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Hagbohm C, Ouellette R, Flanagan EP, Jonsson DI, Piehl F, Banwell B, Wickström R, Iacobaeus E, Granberg T, Ineichen BV. Clinical and neuroimaging phenotypes of autoimmune glial fibrillary acidic protein astrocytopathy: A systematic review and meta-analysis. Eur J Neurol 2024; 31:e16284. [PMID: 38506182 DOI: 10.1111/ene.16284] [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: 11/09/2023] [Revised: 02/13/2024] [Accepted: 03/05/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVE This study was undertaken to provide a comprehensive review of neuroimaging characteristics and corresponding clinical phenotypes of autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A), a rare but severe neuroinflammatory disorder, to facilitate early diagnosis and appropriate treatment. METHODS A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis)-conforming systematic review and meta-analysis was performed on all available data from January 2016 to June 2023. Clinical and neuroimaging phenotypes were extracted for both adult and paediatric forms. RESULTS A total of 93 studies with 681 cases (55% males; median age = 46, range = 1-103 years) were included. Of these, 13 studies with a total of 535 cases were eligible for the meta-analysis. Clinically, GFAP-A was often preceded by a viral prodromal state (45% of cases) and manifested as meningitis, encephalitis, and/or myelitis. The most common symptoms were headache, fever, and movement disturbances. Coexisting autoantibodies (45%) and neoplasms (18%) were relatively frequent. Corticosteroid treatment resulted in partial/complete remission in a majority of cases (83%). Neuroimaging often revealed T2/fluid-attenuated inversion recovery (FLAIR) hyperintensities (74%) as well as perivascular (45%) and/or leptomeningeal (30%) enhancement. Spinal cord abnormalities were also frequent (49%), most commonly manifesting as longitudinally extensive myelitis. There were 88 paediatric cases; they had less prominent neuroimaging findings with lower frequencies of both T2/FLAIR hyperintensities (38%) and contrast enhancement (19%). CONCLUSIONS This systematic review and meta-analysis provide high-level evidence for clinical and imaging phenotypes of GFAP-A, which will benefit the identification and clinical workup of suspected cases. Differential diagnostic cues to distinguish GFAP-A from common clinical and imaging mimics are provided as well as suitable magnetic resonance imaging protocol recommendations.
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Affiliation(s)
- Caroline Hagbohm
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Russell Ouellette
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Eoin P Flanagan
- Department of Neurology, Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Dagur I Jonsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurophysiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Centre for Neurology, Academic Specialist Centre, Karolinska University Hospital, Stockholm, Sweden
| | - Brenda Banwell
- Division of Child Neurology, Children's Hospital of Philadelphia, Department of Neurology and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ronny Wickström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Ellen Iacobaeus
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Tobias Granberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Benjamin V Ineichen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Reproducible Science, University of Zürich, Zürich, Switzerland
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Gilligan M, Lesnick CE, Guo Y, Bradshaw MJ, Ladha SS, Nowak M, Shah MP, Wittenborn JR, Basal E, Hinson S, Yang B, Dubey D, Mills JR, Pittock SJ, Zekeridou A, McKeon A. Paraneoplastic Calmodulin Kinase-Like Vesicle-Associated Protein (CAMKV) Autoimmune Encephalitis. Ann Neurol 2024; 96:21-33. [PMID: 38634529 PMCID: PMC11186719 DOI: 10.1002/ana.26943] [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: 01/24/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVES To report an autoimmune paraneoplastic encephalitis characterized by immunoglobulin G (IgG) antibody targeting synaptic protein calmodulin kinase-like vesicle-associated (CAMKV). METHODS Serum and cerebrospinal fluid (CSF) samples harboring unclassified antibodies on murine brain-based indirect immunofluorescence assay (IFA) were screened by human protein microarray. In 5 patients with identical cerebral IFA staining, CAMKV was identified as top-ranking candidate antigen. Western blots, confocal microscopy, immune-absorption, and mass spectrometry were performed to substantiate CAMKV specificity. Recombinant CAMKV-specific assays (cell-based [fixed and live] and Western blot) provided additional confirmation. RESULTS Of 5 CAMKV-IgG positive patients, 3 were women (median symptom-onset age was 59 years; range, 53-74). Encephalitis-onset was subacute (4) or acute (1) and manifested with: altered mental status (all), seizures (4), hyperkinetic movements (4), psychiatric features (3), memory loss (2), and insomnia (2). Paraclinical testing revealed CSF lymphocytic pleocytosis (all 4 tested), electrographic seizures (3 of 4 tested), and striking MRI abnormalities in all (mesial temporal lobe T2 hyperintensities [all patients], caudate head T2 hyperintensities [3], and cortical diffusion weighted hyperintensities [2]). None had post-gadolinium enhancement. Cancers were uterine adenocarcinoma (3 patients: poorly differentiated or neuroendocrine-differentiated in 2, both demonstrated CAMKV immunoreactivity), bladder urothelial carcinoma (1), and non-Hodgkin lymphoma (1). Two patients developed encephalitis following immune checkpoint inhibitor cancer therapy (atezolizumab [1], pembrolizumab [1]). All treated patients (4) demonstrated an initial response to immunotherapy (corticosteroids [4], IVIG [2]), though 3 died from cancer. INTERPRETATION CAMKV-IgG is a biomarker of immunotherapy-responsive paraneoplastic encephalitis with temporal and extratemporal features and uterine cancer as a prominent oncologic association. ANN NEUROL 2024;96:21-33.
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Affiliation(s)
- Michael Gilligan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, University College Dublin, St Vincent's Hospital Elm Park, Dublin, Ireland
| | - Connie E Lesnick
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Yong Guo
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Michael J Bradshaw
- Department of Neurology, University of Washington and Billings Clinic, Billings, MT, USA
| | - Shafeeq S Ladha
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Mihaela Nowak
- Department of Neurology, Jefferson Hospital, Jefferson Hills, PA, USA
| | - Maulik P Shah
- Department of Neurology, University of California, San Francisco, CA, USA
| | - John R Wittenborn
- Department of Neurology, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Eati Basal
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Shannon Hinson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Binxia Yang
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Divyanshu Dubey
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Sean J Pittock
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Anastasia Zekeridou
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Andrew McKeon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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3
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Willis MD, Kreft KL, Dancey B. Oligoclonal bands. Pract Neurol 2024:pn-2023-003814. [PMID: 38937092 DOI: 10.1136/pn-2023-003814] [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: 05/14/2024] [Indexed: 06/29/2024]
Abstract
Oligoclonal bands (OCBs) represent the presence of intrathecal immunoglobulin G (IgG) as detected by isoelectric focusing and immunofixation. Cerebrospinal fluid (CSF) analysed alongside a paired serum sample gives five different immunofixation patterns. These are: type 1-the normal physiological state with no intrathecal IgG synthesis; type 2-evidence for intrathecal IgG synthesis, with CSF-restricted OCBs; type 3-evidence for intrathecal IgG synthesis, with CSF-restricted OCBs, but with additional, identical bands in the CSF and serum; type 4-absence of intrathecal IgG synthesis, but with identical OCBs in CSF and serum; and type 5-absence of intrathecal IgG synthesis, with a monoclonal band in CSF and serum. Analysis of these patterns can help to diagnose a range of neurological conditions, including multiple sclerosis. However, it is important to interpret OCB results alongside other CSF tests and their clinical context.
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Affiliation(s)
- Mark D Willis
- Helen Durham Centre for Neuroinflammatory Disease, Department of Neurology, University Hospital of Wales, Cardiff, UK
| | - Karim L Kreft
- Helen Durham Centre for Neuroinflammatory Disease, Department of Neurology, University Hospital of Wales, Cardiff, UK
| | - Bethan Dancey
- Department of Clinical Immunology & Allergy, University Hospital of Wales, Cardiff, UK
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Yonesu M, Hosokawa A, Yutani K, Kimura A, Shimohata T, Nakano M. [A case of autoimmune glial fibrillary acidic protein astrocytopathy with various symptoms such as optic disc edema and cerebellar ataxia]. Rinsho Shinkeigaku 2024; 64:408-412. [PMID: 38811204 DOI: 10.5692/clinicalneurol.cn-001949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
A 59-year-old man had developed visual abnormality, nausea, headache, and weight loss since three months before. The ophthalmologist found severe optic disc edema in both eyes, and referred him to our hospital. The patient had mild cerebellar ataxia. Increased cerebrospinal fluid pressure, increased protein and cell counts, positive oligoclonal band, and contrast-enhanced head MRI showed multiple linear perivascular radial gadolinium enhancement around bilateral lateral ventricles. His subjective and objective findings significantly improved with steroid treatment. The cerebrospinal fluid was found to be positive for glial fibrillary acidic protein (GFAP) antibodies, and a diagnosis of GFAP astrocytopathy was obtained. When optic edema or radial contrast effects was observed on contrast-enhanced MRI, GFAP astrocytopathy should be considerd. Prompt immunotherapy is required to circumvent the development of permanent visual impairment.
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Affiliation(s)
| | | | - Kenji Yutani
- Department of Radiology, Suita Municipal Hospital
| | | | | | - Misa Nakano
- Department of Neurology, Suita Municipal Hospital
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Ohashi N, Kamijima S, Watanabe R, Tazawa KI. [Peripheral neuropathy associated with severe glial fibrillary acidic protein (GFAP) astrocytopathy: a case report]. Rinsho Shinkeigaku 2024; 64:403-407. [PMID: 38797687 DOI: 10.5692/clinicalneurol.cn-001940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
A 44-year-old man was admitted due to a fever. He developed unconsciousness and respiratory failure, necessitating mechanical ventilation. After the administration of methylprednisolone and intravenous immunoglobulin for suspected autoimmune encephalitis, his consciousness and respiratory state improved. However, he exhibited pronounced tetraparalysis and impaired sensation below the neck. A spinal MRI revealed swelling of the entire spinal cord, indicating myelitis. Deep tendon reflexes were diminished in all extremities, and a nerve conduction study confirmed motor-dominant axonal polyneuropathy. Subsequently, he developed a fever and headache. Brain MRI demonstrated FLAIR hyperintensities in the basal ganglia and brain stem. CSF analysis for anti-glial fibrillary acidic protein (GFAP) antibody turned out positive, leading to the diagnosis of GFAP astrocytopathy. Although the steroid re-administration improved muscle strength in his upper limbs and reduced the range of diminished sensation, severe hemiparalysis remained. Severe GFAP astrocytopathy can be involved with polyneuropathy. Early detection and therapeutic intervention for this condition may lead to a better prognosis.
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Affiliation(s)
| | | | - Rie Watanabe
- Department of Neurology, Nagano Red Cross Hospital
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Rohdin C, Ljungvall I, Jäderlund KH, Svensson A, Lindblad-Toh K, Häggström J. Assessment of glial fibrillary acidic protein and anti-glial fibrillary acidic protein autoantibody concentrations and necrotising meningoencephalitis risk genotype in dogs with pug dog myelopathy. Vet Rec 2024; 194:e3895. [PMID: 38704817 DOI: 10.1002/vetr.3895] [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: 02/07/2023] [Revised: 12/16/2023] [Accepted: 01/05/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Pugs commonly present with thoracolumbar myelopathy, also known as pug dog myelopathy (PDM), which is clinically characterised by progressive signs involving the pelvic limbs, no apparent signs of pain and, often, incontinence. In addition to meningeal fibrosis and focal spinal cord destruction, histopathology has confirmed lymphohistiocytic infiltrates in the central nervous system (CNS) in a considerable number of pugs with PDM. Lymphohistiocytic CNS inflammation also characterises necrotising meningoencephalitis (NME) in pugs. This study aimed to investigate the potential contribution of an immunological aetiology to the development of PDM. METHODS The concentrations of glial fibrillary acidic protein (GFAP) in serum and CSF and of anti-GFAP autoantibodies in CSF were measured with an ELISA. In addition, a commercial test was used for genetic characterisation of the dog leukocyte antigen class II haplotype, which is associated with NME susceptibility. RESULTS This study included 87 dogs: 52 PDM pugs, 14 control pugs, four NME pugs and 17 dogs of breeds other than pugs that were investigated for neurological disease (neuro controls). Anti-GFAP autoantibodies were present in 15 of 19 (79%) of the PDM pugs tested versus six of 16 (38%) of the neuro controls tested (p = 0.018). All 18 PDM pugs evaluated had detectable CSF GFAP. Serum GFAP was detected in two of three (67%) of the NME pugs and in two of 11 (18%) of the control pugs but not in any of the 40 tested PDM pugs. Male pugs heterozygous for the NME risk haplotype had an earlier onset of clinical signs (70 months) compared to male pugs without the risk haplotype (78 months) (p = 0.036). LIMITATIONS The study was limited by the lack of healthy dogs of breeds other than pugs and the small numbers of control pugs and pugs with NME. CONCLUSIONS The high proportion of PDM pugs with anti-GFAP autoantibodies and high CSF GFAP concentrations provide support for a potential immunological contribution to the development of PDM.
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Affiliation(s)
- Cecilia Rohdin
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
- Anicura, Albano Small Animal Hospital, Danderyd, Sweden
| | - Ingrid Ljungvall
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Karin Hultin Jäderlund
- Department of Companion Animal Clinical Sciences, Norwegian University of Life Sciences, Ås, Norway
| | - Anna Svensson
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Kerstin Lindblad-Toh
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
- Broad Institute, Cambridge, Massachusetts, USA
| | - Jens Häggström
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
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De Decker S. Pug thoracolumbar myelopathy: vertebral instability, immune-mediated disorder or a combination of factors? Vet Rec 2024; 194:475-477. [PMID: 38874140 DOI: 10.1002/vetr.4421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Affiliation(s)
- Steven De Decker
- Queen Mother Hospital for Animals, Royal Veterinary College, Hatfield, UK
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8
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Liu P, Wang S, Zhang C, Li Y. Paraneoplastic neuromyelitis optica spectrum disorder associated with ovarian dysgerminoma: a case report and literature review. Front Immunol 2024; 15:1424243. [PMID: 38947316 PMCID: PMC11211867 DOI: 10.3389/fimmu.2024.1424243] [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: 04/27/2024] [Accepted: 06/03/2024] [Indexed: 07/02/2024] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a clinical syndrome characterized by attacks of acute optic neuritis and transverse myelitis. We report a case with paraneoplastic NMOSD that improved after immunosuppressive therapy, surgical resection, and chemotherapy. A 48-year-old woman initially presented with gradual binocular visual loss over the course of one week. The patient was evaluated using magnetic resonance imaging (MRI), computed tomography (CT), visual evoked potential (VEP), pathological biopsy, immunohistochemistry, and autoimmune antibody testing. The brain MRI findings were normal. The VEP revealed prolonged P100 latencies in the right eye and an absence of significant waves in the left eye. Positive serum AQP4-IgG antibodies were found. The patient was diagnosed as NMOSD. Then the patient responded well to treatment with methylprednisolone. An ovarian tumor was found in the patient using abdominal MRI and CT. The tumor was surgically resected, and a pathological biopsy revealed that it was ovarian dysgerminoma. The patient received four rounds of chemotherapy after surgery. One month after the final chemotherapy treatment, a positron emission tomography (PET) scan revealed no tumor. The vision of the patient gradually recovered and serum AQP4 was negative. Furthermore, we summarized the characteristics of patients diagnosed with paraneoplastic NMOSD associated with ovarian neoplasms in previous studies. This is a characteristic case of overlapping NMOSD and ovarian dysgerminoma, demonstrating the importance of tumor therapy in cases of paraneoplastic NMOSD.
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Affiliation(s)
- Pan Liu
- Department of Neurology, The Central Hospital of Shaoyang, Shaoyang, China
| | - Shuangying Wang
- Department of Clinical Pharmacy, The Central Hospital of Shaoyang, Shaoyang, China
| | - Chunhua Zhang
- Department of Neurology, The Central Hospital of Shaoyang, Shaoyang, China
| | - Yanfang Li
- Department of Neurology, The Central Hospital of Shaoyang, Shaoyang, China
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Oka H, Nakamura T, Sugawara T, Ishizawa K, Amari M, Kawarabayashi T, Okamoto K, Takatama M, Nakata S, Yoshimoto Y, Yamazaki A, Yokoo H, Kimura A, Shimohata T, Ikeda Y, Shoji M. A case of chronic progressive autoimmune GFAP astrocytopathy with extensive meningoencephalomyelitis and contrast enhancement on MRI. eNeurologicalSci 2024; 35:100507. [PMID: 38911509 PMCID: PMC11192973 DOI: 10.1016/j.ensci.2024.100507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 05/20/2024] [Accepted: 05/31/2024] [Indexed: 06/25/2024] Open
Abstract
•We herein present a case of chronic progressive autoimmune GFAP astrocytopathy.•Symmetrical high-intensity signals on FLAIR were observed in the white matter of the temporal and occipital lobes, lateral cerebral ventricle walls, hippocampus, amygdala, and occipital cortex, with extensive Gd enhancement in radial perivascular lesions and the ependyma in the choroid plexus.•Improvements were achieved by 4 courses of IVMP and one of IVIg.
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Affiliation(s)
- Hironori Oka
- Department of Neurology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-0034, Japan
- Geriatrics Research Institute and Hospital, 3-26-8 Otomo-machi, Maebashi 371-0847, Japan
| | - Takumi Nakamura
- Department of Neurology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-0034, Japan
| | - Takashi Sugawara
- Geriatrics Research Institute and Hospital, 3-26-8 Otomo-machi, Maebashi 371-0847, Japan
| | - Kunihiko Ishizawa
- Geriatrics Research Institute and Hospital, 3-26-8 Otomo-machi, Maebashi 371-0847, Japan
| | - Masakuni Amari
- Geriatrics Research Institute and Hospital, 3-26-8 Otomo-machi, Maebashi 371-0847, Japan
| | - Takeshi Kawarabayashi
- Geriatrics Research Institute and Hospital, 3-26-8 Otomo-machi, Maebashi 371-0847, Japan
| | - Koichi Okamoto
- Geriatrics Research Institute and Hospital, 3-26-8 Otomo-machi, Maebashi 371-0847, Japan
| | - Masamitsu Takatama
- Geriatrics Research Institute and Hospital, 3-26-8 Otomo-machi, Maebashi 371-0847, Japan
| | - Satoshi Nakata
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Japan
| | - Yuhei Yoshimoto
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Japan
| | - Ayako Yamazaki
- Department of Human Pathology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Japan
| | - Hideaki Yokoo
- Department of Human Pathology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Japan
| | - Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagito-machi, Gifu 501-1112, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagito-machi, Gifu 501-1112, Japan
| | - Yoshio Ikeda
- Department of Neurology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-0034, Japan
| | - Mikio Shoji
- Geriatrics Research Institute and Hospital, 3-26-8 Otomo-machi, Maebashi 371-0847, Japan
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Abunada M, Nierobisch N, Ludovichetti R, Simmen C, Terziev R, Togni C, Michels L, Kulcsar Z, Hainc N. Autoimmune encephalitis: Early and late findings on serial MR imaging and correlation to treatment timepoints. Eur J Radiol Open 2024; 12:100552. [PMID: 38327544 PMCID: PMC10847996 DOI: 10.1016/j.ejro.2024.100552] [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: 11/28/2023] [Revised: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/09/2024] Open
Abstract
Introduction MRI is negative in a large percentage of autoimmune encephalitis cases or lacks findings specific to an antibody. Even rarer is literature correlating the evolution of imaging findings with treatment timepoints. We aim to characterize imaging findings in autoimmune encephalitis at presentation and on follow up correlated with treatment timepoints for this rare disease. Methods A full-text radiological information system search was performed for "autoimmune encephalitis" between January 2012 and June 2022. Patients with laboratory-identified autoantibodies were included. MRI findings were assessed in correlation to treatment timepoints by two readers in consensus. For statistical analysis, cell-surface vs intracellular antibody groups were assessed for the presence of early limbic, early extralimbic, late limbic, and late extralimbic findings using the χ2 test. Results Thirty-seven patients (female n = 18, median age 58.8 years; range 25.7 to 82.7 years) with 15 different autoantibodies were included in the study. Twenty-three (62%) patients were MRI-negative at time of presentation; 5 of these developed MRI findings on short-term follow up. Of the 19 patients with early MRI findings, 9 (47%) demonstrated improvement upon treatment initiation (7/9 cell-surface group). There was a significant difference (p = 0.046) between the MRI spectrum of cell-surface vs intracellular antibody syndromes as cell-surface antibody syndromes demonstrated more early classic findings of limbic encephalitis and intracellular antibody syndromes demonstrated more late extralimbic abnormalities. Conclusion MRI can be used to help narrow the differential diagnosis in autoimmune encephalitis and can be used as a monitoring tool for certain subtypes of this rare disease.
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Affiliation(s)
- Mahmoud Abunada
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Nathalie Nierobisch
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Riccardo Ludovichetti
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Cyril Simmen
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Robert Terziev
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Claudio Togni
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Lars Michels
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Nicolin Hainc
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
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Biddle G, Beck RT, Raslan O, Ebinu J, Jenner Z, Hamer J, Hacein-Bey L, Apperson M, Ivanovic V. Autoimmune diseases of the spine and spinal cord. Neuroradiol J 2024; 37:285-303. [PMID: 37394950 PMCID: PMC11138326 DOI: 10.1177/19714009231187340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
Magnetic resonance imaging (MRI) and clinicopathological tools have led to the identification of a wide spectrum of autoimmune entities that involve the spine. A clearer understanding of the unique imaging features of these disorders, along with their clinical presentations, will prove invaluable to clinicians and potentially limit the need for more invasive procedures such as tissue biopsies. Here, we review various autoimmune diseases affecting the spine and highlight salient imaging features that distinguish them radiologically from other disease entities.
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Affiliation(s)
- Garrick Biddle
- Radiology Department, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Ryan T Beck
- Neuroradiology, Radiology Department, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Osama Raslan
- Radiology Department, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Julius Ebinu
- Neurosurgery Department, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Zach Jenner
- Radiology Department, University of California Davis School of Medicine, Sacramento, CA, USA
| | - John Hamer
- Neuroradiology, Radiology Department, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lotfi Hacein-Bey
- Radiology Department, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Michelle Apperson
- Neurology Department, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Vladimir Ivanovic
- Neuroradiology, Radiology Department, Medical College of Wisconsin, Milwaukee, WI, USA
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Muñiz-Castrillo S, Honnorat J. Genetic predisposition to autoimmune encephalitis and paraneoplastic neurological syndromes. Curr Opin Neurol 2024; 37:329-337. [PMID: 38483154 DOI: 10.1097/wco.0000000000001263] [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 We summarize the recent discoveries on genetic predisposition to autoimmune encephalitis and paraneoplastic neurological syndromes (PNS), emphasizing clinical and pathophysiological implications. RECENT FINDINGS The human leukocyte antigen (HLA) is the most studied genetic factor in autoimmune encephalitis and PNS. The HLA haplotype 8.1, which is widely known to be related to systemic autoimmunity, has been only weakly associated with a few types of autoimmune encephalitis and PNS. However, the strongest and most specific associations have been reported in a subgroup of autoimmune encephalitis that comprises antileucine-rich glioma-inactivated 1 (LGI1) limbic encephalitis, associated with DRB1∗07 : 01 , anticontactin-associated protein-like 2 (CASPR2) limbic encephalitis, associated with DRB1∗11 : 01 , and anti-IgLON5 disease, associated with DRB1∗10 : 01∼DQA1∗01∼DQB1∗05 . Non-HLA genes have been poorly investigated so far in autoimmune encephalitis, mainly in those lacking HLA associations such as anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis, with only a few genome-wide association studies (GWAS) reporting equivocal results principally limited by small sample size. SUMMARY Genetic predisposition seems to be driven mostly by HLA in a group of autoimmune encephalitis characterized by being nonparaneoplastic and having predominantly IgG4 autoantibodies. The contribution of non-HLA genes, especially in those diseases lacking known or strong HLA associations, will require large cohorts enabling GWAS to be powerful enough to render meaningful results.
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Affiliation(s)
- Sergio Muñiz-Castrillo
- Stanford Center for Sleep Sciences and Medicine, Stanford University, Palo Alto, California, USA
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon
| | - Jérôme Honnorat
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon
- MeLiS Institute - UCBL-CNRS UMR 5284 - INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
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13
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Berkowitz AL. Diagnostic reasoning in challenging cases. Pract Neurol 2024:pn-2023-003991. [PMID: 38816200 DOI: 10.1136/pn-2023-003991] [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: 05/01/2024] [Indexed: 06/01/2024]
Abstract
Diagnostic reasoning relies on cognitive heuristics to recognise patterns of symptoms and signs in order to arrive at a diagnosis. These rules of thumb allow us to rapidly diagnose common conditions that present in typical ways. However, they may lead us astray when common conditions present atypically or when a patient has a rare condition or multiple conditions causing their constellation of symptoms, signs, and test results, rather than having a single diagnosis to explain them all. This article describes strategies to help counteract diagnostic pitfalls, to expand diagnostic possibilities and to make diagnostic progress with complex, multielement cases.
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14
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Zhao CW, Gheihman G, Nigam M, Manzano GS. Autoimmune encephalitis in glial fibrillary acidic protein astrocytopathy. BMJ Case Rep 2024; 17:e260628. [PMID: 38724215 PMCID: PMC11085714 DOI: 10.1136/bcr-2024-260628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024] Open
Abstract
Autoimmune encephalitis due to glial fibrillar acidic protein (GFAP) astrocytopathy is a rare cause of subacute neuropsychiatric changes. In this case, a young patient presented with a viral prodrome and meningismus, followed by progressive encephalopathy and movement disorders over the span of 2 weeks. Due to his clinical trajectory, inflammatory cerebrospinal fluid (CSF) analysis, initial normal brain imaging and negative serum autoimmune encephalopathy panel, his initial diagnosis was presumed viral meningoencephalitis. The recurrence and progression of neuropsychiatric symptoms and myoclonus despite antiviral treatment prompted further investigation, inclusive of testing for CSF autoimmune encephalopathy autoantibodies, yielding a clinically meaningful, positive GFAP autoantibody. This case highlights the importance of appropriately testing both serum and CSF autoantibodies when an autoimmune encephalitic process is considered. Through this case, we review the clinical and radiographic manifestations of GFAP astrocytopathy, alongside notable pearls pertaining to this autoantibody syndrome and its management.
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Affiliation(s)
- Charlie Weige Zhao
- Harvard Medical School, Boston, Massachusetts, USA
- Neurology, Mass General Brigham Inc, Boston, Massachusetts, USA
| | - Galina Gheihman
- Harvard Medical School, Boston, Massachusetts, USA
- Neurology, Mass General Brigham Inc, Boston, Massachusetts, USA
| | - Minali Nigam
- Harvard Medical School, Boston, Massachusetts, USA
- Neurology, Mass General Brigham Inc, Boston, Massachusetts, USA
| | - Giovanna S Manzano
- Harvard Medical School, Boston, Massachusetts, USA
- Neurology, Mass General Brigham Inc, Boston, Massachusetts, USA
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15
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Shu Y, Huang R, Li Q, Lu Y, Yin J, Li H, Lan Z, Zheng X, Ye J, Long Y, Wang Z, Xiao L, Zhou Q, Liu X, Fu Y, Chen H, Chen J, Zhou Y, Zhou J, Zhang L, Zhou J, Jiang Y, Peng F, Lu Z, Petersen F, Qiu W, Yu X. Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy Is Associated with HLA-A*3303 and HLA-DPB1*0501. Ann Neurol 2024; 95:901-906. [PMID: 38400794 DOI: 10.1002/ana.26899] [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: 11/27/2023] [Revised: 01/26/2024] [Accepted: 02/05/2024] [Indexed: 02/26/2024]
Abstract
We determined the genetic association between specific human leucocyte antigen (HLA) loci and autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy. Our results showed that autoimmune GFAP astrocytopathy was associated with HLA-A*3303 (odds ratio [OR] = 2.02, 95% confidence interval [CI] = 1.32-3.06, p = 0.00072, padj. = 0.046) and HLA-DBP1*0501 (OR = 0.51, 95% CI = 0.36-0.71, p = 0.000048, padj. = 0.0062). Moreover, HLA-A*3303 carriers with the disease had a longer hospital stay (p = 0.0005) than non-carriers. This study for the first time provides evidence for a role of genetic factor in the development of autoimmune GFAP astrocytopathy. ANN NEUROL 2024;95:901-906.
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Affiliation(s)
- Yaqing Shu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Renliang Huang
- Department of Genetics and Prenatal Diagnosis, Hainan Women and Children's Medical Center, Haikou, Hainan, China
| | - Qihui Li
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yi Lu
- Department of Neurology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Junping Yin
- Institute of Molecular Medicine and Experimental Immunology, University of Bonn, Bonn, Germany
| | - Huilu Li
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhike Lan
- Department of Neurology, GuangDong 999 Brain Hospital, Guangzhou, China
| | - Xiujun Zheng
- Department of Neurology, Shantou Central Hospital, Affiliated Shantou Hospital of Sun Yat-Sen University, Shantou, China
| | - Jinlong Ye
- Department of Neurology, GuangDong 999 Brain Hospital, Guangzhou, China
| | - Youming Long
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhanhang Wang
- Department of Neurology, GuangDong 999 Brain Hospital, Guangzhou, China
| | - Li Xiao
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Qiaomiao Zhou
- Department of Genetics and Prenatal Diagnosis, Hainan Women and Children's Medical Center, Haikou, Hainan, China
| | - Xu Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Ying Fu
- Department of Neurology and Institute of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Hao Chen
- Department of Neurology, The First Affiliated Hospital Nanchang University, Nanchang, China
| | - Juanjuan Chen
- Department of Neurology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Yanxia Zhou
- Department of Neurology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
| | - Juan Zhou
- Department of Neurology, Chenzhou First People's Hospital, Chenzhou, China
| | - Liting Zhang
- Department of Neurology, Jiangxi Chest Hospital, Jiangxi, China
| | - Jing Zhou
- Department of Neurology, Foshan First People's Hospital, Foshan, China
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Fuhua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhengqi Lu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Frank Petersen
- Division of Pulmonary Immune Diseases, Priority Area Chronic Lung Diseases, Research Center Borstel, Borstel, Germany
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xinhua Yu
- Department of Genetics and Prenatal Diagnosis, Hainan Women and Children's Medical Center, Haikou, Hainan, China
- Division of Pulmonary Immune Diseases, Priority Area Chronic Lung Diseases, Research Center Borstel, Borstel, Germany
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16
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Charan BD, Priya S, Goel V, Chhatarpal P, Jain S, Gupta A, Garg A. Unveiling Distinctive MRI Characteristics in the Diagnosis of GFAP Astrocytopathy: A Rare Autoimmune Neuroinflammatory Disorder. Ann Indian Acad Neurol 2024; 27:316-318. [PMID: 38856160 DOI: 10.4103/aian.aian_1134_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 04/21/2024] [Indexed: 06/11/2024] Open
Abstract
Glial fibrillary acidic protein (GFAP) astrocytopathy is a rare autoimmune inflammatory disorder affecting the central nervous system, involving the meninges, brain parenchyma, and spinal cord. The distinctive radiologic feature observed on magnetic resonance imaging (MRI) is characterized by periventricular radial and linear contrast enhancement. This case report details a 45-year-old male who initially exhibited constitutional symptoms, followed by encephalitis, lower limb weakness, and urinary retention. The MRI findings revealed meningoencephalitis with longitudinal extensive myelitis. Notably, the cerebrospinal fluid analysis confirmed the presence of anti-GFAP antibodies.
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Affiliation(s)
- Bheru D Charan
- Department of Neuroimaging and Interventional Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Shikha Priya
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Vinay Goel
- Department of Neuroimaging and Interventional Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Pinky Chhatarpal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Savyasachi Jain
- Department of Neuroimaging and Interventional Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Anu Gupta
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Garg
- Department of Neuroimaging and Interventional Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
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17
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Sanvito F, Pichiecchio A, Paoletti M, Rebella G, Resaz M, Benedetti L, Massa F, Morbelli S, Caverzasi E, Asteggiano C, Businaro P, Masciocchi S, Castellan L, Franciotta D, Gastaldi M, Roccatagliata L. Autoimmune encephalitis: what the radiologist needs to know. Neuroradiology 2024; 66:653-675. [PMID: 38507081 PMCID: PMC11031487 DOI: 10.1007/s00234-024-03318-x] [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: 11/15/2023] [Accepted: 02/20/2024] [Indexed: 03/22/2024]
Abstract
Autoimmune encephalitis is a relatively novel nosological entity characterized by an immune-mediated damage of the central nervous system. While originally described as a paraneoplastic inflammatory phenomenon affecting limbic structures, numerous instances of non-paraneoplastic pathogenesis, as well as extra-limbic involvement, have been characterized. Given the wide spectrum of insidious clinical presentations ranging from cognitive impairment to psychiatric symptoms or seizures, it is crucial to raise awareness about this disease category. In fact, an early diagnosis can be dramatically beneficial for the prognosis both to achieve an early therapeutic intervention and to detect a potential underlying malignancy. In this scenario, the radiologist can be the first to pose the hypothesis of autoimmune encephalitis and refer the patient to a comprehensive diagnostic work-up - including clinical, serological, and neurophysiological assessments.In this article, we illustrate the main radiological characteristics of autoimmune encephalitis and its subtypes, including the typical limbic presentation, the features of extra-limbic involvement, and also peculiar imaging findings. In addition, we review the most relevant alternative diagnoses that should be considered, ranging from other encephalitides to neoplasms, vascular conditions, and post-seizure alterations. Finally, we discuss the most appropriate imaging diagnostic work-up, also proposing a suggested MRI protocol.
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Affiliation(s)
- Francesco Sanvito
- Unit of Radiology, Department of Clinical, Surgical, Diagnostic, and Paediatric Sciences, University of Pavia, Viale Camillo Golgi, 19, 27100, Pavia, Italy.
- UCLA Brain Tumor Imaging Laboratory (BTIL), Center for Computer Vision and Imaging Biomarkers, University of California Los Angeles, Los Angeles, CA, USA.
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | - Anna Pichiecchio
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Matteo Paoletti
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Giacomo Rebella
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Martina Resaz
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Luana Benedetti
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Federico Massa
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Largo Daneo 3, 16132, Genoa, Italy
| | - Silvia Morbelli
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Via Antonio Pastore 1, 16132, Genoa, Italy
| | - Eduardo Caverzasi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Carlo Asteggiano
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Pietro Businaro
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Stefano Masciocchi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Lucio Castellan
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Diego Franciotta
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Luca Roccatagliata
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Via Antonio Pastore 1, 16132, Genoa, Italy
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18
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Chen Y, Luo C, Zhou G, Wang H, Dai K, Wu W, Wang S, Su Z, Peng F, Jiang Y. The discrimination between autoimmune glial fibrillary acidic protein astrocytopathy and tuberculous meningitis. Mult Scler Relat Disord 2024; 85:105527. [PMID: 38432014 DOI: 10.1016/j.msard.2024.105527] [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: 11/16/2023] [Revised: 02/25/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE The differential diagnosis between autoimmune glial fibrillary acidic protein astrocytopathy (AGFAPA) mimicking tuberculous meningitis and tuberculous meningitis (TBM) remains challenging in clinical practice. This study aims to identify the clinical, laboratory parameters, and clinical score systems that may be helpful in differentiating AGFAPA from TBM. METHOD Overall 22 AGFAPA patients who were initially misdiagnosed as TBM (AGFAPA-TBM) and 30 confirmed TBM patients were included. The clinical, laboratory, imaging parameters, Thwaites systems, and Lancet consensus scoring systems (LCSS) of all patients were reviewed. Logistic regression was employed to establish a diagnostic formula to differentiate AGFAPA-TBM from TBM. The receiver operating characteristic (ROC) curve was applied to determine the best diagnostic critical point of the formula. RESULTS Urinary retention was more frequent in AGFAPA-TBM patients (72.7% vs 33.3%, p = 0.012). A significantly lower ratio of T-SPOT. TB was noted in AGFAPA-TBM patients (9.1% vs 82.1%, p < 0.001). We found the LCSS was able to differentiate AGFAPA-TBM from TBM (AUC value 0.918, 95% CI=0.897-0.924). Furthermore, we set up a new scoring system with three variables: urinary retention, T-SPOT. TB, and cerebral imaging criteria in LCSS. The proposed diagnostic score ranges from -8 to 2, and a score of ≥ 0 was suggestive of AGFAPA-TBM (AUC value 0.938, 95% CI=0.878-0.951). CONCLUSIONS This study is the first to evaluate the Thwaites system and LCSS in AGFAPA-TBM and TBM. We provide an alternative diagnostic formula to differentiate AGFAPA-TBM from TBM and suggest testing for GFAP antibodies to avoid misdiagnosis when this scoring system meets AGFAPA-TBM.
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Affiliation(s)
- Yanxiang Chen
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China; Department of Neurology, Xiaolan People's Hospital of Zhongshan, 65#, Middle Section of Jucheng Avenue, Xiaolan, Zhongshan, Guangdong Province 528400, China
| | - Chongliang Luo
- Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St Louis, MO 63110, USA
| | - Guonan Zhou
- Department of Encephalopathy, Zhongshan Chenxinghai Hospital of Integrated Traditional Chinese and Western Medicine, 18# Zhuyuan Road, Zhongshan, Guangdong Province 528400, China
| | - Hui Wang
- Department of Neurology, Xiaolan People's Hospital of Zhongshan, 65#, Middle Section of Jucheng Avenue, Xiaolan, Zhongshan, Guangdong Province 528400, China
| | - Kai Dai
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China
| | - Weijuan Wu
- Department of Neurology, Sanshui District People's Hospital, Sanshui, Foshan, Guangdong Province 528100, China
| | - Siguang Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China
| | - Zhihui Su
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China
| | - Fuhua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China.
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China.
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19
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Shosha E, Connolly C, Budhram A. Case report: Headache as the sole neurological symptom in autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy. Front Neurol 2024; 15:1366263. [PMID: 38699059 PMCID: PMC11063300 DOI: 10.3389/fneur.2024.1366263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/14/2024] [Indexed: 05/05/2024] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a recently emerging autoimmune disease of the central nervous system (CNS); GFAP astrocytopathy is characterized by optic neuritis and meningoencephalomyelitis. We report the case of a 55-year-old man, otherwise healthy, who presented with isolated headaches for three months, without other features of meningoencephalitis or myelitis. His neurological examination and fundoscopy were unremarkable. Gadolinium-enhanced brain MRI demonstrated increased T2 hyperintensity within the right sub-lenticular basal ganglia, with additional leptomeningeal enhancement along the bilateral perisylvian regions and mesial temporal lobes. Cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis, elevated protein, matching oligoclonal bands, and a negative infectious and cytological workup. Cell-based assays for anti-aquaporin-4, anti-myelin oligodendrocyte glycoprotein, autoimmune encephalitis panel, and vasculitis workup were all negative, except for CSF positivity for GFAP α antibody. Oncological screening, including CT of the chest, abdomen, pelvis, and scrotal US, was unremarkable. Immunotherapy with high-dose intravenous steroids for five days and subsequent single four-weekly doses resulted in the resolution of both clinical and radiographic features, with a maintained status 24 months after onset. This case highlights isolated headache and basal ganglia, mesial temporal lobe involvement as a rare presentation of autoimmune GFAP astrocytopathy.
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Affiliation(s)
- Eslam Shosha
- Neurology Division, Department of Medicine, McMaster University, Hamilton Health Science Center, Hamilton, ON, Canada
| | - Colleen Connolly
- Neurology Division, Department of Medicine, McMaster University, Hamilton Health Science Center, Hamilton, ON, Canada
| | - Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Science Center, London, ON, Canada
- Department of Pathology and Laboratory Medicine, Western University, London Health Science Center, London, ON, Canada
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20
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Linnoila JJ, Rapalino O, Walker MA, Martinez-Lage M. Case 12-2024: A 58-Year-Old Woman with Confusion, Aphasia, and Abnormal Head Imaging. N Engl J Med 2024; 390:1421-1430. [PMID: 38631006 DOI: 10.1056/nejmcpc2312732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Affiliation(s)
- Jenny J Linnoila
- From the Department of Neurology, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh (J.J.L.); and the Departments of Radiology (O.R.), Neurology (M.A.W.), and Pathology (M.M.-L.), Massachusetts General Hospital, and the Departments of Radiology (O.R.), Neurology (M.A.W.), and Pathology (M.M.-L.), Harvard Medical School - both in Boston
| | - Otto Rapalino
- From the Department of Neurology, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh (J.J.L.); and the Departments of Radiology (O.R.), Neurology (M.A.W.), and Pathology (M.M.-L.), Massachusetts General Hospital, and the Departments of Radiology (O.R.), Neurology (M.A.W.), and Pathology (M.M.-L.), Harvard Medical School - both in Boston
| | - Melissa A Walker
- From the Department of Neurology, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh (J.J.L.); and the Departments of Radiology (O.R.), Neurology (M.A.W.), and Pathology (M.M.-L.), Massachusetts General Hospital, and the Departments of Radiology (O.R.), Neurology (M.A.W.), and Pathology (M.M.-L.), Harvard Medical School - both in Boston
| | - Maria Martinez-Lage
- From the Department of Neurology, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh (J.J.L.); and the Departments of Radiology (O.R.), Neurology (M.A.W.), and Pathology (M.M.-L.), Massachusetts General Hospital, and the Departments of Radiology (O.R.), Neurology (M.A.W.), and Pathology (M.M.-L.), Harvard Medical School - both in Boston
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21
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John DS, Kankara SR, Palasamudram Kumaran S, Hussain AS. Clinicoradiological features of probable chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) syndrome. BMJ Case Rep 2024; 17:e258067. [PMID: 38627057 PMCID: PMC11029188 DOI: 10.1136/bcr-2023-258067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a recently described chronic inflammatory central nervous system disease. This case report describes a young female patient presenting with weakness in bilateral upper and lower limbs and tinnitus for 2 months. A neurological examination revealed signs of brainstem and cerebellar involvement. MRI brain showed characteristic features of CLIPPERS, with punctate and nodular enhancement in the pons and cerebellum. Differential diagnoses were systematically considered and excluded. The patient showed significant clinical and radiological improvement with steroid therapy. No clinical or radiological red flags occurred during the follow-up. This case underscores the critical role of integrating clinical and radiological findings to effectively diagnose and manage CLIPPERS. It emphasises the importance of ruling out alternative diagnoses through a thorough evaluation.
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Affiliation(s)
- Deepa Susan John
- Department of Radiology, St John's Medical College Hospital, Bangalore, Karnataka, India
| | - Shreyas Reddy Kankara
- Department of Radiology, St John's Medical College Hospital, Bangalore, Karnataka, India
| | | | - Adnan Sarfaraz Hussain
- Department of Radiology, St John's Medical College Hospital, Bangalore, Karnataka, India
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22
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Morishima Y, Hata T, Nakajima S, Shindo K, Tsuchiya M, Watanabe T, Tahara I, Kondo T, Kimura A, Shimohata T, Ueno Y. Case report: Atypical case of autoimmune glial fibrillary acidic protein astrocytopathy following COVID-19 vaccination refractory to immunosuppressive treatments. Front Immunol 2024; 15:1361685. [PMID: 38665914 PMCID: PMC11043467 DOI: 10.3389/fimmu.2024.1361685] [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: 12/26/2023] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
A 54-year-old Japanese man presented with headache and fever the day after SARS-CoV-2 vaccination. He became deeply unconscious within a week. Brain MRI showed periventricular linear enhancements and a few spotty lesions in the cerebral white matter. Cerebrospinal fluid (CSF) testing showed mild pleocytosis. He was treated with intravenous methylprednisolone and plasma exchange. However, the white matter lesions enlarged to involve the brainstem and cerebellum, and long cord spinal lesions appeared. Anti-glial fibrillary acidic protein (GFAP) antibody was positive in the CSF and serum, and he was therefore diagnosed as autoimmune GFAP-astrocytopathy (GFAP-A). In addition, high-dose immunoglobulin therapy was administered twice, but his symptoms did not improve; the white matter lesions enlarged further, and modified Rankin Scale score increased to 5. A brain biopsy specimen showed infiltration of macrophages and CD4 + lymphocytes together with neuron and oligodendrocytic injuries and glial scar. Although GFAP-A generally responds well to steroids, the present case developed GFAP-A following SARS-CoV-2 vaccination, with refractory to intensive immunosuppressive therapy and atypical pathologic findings of infiltration of CD4 + lymphocytes and demyelination.
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Affiliation(s)
- Yuto Morishima
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | - Takanori Hata
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | - Sho Nakajima
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | - Kazumasa Shindo
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | - Mai Tsuchiya
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | | | - Ippei Tahara
- Department of Pathology, University of Yamanashi, Chuo, Japan
| | - Tetsuo Kondo
- Department of Pathology, University of Yamanashi, Chuo, Japan
| | - Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yuji Ueno
- Department of Neurology, University of Yamanashi, Chuo, Japan
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Gilligan M, McGuigan C, McKeon A. Autoimmune central nervous system disorders: Antibody testing and its clinical utility. Clin Biochem 2024; 126:110746. [PMID: 38462203 PMCID: PMC11016295 DOI: 10.1016/j.clinbiochem.2024.110746] [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: 12/22/2023] [Revised: 02/16/2024] [Accepted: 03/05/2024] [Indexed: 03/12/2024]
Abstract
A rapidly expanding repertoire of neural antibody biomarkers exists for autoimmune central nervous system (CNS) disorders. Following clinical recognition of an autoimmune CNS disorder, the detection of a neural antibody facilitates diagnosis and informs prognosis and management. This review considers the phenotypes, diagnostic assay methodologies, and clinical utility of neural antibodies in autoimmune CNS disorders. Autoimmune CNS disorders may present with a diverse range of clinical features. Clinical phenotype should inform the neural antibodies selected for testing via the use of phenotype-specific panels. Both serum and cerebrospinal fluid (CSF) are preferred in the vast majority of cases but for some analytes either CSF (e.g. N-methyl-D-aspartate receptor [NMDA-R] IgG) or serum (e.g. aquaporin-4 [AQP4] IgG) specimens may be preferred. Screening using 2 methods is recommended for most analytes, particularly paraneoplastic antibodies. We utilize murine tissue-based indirect immunofluorescence assay (TIFA) with subsequent confirmatory protein-specific testing. The cellular location of the target antigen informs choice of confirmatory diagnostic assay (e.g. blot for intracellular antigens such as Hu; cell-based assay for cell surface targets such as leucine-rich glioma inactivated 1 [LGI1]). Titers of positive results have limited diagnostic utility with the exception of glutamic acid decarboxylase (GAD) 65 IgG autoimmunity, which is associated with neurological disease at higher values. While novel antibodies are typically discovered using established techniques such as TIFA and immunoprecipitation-mass spectrometry, more recent high-throughput molecular technologies (such as protein microarray and phage-display immunoprecipitation sequencing) may expedite the process of antibody discovery. Individual neural antibodies inform the clinician regarding the clinical associations, oncological risk stratification and tumor histology, the likely prognosis, and immunotherapy choice. In the era of neural antibody biomarkers for autoimmune CNS disorders, access to appropriate laboratory assays for neural antibodies is of critical importance in the diagnosis and management of these disorders.
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Affiliation(s)
- Michael Gilligan
- Departments of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Neurology, St Vincent's University Hospital, Dublin, Ireland
| | | | - Andrew McKeon
- Departments of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Neurology, Mayo Clinic, Rochester, MN, USA.
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24
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Ke G, Jian S, Yang T, Zhao X. Clinical characteristics and MRI features of autoimmune glial fibrillary acidic protein astrocytopathy: a case series of 34 patients. Front Neurol 2024; 15:1375971. [PMID: 38585352 PMCID: PMC10995392 DOI: 10.3389/fneur.2024.1375971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 03/11/2024] [Indexed: 04/09/2024] Open
Abstract
Objectives To analyze the clinical and imaging characteristics of autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A). Methods Forty-three patients diagnosed with GFAP-A between March 2017 and July 2023 were retrospectively recruited. The clinical characteristics and magnetic resonance imaging (MRI) features were collected. Results Twenty-one patients (61.8%) had a fever and 16 (47.1%) had a headache. Five patients (14.7%) had coexisting neural autoantibodies and one patient (2.9%) had a coexisting neoplasm. The most common presentation was meningoencephalomyelitis (13/34, 38.3%), followed by meningoencephalitis (12/34, 35.3%). The other clinical manifestations included blurred visions (5/34, 14.7%) and peripheral nervous system involvement (4/34, 11.8%). Twenty-six patients (76.5%) had elevated nucleated cell count, predominantly lymphocytes (15/15, 100%), and 27 (79.4%) had elevated protein levels of cerebrospinal fluid. One-half (50%) of the patients presented with hyponatremia. A majority of the patients (30/33, 90.9%) exhibited abnormal hyperintense lesions on T2WI, which were often located in juxtacortical white matter (18/33, 54.5%), followed by periventricular white matter (16/33, 48.5%), basal ganglia (15/ 33, 45.5%), brainstem (11/33, 33.3%), and thalamic lesions (9/33, 27.3%). Twenty-four patients (72.7%) had abnormal brain enhancement, with supratentorial leptomeningeal enhancement being the most frequent enhancement pattern (15/33, 45.5%), followed by linear perivascular radial enhancement (14/33, 42.4%). Nineteen patients (70.4%) had hyperintense intramedullary spinal cord lesions, with long segments (15/27, 55.6%) and transverse lesions (14/27, 51.9%) being the most frequent lesions. Most cases were sensitive to immunotherapy, such as glucocorticoids, intravenous immunoglobulin, and tacrolimus, with three patients (8.8%) experiencing relapses. Patients with brainstem lesions had higher onset modified Rankin scale scores and were more prone to intensive care unit admissions. Linear perivascular radial enhancement was positively associated with poor prognosis (p < 0.05). Conclusion GFAP-A presented with meningoencephalomyelitis and meningoencephalitis. The brain lesions were often located in juxtacortical white matter, periventricular white matter, basal ganglia, brainstem, and thalamus. Long segments and transverse were the most frequent spine lesions. Leptomeningeal enhancement was the most frequent enhancement pattern, followed by linear perivascular radial enhancement, which may provide new insight into the differential diagnosis of GFAP-A.
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Affiliation(s)
| | | | | | - Xu Zhao
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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25
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Guo Y, Guo J, Wang X, Ma A, Gao Y, Chen J, Nie C, Chen N. Glial fibrillary acidic protein astrocytopathy presented as meningitis: A case report. Heliyon 2024; 10:e26827. [PMID: 38434407 PMCID: PMC10907785 DOI: 10.1016/j.heliyon.2024.e26827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 02/02/2024] [Accepted: 02/20/2024] [Indexed: 03/05/2024] Open
Abstract
Introduction Glial fibrillary acidic protein (GFAP) astrocytopathy is a novel autoimmune neurological disorder and is diagnosed by GFAP-IgG in cerebrospinal fluid (CSF) measurement. Case report Herein, we described a 10-year-old boy with abnormal neurological symptoms and signs. GFAP-IgG was detected in CSF using cell-based assay (CBA), and his CSF showed an increase in lymphocytes, a slight decrease in glucose and an increase in protein level in the early stage. The cranial MRI showed multiple strips of T2-FLAIR hyperintense signal changes on the surface of medulla oblongata, pons, and gyrus in bilateral cerebral hemispheres. He was treated with immunoglobulin (IVIG) and high-dose methylprednisolone pulse treatment, and his clinical presentations gradually improved. Conclusion We highlight that patients with normal inflammatory markers in peripheral blood have obvious meningitis-like symptoms, and clinicians need to consider GFAP astrocytopathy. The early diagnosis and treatment of GFAP astrocytopathy are important for improving the prognosis.
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Affiliation(s)
- Ya Guo
- Department of Pediatric, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Jiamin Guo
- Department of Pediatric, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Xueyu Wang
- Department of Pediatric, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Aihua Ma
- Department of Pediatric, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Yuxing Gao
- Department of Pediatric, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Jiacheng Chen
- Department of Pediatric, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Cuili Nie
- Department of Pediatric, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Na Chen
- Department of Pediatric, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
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26
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Levstek L, Janžič L, Ihan A, Kopitar AN. Biomarkers for prediction of CAR T therapy outcomes: current and future perspectives. Front Immunol 2024; 15:1378944. [PMID: 38558801 PMCID: PMC10979304 DOI: 10.3389/fimmu.2024.1378944] [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: 01/30/2024] [Accepted: 03/04/2024] [Indexed: 04/04/2024] Open
Abstract
Chimeric antigen receptor (CAR) T cell therapy holds enormous potential for the treatment of hematologic malignancies. Despite its benefits, it is still used as a second line of therapy, mainly because of its severe side effects and patient unresponsiveness. Numerous researchers worldwide have attempted to identify effective predictive biomarkers for early prediction of treatment outcomes and adverse effects in CAR T cell therapy, albeit so far only with limited success. This review provides a comprehensive overview of the current state of predictive biomarkers. Although existing predictive metrics correlate to some extent with treatment outcomes, they fail to encapsulate the complexity of the immune system dynamics. The aim of this review is to identify six major groups of predictive biomarkers and propose their use in developing improved and efficient prediction models. These groups include changes in mitochondrial dynamics, endothelial activation, central nervous system impairment, immune system markers, extracellular vesicles, and the inhibitory tumor microenvironment. A comprehensive understanding of the multiple factors that influence therapeutic efficacy has the potential to significantly improve the course of CAR T cell therapy and patient care, thereby making this advanced immunotherapy more appealing and the course of therapy more convenient and favorable for patients.
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Affiliation(s)
| | | | | | - Andreja Nataša Kopitar
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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27
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Varma-Doyle A, Chwalisz BK, Linnoila J. Anti-Immunoglobulin-Like Cell Adhesion Molecule-5 (IgLON5) Associated Neurological Disease Presenting With Bilateral Intraocular Optic Neuritis as an Initial Presentation: Expanding Clinical Phenotype of the Disease. J Neuroophthalmol 2024:00041327-990000000-00586. [PMID: 38437022 DOI: 10.1097/wno.0000000000002114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Affiliation(s)
- Aditi Varma-Doyle
- Department of Neurology (AVD, BKC, JL), Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts; Department of Ophthalmology (BKC), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston, Massachusetts; and Johns Hopkins Bloomberg School of Public Health (AVD), Baltimore, Maryland
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28
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Arlt FA, Miske R, Machule ML, Broegger Christensen P, Mindorf S, Teegen B, Borowski K, Buthut M, Rößling R, Sánchez-Sendín E, van Hoof S, Cordero-Gómez C, Bünger I, Radbruch H, Kraft A, Ayzenberg I, Klausewitz J, Hansen N, Timäus C, Körtvelyessy P, Postert T, Baur-Seack K, Rost C, Brunkhorst R, Doppler K, Haigis N, Hamann G, Kunze A, Stützer A, Maschke M, Melzer N, Rosenow F, Siebenbrodt K, Stenør C, Dichgans M, Georgakis MK, Fang R, Petzold GC, Görtler M, Zerr I, Wunderlich S, Mihaljevic I, Turko P, Schmidt Ettrup M, Buchholz E, Foverskov Rasmussen H, Nasouti M, Talucci I, Maric HM, Heinemann SH, Endres M, Komorowski L, Prüss H. KCNA2 IgG autoimmunity in neuropsychiatric diseases. Brain Behav Immun 2024; 117:399-411. [PMID: 38309639 DOI: 10.1016/j.bbi.2024.01.220] [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: 08/25/2023] [Revised: 01/04/2024] [Accepted: 01/25/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Autoantibodies against the potassium voltage-gated channel subfamily A member 2 (KCNA2) have been described in a few cases of neuropsychiatric disorders, but their diagnostic and pathophysiological role is currently unknown, imposing challenges to medical practice. DESIGN / METHODS We retrospectively collected comprehensive clinical and paraclinical data of 35 patients with KCNA2 IgG autoantibodies detected in cell-based and tissue-based assays. Patients' sera and cerebrospinal fluid (CSF) were used for characterization of the antigen, clinical-serological correlations, and determination of IgG subclasses. RESULTS KCNA2 autoantibody-positive patients (n = 35, median age at disease onset of 65 years, range of 16-83 years, 74 % male) mostly presented with cognitive impairment and/or epileptic seizures but also ataxia, gait disorder and personality changes. Serum autoantibodies belonged to IgG3 and IgG1 subclasses and titers ranged from 1:32 to 1:10,000. KCNA2 IgG was found in the CSF of 8/21 (38 %) patients and in the serum of 4/96 (4.2 %) healthy blood donors. KCNA2 autoantibodies bound to characteristic anatomical areas in the cerebellum and hippocampus of mammalian brain and juxtaparanodal regions of peripheral nerves but reacted exclusively with intracellular epitopes. A subset of four KCNA2 autoantibody-positive patients responded markedly to immunotherapy alongside with conversion to seronegativity, in particular those presenting an autoimmune encephalitis phenotype and receiving early immunotherapy. An available brain biopsy showed strong immune cell invasion. KCNA2 autoantibodies occurred in less than 10 % in association with an underlying tumor. CONCLUSION Our data suggest that KCNA2 autoimmunity is clinically heterogeneous. Future studies should determine whether KCNA2 autoantibodies are directly pathogenic or develop secondarily. Early immunotherapy should be considered, in particular if autoantibodies occur in CSF or if clinical or diagnostic findings suggest ongoing inflammation. Suspicious clinical phenotypes include autoimmune encephalitis, atypical dementia, new-onset epilepsy and unexplained epileptic seizures.
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Affiliation(s)
- Friederike A Arlt
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Ramona Miske
- Institute for Experimental Immunology, affiliated to EUROIMMUN Medizinische Labordiagnostika AG, Lübeck, Germany
| | - Marie-Luise Machule
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | | | - Swantje Mindorf
- Institute for Experimental Immunology, affiliated to EUROIMMUN Medizinische Labordiagnostika AG, Lübeck, Germany
| | - Bianca Teegen
- Clinical immunological Laboratory Prof. Stöcker, Groß Grönau, Germany
| | - Kathrin Borowski
- Clinical immunological Laboratory Prof. Stöcker, Groß Grönau, Germany
| | - Maria Buthut
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Rosa Rößling
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Elisa Sánchez-Sendín
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Scott van Hoof
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - César Cordero-Gómez
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Isabel Bünger
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Helena Radbruch
- Department of Neuropathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Andrea Kraft
- Department of Neurology, Hospital Martha-Maria, Halle, Germany
| | - Ilya Ayzenberg
- Department of Neurology, St Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Jaqueline Klausewitz
- Department of Neurology, St Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Niels Hansen
- Department of Psychiatry and Psychotherapy, University Göttingen Medical Center, Göttingen, Germany
| | - Charles Timäus
- Department of Psychiatry and Psychotherapy, University Göttingen Medical Center, Göttingen, Germany
| | - Peter Körtvelyessy
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany; German Center for Neurodegenerative Diseases (DZNE) Magdeburg, Magdeburg, Germany
| | - Thomas Postert
- Department of Neurology, St. Vincenz-Krankenhaus Paderborn, Paderborn, Germany
| | - Kirsten Baur-Seack
- Department of Neurology, St. Vincenz-Krankenhaus Paderborn, Paderborn, Germany
| | - Constanze Rost
- Department of Neurology, St. Vincenz-Krankenhaus Paderborn, Paderborn, Germany
| | - Robert Brunkhorst
- Department of Neurology, University Hospital Aachen, Aachen, Germany
| | - Kathrin Doppler
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Niklas Haigis
- Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, University of Heidelberg, Heidelberg, Germany
| | - Gerhard Hamann
- Department of Neurology and Neurological Rehabilitation, BKH Günzburg, Günzburg, Germany
| | - Albrecht Kunze
- Department of Neurology, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Alexandra Stützer
- Department of Neurology, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Matthias Maschke
- Department of Neurology, Campus Trier, University of Mainz, Trier, Germany
| | - Nico Melzer
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe University Frankfurt, Frankfurt on the Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University, Frankfurt, Germany
| | - Kai Siebenbrodt
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe University Frankfurt, Frankfurt on the Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University, Frankfurt, Germany
| | - Christian Stenør
- Department of Neurology, Copenhagen University Hospital, Herlev-Gentofte, Denmark
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany; German Center for Neurodegenerative Diseases (DZNE) Munich, Munich, Germany
| | - Marios K Georgakis
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Rong Fang
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Gabor C Petzold
- German Center for Neurodegenerative Diseases (DZNE) Bonn, Bonn, Germany; Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Michael Görtler
- German Center for Neurodegenerative Diseases (DZNE) Magdeburg, Magdeburg, Germany; Department of Neurology, University Hospital, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Inga Zerr
- German Center for Neurodegenerative Diseases (DZNE) Göttingen, Göttingen, Germany; Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Silke Wunderlich
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | | | - Paul Turko
- Institute for Integrative Neuroanatomy, Charité-Universitätsmedizin, Berlin, Germany
| | | | - Emilie Buchholz
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Helle Foverskov Rasmussen
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Mahoor Nasouti
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Ivan Talucci
- Department of Neurology, University of Würzburg, Würzburg, Germany; Rudolf Virchow Center, Center for Integrative and Translational Bioimaging, University of Würzburg, Würzburg, Germany
| | - Hans M Maric
- Rudolf Virchow Center, Center for Integrative and Translational Bioimaging, University of Würzburg, Würzburg, Germany
| | - Stefan H Heinemann
- Friedrich Schiller University and Jena University Hospital, Center for Molecular Biomedicine, Department of Biophysics, Jena, Germany
| | - Matthias Endres
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Lars Komorowski
- Institute for Experimental Immunology, affiliated to EUROIMMUN Medizinische Labordiagnostika AG, Lübeck, Germany
| | - Harald Prüss
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany.
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Fournel J, Hermier M, Martin A, Gamondès D, Tommasino E, Broussolle T, Morgado A, Baassiri W, Cotton F, Berthezène Y, Bani-Sadr A. It Looks Like a Spinal Cord Tumor but It Is Not. Cancers (Basel) 2024; 16:1004. [PMID: 38473365 DOI: 10.3390/cancers16051004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 02/23/2024] [Accepted: 02/26/2024] [Indexed: 03/14/2024] Open
Abstract
Differentiating neoplastic from non-neoplastic spinal cord pathologies may be challenging due to overlapping clinical and radiological features. Spinal cord tumors, which comprise only 2-4% of central nervous system tumors, are rarer than non-tumoral myelopathies of inflammatory, vascular, or infectious origins. The risk of neurological deterioration and the high rate of false negatives or misdiagnoses associated with spinal cord biopsies require a cautious approach. Facing a spinal cord lesion, prioritizing more common non-surgical myelopathies in differential diagnoses is essential. A comprehensive radiological diagnostic approach is mandatory to identify spinal cord tumor mimics. The diagnostic process involves a multi-step approach: detecting lesions primarily using MRI techniques, precise localization of lesions, assessing lesion signal intensity characteristics, and searching for potentially associated anomalies at spinal cord and cerebral MRI. This review aims to delineate the radiological diagnostic approach for spinal cord lesions that may mimic tumors and briefly highlight the primary pathologies behind these lesions.
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Affiliation(s)
- Julien Fournel
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Marc Hermier
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Anna Martin
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Delphine Gamondès
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Emanuele Tommasino
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Théo Broussolle
- Department of Spine and Spinal Cord Neurosurgery, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Alexis Morgado
- Department of Spine and Spinal Cord Neurosurgery, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Wassim Baassiri
- Department of Spine and Spinal Cord Neurosurgery, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Francois Cotton
- CREATIS Laboratory, CNRS UMR 5220, INSERM U1294, Claude Bernard Lyon I University, 7 Avenue Jean Capelle, 69100 Villeurbanne, France
- Department of Radiology, South Lyon Hospital, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69495 Pierre-Bénite, France
| | - Yves Berthezène
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
- CREATIS Laboratory, CNRS UMR 5220, INSERM U1294, Claude Bernard Lyon I University, 7 Avenue Jean Capelle, 69100 Villeurbanne, France
| | - Alexandre Bani-Sadr
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
- CREATIS Laboratory, CNRS UMR 5220, INSERM U1294, Claude Bernard Lyon I University, 7 Avenue Jean Capelle, 69100 Villeurbanne, France
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Kimura A. [Clinical features and pathogenesis of Glial fibrillary acidic protein (GFAP) antibody-associated disorders]. Rinsho Shinkeigaku 2024; 64:75-84. [PMID: 38281748 DOI: 10.5692/clinicalneurol.cn-001925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Glial fibrillary acidic protein (GFAP) antibody-associated disorders (AD) were recently proposed to be immune-mediated neurological disorders. The pathogenesis of GFAP antibody-AD is poorly understood. Pathologically, there is a marked infiltration of large numbers of lymphocytes, including CD8+ and CD4+ T cells, into the meningeal and brain parenchyma, especially around the perivascular areas. GFAP-specific cytotoxic T cells are considered to be the effector cells of GFAP antibody-AD. The common phenotype of GFAP antibody-AD includes meningoencephalitis with or without myelitis. During the clinical disease course, patients present with consciousness disturbances, urinary dysfunction, movement disorders, meningeal irritation, and cognitive dysfunction. The detection of GFAP antibodies in the cerebrospinal fluid (CSF) by cell-based assay is essential for a diagnosis of GFAP antibody-AD. The CSF can be examined for lymphocyte-predominant pleocytosis and elevated protein levels. Brain linear perivascular radial enhancement patterns are observed in about half of GFAP antibody-AD patients. Spinal cord magnetic resonance imaging is used to detect longitudinal extensive spinal cord lesions. Although corticosteroid therapy is generally effective, some patients have a poor prognosis and relapse.
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Affiliation(s)
- Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine
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Hahn C, Budhram A, Alikhani K, AlOhaly N, Beecher G, Blevins G, Brooks J, Carruthers R, Comtois J, Cowan J, de Robles P, Hébert J, Kapadia RK, Lapointe S, Mackie A, Mason W, McLane B, Muccilli A, Poliakov I, Smyth P, Williams KG, Uy C, McCombe JA. Canadian Consensus Guidelines for the Diagnosis and Treatment of Autoimmune Encephalitis in Adults. Can J Neurol Sci 2024:1-21. [PMID: 38312020 DOI: 10.1017/cjn.2024.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Abstract
Autoimmune encephalitis is increasingly recognized as a neurologic cause of acute mental status changes with similar prevalence to infectious encephalitis. Despite rising awareness, approaches to diagnosis remain inconsistent and evidence for optimal treatment is limited. The following Canadian guidelines represent a consensus and evidence (where available) based approach to both the diagnosis and treatment of adult patients with autoimmune encephalitis. The guidelines were developed using a modified RAND process and included input from specialists in autoimmune neurology, neuropsychiatry and infectious diseases. These guidelines are targeted at front line clinicians and were created to provide a pragmatic and practical approach to managing such patients in the acute setting.
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Affiliation(s)
- Christopher Hahn
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Adrian Budhram
- Clinical Neurological Sciences, London Health Sciences Centre, London, ON, Canada
- Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada
| | - Katayoun Alikhani
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Nasser AlOhaly
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Grayson Beecher
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - Gregg Blevins
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - John Brooks
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Robert Carruthers
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Jacynthe Comtois
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Juthaporn Cowan
- Division of Infectious Diseases, Department of Medicine Ottawa Hospital, Ottawa, ON, Canada
| | - Paula de Robles
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Julien Hébert
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Ronak K Kapadia
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Sarah Lapointe
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Aaron Mackie
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Warren Mason
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Brienne McLane
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | | | - Ilia Poliakov
- Division of Neurology, University of Saskatchewan College of Medicine, Saskatoon, SK, Canada
| | - Penelope Smyth
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | | | - Christopher Uy
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
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Guo Y, Endmayr V, Zekeridou A, McKeon A, Leypoldt F, Hess K, Kalinowska-Lyszczarz A, Klang A, Pakozdy A, Höftberger E, Hametner S, Haider C, De Simoni D, Peters S, Gelpi E, Röcken C, Oberndorfer S, Lassmann H, Lucchinetti CF, Höftberger R. New insights into neuropathology and pathogenesis of autoimmune glial fibrillary acidic protein meningoencephalomyelitis. Acta Neuropathol 2024; 147:31. [PMID: 38310187 PMCID: PMC10838242 DOI: 10.1007/s00401-023-02678-7] [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: 09/05/2023] [Revised: 12/06/2023] [Accepted: 12/24/2023] [Indexed: 02/05/2024]
Abstract
Anti-glial fibrillary acidic protein (GFAP) meningoencephalomyelitis (autoimmune GFAP astrocytopathy) is a new autoimmune central nervous system (CNS) disease diagnosable by the presence of anti-GFAP autoantibodies in the cerebrospinal fluid and presents as meningoencephalomyelitis in the majority of patients. Only few neuropathological reports are available and little is known about the pathogenic mechanisms. We performed a histopathological study of two autopsies and nine CNS biopsies of patients with anti-GFAP autoantibodies and found predominantly a lymphocytic and in one autopsy case a granulomatous inflammatory phenotype. Inflammatory infiltrates were composed of B and T cells, including tissue-resident memory T cells. Although obvious astrocytic damage was absent in the GFAP-staining, we found cytotoxic T cell-mediated reactions reflected by the presence of CD8+/perforin+/granzyme A/B+ cells, polarized towards astrocytes. MHC-class-I was upregulated in reactive astrocytes of all biopsies and two autopsies but not in healthy controls. Importantly, we observed a prominent immunoreactivity of astrocytes with the complement factor C4d. Finally, we provided insight into an early phase of GFAP autoimmunity in an autopsy of a pug dog encephalitis that was characterized by marked meningoencephalitis with selective astrocytic damage with loss of GFAP and AQP4 in the lesions.Our histopathological findings indicate that a cytotoxic T cell-mediated immune reaction is present in GFAP autoimmunity. Complement C4d deposition on astrocytes could either represent the cause or consequence of astrocytic reactivity. Selective astrocytic damage is prominent in the early phase of GFAP autoimmunity in a canine autopsy case, but mild or absent in subacute and chronic stages in human disease, probably due to the high regeneration potential of astrocytes. The lymphocytic and granulomatous phenotypes might reflect different stages of lesion development or patient-specific modifications of the immune response. Future studies will be necessary to investigate possible implications of pathological subtypes for clinical disease course and therapeutic strategies.
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Affiliation(s)
- Yong Guo
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Verena Endmayr
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
- Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
- Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Frank Leypoldt
- Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein Kiel, Lübeck, Germany
- Department of Neurology, University Medical Center Schleswig-Holstein and Kiel University, Kiel, Germany
| | - Katharina Hess
- Institute of Neuropathology, University Hospital Muenster, Muenster, North Rhine Westphalia, Germany
- Department of Pathology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Alicja Kalinowska-Lyszczarz
- Department of Neurology, Division of Neurochemistry and Neuropathology, Poznan University of Medical Sciences, Poznań, Poland
| | - Andrea Klang
- Institute of Pathology, University of Veterinary Medicine, Vienna, Austria
| | - Akos Pakozdy
- Internal Medicine, University Clinic for Small Animals, University of Veterinary Medicine, Vienna, Austria
| | - Elisabeth Höftberger
- Internal Medicine, University Clinic for Small Animals, University of Veterinary Medicine, Vienna, Austria
| | - Simon Hametner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Carmen Haider
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Désirée De Simoni
- Division of Neurology, Karl Landsteiner University of Health Sciences, University Hospital, St. Pölten, Austria
| | - Sönke Peters
- Clinic for Radiology and Neuroradiology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Ellen Gelpi
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christoph Röcken
- Department of Pathology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Stefan Oberndorfer
- Division of Neurology, Karl Landsteiner University of Health Sciences, University Hospital, St. Pölten, Austria
| | - Hans Lassmann
- Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | | | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Tajiri M, Takasone K, Kodaira M, Kimura A, Shimohata T, Sekijima Y. Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy Following SARS-CoV-2 Infection. Intern Med 2024; 63:337-339. [PMID: 37952950 PMCID: PMC10864074 DOI: 10.2169/internalmedicine.2751-23] [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: 08/15/2023] [Accepted: 10/01/2023] [Indexed: 11/14/2023] Open
Abstract
We herein report the first case of autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy after coronavirus disease 2019 (COVID-19). A 23-year-old man experienced fatigue, a fever, and headache 14 days after the resolution of COVID-19. He was severely disoriented and admitted to our hospital. On admission, the patient exhibited disorientation, headache, neck stiffness, myoclonus of both upper limbs, dysuria, and pyramidal signs. A blood examination revealed hyponatremia, and a cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis. The CSF test results were positive for anti-GFAPα antibodies. The patient was treated with methylprednisolone pulse therapy, followed by oral prednisolone, which quickly ameliorated his neurological abnormalities.
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Affiliation(s)
- Masateru Tajiri
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
| | - Ken Takasone
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
| | - Minori Kodaira
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
| | - Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine, Japan
| | | | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
- Institute for Biomedical Sciences, Shinshu University, Japan
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Zheng X, Yang J, Hou Y, Shi X, Liu K. Prediction of clinical progression in nervous system diseases: plasma glial fibrillary acidic protein (GFAP). Eur J Med Res 2024; 29:51. [PMID: 38216970 PMCID: PMC10785482 DOI: 10.1186/s40001-023-01631-4] [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: 10/07/2023] [Accepted: 12/29/2023] [Indexed: 01/14/2024] Open
Abstract
Glial fibrillary acidic protein (GFAP), an intracellular type III intermediate filament protein, provides structural support and maintains the mechanical integrity of astrocytes. It is predominantly found in the astrocytes which are the most abundant subtypes of glial cells in the brain and spinal cord. As a marker protein of astrocytes, GFAP may exert a variety of physiological effects in neurological diseases. For example, previous published literatures showed that autoimmune GFAP astrocytopathy is an inflammatory disease of the central nervous system (CNS). Moreover, the studies of GFAP in brain tumors mainly focus on the predictive value of tumor volume. Furthermore, using biomarkers in the early setting will lead to a simplified and standardized way to estimate the poor outcome in traumatic brain injury (TBI) and ischemic stroke. Recently, observational studies revealed that cerebrospinal fluid (CSF) GFAP, as a valuable potential diagnostic biomarker for neurosyphilis, had a sensitivity of 76.60% and specificity of 85.56%. The reason plasma GFAP could serve as a promising biomarker for diagnosis and prediction of Alzheimer's disease (AD) is that it effectively distinguished AD dementia from multiple neurodegenerative diseases and predicted the individual risk of AD progression. In addition, GFAP can be helpful in differentiating relapsing-remitting multiple sclerosis (RRMS) versus progressive MS (PMS). This review article aims to provide an overview of GFAP in the prediction of clinical progression in neuroinflammation, brain tumors, TBI, ischemic stroke, genetic disorders, neurodegeneration and other diseases in the CNS and to explore the potential therapeutic methods.
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Affiliation(s)
- Xiaoxiao Zheng
- Department of Neurology, Neuroscience Center, The First Hospital of Jilin University, Xinmin Street 1#, Changchun, China
| | - Jingyao Yang
- Institute of Physiology, School of Basic Medical Sciences, Shanxi Medical University, Taiyuan, China
| | - Yiwei Hou
- Department of Neurology, Neuroscience Center, The First Hospital of Jilin University, Xinmin Street 1#, Changchun, China
| | - Xinye Shi
- Department of Cardiology, Shanxi Yingkang Yisheng General Hospital, Renmin North Road 5188#, Yuncheng, China
| | - Kangding Liu
- Department of Neurology, Neuroscience Center, The First Hospital of Jilin University, Xinmin Street 1#, Changchun, China.
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35
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McCombe JA, Sechi E, Zekeridou A. Neurologic manifestations of autoimmunity with immune checkpoint inhibitors. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:449-465. [PMID: 38494296 DOI: 10.1016/b978-0-12-823912-4.00024-4] [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
Immune checkpoint inhibitors (ICIs) are cancer immunotherapies that enhance the body's own immune system to treat cancer. ICI treatment, however, can cause immune-related adverse events (irAEs) that can affect any organ, resulting in significant morbidity and mortality. Neurologic irAEs (nirAEs) are rare and can affect the peripheral nervous system more commonly than the central nervous system. Treatment is dependent on the severity of the neurologic manifestations and often includs discontinuation of the ICI and initiation of steroid therapy as the first line; other treatments have also been used. NirAEs and cardiac irAEs have higher fatality rates underlying the importance of early recognition and appropriate management. This chapter reviews the clinical manifestations of neurologic immune-related adverse events associated with ICI treatment as well as diagnostic and therapeutic modalities.
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Affiliation(s)
- Jennifer A McCombe
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Elia Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Center of MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States.
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36
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Kvam KA, Stahl JP, Chow FC, Soldatos A, Tattevin P, Sejvar J, Mailles A. Outcome and Sequelae of Autoimmune Encephalitis. J Clin Neurol 2024; 20:3-22. [PMID: 38179628 PMCID: PMC10782092 DOI: 10.3988/jcn.2023.0242] [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: 07/04/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 01/06/2024] Open
Abstract
Autoimmune etiologies are a common cause for encephalitis. The clinical syndromes consistent with autoimmune encephalitis are both distinct and increasingly recognized, but less is known about persisting sequelae or outcomes. We searched PubMed for reports on outcomes after autoimmune encephalitis. Studies assessing validated, quantitative outcomes were included. We performed a narrative review of the published literature of outcomes after autoimmune encephalitis. We found 146 studies that produced outcomes data. The mortality rates were 6%-19% and the relapse risks were 10%-62%. Most patients achieved a good outcome based on a score on the modified Rankin Scale (mRS) of ≤2. Forty-nine studies evaluated outcomes beyond mRS; these studies investigated cognitive outcome, psychiatric sequelae, neurological deficits, global function, and quality-of-life/patient-reported outcomes using various tools at varying time points after the index hospital discharge. These more-detailed assessments revealed that most patients had persistent impairments, with frequent deficits in cognitive function, especially memory and attention. Depression and anxiety were also common. Many of these sequelae continued to improve over months or even years after the acute illness. While we found that lasting impairments were common among survivors of autoimmune encephalitis, additional research is needed to better understand the nature and impact of these sequelae. Standardized evaluation protocols are needed to improve the ability to compare outcomes across studies, guide rehabilitation strategies, and inform outcomes of interest in treatment trials as the field advances.
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Affiliation(s)
- Kathryn A Kvam
- Department of Neurology & Neurological Sciences, Center for Academic Medicine, Stanford University, Stanford, CA, USA.
| | | | - Felicia C Chow
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, CA, USA
| | - Ariane Soldatos
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - James Sejvar
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alexandra Mailles
- Department of Infectious Diseases, Santé publique France, Saint-Maurice, France
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37
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McKeon A, Tracy J. Paraneoplastic movement disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:211-227. [PMID: 38494279 DOI: 10.1016/b978-0-12-823912-4.00004-9] [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 movement disorders are diverse autoimmune neurological illnesses occurring in the context of systemic cancer, either in isolation or as part of a multifocal neurological disease. Movement phenomena may be ataxic, hypokinetic (parkinsonian), or hyperkinetic (myoclonus, chorea, or other dyskinetic disorders). Some disorders mimic neurodegenerative or hereditary illnesses. The subacute onset and coexisting nonclassic features of paraneoplastic disorders aid distinction. Paraneoplastic autoantibodies provide further information regarding differentiating cancer association, disease course, and treatment responses. A woman with cerebellar ataxia could have metabotropic glutamate receptor 1 autoimmunity, in the setting of Hodgkin lymphoma, a mild neurological phenotype and response to immunotherapy. A different woman, also with cerebellar ataxia, could have Purkinje cytoplasmic antibody type 1 (anti-Yo), accompanying ovarian adenocarcinoma, a rapidly progressive phenotype and persistent disabling deficits despite immune therapy. The list of antibody biomarkers is growing year-on-year, each with its own ideal specimen type for detection (serum or CSF), accompanying neurological manifestations, cancer association, treatment response, and prognosis. Therefore, a profile-based approach to screening both serum and CSF is recommended. Immune therapy trials are generally undertaken, and include one or more of corticosteroids, IVIg, plasma exchange, rituximab, or cyclophosphamide. Symptomatic therapies can also be employed for hyperkinetic disorders.
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Affiliation(s)
- Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
| | - Jennifer Tracy
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
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38
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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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39
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Villagrán-García M, Farina A, Campetella L, Arzalluz-Luque J, Honnorat J. Autonomic nervous system involvement in autoimmune encephalitis and paraneoplastic neurological syndromes. Rev Neurol (Paris) 2024; 180:107-116. [PMID: 38142198 DOI: 10.1016/j.neurol.2023.12.001] [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: 09/11/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 12/25/2023]
Abstract
In autoimmune neurological diseases, the autonomic nervous system can be the primary target of autoimmunity (e.g. autoimmune autonomic ganglionopathy), or, more frequently, be damaged together with other areas of the nervous system (e.g. Guillain-Barré syndrome). Patients with autoimmune encephalitis and paraneoplastic neurological syndromes (PNS) often develop dysautonomia; however, the frequency and spectrum of autonomic signs and symptoms remain ill defined except for those scenarios in which dysautonomia is a core feature of the disease. Such is the case of Lambert-Eaton myasthenic syndrome, Morvan syndrome or anti-NMDAR encephalitis; in the latter, patients with dysautonomia have been reported to carry a more severe disease and to retain higher disability than those without autonomic dysfunction. Likewise, the presence of autonomic involvement indicates a higher risk of death due to neurological cause in patients with anti-Hu PNS. However, in anti-Hu and other PNS, as well as in the context of immune checkpoint inhibitors' toxicities, the characterization of autonomic involvement is frequently overshadowed by the severity of other neurological symptoms and signs. When evaluated with tests specific for autonomic function, patients with autoimmune encephalitis or PNS usually show a more widespread autonomic involvement than clinically suggested, which may reflect a potential gap of care when it comes to diagnosing dysautonomia. This review aims to revise the autonomic involvement in patients with autoimmune encephalitis and PNS, using for that purpose an antibody-based approach. We also discuss and provide general recommendations for the evaluation and management of dysautonomia in these patients.
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Affiliation(s)
- M Villagrán-García
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Inserm U1314, MeLiS-UCBL-CNRS UMR 5284, University Claude-Bernard Lyon 1, Lyon, France
| | - A Farina
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Inserm U1314, MeLiS-UCBL-CNRS UMR 5284, University Claude-Bernard Lyon 1, Lyon, France; Department of Neuroscience, Psychology, Pharmacology and Child Health, University of Florence, Florence, Italy
| | - L Campetella
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Inserm U1314, MeLiS-UCBL-CNRS UMR 5284, University Claude-Bernard Lyon 1, Lyon, France
| | - J Arzalluz-Luque
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - J Honnorat
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Inserm U1314, MeLiS-UCBL-CNRS UMR 5284, University Claude-Bernard Lyon 1, Lyon, France.
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40
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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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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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Linnoila JJ. Paraneoplastic antibodies targeting intracellular antigens. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:335-346. [PMID: 38494288 DOI: 10.1016/b978-0-12-823912-4.00021-9] [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
Although they are relatively rare, the diagnosis of paraneoplastic neurologic syndromes (PNS) can be aided by the identification of neural autoantibodies in patients' serum and cerebrospinal fluid (CSF). They often clinically manifest as characteristic syndromes, including limbic encephalitis, opsoclonus-myoclonus syndrome, paraneoplastic cerebellar degeneration, and paraneoplastic encephalomyelitis. The antibodies are directed either toward intracellular targets, or epitopes on the cell surface. As compared to cell surface antibodies, intracellular paraneoplastic autoantibodies are more classically associated with cancer, most often lung, breast, thymoma, gynecologic, testicular, and/or neuroendocrine cancers. The malignancies themselves tend to be small and regionally contained, attesting to the strength of the immune system in cancer immunosurveillance. Typically, the intracellular antibodies are not directly pathogenic and tend to be associated with PNS that are poorly responsive to treatment. With some notable exceptions, including patients with PNS associated with testicular cancer, patients with intracellular antibodies are typically older individuals, in their 7th decade of life and beyond. Many of them are current or former smokers. Treatment strategies include tumor removal as well as immunotherapy to treat the concomitant PNS. Newer technologies and the ever-broadening use of cancer immunotherapies are contributing to the continued identification of novel intracellularly targeted autoantibodies.
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Affiliation(s)
- Jenny J Linnoila
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States.
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Bien CG, Büttner T, Reichen IC, Thomas A, Vlad B, Woermann F, Bien CI, Jelcic I. Glial Fibrillary Acidic Protein Autoimmunity After Aseptic Meningitis: A Report of 2 Cases. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200180. [PMID: 37949666 PMCID: PMC10691222 DOI: 10.1212/nxi.0000000000200180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/21/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVES We describe 2 patients with glial fibrillary acidic protein (GFAP) autoimmunity secondary to aseptic viral meningitis or meningoencephalomyelitis. METHODS This study involved a retrospective chart review. RESULTS Two female patients, 45 and 55 years of age, developed aseptic meningoencephalomyelitis or meningitis; in one patient, it was likely caused by herpes simplex virus 2. The patients were recovering from the infectious condition when they, 51 and 5 days after onset, had new symptoms with detection of GFAP antibodies in the CSF; CSF and serum samples from the initial lumbar punctures had been negative for GFAP antibodies. Both patients recovered with steroid treatment (in one case, plus rituximab; in the other, plus azathioprine) including resolution of MRI and CSF abnormalities. DISCUSSION These 2 patients had GFAP autoimmunity secondary to viral meningoencephalomyelitis or meningitis. This suggests that GFAP astrocytopathy might not always be a primary disease entity; it may follow another brain injury that triggers this autoimmune response.
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Affiliation(s)
- Christian G Bien
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany.
| | - Thomas Büttner
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Ina C Reichen
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Annette Thomas
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Benjamin Vlad
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Friedrich Woermann
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Corinna I Bien
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany.
| | - Ilijas Jelcic
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
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Montalvo M, Flanagan EP. Paraneoplastic/autoimmune myelopathies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:193-201. [PMID: 38494277 DOI: 10.1016/b978-0-12-823912-4.00017-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic myelopathies are a rare but important category of myelopathy. They usually present with an insidious or subacute progressive neurologic syndrome. Risk factors include tobacco use and family history of cancer. Cerebrospinal fluid analysis usually shows lymphocytic pleocytosis with elevated protein. MRI findings suggest that paraneoplastic myelopathies include longitudinally extensive T2 hyperintensities that are tract-specific and accompanied by enhancement, but spinal MRIs can also be normal. The most commonly associated neural antibodies include amphiphysin and collapsin-response-mediator-protein-5 (CRMP5/anti-CV2) antibodies with lung and breast cancers being the most frequent oncologic accompaniments. The differential diagnosis of paraneoplastic myelopathies includes nutritional deficiency myelopathy (B12, copper) as well as autoimmune/inflammatory conditions such as primary progressive multiple sclerosis or spinal cord sarcoidosis. Patients treated with immune checkpoint inhibitors for cancer may develop myelitis, that can be considered along the spectrum of paraneoplastic myelopathies. Management of paraneoplastic myelopathy includes oncologic treatment and immunotherapy. Despite these treatments, the prognosis is poor and the majority of patients eventually become wheelchair-dependent.
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Affiliation(s)
- Mayra Montalvo
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - 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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45
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Tang M, Huang S, Guo W, Zhou J, Huang Z, Li W, Sun Q, Wang Z. Case report: Excessive daytime sleepiness as a presenting manifestation of autoimmune glial fibrillary acidic protein astrocytopathy. Front Immunol 2023; 14:1302514. [PMID: 38173730 PMCID: PMC10761546 DOI: 10.3389/fimmu.2023.1302514] [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: 09/26/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
Autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A) is a recently discovered autoimmune inflammatory disease of the central nervous system. It presents with a variety of clinical symptoms, including fever, seizures, psychiatric symptoms, limber weakness, and sensory symptoms. However, the symptoms of sleep disorders have not been sufficiently addressed. Here, we report a case of GFAP-A in which the patient complained of excessive daytime sleepiness and an excessive need for sleep. Our patient was a 58-year-old male who experienced excessive daytime sleepiness for 50 days following SARS-CoV-2 infection. He was diagnosed with coronavirus disease 2019 on June 1st. On the 7th of June, he experienced excessive daytime sleepiness, nausea, reduced food intake, lower limb weakness, and dysuria. Subsequently, his sleepiness significantly deteriorated on July 21st. Five months prior, the patient underwent laparoscopic partial right nephrectomy for clear-cell renal cell carcinoma. Brain MRI revealed abnormal hyperintense lesions in the pontine brain and around the mesencephalic aqueduct on T2 and T2-fluid attenuated inversion recovery (T2-FLAIR) sequences However, these lesions did not exhibit any pathological enhancement. Spinal cord MRI revealed lesions in the C6-C7 and T2-T3 segments on the T2 sequence. His Epworth Sleepiness Scale (ESS) score was 16 (reference range, <10), and 24-hour polysomnography supported the diagnosis of rapid-eye-movement sleep disorder and severe sleep apnea-hypopnea syndrome. Glial fibrillary acidic protein IgG antibodies were detected in the cerebrospinal fluid (1:32, cell-based assay) but not in the serum. The level of hypocretin in the cerebrospinal fluid was 29.92 pg/mL (reference range ≥110 pg/mL), suggesting narcolepsy type 1. After treatment with corticosteroids for approximately 1 month, the patient showed considerable clinical and radiological improvement, as well as an increase in hypocretin levels. Although repeated polysomnography and multiple sleep latency tests suggested narcolepsy, his ESS score decreased to 8. Our findings broaden the range of clinical manifestations associated with GFAP-A, thereby enhancing diagnostic and therapeutic strategies for this disease. Additionally, our results indicate a potential common autoimmune mechanism involving GFAP-A and orexin system dysregulation, warranting further investigation.
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Affiliation(s)
| | | | | | | | | | | | | | - Zan Wang
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin, China
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Jin TY, Lin BT, Dai LJ, Lu X, Gao H, Hu J. Anti-glial fibrillary acidic protein antibody and anti-aquaporin-4 antibody double-positive neuromyelitis optica spectrum disorder: A case report. World J Clin Cases 2023; 11:8192-8199. [PMID: 38130792 PMCID: PMC10731168 DOI: 10.12998/wjcc.v11.i34.8192] [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: 09/18/2023] [Revised: 11/20/2023] [Accepted: 11/29/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND A case of neuromyelitis optica spectrum disorder (NMOSD) with positive cerebrospinal fluid (CSF) anti-aquaporin-4 antibody (AQP4-IgG) and anti-glial fibrillary acidic protein IgG (GFAP-IgG) at the time of relapse was reported. The exact roles of GFAP-IgG in NMOSD are not fully understood and are the subject of ongoing research. This study revealed the possible connection between GFAP-IgG and the occurrence or development of diseases. CASE SUMMARY A 19-year-old woman was admitted to the hospital due to a constellation of symptoms, including dizziness, nausea, and vomiting that commenced 1 year prior, reoccurred 2 mo ago, and were accompanied by visual blurring that also began 2 mo ago. Additionally, she presented with slurred speech and ptosis, both of which emerged 1 mo ago. Notably, her symptoms deteriorated 10 d prior to admission, leading to the onset of arm and leg weakness. During hospitalization, magnetic resonance imaging showed high T2-fluid attenuated inversion recovery signals, and slightly high and equal diffusion-weighted imaging signals. The serum antibody of AQP4-IgG tested positive at a dilution of 1:100. CSF antibody testing showed positive results for GFAP-IgG at a dilution of 1:10 and AQP4-IgG at a dilution of 1:32. Based on these findings, the patient was diagnosed with NMOSD. She received intravenous methylprednisolone at a daily dose of 500 mg for 5 d, followed by a tapering-off period. Afterward, the rate of reduction was gradually slowed down and the timely use of immunosuppressants was implemented. CONCLUSION The CFS was slightly GFAP-IgG-positive during the relapse period, which can aid in the diagnosis and treatment of the disease.
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Affiliation(s)
- Ting-Yu Jin
- Department of Neurology, First Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Bing-Tong Lin
- Department of Neurology, First Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Li-Jv Dai
- Department of Neurology, First Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Xia Lu
- Department of Neurology, First Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Han Gao
- Department of Neurology, First Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Jin Hu
- Department of Neurology, First Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
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Xu T, Chen J, Xuan T, Cheng J, Li H. Autoimmune glial fibrillary acidic protein astrocytopathy complicated with low flow perimedullary arteriovenous fistula: a case report. Front Immunol 2023; 14:1293425. [PMID: 38111582 PMCID: PMC10726202 DOI: 10.3389/fimmu.2023.1293425] [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: 09/13/2023] [Accepted: 11/20/2023] [Indexed: 12/20/2023] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy and low-flow perimedullary arteriovenous fistulas (PMAVFs) may cause longitudinal widespread myelopathy. We report a middle-aged male patient with autoimmune GFAP astrocytopathy complicated with low flow PMAVFs disease, presenting with lower extremity weakness and dysuria. Magnetic resonance imaging (MRI) of the spinal cord revealed a significant longitudinal extent of T2 high signal from T11 to L1, with the lesion located proximal to the vascular territory supplied by the anterior spinal artery. Multiple patchy abnormal signals were seen adjacent to the anterior and posterior horns of the lateral ventricles bilaterally and at the centers of the semi-ovals on MRI of the cranial brain, with iso signal in T1Flair, the high signal in T2WI, and no high signal seen in Diffusion Weighted Imaging (DWI). Subsequently, the presence of anti-GFAP antibodies was detected in the cerebrospinal fluid (CSF), and the diagnosis of autoimmune GFAP astrocytopathy in conjunction with low-flow PMAVFs was confirmed through spinal digital subtraction angiography (DSA). This case report aims to increase neurologists' awareness of this disease and avoid missed or misdiagnosed cases that may lead to delayed treatment.
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Affiliation(s)
- Ting Xu
- Department of Neuroelectrophysiology, Cardiovascular and Cerebrovascular Disease Hospital Branch, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Jingyun Chen
- Department of Neuroelectrophysiology, Cardiovascular and Cerebrovascular Disease Hospital Branch, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Tingting Xuan
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, China
| | - Jiang Cheng
- Diagnosis and Treatment Engineering Technology Research Center of Nevous System Disease of Ningxia Hui Autonomous Region, Yinchuan, China
- Department of Neurology, Cardiovascular and Cerebrovascular Disease Hospital Branch, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Haining Li
- Diagnosis and Treatment Engineering Technology Research Center of Nevous System Disease of Ningxia Hui Autonomous Region, Yinchuan, China
- Department of Neurology, General Hospital of Ningxia Medical University, Yinchuan, China
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Oprea E, Elosegi JA. Autoimmune GFAP-IgG astrocytopathy manifesting with acute cerebellitis and severe gastrointestinal symptoms. Rev Neurol (Paris) 2023; 179:1147-1151. [PMID: 37858434 DOI: 10.1016/j.neurol.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/31/2023] [Accepted: 08/04/2023] [Indexed: 10/21/2023]
Affiliation(s)
- E Oprea
- Neurology department, Cliniques Universitaires Saint Luc, Bruxelles, Belgique.
| | - J A Elosegi
- Neurology department, CHU Ambroise-Paré, Mons, Belgique
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Weidauer S, Hattingen E, Arendt CT. Cervical myelitis: a practical approach to its differential diagnosis on MR imaging. ROFO-FORTSCHR RONTG 2023; 195:1081-1096. [PMID: 37479218 DOI: 10.1055/a-2114-1350] [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: 07/23/2023]
Abstract
BACKGROUND Differential diagnosis of non-compressive cervical myelopathy encompasses a broad spectrum of inflammatory, infectious, vascular, neoplastic, neurodegenerative, and metabolic etiologies. Although the speed of symptom onset and clinical course seem to be specific for certain neurological diseases, lesion pattern on MR imaging is a key player to confirm diagnostic considerations. METHODS The differentiation between acute complete transverse myelitis and acute partial transverse myelitis makes it possible to distinguish between certain entities, with the latter often being the onset of multiple sclerosis. Typical medullary MRI lesion patterns include a) longitudinal extensive transverse myelitis, b) short-range ovoid and peripheral lesions, c) polio-like appearance with involvement of the anterior horns, and d) granulomatous nodular enhancement prototypes. RESULTS AND CONCLUSION Cerebrospinal fluid analysis, blood culture tests, and autoimmune antibody testing are crucial for the correct interpretation of imaging findings. The combination of neuroradiological features and neurological and laboratory findings including cerebrospinal fluid analysis improves diagnostic accuracy. KEY POINTS · The differentiation of medullary lesion patterns, i. e., longitudinal extensive transverse, short ovoid and peripheral, polio-like, and granulomatous nodular, facilitates the diagnosis of myelitis.. · Discrimination of acute complete and acute partial transverse myelitis makes it possible to categorize different entities, with the latter frequently being the overture of multiple sclerosis (MS).. · Neuromyelitis optica spectrum disorders (NMOSD) may start as short transverse myelitis and should not be mistaken for MS.. · The combination of imaging features and neurological and laboratory findings including cerebrospinal fluid analysis improves diagnostic accuracy.. · Additional brain imaging is mandatory in suspected demyelinating, systemic autoimmune, infectious, paraneoplastic, and metabolic diseases..
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Affiliation(s)
- Stefan Weidauer
- Institute for Neuroradiology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Elke Hattingen
- Institute for Neuroradiology, Goethe University Frankfurt, Frankfurt am Main, Germany
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Li Y, Luo H, Zheng Y, Zhou L, Jiang Y, Li X, Ma J, Jiang L. Pediatric anti-NMDAR encephalitis with demyelination on brain MRI: A single center study. Mult Scler Relat Disord 2023; 80:105063. [PMID: 37913674 DOI: 10.1016/j.msard.2023.105063] [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: 12/14/2022] [Revised: 09/10/2023] [Accepted: 10/08/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE To explore the clinical characteristics, immunotherapy response, and prognosis of pediatric anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis associated with demyelination on brain magnetic resonance (MRI). METHODS We retrospectively reviewed the medical records of children diagnosed with anti-NMDAR encephalitis in our hospital between January 2016 and December 2021. All children with evidence of demyelination on brain MRI were included. RESULTS A total of 183 anti-NMDAR encephalitis children were included; 8.7 % (16/183) of them had demyelination on brain MRI. Nine were positive for myelin oligodendrocyte glycoprotein (MOG)-IgG, while two were positive for both MOG-IgG and glial fibrillary acidic protein (GFAP)-IgG. Four patients had a history of acquired demyelinating syndromes and encephalitis, respectively, while nine (56.3 %) had atypical symptoms of anti-NMDAR encephalitis. All children had supratentorial demyelination on brain MRI; four of them had additional infratentorial lesions. All children received first-line immunotherapy; four were administered repeated first-line immunotherapy and/or rituximab because of poor initial response. During the follow-up, 37.5 % (6/16) of the children relapsed, but all responded well to immunotherapy. There were no significant differences in mRS score before immunotherapy, response to first-line immunotherapy, and long-term prognosis between anti-NMDAR encephalitis children with and without demyelination. However, patients with demyelination were more likely to have a history of acquired demyelinating syndromes or unexplained cortical encephalitis and to relapse. CONCLUSION Pediatric anti-NMDAR encephalitis can co-occur with demyelination and has a high rate of MOG-IgG positivity. A history of acquired demyelinating syndromes or unexplained cortical encephalitis and atypical symptoms may indicate demyelination in children with anti-NMDAR encephalitis. Pediatric anti-NMDAR encephalitis with demyelination is more likely to relapse and needs a closer follow-up. However, it remains unknown whether more intensive immunotherapy is required in these patients.
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Affiliation(s)
- Yuhang Li
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Paediatrics, 2 Zhongshan Rd, Chongqing 400013, China
| | - Hanyu Luo
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Paediatrics, 2 Zhongshan Rd, Chongqing 400013, China
| | - Yaxin Zheng
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Paediatrics, 2 Zhongshan Rd, Chongqing 400013, China
| | - Lvli Zhou
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Paediatrics, 2 Zhongshan Rd, Chongqing 400013, China
| | - Yan Jiang
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Paediatrics, 2 Zhongshan Rd, Chongqing 400013, China
| | - Xiujuan Li
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Paediatrics, 2 Zhongshan Rd, Chongqing 400013, China
| | - Jiannan Ma
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Paediatrics, 2 Zhongshan Rd, Chongqing 400013, China.
| | - Li Jiang
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Paediatrics, 2 Zhongshan Rd, Chongqing 400013, China.
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