunotherapies. Finally, we highlight available clinical rating scales which can guide autoantibody testing and immunotherapy in patients with seizures of unknown etiology. Throughout, we relate the clinical and therapeutic observations to the immunobiology and neuroscience which drive these seizures.
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Affiliation(s)
- Barbara Wagner
- Neuroscience Department, NDCN, University of Oxford and Oxford University Hospitals, Oxford, United Kingdom; Kantonsspital Aarau Switzerland, Tellstrasse, Aarau, Switzerland
| | - Sarosh Irani
- Neuroscience Department, NDCN, University of Oxford and Oxford University Hospitals, Oxford, United Kingdom.
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13
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Budhram A, Flanagan EP. Optimizing the diagnostic performance of neural antibody testing for paraneoplastic and autoimmune encephalitis in clinical practice. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:365-382. [PMID: 38494290 DOI: 10.1016/b978-0-12-823912-4.00002-5] [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
The detection of neural antibodies in patients with paraneoplastic and autoimmune encephalitis has majorly advanced the diagnosis and management of neural antibody-associated diseases. Although testing for these antibodies has historically been restricted to specialized centers, assay commercialization has made this testing available to clinical chemistry laboratories worldwide. This improved test accessibility has led to reduced turnaround time and expedited diagnosis, which are beneficial to patient care. However, as the utilization of these assays has increased, so too has the need to evaluate how they perform in the clinical setting. In this chapter, we discuss assays for neural antibody detection that are in routine use, draw attention to their limitations and provide strategies to help clinicians and laboratorians overcome them, all with the aim of optimizing neural antibody testing for paraneoplastic and autoimmune encephalitis in clinical practice.
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Affiliation(s)
- Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, ON, Canada; Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada.
| | - Eoin P Flanagan
- 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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14
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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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15
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Dalmau J. Changing landscape in the field of paraneoplastic neurology: Personal perspectives over a 35-year career. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:11-32. [PMID: 38494272 DOI: 10.1016/b978-0-12-823912-4.00013-x] [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 are a group of rare disorders that have fascinated neurologists for more than a century. The discovery in the 1980s that many of these disorders occurred in association with antibodies against neuronal proteins revived the interest for these diseases. This chapter first traces the history of the paraneoplastic neurologic syndromes during the era that preceded the discovery of immune mechanisms and then reviews the immunologic period during which many of these syndromes were found to be associated with antibodies against intracellular onconeuronal proteins and pathogenic cytotoxic T-cell mechanisms. Alongside these developments, investigations on the antibody-mediated disorders of the peripheral nervous system, such as the myasthenic syndromes or neuromyotonia, provided suggestions for the study of the central nervous system (CNS) syndromes. These converging areas of research culminated with the groundbreaking discovery of a new category of CNS disorders mediated by antibodies against neuronal surface proteins or receptors. These disorders are not always paraneoplastic, and the understanding of these syndromes and mechanisms has changed the landscape of neurology and neurosciences.
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Affiliation(s)
- Josep Dalmau
- IDIBAPS-Hospital Clinic, University of Barcelona, Barcelona, Spain; Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain.
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16
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Iorio R, Lennon VA. Paraneoplastic autoimmune neurologic disorders associated with thymoma. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:385-396. [PMID: 38494291 DOI: 10.1016/b978-0-12-823912-4.00008-6] [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
Thymoma is often associated with paraneoplastic neurologic diseases. Neural autoantibody testing is an important tool aiding diagnosis of thymoma and its autoimmune neurologic complications. Autoantibodies specific for muscle striational antigens and ion channels of the ligand-gated nicotinic acetylcholine receptor superfamily are the most prevalent biomarkers. The autoimmune neurologic disorders associating most commonly with thymoma are myasthenia gravis (MG), peripheral nerve hyperexcitability (neuromyotonia and Morvan syndrome), dysautonomia, and encephalitis. Patients presenting with these neurologic disorders should be screened for thymoma at diagnosis. Although they can cause profound disability, they usually respond to immunotherapy and treatment of the thymoma. Worsening of the neurologic disorder following surgical removal of a thymoma may herald tumor recurrence. Prompt recognition of paraneoplastic neurologic disorders is critical for patient management. A multidisciplinary approach is required for optimal management of neurologic autoimmunity associated with thymoma.
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Affiliation(s)
- Raffaele Iorio
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Vanda A Lennon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Immunology, Mayo Clinic, Rochester, MN, United States
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17
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Chen LW, Guasp M, Olivé-Cirera G, Martínez-Hernandez E, Ruiz García R, Naranjo L, Saiz A, Armangue T, Dalmau J. Antibody Investigations in 2,750 Children With Suspected Autoimmune Encephalitis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200182. [PMID: 37968128 PMCID: PMC10683852 DOI: 10.1212/nxi.0000000000200182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/06/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVES To assess the frequency and types of neuronal and glial (neural) antibodies in children with suspected autoimmune encephalitis (AE). METHODS Patients younger than 18 years with suspected AE other than acute disseminated encephalomyelitis, whose serum or CSF samples were examined in our center between January 1, 2011, and April 30, 2022, were included in this study. Samples were systematically examined using brain immunohistochemistry; positive immunostaining was further investigated with cell-based assays (CBA), immunoblot, or live neuronal immunofluorescence. RESULTS Of 2,750 children, serum or CSF samples of 542 (20%) showed brain immunoreactivity, mostly (>90%) against neural cell surface antigens, and 19 had antibodies only identified by CBA. The most frequent targets were N-methyl-d-aspartate receptor (NMDAR, 76%) and myelin oligodendrocyte glycoprotein (MOG, 5%), followed by glutamic acid decarboxylase 65 (2%) and γ-aminobutyric acid A receptor (2%). Antibodies against other known cell surface or intracellular neural antigens (altogether 6% of positive cases) and unknown antigens (9%) were very infrequent. DISCUSSION The repertoire of antibodies in children with AE is different from that of the adults. Except for NMDAR and MOG antibodies, many of the antibodies included in diagnostic panels are rarely positive and their up-front testing in children seems unneeded.
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Affiliation(s)
- Li-Wen Chen
- From the Neuroimmunology Program (L.-W.C., M.G., G.O.-C., E.M.-H., R.R.G., A.S., T.A., J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Department of Pediatrics (L.-W.C.), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Neurology Department (M.G., E.M.-H., A.S., J.D.), University of Barcelona; Centro de Investigación Biomédica en Red (M.G., J.D.), Enfermedades Raras (CIBERER) Madrid, Spain; Pediatric Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell; Immunology Department (R.R.G., L.N.), Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institution for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Mar Guasp
- From the Neuroimmunology Program (L.-W.C., M.G., G.O.-C., E.M.-H., R.R.G., A.S., T.A., J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Department of Pediatrics (L.-W.C.), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Neurology Department (M.G., E.M.-H., A.S., J.D.), University of Barcelona; Centro de Investigación Biomédica en Red (M.G., J.D.), Enfermedades Raras (CIBERER) Madrid, Spain; Pediatric Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell; Immunology Department (R.R.G., L.N.), Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institution for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Gemma Olivé-Cirera
- From the Neuroimmunology Program (L.-W.C., M.G., G.O.-C., E.M.-H., R.R.G., A.S., T.A., J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Department of Pediatrics (L.-W.C.), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Neurology Department (M.G., E.M.-H., A.S., J.D.), University of Barcelona; Centro de Investigación Biomédica en Red (M.G., J.D.), Enfermedades Raras (CIBERER) Madrid, Spain; Pediatric Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell; Immunology Department (R.R.G., L.N.), Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institution for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Eugenia Martínez-Hernandez
- From the Neuroimmunology Program (L.-W.C., M.G., G.O.-C., E.M.-H., R.R.G., A.S., T.A., J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Department of Pediatrics (L.-W.C.), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Neurology Department (M.G., E.M.-H., A.S., J.D.), University of Barcelona; Centro de Investigación Biomédica en Red (M.G., J.D.), Enfermedades Raras (CIBERER) Madrid, Spain; Pediatric Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell; Immunology Department (R.R.G., L.N.), Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institution for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Raquel Ruiz García
- From the Neuroimmunology Program (L.-W.C., M.G., G.O.-C., E.M.-H., R.R.G., A.S., T.A., J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Department of Pediatrics (L.-W.C.), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Neurology Department (M.G., E.M.-H., A.S., J.D.), University of Barcelona; Centro de Investigación Biomédica en Red (M.G., J.D.), Enfermedades Raras (CIBERER) Madrid, Spain; Pediatric Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell; Immunology Department (R.R.G., L.N.), Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institution for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Laura Naranjo
- From the Neuroimmunology Program (L.-W.C., M.G., G.O.-C., E.M.-H., R.R.G., A.S., T.A., J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Department of Pediatrics (L.-W.C.), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Neurology Department (M.G., E.M.-H., A.S., J.D.), University of Barcelona; Centro de Investigación Biomédica en Red (M.G., J.D.), Enfermedades Raras (CIBERER) Madrid, Spain; Pediatric Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell; Immunology Department (R.R.G., L.N.), Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institution for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Albert Saiz
- From the Neuroimmunology Program (L.-W.C., M.G., G.O.-C., E.M.-H., R.R.G., A.S., T.A., J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Department of Pediatrics (L.-W.C.), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Neurology Department (M.G., E.M.-H., A.S., J.D.), University of Barcelona; Centro de Investigación Biomédica en Red (M.G., J.D.), Enfermedades Raras (CIBERER) Madrid, Spain; Pediatric Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell; Immunology Department (R.R.G., L.N.), Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institution for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Thaís Armangue
- From the Neuroimmunology Program (L.-W.C., M.G., G.O.-C., E.M.-H., R.R.G., A.S., T.A., J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Department of Pediatrics (L.-W.C.), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Neurology Department (M.G., E.M.-H., A.S., J.D.), University of Barcelona; Centro de Investigación Biomédica en Red (M.G., J.D.), Enfermedades Raras (CIBERER) Madrid, Spain; Pediatric Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell; Immunology Department (R.R.G., L.N.), Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institution for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Josep Dalmau
- From the Neuroimmunology Program (L.-W.C., M.G., G.O.-C., E.M.-H., R.R.G., A.S., T.A., J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Department of Pediatrics (L.-W.C.), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Neurology Department (M.G., E.M.-H., A.S., J.D.), University of Barcelona; Centro de Investigación Biomédica en Red (M.G., J.D.), Enfermedades Raras (CIBERER) Madrid, Spain; Pediatric Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell; Immunology Department (R.R.G., L.N.), Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institution for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain.
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18
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Budhram A, Sechi E. Antibodies to neural cell surface and synaptic proteins in paraneoplastic neurologic syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:347-364. [PMID: 38494289 DOI: 10.1016/b978-0-12-823912-4.00006-2] [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
Among patients with paraneoplastic neurologic syndromes (PNS), emphasis has historically been placed on neural antibodies against intracellular proteins that have a strong association with malignancy. Because of the intracellular location of their antigenic targets, these antibodies are typically considered to be non-pathogenic surrogate markers of immune cell-mediated neural injury. Unfortunately, patients with these antibodies often have suboptimal response to immunotherapy and poor prognosis. Over the last two decades, however, dramatic advancements have been made in the discovery and clinical characterization of neural antibodies against extracellular targets. These antibodies are generally considered to be pathogenic, given their potential to directly alter antigen structure or function, and patients with these antibodies often respond favorably to prompt immunotherapy. These antibodies also associate with tumors and may thus occur as PNS, albeit more variably than neural antibodies against intracellular targets. The updated 2021 PNS diagnostic criteria, which classifies antibodies as high-risk, intermediate-risk, or lower-risk for an associated cancer, better clarifies how neural antibodies against extracellular targets relate to PNS. Using this recently created framework, the clinical presentations, ancillary test findings, oncologic associations, and treatment responses of syndromes associated with these antibodies are discussed.
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Affiliation(s)
- Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, ON, Canada; Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada.
| | - Elia Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
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19
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Casagrande S, Zuliani L, Grisold W. Paraneoplastic encephalitis. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:131-149. [PMID: 38494274 DOI: 10.1016/b978-0-12-823912-4.00019-0] [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
The first reports of encephalitis associated with cancer date to the 1960s and were characterized by clinical and pathologic involvement of limbic areas. This specific association was called limbic encephalitis (LE). The subsequent discovery of several "onconeural" antibodies (Abs), i.e., Abs targeting an antigen shared by neurons and tumor cells, supported the hypothesis of an autoimmune paraneoplastic etiology of LE and other forms of rapidly progressive encephalopathy. Over the past 20 years, similar clinical pictures with different clinical courses have been described in association with novel Abs-binding neuronal membrane proteins and proved to be pathogenic. The most well-known encephalitis in this group was described in 2007 as an association of a complex neuro-psychiatric syndrome, N-methyl-d-aspartate (NMDA) receptor-Abs, and ovarian teratoma in young women. Later on, nonparaneoplastic cases of NMDA receptor encephalitis were also described. Since then, the historical concept of LE and Ab associated encephalitis has changed. Some of these occur in fact more commonly in the absence of a malignancy (e.g., anti-LG1 Abs). Lastly, seronegative cases were also described. The term paraneoplastic encephalitis nowadays encompasses different syndromes that may be triggered by occult tumors.
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Affiliation(s)
- Silvia Casagrande
- Neurology Unit, Rovereto Hospital, Trento, Italy; Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy.
| | - Luigi Zuliani
- Department of Neurology, San Bortolo Hospital, Azienda ULSS8 Berica, Vicenza, Italy
| | - Wolfgang Grisold
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
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20
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Hammami MB, Rezk M, Dubey D. Paraneoplastic neurologic syndrome and autoantibody accompaniments of germ cell tumors. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:431-445. [PMID: 38494295 DOI: 10.1016/b978-0-12-823912-4.00001-3] [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 (PNSs) are a group of diseases affecting the central and/or peripheral nervous system caused by immune-mediated processes directed toward antigens with shared expression in tumor and neural tissue. Germ cell tumors (GCTs) are associated with PNSs with varied clinical phenotypes. Early diagnosis of PNS is vital to potentially uncover and treat underlying tumors, improving the chances of recovery, and preventing permanent neurologic complications. In this chapter, we outline the pathophysiology and epidemiology of PNS. We briefly provide a summary of GCTs in males and females. We review the neural-specific autoantibodies and PNSs associated with GCTs and their clinical and radiologic accompaniments. We also provide an overview of the treatment and prognosis of these disorders.
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Affiliation(s)
- M Bakri Hammami
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States
| | - Mohamed Rezk
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Divyanshu Dubey
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Neurology, Mayo Clinic, Rochester, MN, United States.
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21
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Quinot V, Höftberger R. Pathogenesis and immunopathology of paraneoplastic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:33-54. [PMID: 38494287 DOI: 10.1016/b978-0-12-823912-4.00027-x] [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) represent a rare group of immune-mediated complications associated with an underlying tumor. Ectopic protein expression in neoplastic cells or an aberrant immune regulation in the course of hematooncologic diseases or thymomas trigger an autoimmune response that may affect any part of the central and/or peripheral nervous system. Recent advances in drug therapies as well as novel animal models and neuropathologic studies have led to further insights on the immune pathomechanisms of PNS. Although the syndromes share common paths in pathogenesis, they may differ in the disease course, prognosis, and therapy targets, depending on the localization and type of antibody epitope. Neuropathologic hallmarks of PNS associated with antibodies directed against intracellular epitopes are characterized by T cell-dominated inflammation, reactive gliosis including microglial nodules, and neuronal degeneration. By contrast, the neuropathology of cell surface antibody-mediated PNS strongly depends on the targeted antigen and varies from B cell/plasma cell-dominated inflammation and well-preserved neurons together with a reduced expression of the target antigen in anti-NMDAR encephalitis to irreversible Purkinje cell loss in anti-P/Q-type VGCC antibody-associated paraneoplastic cerebellar degeneration. The understanding of different pathomechanisms in PNS is important because they strongly correspond with therapy response and prognosis, and should guide treatment decisions.
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Affiliation(s)
- Valérie Quinot
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria.
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22
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Waters P, Mills JR, Fox H. Evolution of methods to detect paraneoplastic antibodies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:113-130. [PMID: 38494273 DOI: 10.1016/b978-0-12-823912-4.00010-4] [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
An adaptive immune response in less than 1% of people who develop cancer produces antibodies against neuronal proteins. These antibodies can be associated with paraneoplastic syndromes, and their accurate detection should instigate a search for a specific cancer. Over the years, multiple systems, from indirect immunofluorescence to live cell-based assays, have been developed to identify these antibodies. As the specific antigens were identified, high throughput, multi-antigen substrates such as line blots and ELISAs were developed for clinical laboratories. However, the evolution of assays required to identify antibodies to membrane targets has shone a light on the importance of antigen conformation for antibody detection. This chapter discusses the early antibody assays used to detect antibodies to nuclear and cytosolic targets and how new approaches are required to detect antibodies to membrane targets. The chapter presents recent data that support international recommendations against the sole use of line blots for antibody detection and highlights a new antigen-specific approach that appears promising for the detection of submembrane targets.
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Affiliation(s)
- Patrick Waters
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Hannah Fox
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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23
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Masciocchi S, Businaro P, Scaranzin S, Morandi C, Franciotta D, Gastaldi M. General features, pathogenesis, and laboratory diagnostics of autoimmune encephalitis. Crit Rev Clin Lab Sci 2024; 61:45-69. [PMID: 37777038 DOI: 10.1080/10408363.2023.2247482] [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] [Received: 03/23/2023] [Accepted: 08/09/2023] [Indexed: 10/02/2023]
Abstract
Autoimmune encephalitis (AE) is a group of inflammatory conditions that can associate with the presence of antibodies directed to neuronal intracellular, or cell surface antigens. These disorders are increasingly recognized as an important differential diagnosis of infectious encephalitis and of other common neuropsychiatric conditions. Autoantibody diagnostics plays a pivotal role for accurate diagnosis of AE, which is of utmost importance for the prompt recognition and early treatment. Several AE subgroups can be identified, either according to the prominent clinical phenotype, presence of a concomitant tumor, or type of neuronal autoantibody, and recent diagnostic criteria have provided important insights into AE classification. Antibodies to neuronal intracellular antigens typically associate with paraneoplastic neurological syndromes and poor prognosis, whereas antibodies to synaptic/neuronal cell surface antigens characterize many AE subtypes that associate with tumors less frequently, and that are often immunotherapy-responsive. In addition to the general features of AE, we review current knowledge on the pathogenic mechanisms underlying these disorders, focusing mainly on the potential role of neuronal antibodies in the most frequent conditions, and highlight current theories and controversies. Then, we dissect the crucial aspects of the laboratory diagnostics of neuronal antibodies, which represents an actual challenge for both pathologists and neurologists. Indeed, this diagnostics entails technical difficulties, along with particularly interesting novel features and pitfalls. The novelties especially apply to the wide range of assays used, including specific tissue-based and cell-based assays. These assays can be developed in-house, usually in specialized laboratories, or are commercially available. They are widely used in clinical immunology and in clinical chemistry laboratories, with relevant differences in analytic performance. Indeed, several data indicate that in-house assays could perform better than commercial kits, notwithstanding that the former are based on non-standardized protocols. Moreover, they need expertise and laboratory facilities usually unavailable in clinical chemistry laboratories. Together with the data of the literature, we critically evaluate the analytical performance of the in-house vs commercial kit-based approach. Finally, we propose an algorithm aimed at integrating the present strategies of the laboratory diagnostics in AE for the best clinical management of patients with these disorders.
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Affiliation(s)
- Stefano Masciocchi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, Università degli Studi di Pavia, Pavia, Italy
| | - Pietro Businaro
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, Università degli Studi di Pavia, Pavia, Italy
| | - Silvia Scaranzin
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Chiara Morandi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Diego Franciotta
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Matteo Gastaldi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
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24
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Ryding M, Mikkelsen AW, Nissen MS, Nilsson AC, Blaabjerg M. Pathophysiological Effects of Autoantibodies in Autoimmune Encephalitides. Cells 2023; 13:15. [PMID: 38201219 PMCID: PMC10778077 DOI: 10.3390/cells13010015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
The heterogeneity of autoantibody targets in autoimmune encephalitides presents a challenge for understanding cellular and humoral pathophysiology, and the development of new treatment strategies. Thus, current treatment aims at autoantibody removal and immunosuppression, and is primarily based on data generated from other autoimmune neurological diseases and expert consensus. There are many subtypes of autoimmune encephalitides, which now entails both diseases with autoantibodies targeting extracellular antigens and classical paraneoplastic syndromes with autoantibodies targeting intracellular antigens. Here, we review the current knowledge of molecular and cellular effects of autoantibodies associated with autoimmune encephalitis, and evaluate the evidence behind the proposed pathophysiological mechanisms of autoantibodies in autoimmune encephalitis.
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Affiliation(s)
- Matias Ryding
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark;
- Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5000 Odense, Denmark
| | - Anne With Mikkelsen
- Department of Clinical Immunology, Odense University Hospital, 5000 Odense, Denmark;
| | | | - Anna Christine Nilsson
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark;
- Department of Clinical Immunology, Odense University Hospital, 5000 Odense, Denmark;
| | - Morten Blaabjerg
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark;
- Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5000 Odense, Denmark
- Department of Neurology, Odense University Hospital, 5000 Odense, Denmark;
- Brain Research—Inter Disciplinary Guided Excellence (BRIDGE), 5000 Odense, Denmark
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25
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Akkus S, Elkhooly M, Amatya S, Shrestha K, Sharma K, Kagzi Y, Khan E, Gupta R, Piquet AL, Jaiswal S, Wen S, Tapia M, Samant R, Sista SR, Sriwastava S. Autoimmune and paraneoplastic neurological disorders: A review of relevant neuroimaging findings. J Neurol Sci 2023; 454:120830. [PMID: 37856996 DOI: 10.1016/j.jns.2023.120830] [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] [Received: 08/21/2023] [Revised: 09/28/2023] [Accepted: 10/04/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Paraneoplastic neurologic syndromes (PNS) and autoimmune encephalitis (AIE) are immune-mediated disorders. PNS is linked to cancer, while AIE may not Their clinical manifestations and imaging patterns need further elucidation. OBJECTIVE/AIMS To investigate the clinical profiles, antibody associations, neuroimaging patterns, treatments, and outcomes of PNS and AIE. METHODS A systematic review of 379 articles published between 2014 and 2023 was conducted. Of the 55 studies screened, 333 patients were diagnosed with either PNS or AIE and tested positive for novel antibodies. Data on demographics, symptoms, imaging, antibodies, cancer associations, treatment, and outcomes were extracted. RESULTS The study included 333 patients (mean age 54 years, 67% males) with PNS and AIE positive for various novel antibodies. 84% had central nervous system issues like cognitive impairment (53%), rhombencephalitis (17%), and cerebellar disorders (24%). Neuroimaging revealed distinct patterns with high-risk antibodies associated with brainstem lesions in 98%, cerebellar in 91%, hippocampal in 98%, basal ganglia in 75%, and spinal cord in 91%, while low/intermediate-risk antibodies were associated with medial temporal lobe lesions in 71% and other cortical/subcortical lesions in 55%. High-risk antibodies were associated with younger males, deep brain lesions, and increased mortality of 61%, while low/intermediate-risk antibodies were associated with females, cortical/subcortical lesions, and better outcomes with 39% mortality. Associated cancers included seminomas (23%), lung (19%), ovarian (2%), and breast (2%). Treatments included IVIG, chemotherapy, and plasmapheresis. Overall mortality was 25% in this cohort. CONCLUSION PNS and AIE have distinct clinical and radiological patterns based on antibody profiles. High-risk antibodies are associated with increased mortality while low/intermediate-risk antibodies are associated with improved outcomes. Appropriate imaging and antibody testing are critical for accurate diagnosis.
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Affiliation(s)
- Sema Akkus
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mahmoud Elkhooly
- Department of Neurology, Wayne state University, Detroit, MI, USA; Department of Neurology, Southern Illinois university, Springfield, IL, USA; Department of Neuropsychiatry, Minia University, Egypt
| | - Suban Amatya
- Department of Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Kriti Shrestha
- Department of Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Kanika Sharma
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA
| | - Yusuf Kagzi
- Mahatma Gandhi Memorial Medical College, Indore, India
| | - Erum Khan
- Department of Neurology, University of Alabama at Birmingham, Al, USA
| | - Rajesh Gupta
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA
| | - Amanda L Piquet
- Neuroimmunology, Neuroinfectious Disease and Neurohospitalist Sections, University of Colorado School of Medicine, CO, USA
| | - Shruti Jaiswal
- Department of Neuro-oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Sijin Wen
- West Virginia Clinical Transitional Science, Morgantown, WV, USA
| | - Michaela Tapia
- West Virginia Clinical Transitional Science, Morgantown, WV, USA
| | - Rohan Samant
- Department of Neuroradiology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sri Raghav Sista
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA
| | - Shitiz Sriwastava
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA.
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26
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Olivero G, Roggeri A, Pittaluga A. Anti-NMDA and Anti-AMPA Receptor Antibodies in Central Disorders: Preclinical Approaches to Assess Their Pathological Role and Translatability to Clinic. Int J Mol Sci 2023; 24:14905. [PMID: 37834353 PMCID: PMC10573896 DOI: 10.3390/ijms241914905] [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: 09/08/2023] [Revised: 09/30/2023] [Accepted: 10/03/2023] [Indexed: 10/15/2023] Open
Abstract
Autoantibodies against NMDA and AMPA receptors have been identified in the central nervous system of patients suffering from brain disorders characterized by neurological and psychiatric symptoms. It has been demonstrated that these autoantibodies can affect the functions and/or the expression of the targeted receptors, altering synaptic communication. The importance to clarify, in preclinical models, the molecular mechanisms involved in the autoantibody-mediated effects has emerged in order to understand their pathogenic role in central disorders, but also to propose new therapeutic approaches for preventing the deleterious central consequences. In this review, we describe some of the available preclinical literature concerning the impact of antibodies recognizing NMDA and AMPA receptors in neurons. This review discusses the cellular events that would support the detrimental roles of the autoantibodies, also illustrating some contrasting findings that in our opinion deserve attention and further investigations before translating the preclinical observations to clinic.
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Affiliation(s)
- Guendalina Olivero
- Department of Pharmacy (DiFar), University of Genoa, Viale Cembrano 4, 16148 Genoa, Italy; (G.O.); (A.R.)
| | - Alessandra Roggeri
- Department of Pharmacy (DiFar), University of Genoa, Viale Cembrano 4, 16148 Genoa, Italy; (G.O.); (A.R.)
| | - Anna Pittaluga
- Center of Excellence for Biomedical Research, 3Rs Center, Department of Pharmacy (DiFar), University of Genoa, Viale Cembrano 4, 16148 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16145 Genoa, Italy
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27
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Huang Y, Zhou M, Zhou J, Wu B, Yang X, Min W, Li Z. Anti-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor encephalitis developed after ovarian cancer cytoreduction surgery: a case report and literature review. BMC Womens Health 2023; 23:507. [PMID: 37735388 PMCID: PMC10512534 DOI: 10.1186/s12905-023-02636-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 09/06/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Anti-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) encephalitis, a rare subtype of autoimmune encephalitis (AE), is often found associated with tumors such as thymoma, lung cancer, ovarian tumors, and breast cancer, and the tumors were generally detected during the screening process after the encephalitis initiated. The tumor is considered a trigger of AE, but the mechanism remains unclear. CASE PRESENTATION A 53-year-old woman presented short-term memory loss two days after the primary cytoreduction for high-grade serous ovarian cancer (HGSOC, FIGO stage IC3). Cell-based assay found AMPAR CluA2 IgG positive in both serum (1:3.2) and cerebrospinal fluid (1:32). Moreover, mild AMPAR GluA1 and strong GluA2 expressions were also found positive in the paraffin sections of ovarian tumor tissue, indicating the ovarian cytoreduction surgery might stimulate the release of receptor antigens into the circulation system. The patient's condition deteriorated within two weeks, developing consciousness and autonomic dysfunction, leading to ICU admission. With oral steroids, intravenous immunoglobulin, plasmapheresis, and rituximab treatment, the patient's consciousness markedly improved after three months. CONCLUSION We presented the first case of anti-AMPAR encephalitis developed right after the primary cytoreduction of a patient with HGSOC and retrieved paraneoplastic anti-AMPAR encephalitis cases (n = 66). Gynecologists should pay attention to patients who develop cognitive dysfunction or psychiatric symptoms shortly after the ovarian tumor resection and always include AE in the differentiation diagnosis.
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Affiliation(s)
- Yue Huang
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, 610041, People's Republic of China
| | - Muke Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Jing Zhou
- Department of Gynecology and Obstetrics, Chengdu Fifth People's Hospital, Chengdu, 610041, People's Republic of China
| | - Bo Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Xi Yang
- Department of Anesthesiology, West China Hospital, Sichuan university, Chengdu, 610041, People's Republic of China
| | - Wenjiao Min
- Department of Psychosomatic Medicine, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, Chengdu, 610041, People's Republic of China
| | - Zhengyu Li
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, 610041, People's Republic of China.
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28
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Şorodoc V, Constantin M, Asaftei A, Lionte C, Ceasovschih A, Sîrbu O, Haliga RE, Şorodoc L. The use of intravenous immunoglobulin in the treatment of Hashimoto's encephalopathy: case based review. Front Neurol 2023; 14:1243787. [PMID: 37745658 PMCID: PMC10513043 DOI: 10.3389/fneur.2023.1243787] [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: 07/11/2023] [Accepted: 08/25/2023] [Indexed: 09/26/2023] Open
Abstract
Background Hashimoto's encephalopathy (HE) is a controversial immunological neuropsychiatric disease, with a poorly understood pathogenesis. It is characterized by symptoms of acute or subacute encephalopathy which usually occur in the presence of elevated levels of antithyroid antibodies. Even though it is also known as steroid responsive encephalopathy associated with autoimmune thyroiditis (SREAT), some cases appear to be steroid-resistant. This review examined whether treatment of Hashimoto's encephalopathy with intravenous immunoglobulin (IVIG) is associated with better clinical outcomes than the standard therapy. Additionally, we presented a case of a 59-year-old man who presented with severe neurological manifestations and was successfully treated with intravenous immunoglobulin. Methods The online databases PubMed and EMBASE were searched. Results A total of 1,365 articles were identified. After the deletion of 112 duplicates, 1,253 studies were screened by evaluating the title and abstract, focusing on Hashimoto's encephalopathy cases where IVIG were used. 846 studies were excluded because they were not relevant to the topic or included pediatric population. Therefore, 407 full-text articles were assessed for eligibility. The final analysis included 14 eligible articles after 393 were excluded (irrelevant texts, not written in English, full-text not available). In the majority of the selected case-reports, IVIG was associated with a good outcome, sometimes even with dramatic improvements in patient's status. Conclusion In last years, intravenous immunoglobulin therapy proved its utility in Hashimoto's encephalopathy's treatment, being a well tolerated therapy associated with remarkable improvement in patient's status. Further research is still needed in order to define the optimal treatment protocol for Hashimoto's encephalopathy and to establish if intravenous immunoglobulin can also be used as a first-line therapy, alone or in combination with steroids.
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Affiliation(s)
- Victoriţa Şorodoc
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Mihai Constantin
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Andreea Asaftei
- 2nd Rheumatology Department, Clinical Rehabilitation Hospital, Iasi, Romania
| | - Cătălina Lionte
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Alexandr Ceasovschih
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Oana Sîrbu
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Raluca Ecaterina Haliga
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Laurenţiu Şorodoc
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
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Vegda M, Mehndiratta M. GAD-65-Associated Limbic Encephalitis - Early Diagnosis and Course of Disease, Treated with IV Methylprednisolone. Ann Indian Acad Neurol 2023; 26:785-787. [PMID: 38022474 PMCID: PMC10666888 DOI: 10.4103/aian.aian_644_23] [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: 07/21/2023] [Revised: 07/31/2023] [Accepted: 08/08/2023] [Indexed: 12/01/2023] Open
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Yu X, Wax J, Riemekasten G, Petersen F. Functional autoantibodies: Definition, mechanisms, origin and contributions to autoimmune and non-autoimmune disorders. Autoimmun Rev 2023; 22:103386. [PMID: 37352904 DOI: 10.1016/j.autrev.2023.103386] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/06/2023] [Accepted: 06/18/2023] [Indexed: 06/25/2023]
Abstract
A growing body of evidence underscores the relevance of functional autoantibodies in the development of various pathogenic conditions but also in the regulation of homeostasis. However, the definition of functional autoantibodies varies among studies and a comprehensive overview on this emerging topic is missing. Here, we do not only explain functional autoantibodies but also summarize the mechanisms underlying the effect of such autoantibodies including receptor activation or blockade, induction of receptor internalization, neutralization of ligands or other soluble extracellular antigens, and disruption of protein-protein interactions. In addition, in this review article we discuss potential triggers of production of functional autoantibodies, including infections, immune deficiency and tumor development. Finally, we describe the contribution of functional autoantibodies to autoimmune diseases including autoimmune thyroid diseases, myasthenia gravis, autoimmune pulmonary alveolar proteinosis, autoimmune autonomic ganglionopathy, pure red cell aplasia, autoimmune encephalitis, pemphigus, acquired thrombotic thrombocytopenic purpura, idiopathic dilated cardiomyopathy and systemic sclerosis, as well as non-autoimmune disorders such as allograft rejection, infectious diseases and asthma.
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Affiliation(s)
- Xinhua Yu
- Priority Area Chronic Lung Diseases, Research Center Borstel, Members of the German Center for Lung Research (DZL), 23845 Borstel, Germany.
| | - Jacqueline Wax
- Priority Area Chronic Lung Diseases, Research Center Borstel, Members of the German Center for Lung Research (DZL), 23845 Borstel, Germany
| | - Gabriela Riemekasten
- Department of Rheumatology and Clinical Immunology, University Clinic of Schleswig Holstein, University of Lübeck, 23538 Lübeck, Germany
| | - Frank Petersen
- Priority Area Chronic Lung Diseases, Research Center Borstel, Members of the German Center for Lung Research (DZL), 23845 Borstel, Germany
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He J, Lian Y. Clinical study of autonomic dysfunction in patients with autoimmune encephalitis. Immunobiology 2023; 228:152711. [PMID: 37543010 DOI: 10.1016/j.imbio.2023.152711] [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] [Received: 04/20/2023] [Revised: 06/25/2023] [Accepted: 07/15/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Autoimmune encephalitis (AE) is a collective name, covering an emerging spectrum of autoimmune-mediated neurological diseases related to antibodies and synaptic or intracellular proteins. Anti-NMDAR, anti-LGI1, and anti-GABABR are three types of neuronal cell surface antibodies. Autonomic dysfunction represents a frequently occurring clinical manifestation. This observational study purposes to investigate comparisons between two groups with or without autonomic dysfunction and detect the autonomic dysfunction and other indexes in anti-NMDAR, anti-LGI1, and anti-GABABR cohorts. METHODS Patients with anti-NMDAR, anti-LGI1 and anti-GABABR encephalitis were recruited from the May 2017 to the April 2022. The following information was recorded: age, age at onset, tumor presence, gender, prodromal symptoms, clinical manifestations, cranial magnetic resonance imaging, cerebrospinal fluid and blood examinations, and immunotherapy. RESULTS There were totally 161 patients enrolled in this study. Among these participants, 104 individuals (64.6%) presented autonomic dysfunction and the remaining 57 (35.4%) were free of autonomic dysfunction. Sinus tachycardia was the most common autonomic dysfunction, followed by pollakiuria/uroclepsia, feverscence, central hypoventilation, sinus bradycardia, constipation, uroschesis, hyperhidrosis, hypersalivation, hypotension, and early satiety/emesis. Compared to patients without autonomic dysfunction, those with autonomic dysfunction had a higher incidence of central hypoventilation and ICU admissions. Meanwhile, in both groups with or without autonomic dysfunction, meatal behavior disorder, cognitive impairment, and epileptic seizure were three most common clinical manifestations. There were no significant differences in cranial magnetic resonance imaging (MRI), cerebrospinal fluid (CSF) examination, antibody titers and number of immunotherapy types. Further analysis of AE mediated by distinct neuronal surface antibodies demonstrated that there were 85 anti-NMDAR, 56 anti-LGI1, and 20 anti-GABABR encephalitis patients. The significant differences between these three cohorts appeared in age, tumor presence, fervescence presence and antibody titers. CONCLUSION This study demonstrated the comparisons between autonomic dysfunction group and autonomic dysfunction-free group and provided insights into better diagnosis and treatment.
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Affiliation(s)
- Jiao He
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450000, China
| | - Yajun Lian
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450000, China.
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Lin J, Wang J, Li J. Patient characteristics and outcome in patients with anti-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) encephalitis. Neurol Sci 2023; 44:3253-3259. [PMID: 37010671 DOI: 10.1007/s10072-023-06769-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 03/21/2023] [Indexed: 04/04/2023]
Abstract
OBJECTIVE Anti-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) encephalitis is a rare subtype of autoimmune encephalitis. We report patients diagnosed with anti-AMPAR encephalitis in western China, focusing on their clinical presentations, imaging results, treatment strategies, and prognosis. METHODS Data from patients diagnosed with anti-AMPAR encephalitis in the neurology center of West China Hospital from August 2018 to July 2021 were retrospectively collected and analyzed. Based on the diagnostic criteria of autoimmune encephalitis, nine cases were included. RESULTS Four patients (44%) were males, and the median age at presentation was 54 years (range, 25-85). Short-term memory loss was the most common initial symptom. Additional types of autoantibodies were identified in three patients. After presentation, four patients were found to have tumors: two with small cell lung cancer, one with ovarian teratoma, and one with thymoma. All patients accepted first-line immune therapy, and follow-up was available from 8 patients (median 20 weeks, range 4-78). At the last follow-up, three patients showed good outcomes (modified Rankin scale [mRS] 0-2; 37.5%). Five patients showed poor outcomes (mRS 3-6; 62.5%): two had minimal changes and remained hospitalized, two had residual severe cognitive impairments, and one patient died during follow-up. Outcomes were worse among patients with tumors. Finally, only one patient experienced relapse during follow-up. CONCLUSION Anti-AMPAR encephalitis should be considered in the differential diagnosis for middle- and senior-aged patients who present with predominantly acute or subacute short-term memory impairment. The long-term prognosis is correlated with the presence of a tumor.
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Affiliation(s)
- Jingfang Lin
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, China
| | - Jierui Wang
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, China
| | - Jinmei Li
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, China.
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Braczkowski M, Soszyński D, Sierakowska A, Braczkowski R, Kufel K, Łabuz-Roszak B. Autoimmune Encephalitis with Antibodies: Anti-NMDAR, Anti-AMPAR, Anti-GQ1b, Anti-DPPX, Anti-CASPR2, Anti-LGI1, Anti-RI, Anti-Yo, Anti-Hu, Anti-CV2 and Anti-GABAAR, in the Course of Psychoses, Neoplastic Diseases, and Paraneoplastic Syndromes. Diagnostics (Basel) 2023; 13:2589. [PMID: 37568953 PMCID: PMC10417199 DOI: 10.3390/diagnostics13152589] [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: 05/25/2023] [Revised: 07/25/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023] Open
Abstract
Encephalitis is a condition with a variety of etiologies, clinical presentations, and degrees of severity. The causes of these disorders include both neuroinfections and autoimmune diseases in which host antibodies are pathologically directed against self-antigens. In autoimmune encephalitis, autoantibodies are expressed in the central nervous system. The incidence of this disease is approximately 4% of all reported cases of encephalitis. Autoimmune encephalitis can be induced by antibodies against neuronal surface antigens such as N-methyl-D-aspartate-activated glutamate receptors (NMDAR), α-amino-3-hydroxy-5-methyl-4-isoxazole propionate receptors (AMPAR) or gangliosides GQ1b, DPPX, CASPR2, LGI1, as well as by antibodies against neuronal intracellular antigens. The paper presents a number of both mental and neurological symptoms of autoimmune encephalitis. Moreover, the coexistence of psychoses, neoplastic diseases, and the methods of diagnosing autoimmune encephalitis are discussed. Attention was also drawn to the fact that early diagnosis, as well as early initiation of targeted treatment, increases the chance of a successful course of the therapeutic process. Strategy and Methodology: The articles on which the following paper was based were searched using search engines such as PubMed and Medline. Considering that anti-NMDAR antibodies were first described in 2007, the articles were from 2007 to 2023. The selection of papers was made by entering the phrases "autoimmune encephalitis and psychosis/paraneplastic syndromes or cancer". The total number of articles that could be searched was 747, of which 100 items were selected, the most recent reports illustrating the presented topic. Thirty-four of them were rejected in connection with case reports or papers that could not be accessed.
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Affiliation(s)
- Michał Braczkowski
- Department of Physiology, Institute of Medical Sciences, University of Opole, 45040 Opole, Poland
| | - Dariusz Soszyński
- Department of Physiology, Institute of Medical Sciences, University of Opole, 45040 Opole, Poland
- Department of Human Physiology, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, 87100 Torun, Poland
| | - Alicja Sierakowska
- Student Scientific Society of Physiology, Department of Physiology, Institute of Medical Sciences, University of Opole, 45040 Opole, Poland; (A.S.)
- Student Association of Neurology, Department of Neurology, Institute of Medical Sciences, University of Opole, 45040 Opole, Poland
| | | | - Klaudia Kufel
- Student Scientific Society of Physiology, Department of Physiology, Institute of Medical Sciences, University of Opole, 45040 Opole, Poland; (A.S.)
| | - Beata Łabuz-Roszak
- Department of Neurology, Institute of Medical Sciences, University of Opole, 45040 Opole, Poland
- Department of Neurology, ST Jadwiga Regional Specialized Hospital, 45040 Opole, Poland
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Sun Y, Tao JX, Han X, Wang X, Zhu Y, Lian Y, Ren G, Wang Q. Clinical features and brain MRI volumetric changes in anti-mGluR5 encephalitis. Ann Clin Transl Neurol 2023; 10:1407-1416. [PMID: 37329164 PMCID: PMC10424662 DOI: 10.1002/acn3.51831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/24/2023] [Accepted: 06/03/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Anti-metabotropic glutamate receptor 5 (mGluR5) encephalitis is a rare and under-recognized autoimmune encephalitis. This study is conducted to characterize its clinical and neuroimaging features. METHODS Twenty-nine patients with anti-mGluR5 encephalitis (15 new cases identified in this study and 14 previously reported cases) were included in this study and their clinical features were characterized. Brain MRI volumetric analysis using FreeSurfer software was performed in 9 new patients and compared with 25 healthy controls at both early (≤6 months of onset) and chronic (>1 year of onset) disease stages. RESULTS The common clinical manifestations of anti-mGluR5 encephalitis included cognitive deficits (n = 21, 72.4%), behavioral and mood disturbances (n = 20, 69%), seizures (n = 16, 55.2%), and sleep disorder (n = 13, 44.8%). Tumors were observed in 7 patients. Brain MRI T2/FLAIR signal hyperintensities were observed predominantly in mesiotemporal and subcortical regions in 75.9% patients. MRI volumetric analysis demonstrated significant amygdala enlargement in both early and chronic disease stages compared to healthy controls (P < 0.001). Twenty-six patients had complete or partial recovery, one remained stable, one died and one was lost to follow-up. CONCLUSION Our findings demonstrated that cognitive impairment, behavioral disturbance, seizures, and sleep disorder are the prominent clinical manifestations of anti-mGluR5 encephalitis. Most patients showed a good prognosis with full recovery, even in the paraneoplastic disease variants. The amygdala enlargement in the early and chronic disease stages is a distinct MRI feature, which exploratively offer a valuable perspective for the study of the disease processes.
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Affiliation(s)
- Yueqian Sun
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- National Center for Clinical Medicine of Neurological DiseasesBeijingChina
| | - James X. Tao
- Department of NeurologyThe University of ChicagoChicagoUSA
| | - Xiong Han
- Department of NeurologyHenan Provincial People's HospitalZhengzhouChina
| | - Xiangqing Wang
- Department of NeurologyChinese PLA General HospitalBeijingChina
| | - Yulan Zhu
- Department of NeurologyThe Second Affiliated Hospital of Harbin Medical UniversityHarbinHeilongjiangChina
| | - Yajun Lian
- Department of NeurologyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouHenanChina
| | - Guoping Ren
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- National Center for Clinical Medicine of Neurological DiseasesBeijingChina
| | - Qun Wang
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- National Center for Clinical Medicine of Neurological DiseasesBeijingChina
- Collaborative Innovation Center for Brain DisordersBeijing Institute of Brain Disorders, Capital Medical UniversityBeijingChina
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Barthel PC, Staabs F, Li LY, Buthut M, Otto C, Ruprecht K, Prüss H, Höltje M. Immunoreactivity to astrocytes in different forms of dementia: High prevalence of autoantibodies to GFAP. Brain Behav Immun Health 2023; 29:100609. [PMID: 36923695 PMCID: PMC10008834 DOI: 10.1016/j.bbih.2023.100609] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/21/2023] [Accepted: 02/25/2023] [Indexed: 03/06/2023] Open
Abstract
Objective To study the prevalence of autoantibodies to glial and neuronal antigens with a focus on glial acidic fibrillary protein (GFAP) in patients with dementia. Methods Sera of 127 patients with different forms of dementia and sera of 82 age-matched patients with various neurological diseases except for dementia, as well as sera from 15 age-matched healthy controls were analyzed for anti-glial or anti-neuronal IgG using 1) primary murine embryonic hippocampus cell cultures, 2) murine brain sections, 3) immunoblotting on mouse brain homogenates and 4) astrocyte cultures. Sera reacting with astrocytes in hippocampus cell cultures were further analyzed using HEK293 cells transfected with human GFAP. Results IgG in serum from 45 of 127 (35.5%) patients with dementia but only 8 of 97 (8.2%, p ≤ 0.001) controls bound to either glial or neuronal structures in cultured murine hippocampus cells. In these cultures antibodies to astrocytes were detected in 35 of 127 (27.5%) of the dementia patients, whereas in controls antibodies to astrocytes were detected in 4 sera only (4.1%, p ≤ 0.001). Among the sera exhibiting reactivity to astrocytes, 14 of 35 (40%) showed immunoreaction to HEK293 cells transfected with GFAP in dementia patients, representing 11% of all sera. Within the 4 immunoreactive control sera reacting with astrocytes one reacted with GFAP (1.0% of total immunoreactivity, p = 0.003). Conclusions Autoantibodies to glial epitopes in general and to GFAP in particular are more frequent in patients with dementia than in age-matched controls without dementia, thus indicating the need for further investigations regarding the potential pathophysiological relevance of these antibodies.
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Affiliation(s)
- Paula Charlotte Barthel
- Institute of Integrative Neuroanatomy Berlin, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Finja Staabs
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lucie Y Li
- Institute of Integrative Neuroanatomy Berlin, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Maria Buthut
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
| | - Carolin Otto
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Harald Prüss
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
| | - Markus Höltje
- Institute of Integrative Neuroanatomy Berlin, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Tyvaert L. How autoimmunity changed our diagnostic practice in epileptology? Rev Neurol (Paris) 2023; 179:316-329. [PMID: 36804011 DOI: 10.1016/j.neurol.2022.11.008] [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] [Received: 09/02/2022] [Revised: 11/06/2022] [Accepted: 11/08/2022] [Indexed: 02/17/2023]
Abstract
Since few years, a new etiology of epilepsy emerges with the labelling of new autoantibodies against the central nervous system. In 2017, the International League Against Epilepsy (ILAE) concluded that autoimmunity is one of six etiologies contributing to epilepsy and that autoimmune epilepsy is directly caused by immune disorders in which seizures constitute a core symptom. Epileptic disorders of immune origin are now distinguished in two different entities: acute symptomatic seizures secondary to autoimmune (ASS) and autoimmune-associated epilepsy (AAE) with different expected clinical outcome under immunotherapy. If acute encephalitis is usually related to ASS with a classic good control of the disease under immunotherapy, clinical phenotype characterized by isolated seizures (new onset seizures and chronic focal epilepsy patients) may be due to either ASS or to AAE. Decision of Abs testing and early immunotherapy initiation needs the development of clinical scores able to select patients with high risk of positive Abs testings. If this selection is now included in the usual medical care of encephalitic patients, specifically with NORSE, the actual bigger challenge is in patients with non or only mild encephalitic symptoms followed for new onset seizures or chronic focal epilepsy patients of unknown origin. The emergence of this new entity provides new therapeutic strategies with specific etiologic and probably anti epileptogenic medication rather than the usual and nonspecific ASM. In the world of the epileptology, this new autoimmune entity appears as a big challenge with an exciting chance to improve or even definitely cure patients of their epilepsy. However, the detection of these patients has to be done in the early phase of the disease to offer the best outcome.
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Affiliation(s)
- L Tyvaert
- Department of neurology, hospital central, CHRU Nancy, Nancy, France; UMR 7039 CRAN, Université de Lorraine, Nancy, France.
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Schäfer J, Christensen PB, Jensen K. AMPA and NMDA receptor antibody autoimmune encephalitis preceded by ocular myasthenia gravis: a case report. BMC Neurol 2023; 23:102. [PMID: 36899302 PMCID: PMC9999510 DOI: 10.1186/s12883-023-03129-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 02/16/2023] [Indexed: 03/12/2023] Open
Abstract
BACKGROUND α-Amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA) and N-methyl-D-aspartate (NMDA) receptors mediate excitatory neurotransmission in the brain and may be targeted by autoantibodies, leading to autoimmune synaptic encephalitis (AE). AE can be associated with other autoimmune diseases. However, the cooccurrence of anti-AMPA and NMDA receptor AE together with myasthenia gravis (MG) is unusual. CASE PRESENTATION A 24-year-old previously healthy male presented with seronegative ocular MG, the diagnosis of which was supported by single-fiber electrophysiology findings. Three months later, he developed AE, initially being positive for AMPA receptor antibodies and subsequently for NMDA receptor antibodies. No underlying malignancy was found. In response to aggressive immunosuppressive treatment, he recovered (modified Rankin Scale (mRS) score change from 5 to 1). Despite some cognitive problems at the 1-year follow-up, which were not revealed using the mRS, he was able to return to his studies. CONCLUSIONS AE may coexist with other autoimmune disorders. Patients with seronegative MG, including ocular MG, may develop autoimmune encephalitis with more than one cell-surface antibody.
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Affiliation(s)
- Jakob Schäfer
- Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Kimmo Jensen
- Department of Neurology, Aalborg University Hospital, Aalborg, Denmark. .,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Abstract
PURPOSE OF REVIEW To provide an overview and highlight recent updates in the field of paraneoplastic neurologic disorders. RECENT FINDINGS The prevalence of paraneoplastic neurologic disorders is greater than previously reported and the incidence has been rising over time, due to improved recognition in the era of antibody biomarkers. Updated diagnostic criteria that are broadly inclusive and also contain diagnostic risk for clinical presentations (high and intermediate) and diagnostic antibodies (high, intermediate, and low) have replaced the original 2004 criteria. Antibody biomarkers continue to be characterized (e.g., KLHL-11 associated with seminoma in men with brainstem encephalitis). Some paraneoplastic antibodies also provide insight into likely immunotherapy response and prognosis. The rise of immune checkpoint inhibitors as cancer therapeutics has been associated with newly observed immune-mediated adverse effects including paraneoplastic neurological disorders. The therapeutic approach to paraneoplastic neurologic disorders is centered around cancer care and trials of immune therapy. The field of paraneoplastic neurologic disorders continues to be advanced by the identification of novel antibody biomarkers which have diagnostic utility, and give insight into likely treatment responses and outcomes.
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Affiliation(s)
- Michael Gilligan
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, St Vincent's University Hospital, Dublin, Ireland
| | | | - Andrew McKeon
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN, USA.
- Department of Neurology, College of Medicine, Mayo Clinic, 200 1st ST SW, Rochester, MN, 55905, USA.
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Galardi MM, Sowa GM, Crockett CD, Rudock R, Smith AE, Shwe EE, San T, Linn K, Aye AMM, Ramachandran PS, Zia M, Wapniarski AE, Hawes IA, Hlaing CS, Kyu EH, Thair C, Mar YY, Nway N, Storch GA, Wylie KM, Wylie TN, Dalmau J, Wilson MR, Mar SS. Pathogen and Antibody Identification in Children with Encephalitis in Myanmar. Ann Neurol 2023; 93:615-628. [PMID: 36443898 DOI: 10.1002/ana.26560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/22/2022] [Accepted: 11/20/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Prospective studies of encephalitis are rare in regions where encephalitis is prevalent, such as low middle-income Southeast Asian countries. We compared the diagnostic yield of local and advanced tests in cases of pediatric encephalitis in Myanmar. METHODS Children with suspected subacute or acute encephalitis at Yangon Children's Hospital, Yangon, Myanmar, were prospectively recruited from 2016-2018. Cohort 1 (n = 65) had locally available diagnostic testing, whereas cohort 2 (n = 38) had advanced tests for autoantibodies (ie, cell-based assays, tissue immunostaining, studies with cultured neurons) and infections (ie, BioFire FilmArray multiplex Meningitis/Encephalitis multiplex PCR panel, metagenomic sequencing, and pan-viral serologic testing [VirScan] of cerebrospinal fluid). RESULTS A total of 20 cases (13 in cohort 1 and 7 in cohort 2) were found to have illnesses other than encephalitis. Of the 52 remaining cases in cohort 1, 43 (83%) had presumed infectious encephalitis, of which 2 cases (4%) had a confirmed infectious etiology. Nine cases (17%) had presumed autoimmune encephalitis. Of the 31 cases in cohort 2, 23 (74%) had presumed infectious encephalitis, of which one (3%) had confirmed infectious etiology using local tests only, whereas 8 (26%) had presumed autoimmune encephalitis. Advanced tests confirmed an additional 10 (32%) infections, 4 (13%) possible infections, and 5 (16%) cases of N-methyl-D-aspartate receptor antibody encephalitis. INTERPRETATION Pediatric encephalitis is prevalent in Myanmar, and advanced technologies increase identification of treatable infectious and autoimmune causes. Developing affordable advanced tests to use globally represents a high clinical and research priority to improve the diagnosis and prognosis of encephalitis. ANN NEUROL 2023;93:615-628.
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Affiliation(s)
- Maria M Galardi
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Gavin M Sowa
- Department of Medicine, McGaw Medical Center of Northwestern University, Chicago, IL
| | - Cameron D Crockett
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Robert Rudock
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Alyssa E Smith
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Ei E Shwe
- Department of Pathology, Yangon Children's Hospital, Institute of Medicine 1, Yangon, Myanmar
| | - Thidar San
- Department of Pathology, Yangon Children's Hospital, Institute of Medicine 1, Yangon, Myanmar
| | - Kyaw Linn
- Department of Pediatrics, Yangon Children's Hospital, Institute of Medicine 1, Yangon, Myanmar
| | - Aye Mya M Aye
- Department of Pediatrics, Yangon Children's Hospital, Institute of Medicine 1, Yangon, Myanmar
| | - Prashanth S Ramachandran
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Maham Zia
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Anne E Wapniarski
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Isobel A Hawes
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Chaw S Hlaing
- Department of Pediatrics, Yangon Children's Hospital, Institute of Medicine 1, Yangon, Myanmar
| | - Ei H Kyu
- Department of Pediatrics, Yangon Children's Hospital, Institute of Medicine 1, Yangon, Myanmar
| | - Cho Thair
- Department of Pediatrics, Yangon Children's Hospital, Institute of Medicine 1, Yangon, Myanmar
| | - Yi Y Mar
- Department of Pediatrics, Yangon Children's Hospital, Institute of Medicine 1, Yangon, Myanmar
| | - Nway Nway
- Department of Pediatrics, Yangon Children's Hospital, Institute of Medicine 1, Yangon, Myanmar
| | - Gregory A Storch
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Kristine M Wylie
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Todd N Wylie
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Josep Dalmau
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer Hospital Clínic, University of Barcelona, Barcelona, Spain.,Department of Neurology, University of Pennsylvania, Philadelphia, PA.,Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain
| | - Michael R Wilson
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Soe S Mar
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
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McCombe JA, Zivelonghi C, Vorasoot N, Majed M, Flanagan EP, Dubey D, Pittock SJ, McKeon A, Zekeridou A. AMPAR autoimmunity: Neurological and oncological accompaniments and co-existing neural autoantibodies. J Neuroimmunol 2023; 375:578012. [PMID: 36608398 PMCID: PMC9905297 DOI: 10.1016/j.jneuroim.2022.578012] [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: 10/26/2022] [Revised: 12/08/2022] [Accepted: 12/21/2022] [Indexed: 12/24/2022]
Abstract
α -amino-3-hydroxy-5-methyl-4-isoxazole propionic acid receptor (AMPAR) encephalitis is rare but treatable. We reviewed the clinical and autoantibody profiles of 52 AMPAR-IgG-positive patients (median age 48 years [range 12-81]; 38 female) identified at the Mayo Clinic neuroimmunology laboratory. Main presentation was encephalitis; symptoms other than encephalitis associated with co-existing antibodies (p = 0.004). A tumor was found in 33/44; mostly thymoma. Most patients had partial (14/29) or complete (11/29) immunotherapy response. Thirty-one patients had at least one co-existing antibody that predicted thymoma in paraneoplastic patients (p = 0.008). In conclusion, in AMPAR encephalitis co-existing antibodies predict clinical presentation other than encephalitis and thymoma.
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Affiliation(s)
- Jennifer A McCombe
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America; Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Cecilia Zivelonghi
- Department of Neurology and Stroke Unit, University Hospital of Verona, Verona, Italy
| | - Nisa Vorasoot
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America; Division of Neurology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America; Center of MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States of America
| | - Masoud Majed
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America; Center of MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States of America
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America; Center of MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States of America
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America; Center of MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States of America
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America; Center of MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States of America.
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Nagata N, Kanazawa N, Mitsuhata T, Iizuka M, Nagashima M, Nakamura M, Kaneko J, Kitamura E, Nishiyama K, Iizuka T. Neuronal surface antigen-specific immunostaining pattern on a rat brain immunohistochemistry in autoimmune encephalitis. Front Immunol 2023; 13:1066830. [PMID: 36726989 PMCID: PMC9885155 DOI: 10.3389/fimmu.2022.1066830] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/08/2022] [Indexed: 01/18/2023] Open
Abstract
A variety of neuronal surface (NS) antibodies (NS-Ab) have been identified in autoimmune encephalitis (AE). Tissue-based assay (TBA) using a rodent brain immunohistochemistry (IHC) is used to screen NS-Ab, while cell-based assay (CBA) to determine NS antigens. Commercial rat brain IHC is currently available but its clinical relevance remains unclear. Immunostaining patterns of NS antigens have not been extensively studied yet. To address these issues, we assessed a predictive value of "neuropil pattern" and "GFAP pattern" on commercial IHC in 261 patients, and characterized an immunostaining pattern of 7 NS antigens (NMDAR, LGI1, GABAaR, GABAbR, AMPAR, Caspr2, GluK2). Sensitivity and specificity of "neuropil pattern" for predicting NS-Ab were 66.0% (95% CI 55.7-75.3), and 98.2% (95% CI 94.8-99.6), respectively. False-positive rate was 1.8% (3/164) while false-negative rate was 34.0% (33/97). In all 3 false-positive patients, neuropil-like staining was attributed to high titers of GAD65-Ab. In 33 false-negative patients, NMDAR was most frequently identified (n=18 [54.5%], 16/18 [88.9%] had low titers [< 1:32]), followed by GABAaR (n=5). Of 261 patients, 25 (9.6%) had either GFAP (n=21) or GFAP-mimicking pattern (n=4). GFAP-Ab were identified in 21 of 31 patients examined with CBA (20 with GFAP pattern, 1 with GFAP-mimicking pattern). Immunostaining pattern of each NS antigen was as follows: 1) NMDAR revealed homogenous reactivity in the dentate gyrus molecular layer (DG-ML) with less intense dot-like reactivity in the cerebellar granular layer (CB-GL); 2) both GABAaR and GluK2 revealed intense dot-like reactivity in the CB-GL, but GABAaR revealed homogenous reactivity in the DG-ML while GluK2 revealed intense reactivity along the inner layer of the DG-ML; and 3) LGI1, Caspr2, GABAbR, and AMPAR revealed intense reactivity in the cerebellar ML (CB-ML) but LGI1 revealed intense reactivity along the middle layer of the DG-ML. Whereas, Caspr2, GABAbR, and AMPAR revealed similar reactivity in the DG-ML but some difference in other regions. TBA is useful not only for screening NS- or GFAP-Ab but also for estimating NS antigens; however, negative results should be interpreted cautiously because "neuropil pattern" may be missed on commercial IHC when antibody titers are low. Antigen-specific immunoreactivity is a useful biomarker of AE.
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Kong DL. Anti-leucine-rich glioma inactivated protein 1 encephalitis with sleep disturbance as the first symptom: A case report and review of literature. World J Clin Cases 2023; 11:408-416. [PMID: 36686352 PMCID: PMC9850984 DOI: 10.12998/wjcc.v11.i2.408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 11/20/2022] [Accepted: 12/05/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Anti-leucine-rich glioma inactivated protein 1 (anti-LGI1) encephalitis is an infrequent type of autoimmune encephalitis (AE) characterized by acute or subacute cognitive and psychiatric disturbance, facio-brachial dystonic seizures (FBDSs), and hyponatremia. Anti-LGI1 AE has increasingly been considered a primary form of AE. Early identification and treatment of this disease are clearly very important.
CASE SUMMARY Here, we report that a male patient developed severe anti-LGI1 encephalitis, which was initially misdiagnosed as a sleep disturbance. He was hospitalized for epileptic seizures and typical FBDSs half a month after he developed sleep disturbances. LGI1 antibodies were detected in his cerebrospinal fluid and serum (1:100 and 1:3.2, respectively), which led to the diagnosis of classic anti-LGI1 AE. No obvious abnormality was observed on brain computed tomography images. T2-weighted fluid-attenuated inversion recovery and T2-weighted scans of brain magnetic resonance imaging (MRI) showed slightly elevated signals within the left basal ganglia area. No tumor was detected within the brain of this patient using MRI. After hormone and antiepileptic drug treatment, the patient’s symptoms improved significantly.
CONCLUSION Anti-LGI1 antibody-associated encephalitis has characteristic clinical manifestations, such as cognitive impairment, psychiatric symptoms, seizures, sleep disorders, hyponatremia, and FBDSs. LGI1 antibodies are present in the serum and/or cerebrospinal fluid, but their production is sensitive to immunosuppressants, and this disease has a relatively good prognosis. In particular, we should be aware of the possibility of anti-LGI1 antibody-associated encephalitis in adolescents with sleep disorders to avoid missed diagnoses and misdiagnoses.
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Affiliation(s)
- De-Lian Kong
- Department of Neurology, The Affiliated Jiangning Hospital with Nanjing Medical University, Nanjing 211000, Jiangsu Province, China
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43
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Liang C, Chu E, Kuoy E, Soun JE. Autoimmune-mediated encephalitis and mimics: A neuroimaging review. J Neuroimaging 2023; 33:19-34. [PMID: 36217010 DOI: 10.1111/jon.13060] [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: 06/15/2022] [Revised: 09/10/2022] [Accepted: 09/20/2022] [Indexed: 02/01/2023] Open
Abstract
Autoimmune encephalitis is a category of autoantibody-mediated neurological disorders that often presents a diagnostic challenge due to its variable clinical and imaging findings. The purpose of this image-based review is to provide an overview of the major subtypes of autoimmune encephalitis and their associated autoantibodies, discuss their characteristic clinical and imaging features, and highlight several disease processes that may mimic imaging findings of autoimmune encephalitis. A literature search on autoimmune encephalitis was performed and publications from neuroradiology, neurology, and nuclear medicine literature were included. Cases from our institutional database that best exemplify major imaging features were presented.
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Affiliation(s)
- Conan Liang
- Department of Radiological Sciences, University of California, Irvine Medical Center, Orange, California, USA
| | - Eleanor Chu
- Department of Radiological Sciences, University of California, Irvine Medical Center, Orange, California, USA
| | - Edward Kuoy
- Department of Radiological Sciences, University of California, Irvine Medical Center, Orange, California, USA
| | - Jennifer E Soun
- Department of Radiological Sciences, University of California, Irvine Medical Center, Orange, California, USA
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Duong SL, Prüss H. Molecular disease mechanisms of human antineuronal monoclonal autoantibodies. Trends Mol Med 2023; 29:20-34. [PMID: 36280535 DOI: 10.1016/j.molmed.2022.09.011] [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: 08/05/2022] [Revised: 09/28/2022] [Accepted: 09/30/2022] [Indexed: 11/22/2022]
Abstract
Autoantibodies targeting brain antigens can mediate a wide range of neurological symptoms ranging from epileptic seizures to psychosis to dementia. Although earlier experimental work indicated that autoantibodies can be directly pathogenic, detailed studies on disease mechanisms, biophysical autoantibody properties, and target interactions were hampered by the availability of human material and the paucity of monospecific disease-related autoantibodies. The emerging generation of patient-derived monoclonal autoantibodies (mAbs) provides a novel platform for the detailed characterization of immunobiology and autoantibody pathogenicity in vitro and in animal models. This Feature Review focuses on recent advances in mAb generation and discusses their potential as powerful scientific tools for high-resolution imaging, antigenic target identification, atomic-level structural analyses, and the development of antibody-selective immunotherapies.
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Affiliation(s)
- Sophie L Duong
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; German Center for Neurodegenerative Diseases (DZNE) Berlin, 10117 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; German Center for Neurodegenerative Diseases (DZNE) Berlin, 10117 Berlin, Germany.
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45
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Pavone P, Corsello G, Raucci U, Lubrano R, Parano E, Ruggieri M, Greco F, Marino S, Falsaperla R. Febrile infection-related Epilepsy Syndrome (FIRES): a severe encephalopathy with status epilepticus. Literature review and presentation of two new cases. Ital J Pediatr 2022; 48:199. [PMID: 36527084 PMCID: PMC9756623 DOI: 10.1186/s13052-022-01389-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022] Open
Abstract
FIRES is defined as a disorder that requires a prior febrile infection starting between 2 weeks and 24 h before the onset of the refractory status epilepticus with or without fever at the onset of status epilepticus. The patients, previously normal, present in the acute phase recurrent seizures and status epilepticus followed by a severe course with usually persistent seizures and residual cognitive impairment. Boundary with "new onset refractory status epilepticus (NORSE) has not clearly established. Pathogenetic hypothesis includes inflammatory or autoimmune mechanism with a possible genetic predisposition for an immune response dysfunction.Various types of treatment have been proposed for the treatment of the acute phase of the disorder to block the rapid seizures evolution to status epilepticus and to treat status epilepticus itself. Prognosis is usually severe both for control of the seizures and for cognitive involvement.FIRES is an uncommon but severe disorder which must be carefully considered in the differential diagnosis with other epileptic encephalopathy.
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Affiliation(s)
- Piero Pavone
- grid.412844.f0000 0004 1766 6239Department of Clinical and Experimental Medicine, University Hospital “Policlinico-San Marco”, Catania Catania, Italy
| | - Giovanni Corsello
- grid.10776.370000 0004 1762 5517Department of Health Promotion, Mather and Child Care, Internal Medicine and Medical Specialities, University of Palermo, Palermo, Italy
| | - Umberto Raucci
- grid.414603.4Department of Emergency and Clinical Pediatrics, Bambin Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Riccardo Lubrano
- grid.7841.aPediatrics and Neonatology Unit, Maternal-Child Department, Santa Maria Goretti Hospital, Sapienza University of Rome, Latina, Italy
| | - Enrico Parano
- grid.5326.20000 0001 1940 4177Unit of Catania, Institute for Research and Biomedical Innovation (IRIB), National Council of Research, Catania, Italy
| | - Martino Ruggieri
- grid.412844.f0000 0004 1766 6239Department of Clinical and Experimental Medicine, University Hospital “Policlinico-San Marco”, Catania Catania, Italy
| | - Filippo Greco
- grid.412844.f0000 0004 1766 6239Department of Clinical and Experimental Medicine, University Hospital “Policlinico-San Marco”, Catania Catania, Italy
| | - Silvia Marino
- grid.8158.40000 0004 1757 1969Unit of Pediatrics and Pediatric Emergency, AOU “Policlinico”- PO “San Marco”, University of Catania, Catania, Italy
| | - Raffaele Falsaperla
- grid.8158.40000 0004 1757 1969Unit of Pediatrics and Pediatric Emergency, AOU “Policlinico”- PO “San Marco”, University of Catania, Catania, Italy
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Muñoz-Sánchez G, Planagumà J, Naranjo L, Couso R, Sabater L, Guasp M, Martínez-Hernández E, Graus F, Dalmau J, Ruiz-García R. The diagnosis of anti-LGI1 encephalitis varies with the type of immunodetection assay and sample examined. Front Immunol 2022; 13:1069368. [PMID: 36591253 PMCID: PMC9798107 DOI: 10.3389/fimmu.2022.1069368] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/25/2022] [Indexed: 12/23/2022] Open
Abstract
Detection of Leucine-rich glioma inactivated 1 (LGI1) antibodies in patients with suspected autoimmune encephalitis is important for diagnostic confirmation and prompt implementation of immunomodulatory treatment. However, the clinical laboratory diagnosis can be challenging. Previous reports have suggested that the type of test and patient's sample (serum or CSF) have different clinical performances, however, there are no studies comparing different diagnostic tests on paired serum/CSF samples of patients with anti-LGI1 encephalitis. Here, we assessed the clinical performance of a commercial and an in house indirect immunofluorescent cell based assays (IIF-CBA) using paired serum/CSF of 70 patients with suspected anti-LGI1 encephalitis and positive rat brain indirect immunohistochemistry (IIHC). We found that all (100%) patients had CSF antibodies when the in house IIF-CBA was used, but only 88 (83%) were positive if the commercial test was used. In contrast, sera positivity rate was higher with the commercial test (94%) than with the in house assay (86%). If both serum and CSF were examined with the commercial IIFA-CBA, 69/70 (98.5%) patients were positive in at least one of the samples. These findings are clinically important for centers in which rat brain IIHC and in house IIFA-CBA are not available. Moreover, the observation that all patients with anti-LGI1 encephalitis have antibodies in CSF is in line with the concept that these antibodies are pathogenic.
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Affiliation(s)
- Guillermo Muñoz-Sánchez
- Immunology Department, Centre Diagnòstic Biomèdic, Hospital Clínic Barcelona, Barcelona, Spain
| | - Jesús Planagumà
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Laura Naranjo
- Immunology Department, Centre Diagnòstic Biomèdic, Hospital Clínic Barcelona, Barcelona, Spain
| | - Rocío Couso
- Immunology Department, Centre Diagnòstic Biomèdic, Hospital Clínic Barcelona, Barcelona, Spain
| | - Lidia Sabater
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Mar Guasp
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain,Neurology Department, Hospital Clínic, and University of Barcelona, Barcelona, Spain,Centro de Investigación Biomédica en Red, Enfermedades Raras (CIBERER), Madrid, Spain
| | - Eugenia Martínez-Hernández
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain,Neurology Department, Hospital Clínic, and University of Barcelona, Barcelona, Spain
| | - Francesc Graus
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Josep Dalmau
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain,Centro de Investigación Biomédica en Red, Enfermedades Raras (CIBERER), Madrid, Spain,Neurology Department, University of Pennsylvania, Philadelphia, PA, United States,Catalan Institution of Research and Advanced Studies (ICREA), Barcelona, Spain
| | - Raquel Ruiz-García
- Immunology Department, Centre Diagnòstic Biomèdic, Hospital Clínic Barcelona, Barcelona, Spain,Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain,*Correspondence: Raquel Ruiz-García,
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Binks S, Lamquet S, Crawford AH, Meurs A, Irani SR, Pakozdy A. Parallel roles of neuroinflammation in feline and human epilepsies. Vet J 2022; 290:105912. [PMID: 36209994 PMCID: PMC10912827 DOI: 10.1016/j.tvjl.2022.105912] [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: 01/22/2022] [Revised: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
Autoimmune encephalitis refers to a group of disorders characterised by a non-infectious encephalitis, often with prominent seizures and surface neuronal autoantibodies. AE is an important cause of new-onset refractory status epilepticus in humans and is frequently responsive to immunotherapies including corticosteroids, plasma exchange, intravenous immunoglobulin G and rituximab. Recent research suggests that parallel autoantibodies can be detected in non-human mammalian species. The best documented example is leucine-rich glioma-inactivated 1 (LGI1)-antibodies in domestic cats with limbic encephalitis (LE). In this review, we discuss the role of neuroinflammation and autoantibodies in human and feline epilepsy and LE.
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Affiliation(s)
- Sophie Binks
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, OX3 9DU, UK; Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals Foundation Trust, Oxford OX3 9DU, UK.
| | - Simon Lamquet
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Abbe H Crawford
- Clinical Science and Services, The Royal Veterinary College, Hertfordshire AL9 7TA, UK
| | - Alfred Meurs
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, OX3 9DU, UK; Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals Foundation Trust, Oxford OX3 9DU, UK
| | - Akos Pakozdy
- University Clinic for Small Animals, University of Veterinary Medicine Vienna, Austria
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Rare Etiologies in Immune-Mediated Cerebellar Ataxias: Diagnostic Challenges. Brain Sci 2022; 12:brainsci12091165. [PMID: 36138901 PMCID: PMC9496914 DOI: 10.3390/brainsci12091165] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/06/2022] [Accepted: 08/26/2022] [Indexed: 12/03/2022] Open
Abstract
The cerebellum is particularly enriched in antigens and represents a vulnerable target to immune attacks. Immune-mediated cerebellar ataxias (IMCAs) have diverse etiologies, such as gluten ataxia (GA), post-infectious cerebellitis (PIC), Miller Fisher syndrome (MFS), paraneoplastic cerebellar degeneration (PCD), opsoclonus myoclonus syndrome (OMS), and anti-GAD ataxia. Apart from these well-established entities, cerebellar ataxia (CA) occurs also in association with autoimmunity against ion channels and related proteins, synaptic adhesion/organizing proteins, transmitter receptors, glial cells, as well as the brainstem antigens. Most of these conditions manifest diverse neurological clinical features, with CAs being one of the main clinical phenotypes. The term primary autoimmune cerebellar ataxia (PACA) refers to ataxic conditions suspected to be autoimmune even in the absence of specific well-characterized pathogenic antibody markers. We review advances in the field of IMCAs and propose a clinical approach for the understanding and diagnosis of IMCAs, focusing on rare etiologies which are likely underdiagnosed. The frontiers of PACA are discussed. The identification of rare immune ataxias is of importance since they are potentially treatable and may lead to a severe clinical syndrome in absence of early therapy.
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Autoimmune Encephalitis: A Physician’s Guide to the Clinical Spectrum Diagnosis and Management. Brain Sci 2022; 12:brainsci12091130. [PMID: 36138865 PMCID: PMC9497072 DOI: 10.3390/brainsci12091130] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/11/2022] [Accepted: 08/15/2022] [Indexed: 11/25/2022] Open
Abstract
The rapidly expanding spectrum of autoimmune encephalitis in the last fifteen years is largely due to ongoing discovery of many neuronal autoantibodies. The diagnosis of autoimmune encephalitis can be challenging due to the wide spectrum of clinical presentations, prevalence of psychiatric features that mimic primary psychiatric illnesses, frequent absence of diagnostic abnormalities on conventional brain MR-imaging, non-specific findings on EEG testing, and the lack of identified IgG class neuronal autoantibodies in blood or CSF in a subgroup of patients. Early recognition and treatment are paramount to improve outcomes and achieve complete recovery from these debilitating, occasionally life threatening, disorders. This review is aimed to provide primary care physicians and hospitalists who, together with neurologist and psychiatrists, are often the first port of call for individuals presenting with new-onset neuropsychiatric symptoms, with up-to-date data and evidence-based approach to the diagnosis and management of individuals with neuropsychiatric disorders of suspected autoimmune origin.
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Mandel‐Brehm C, Benson LA, Tran B, Kung AF, Mann SA, Vazquez SE, Retallack H, Sample HA, Zorn KC, Khan LM, Kerr LM, McAlpine PL, Zhang L, McCarthy F, Elias JE, Katwa U, Astley CM, Tomko S, Dalmau J, Seeley WW, Pleasure SJ, Wilson MR, Gorman MP, DeRisi JL. ZSCAN1 Autoantibodies Are Associated with Pediatric Paraneoplastic ROHHAD. Ann Neurol 2022; 92:279-291. [PMID: 35466441 PMCID: PMC9329235 DOI: 10.1002/ana.26380] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 04/18/2022] [Accepted: 04/21/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Rapid-onset Obesity with Hypothalamic Dysfunction, Hypoventilation and Autonomic Dysregulation (ROHHAD), is a severe pediatric disorder of uncertain etiology resulting in hypothalamic dysfunction and frequent sudden death. Frequent co-occurrence of neuroblastic tumors have fueled suspicion of an autoimmune paraneoplastic neurological syndrome (PNS); however, specific anti-neural autoantibodies, a hallmark of PNS, have not been identified. Our objective is to determine if an autoimmune paraneoplastic etiology underlies ROHHAD. METHODS Immunoglobulin G (IgG) from pediatric ROHHAD patients (n = 9), non-inflammatory individuals (n = 100) and relevant pediatric controls (n = 25) was screened using a programmable phage display of the human peptidome (PhIP-Seq). Putative ROHHAD-specific autoantibodies were orthogonally validated using radioactive ligand binding and cell-based assays. Expression of autoantibody targets in ROHHAD tumor and healthy brain tissue was assessed with immunohistochemistry and mass spectrometry, respectively. RESULTS Autoantibodies to ZSCAN1 were detected in ROHHAD patients by PhIP-Seq and orthogonally validated in 7/9 ROHHAD patients and 0/125 controls using radioactive ligand binding and cell-based assays. Expression of ZSCAN1 in ROHHAD tumor and healthy human brain tissue was confirmed. INTERPRETATION Our results support the notion that tumor-associated ROHHAD syndrome is a pediatric PNS, potentially initiated by an immune response to peripheral neuroblastic tumor. ZSCAN1 autoantibodies may aid in earlier, accurate diagnosis of ROHHAD syndrome, thus providing a means toward early detection and treatment. This work warrants follow-up studies to test sensitivity and specificity of a novel diagnostic test. Last, given the absence of the ZSCAN1 gene in rodents, our study highlights the value of human-based approaches for detecting novel PNS subtypes. ANN NEUROL 2022;92:279-291.
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Affiliation(s)
- Caleigh Mandel‐Brehm
- Department of Biochemistry and BiophysicsUniversity of CaliforniaSan FranciscoCAUSA
| | | | - Baouyen Tran
- Weill Institute for Neurosciences, Department of NeurologyUniversity of CaliforniaSan FranciscoCAUSA
| | - Andrew F. Kung
- Department of Biochemistry and BiophysicsUniversity of CaliforniaSan FranciscoCAUSA
| | - Sabrina A. Mann
- Department of Biochemistry and BiophysicsUniversity of CaliforniaSan FranciscoCAUSA
| | - Sara E. Vazquez
- Department of Biochemistry and BiophysicsUniversity of CaliforniaSan FranciscoCAUSA
| | - Hanna Retallack
- Department of Biochemistry and BiophysicsUniversity of CaliforniaSan FranciscoCAUSA
| | - Hannah A. Sample
- Department of Biochemistry and BiophysicsUniversity of CaliforniaSan FranciscoCAUSA
| | - Kelsey C. Zorn
- Department of Biochemistry and BiophysicsUniversity of CaliforniaSan FranciscoCAUSA
| | - Lillian M. Khan
- Department of Biochemistry and BiophysicsUniversity of CaliforniaSan FranciscoCAUSA
| | - Lauren M. Kerr
- Department of NeurologyBoston Children's HospitalBostonMAUSA
| | - Patrick L. McAlpine
- Otolaryngology Head and Neck Surgery Research DivisionStanford UniversityStanfordCAUSA
| | | | | | | | - Umakanth Katwa
- Department of Pulmonary MedicineSleep Center, Boston Children's HospitalBostonMAUSA
| | - Christina M. Astley
- Division of Endocrinology & Computational EpidemiologyBoston Children's HospitalBostonMAUSA
| | - Stuart Tomko
- Department of NeurologyWashington UniversitySt. LouisMOUSA
| | - Josep Dalmau
- Catalan Institution for Research and Advanced Studies (ICREA), Hospital Clinic‐IdibapsUniversity of BarcelonaBarcelonaSpain
| | - William W. Seeley
- Memory and Aging Center, Department of NeurologyUniversity of CaliforniaSan FranciscoCAUSA
| | - Samuel J. Pleasure
- Weill Institute for Neurosciences, Department of NeurologyUniversity of CaliforniaSan FranciscoCAUSA
| | - Michael R. Wilson
- MAS, Weill Institute for Neurosciences, Department of NeurologyUniversity of CaliforniaSan FranciscoCAUSA
| | - Mark P. Gorman
- Department of NeurologyHarvard Medical SchoolBostonMAUSA
| | - Joseph L. DeRisi
- Chan Zuckerberg Biohub, Department of Biochemistry and BiophysicsUniversity of CaliforniaSan FranciscoCAUSA
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