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Dalakas MC. Stiff-person syndrome and related disorders - diagnosis, mechanisms and therapies. Nat Rev Neurol 2024; 20:587-601. [PMID: 39227464 DOI: 10.1038/s41582-024-01012-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2024] [Indexed: 09/05/2024]
Abstract
Stiff-person syndrome (SPS) is the prototypical and most common autoimmune neuronal hyperexcitability disorder. It presents with stiffness in the limbs and axial muscles, stiff gait with uncontrolled falls, and episodic painful muscle spasms triggered by anxiety, task-specific phobias and startle responses, collectively leading to disability. Increased awareness of SPS among patients and physicians has created concerns about diagnosis, misdiagnosis and treatment. This Review addresses the evolving diagnostic challenges in SPS and overlapping glutamic acid decarboxylase (GAD) antibody spectrum disorders, highlighting the growing number of overdiagnoses and focusing on the progress made in our understanding of SPS pathophysiology, antibodies against GAD and other inhibitory synaptic antigens, and the fundamentals of neuronal hyperexcitability. It considers the role of impaired GABAergic or glycinergic inhibition in the cortex and at multiple levels in the neuraxis; the underlying autoimmunity and involvement of GAD antibodies; immunopathogenic mechanisms beyond antibodies, including environmental triggers; familial and immunogenetic susceptibility; and potential T cell cytotoxicity. Finally, the mechanistic rationale for target-specific therapeutic interventions is presented along with the available therapeutic approaches, including enhancers of GABA signalling drugs and immunotherapies.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit, National and Kapodistrian University of Athens Medical School, Athens, Greece.
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Dalakas MC. Stiff Person Syndrome and GAD Antibody-Spectrum Disorders. Continuum (Minneap Minn) 2024; 30:1110-1135. [PMID: 39088290 DOI: 10.1212/con.0000000000001457] [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: 08/03/2024]
Abstract
OBJECTIVE Antibodies against glutamic acid decarboxylase (GAD), originally associated with stiff person syndrome (SPS), define the GAD antibody-spectrum disorders that also include cerebellar ataxia, autoimmune epilepsy, limbic encephalitis, progressive encephalomyelitis with rigidity and myoclonus (PERM), and eye movement disorders, all of which are characterized by autoimmune neuronal excitability. This article elaborates on the diagnostic criteria for SPS and SPS spectrum disorders, highlights disease mimics and misdiagnoses, describes the electrophysiologic mechanisms and underlying autoimmunity of stiffness and spasms, and provides a step-by-step therapeutic scheme. LATEST DEVELOPMENTS Very-high serum GAD antibody titers are diagnostic for GAD antibody-spectrum disorders and also predict the presence of GAD antibodies in the CSF, increased intrathecal synthesis, and reduced CSF γ-aminobutyric acid (GABA) levels. Low serum GAD antibody titers or the absence of antibodies generates diagnostic challenges that require careful distinction in patients with a variety of painful spasms and stiffness, including functional neurologic disorders. Antibodies against glycine receptors, first found in patients with PERM, are seen in 13% to 15% of patients with SPS, whereas amphiphysin and gephyrin antibodies, seen in 5% of patients with SPS spectrum disorders, predict a paraneoplastic association. GAD-IgG from different SPS spectrum disorders recognizes the same dominant GAD intracellular epitope and, although the pathogenicity is unclear, is an excellent diagnostic marker. The biological basis of muscle stiffness and spasms is related to autoimmune neuronal hyperexcitability caused by impaired reciprocal γ-aminobutyric acid-mediated (GABA-ergic) inhibition, which explains the therapeutic response to GABA-enhancing agents and immunotherapies. ESSENTIAL POINTS It is essential to distinguish SPS spectrum disorders from disease mimics to avoid both overdiagnoses and misdiagnoses, considering that SPS is treatable if managed correctly from the outset to prevent disease progression. A step-by-step, combination therapy of GABA-enhancing medications along with immunotherapies ensures prolonged clinical benefits.
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Patel J, Deschler E, Galang E. Spinal cord stimulation for the symptomatic treatment of rigidity and painful spasm in a case of stiff person syndrome. Pain Pract 2024; 24:798-804. [PMID: 38185725 DOI: 10.1111/papr.13340] [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: 01/09/2024]
Abstract
BACKGROUND Stiff person syndrome (SPS) is a rare neuroimmunological disorder characterized by rigidity and painful spasm primarily affecting the truncal and paraspinal musculature due to autoimmune-mediated neuronal hyperexcitability. Spinal cord stimulation (SCS) is an approved therapy for managing painful neuropathic conditions, including diabetic peripheral neuropathy and refractory angina pectoris. We describe the novel use of SCS for the treatment of spasm and rigidity in a 49-year-old man with seropositive stiff person syndrome (SPS). The patient was treated with intravenous immunoglobulin (IVIG) and oral medications over a 13-month period with minimal improvement, prompting consideration of SCS. To our knowledge, this is the first report of the successful use of SCS in SPS with the demonstration of multifaceted clinical improvement. METHODS Following a successful temporary SCS trial, permanent implantation was performed. Spasm/stiffness (Distribution of Stiffness Index; Heightened Sensitivity Scale; Penn Spasm Frequency Scale, PSFS), disability (Oswestry Disability Index, ODI; Pain Disability Index, PDI), depression (Patient Health Questionnaire-9, PHQ-9), sleep (Pittsburgh Sleep Quality Index, PSQI), fatigue (Fatigue Severity Scale, FSS), pain (Numerical Pain Rating Scale, NPRS), quality of life (EuroQoL 5 Dimension 5 Level, EQ-5D-5L), and medication usage were assessed at baseline, 6-month, and 10-month postimplantation. RESULTS ODI, PHQ-9, FSS, NPRS, PSQI, and EQ-5D-5L scores showed a notable change from baseline and surpassed the defined minimal clinically important difference (MCID) at 6-month and 10-month follow-up. Oral medication dosages were reduced. CONCLUSIONS The novel use of SCS therapy in seropositive SPS resulted in functional improvement and attenuation of symptoms. We present possible mechanisms by which SCS may produce clinical response in patients with SPS and aim to demonstrate proof-of-concept for a future comprehensive pilot study evaluating SCS-mediated response in SPS.
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Affiliation(s)
- Janus Patel
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Emily Deschler
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Enrique Galang
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Wang Y, Hu C, Aljarallah S, Reyes Mantilla M, Mukharesh L, Simpson A, Roy S, Harrison K, Shoemaker T, Comisac M, Balshi A, Obando D, Maldonado DAP, Koshorek J, Snoops S, Fitzgerald KC, Newsome SD. Expanding clinical profiles and prognostic markers in stiff person syndrome spectrum disorders. J Neurol 2024; 271:1861-1872. [PMID: 38078976 PMCID: PMC10973082 DOI: 10.1007/s00415-023-12123-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/15/2023] [Accepted: 11/19/2023] [Indexed: 03/28/2024]
Abstract
OBJECTIVE To describe the clinical features of a cohort of individuals with stiff person syndrome spectrum disorders (SPSD) and identify potential early predictors of future disability. BACKGROUND There is a need to better understand the full spectrum of clinical and paraclinical features and long-term impact of SPSD. DESIGN/METHODS Observational study from 1997 to 2022 at Johns Hopkins. Clinical phenotypes included classic SPS, partial SPS (limb or trunk limited), SPS-plus (classic features plus cerebellar/brainstem involvement), and progressive encephalomyelitis with rigidity and myoclonus (PERM). Outcome measures were modified Rankin scale (mRS) and use of assistive device for ambulation. Multivariate logistic regression was used to assess significant predictors of outcomes. RESULTS Cohort included 227 individuals with SPSD with mean follow-up of 10 years; 154 classic, 48 SPS-plus, 16 PERM, and 9 partial. Mean age at symptom onset was 42.9 ± 14.1 years, majority were white (69.2%) and female (75.8%). Median time to diagnosis was 36.2 months (longest for SPS-plus and PERM) and 61.2% were initially misdiagnosed. Most had systemic co-morbidities and required assistive devices for ambulation. Female sex (OR 2.08; CI 1.06-4.11) and initial brainstem/cerebellar involvement (OR 4.41; CI 1.63-14.33) predicted worse outcome by mRS. Older age at symptom onset (OR 1.04; CI 1.01-1.06), female sex (OR 1.99; CI 1.01-4.01), Black race (OR 4.14; CI 1.79-10.63), and initial brainstem/cerebellar involvement (OR 2.44; CI 1.04-7.19) predicted worse outcome by use of assistive device. Early implementation of immunotherapy was associated with better outcomes by either mRS (OR 0.45; CI 0.22-0.92) or use of assistive device (OR 0.79; CI 0.66-0.94). CONCLUSIONS We present the expanding phenotypic variability of this rare spectrum of disorders and highlight potential predictors of future disability.
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Affiliation(s)
- Yujie Wang
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Chen Hu
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Salman Aljarallah
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Maria Reyes Mantilla
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Loulwah Mukharesh
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Alexandra Simpson
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Shuvro Roy
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Kimystian Harrison
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Thomas Shoemaker
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Michael Comisac
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Alexandra Balshi
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Danielle Obando
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Daniela A Pimentel Maldonado
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Jacqueline Koshorek
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Sarah Snoops
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Kathryn C Fitzgerald
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Scott D Newsome
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA.
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Wiessler AL, Talucci I, Piro I, Seefried S, Hörlin V, Baykan BB, Tüzün E, Schaefer N, Maric HM, Sommer C, Villmann C. Glycine Receptor β-Targeting Autoantibodies Contribute to the Pathology of Autoimmune Diseases. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200187. [PMID: 38215349 PMCID: PMC10786602 DOI: 10.1212/nxi.0000000000200187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 10/02/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND AND OBJECTIVES Stiff-person syndrome (SPS) and progressive encephalomyelitis with rigidity and myoclonus (PERM) are rare neurologic disorders of the CNS. Until now, exclusive GlyRα subunit-binding autoantibodies with subsequent changes in function and surface numbers were reported. GlyR autoantibodies have also been described in patients with focal epilepsy. Autoimmune reactivity against the GlyRβ subunits has not yet been shown. Autoantibodies against GlyRα1 target the large extracellular N-terminal domain. This domain shares a high degree of sequence homology with GlyRβ making it not unlikely that GlyRβ-specific autoantibody (aAb) exist and contribute to the disease pathology. METHODS In this study, we investigated serum samples from 58 patients for aAb specifically detecting GlyRβ. Studies in microarray format, cell-based assays, and primary spinal cord neurons and spinal cord tissue immunohistochemistry were performed to determine specific GlyRβ binding and define aAb binding to distinct protein regions. Preadsorption approaches of aAbs using living cells and the purified extracellular receptor domain were further used. Finally, functional consequences for inhibitory neurotransmission upon GlyRβ aAb binding were resolved by whole-cell patch-clamp recordings. RESULTS Among 58 samples investigated, cell-based assays, tissue analysis, and preadsorption approaches revealed 2 patients with high specificity for GlyRβ aAb. Quantitative protein cluster analysis demonstrated aAb binding to synaptic GlyRβ colocalized with the scaffold protein gephyrin independent of the presence of GlyRα1. At the functional level, binding of GlyRβ aAb from both patients to its target impair glycine efficacy. DISCUSSION Our study establishes GlyRβ as novel target of aAb in patients with SPS/PERM. In contrast to exclusively GlyRα1-positive sera, which alter glycine potency, aAbs against GlyRβ impair receptor efficacy for the neurotransmitter glycine. Imaging and functional analyses showed that GlyRβ aAbs antagonize inhibitory neurotransmission by affecting receptor function rather than localization.
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Affiliation(s)
- Anna-Lena Wiessler
- From the Institute for Clinical Neurobiology (A.-L.W., V.H., N.S., C.V.), University of Wuerzburg; Department of Neurology (I.T., I.P., S.S., C.S.), University Hospital Wuerzburg; Rudolf Virchow Center for Integrative and Translational Bioimaging (I.T., H.M.M.), University of Wuerzburg, Germany; Department of Neurology (B.B.B.), Istanbul Faculty of Medicine; and Institute of Experimental Medical Research (E.T.), Istanbul University, Turkey
| | - Ivan Talucci
- From the Institute for Clinical Neurobiology (A.-L.W., V.H., N.S., C.V.), University of Wuerzburg; Department of Neurology (I.T., I.P., S.S., C.S.), University Hospital Wuerzburg; Rudolf Virchow Center for Integrative and Translational Bioimaging (I.T., H.M.M.), University of Wuerzburg, Germany; Department of Neurology (B.B.B.), Istanbul Faculty of Medicine; and Institute of Experimental Medical Research (E.T.), Istanbul University, Turkey
| | - Inken Piro
- From the Institute for Clinical Neurobiology (A.-L.W., V.H., N.S., C.V.), University of Wuerzburg; Department of Neurology (I.T., I.P., S.S., C.S.), University Hospital Wuerzburg; Rudolf Virchow Center for Integrative and Translational Bioimaging (I.T., H.M.M.), University of Wuerzburg, Germany; Department of Neurology (B.B.B.), Istanbul Faculty of Medicine; and Institute of Experimental Medical Research (E.T.), Istanbul University, Turkey
| | - Sabine Seefried
- From the Institute for Clinical Neurobiology (A.-L.W., V.H., N.S., C.V.), University of Wuerzburg; Department of Neurology (I.T., I.P., S.S., C.S.), University Hospital Wuerzburg; Rudolf Virchow Center for Integrative and Translational Bioimaging (I.T., H.M.M.), University of Wuerzburg, Germany; Department of Neurology (B.B.B.), Istanbul Faculty of Medicine; and Institute of Experimental Medical Research (E.T.), Istanbul University, Turkey
| | - Verena Hörlin
- From the Institute for Clinical Neurobiology (A.-L.W., V.H., N.S., C.V.), University of Wuerzburg; Department of Neurology (I.T., I.P., S.S., C.S.), University Hospital Wuerzburg; Rudolf Virchow Center for Integrative and Translational Bioimaging (I.T., H.M.M.), University of Wuerzburg, Germany; Department of Neurology (B.B.B.), Istanbul Faculty of Medicine; and Institute of Experimental Medical Research (E.T.), Istanbul University, Turkey
| | - Betül B Baykan
- From the Institute for Clinical Neurobiology (A.-L.W., V.H., N.S., C.V.), University of Wuerzburg; Department of Neurology (I.T., I.P., S.S., C.S.), University Hospital Wuerzburg; Rudolf Virchow Center for Integrative and Translational Bioimaging (I.T., H.M.M.), University of Wuerzburg, Germany; Department of Neurology (B.B.B.), Istanbul Faculty of Medicine; and Institute of Experimental Medical Research (E.T.), Istanbul University, Turkey
| | - Erdem Tüzün
- From the Institute for Clinical Neurobiology (A.-L.W., V.H., N.S., C.V.), University of Wuerzburg; Department of Neurology (I.T., I.P., S.S., C.S.), University Hospital Wuerzburg; Rudolf Virchow Center for Integrative and Translational Bioimaging (I.T., H.M.M.), University of Wuerzburg, Germany; Department of Neurology (B.B.B.), Istanbul Faculty of Medicine; and Institute of Experimental Medical Research (E.T.), Istanbul University, Turkey
| | - Natascha Schaefer
- From the Institute for Clinical Neurobiology (A.-L.W., V.H., N.S., C.V.), University of Wuerzburg; Department of Neurology (I.T., I.P., S.S., C.S.), University Hospital Wuerzburg; Rudolf Virchow Center for Integrative and Translational Bioimaging (I.T., H.M.M.), University of Wuerzburg, Germany; Department of Neurology (B.B.B.), Istanbul Faculty of Medicine; and Institute of Experimental Medical Research (E.T.), Istanbul University, Turkey
| | - Hans M Maric
- From the Institute for Clinical Neurobiology (A.-L.W., V.H., N.S., C.V.), University of Wuerzburg; Department of Neurology (I.T., I.P., S.S., C.S.), University Hospital Wuerzburg; Rudolf Virchow Center for Integrative and Translational Bioimaging (I.T., H.M.M.), University of Wuerzburg, Germany; Department of Neurology (B.B.B.), Istanbul Faculty of Medicine; and Institute of Experimental Medical Research (E.T.), Istanbul University, Turkey
| | - Claudia Sommer
- From the Institute for Clinical Neurobiology (A.-L.W., V.H., N.S., C.V.), University of Wuerzburg; Department of Neurology (I.T., I.P., S.S., C.S.), University Hospital Wuerzburg; Rudolf Virchow Center for Integrative and Translational Bioimaging (I.T., H.M.M.), University of Wuerzburg, Germany; Department of Neurology (B.B.B.), Istanbul Faculty of Medicine; and Institute of Experimental Medical Research (E.T.), Istanbul University, Turkey
| | - Carmen Villmann
- From the Institute for Clinical Neurobiology (A.-L.W., V.H., N.S., C.V.), University of Wuerzburg; Department of Neurology (I.T., I.P., S.S., C.S.), University Hospital Wuerzburg; Rudolf Virchow Center for Integrative and Translational Bioimaging (I.T., H.M.M.), University of Wuerzburg, Germany; Department of Neurology (B.B.B.), Istanbul Faculty of Medicine; and Institute of Experimental Medical Research (E.T.), Istanbul University, Turkey
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Celli SI, Nash R, Money KM, Garza M, Borko TL, Mizenko C, McMenamin C, Von Geldern G, Georges G, Piquet AL. Successful Autologous Hematopoietic Stem Cell Transplant in Glycine Receptor Antibody-Positive Stiff Person Syndrome: A Case Report. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200197. [PMID: 38170953 PMCID: PMC10766081 DOI: 10.1212/nxi.0000000000200197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/09/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND AND OBJECTIVES To describe a case of glycine receptor (GlyR) antibody-positive stiff person syndrome (SPS) treated with autologous hematopoietic stem cell transplant (aHSCT). METHODS This was a multicenter collaboration for the treatment of a single patient who underwent aHSCT as part of a clinical trial (NCT00716066). To objectively assess the response to transplantation, several clinical outcome measures were evaluated pretransplant and up to 18 months post-transplant, including modified Rankin Score (mRS), stiffness index, Hauser Ambulation Score (HAS), hypersensitivity index, timed 25-foot walk, and Montreal Cognitive Assessment. RESULTS After transplant, the patient achieved sustained clinical improvement evidenced across various clinical scales, including mRS, stiffness index, HAS, and 25-foot walk time. DISCUSSION aHSCT represents a promising treatment option for SPS, including for GlyR-positive patients. In addition, this case represents the need to validate and standardize best clinical outcome measures for patients with SPS. CLASSIFICATION OF EVIDENCE Class IV; this is a single observational study without controls.
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Affiliation(s)
- Sofia I Celli
- From the Department of Neurology (S.I.C., K.M.M., M.G., T.L.B., C. Mizenko, C. McMenamin, A.L.P.), University of Colorado, Aurora Colorado Blood Cancer Institute (R.N.), Presbyterian St. Luke's Medical Center, Denver, CO; Department of Neurology (G.V.G.); Fred Hutchinson Cancer Center (G.G.), University of Washington, Seattle, WA; and Northwestern University (G.G.), Feinberg School of Medicine, Chicago, IL
| | - Richard Nash
- From the Department of Neurology (S.I.C., K.M.M., M.G., T.L.B., C. Mizenko, C. McMenamin, A.L.P.), University of Colorado, Aurora Colorado Blood Cancer Institute (R.N.), Presbyterian St. Luke's Medical Center, Denver, CO; Department of Neurology (G.V.G.); Fred Hutchinson Cancer Center (G.G.), University of Washington, Seattle, WA; and Northwestern University (G.G.), Feinberg School of Medicine, Chicago, IL
| | - Kelli M Money
- From the Department of Neurology (S.I.C., K.M.M., M.G., T.L.B., C. Mizenko, C. McMenamin, A.L.P.), University of Colorado, Aurora Colorado Blood Cancer Institute (R.N.), Presbyterian St. Luke's Medical Center, Denver, CO; Department of Neurology (G.V.G.); Fred Hutchinson Cancer Center (G.G.), University of Washington, Seattle, WA; and Northwestern University (G.G.), Feinberg School of Medicine, Chicago, IL
| | - Madeline Garza
- From the Department of Neurology (S.I.C., K.M.M., M.G., T.L.B., C. Mizenko, C. McMenamin, A.L.P.), University of Colorado, Aurora Colorado Blood Cancer Institute (R.N.), Presbyterian St. Luke's Medical Center, Denver, CO; Department of Neurology (G.V.G.); Fred Hutchinson Cancer Center (G.G.), University of Washington, Seattle, WA; and Northwestern University (G.G.), Feinberg School of Medicine, Chicago, IL
| | - Tyler L Borko
- From the Department of Neurology (S.I.C., K.M.M., M.G., T.L.B., C. Mizenko, C. McMenamin, A.L.P.), University of Colorado, Aurora Colorado Blood Cancer Institute (R.N.), Presbyterian St. Luke's Medical Center, Denver, CO; Department of Neurology (G.V.G.); Fred Hutchinson Cancer Center (G.G.), University of Washington, Seattle, WA; and Northwestern University (G.G.), Feinberg School of Medicine, Chicago, IL
| | - Christopher Mizenko
- From the Department of Neurology (S.I.C., K.M.M., M.G., T.L.B., C. Mizenko, C. McMenamin, A.L.P.), University of Colorado, Aurora Colorado Blood Cancer Institute (R.N.), Presbyterian St. Luke's Medical Center, Denver, CO; Department of Neurology (G.V.G.); Fred Hutchinson Cancer Center (G.G.), University of Washington, Seattle, WA; and Northwestern University (G.G.), Feinberg School of Medicine, Chicago, IL
| | - Constance McMenamin
- From the Department of Neurology (S.I.C., K.M.M., M.G., T.L.B., C. Mizenko, C. McMenamin, A.L.P.), University of Colorado, Aurora Colorado Blood Cancer Institute (R.N.), Presbyterian St. Luke's Medical Center, Denver, CO; Department of Neurology (G.V.G.); Fred Hutchinson Cancer Center (G.G.), University of Washington, Seattle, WA; and Northwestern University (G.G.), Feinberg School of Medicine, Chicago, IL
| | - Gloria Von Geldern
- From the Department of Neurology (S.I.C., K.M.M., M.G., T.L.B., C. Mizenko, C. McMenamin, A.L.P.), University of Colorado, Aurora Colorado Blood Cancer Institute (R.N.), Presbyterian St. Luke's Medical Center, Denver, CO; Department of Neurology (G.V.G.); Fred Hutchinson Cancer Center (G.G.), University of Washington, Seattle, WA; and Northwestern University (G.G.), Feinberg School of Medicine, Chicago, IL
| | - George Georges
- From the Department of Neurology (S.I.C., K.M.M., M.G., T.L.B., C. Mizenko, C. McMenamin, A.L.P.), University of Colorado, Aurora Colorado Blood Cancer Institute (R.N.), Presbyterian St. Luke's Medical Center, Denver, CO; Department of Neurology (G.V.G.); Fred Hutchinson Cancer Center (G.G.), University of Washington, Seattle, WA; and Northwestern University (G.G.), Feinberg School of Medicine, Chicago, IL
| | - Amanda L Piquet
- From the Department of Neurology (S.I.C., K.M.M., M.G., T.L.B., C. Mizenko, C. McMenamin, A.L.P.), University of Colorado, Aurora Colorado Blood Cancer Institute (R.N.), Presbyterian St. Luke's Medical Center, Denver, CO; Department of Neurology (G.V.G.); Fred Hutchinson Cancer Center (G.G.), University of Washington, Seattle, WA; and Northwestern University (G.G.), Feinberg School of Medicine, Chicago, IL
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Shukla V, Singh VRS, Edwards AM, Fernandes M. Axial dystonia as a manifestation of stiff-person syndrome in a paediatric patient. BMJ Case Rep 2024; 17:e256448. [PMID: 38359959 PMCID: PMC10875472 DOI: 10.1136/bcr-2023-256448] [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: 02/17/2024] Open
Abstract
Stiff-person syndrome (SPS) is a rare neurological condition that frequently affects adults, with the neurologist diagnosing only one or two cases during his or her career. Reports of paediatric SPS are exceedingly rare, with less than 20 cases described in the literature.The patient presented was initially diagnosed with a functional movement disorder then a genetic dystonia, with a poor response to treatment trials and negative genetic testing. Consideration of Wilson's disease was refuted with non-supportive investigations and assessments.We aim to present the long road to diagnosing our first paediatric patient with SPS, who presented in middle childhood.
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Affiliation(s)
- Vanita Shukla
- Paediatric Department, NCRHA, Champ Fleurs, Trinidad and Tobago
- Child Health Unit, The University of the West Indies at St Augustine Faculty of Medical Sciences, Saint Augustine, Trinidad and Tobago
| | - Virendra Rajesh Sarabjit Singh
- Child Health Unit, The University of the West Indies at St Augustine Faculty of Medical Sciences, Saint Augustine, Trinidad and Tobago
| | | | - Maritza Fernandes
- Child Health Unit, The University of the West Indies at St Augustine Faculty of Medical Sciences, Saint Augustine, Trinidad and Tobago
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Zaharova VV, Ruina EA, Antipenko EA. [Stiff-person syndrome]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:139-144. [PMID: 39072580 DOI: 10.17116/jnevro2024124061139] [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: 07/30/2024]
Abstract
Stiff-person syndrome is a rare autoimmune disorder manifested by stiffness in the trunk and proximal limb muscles and painful muscle spasms in them. The disease is associated with the production of glutamate decarboxylase autoantibodies, an enzyme converting glutamate into gamma-aminobutyric acid. An increase of anti-GAD antibody serum levels above 10.000 IU/mL is specific for stiff-person syndrome. Our own clinical observation of a patient diagnosed with stiff-person syndrome is presented.
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Affiliation(s)
- V V Zaharova
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - E A Ruina
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - E A Antipenko
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
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Kerstens J, Titulaer MJ. Overview of treatment strategies in paraneoplastic neurological syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:97-112. [PMID: 38494299 DOI: 10.1016/b978-0-12-823912-4.00015-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Treatment strategies in paraneoplastic neurological syndromes rely on the three pillars of tumor treatment, immunotherapy, and symptomatic treatment, the first one being by far the most important in the majority of patients and syndromes. Classically, antibodies against extracellular antigens are directly pathogenic, and patients with these syndromes are more responsive to immunomodulatory or immunosuppressive treatments than the ones with antibodies against intracellular targets. This chapter first discusses some general principles of tumor treatment and immunotherapy, followed by a closer look at specific treatment options for different clinical syndromes, focusing on symptomatic treatments.
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Affiliation(s)
- Jeroen Kerstens
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Maarten J Titulaer
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands.
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Matsui N, Tanaka K, Ishida M, Yamamoto Y, Matsubara Y, Saika R, Iizuka T, Nakamura K, Kuriyama N, Matsui M, Arisawa K, Nakamura Y, Kaji R, Kuwabara S, Izumi Y. Prevalence, Clinical Profiles, and Prognosis of Stiff-Person Syndrome in a Japanese Nationwide Survey. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200165. [PMID: 37739810 PMCID: PMC10519438 DOI: 10.1212/nxi.0000000000200165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/17/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND AND OBJECTIVES To elucidate current epidemiologic, clinical, and immunologic profiles and treatments of stiff-person syndrome (SPS) in Japan. METHODS A nationwide mail survey was conducted using an established method. Data processing sheets were sent to randomly selected departments of internal medicine, neurology, pediatrics, psychiatry, and neurosurgery in hospitals and clinics throughout Japan to identify patients with SPS who were seen between January 2015 and December 2017. RESULTS Thirty cases were identified as glutamic acid decarboxylase 65 (GAD65)-positive SPS cases on the basis of detailed clinical data of 55 cases. Four patients had α1 subunit of glycine receptor (GlyR) antibodies, and 1 patient had both GAD65 and GlyR antibodies. The total estimated number of patients with GAD65-positive SPS was 140, and the estimated prevalence was 0.11 per 100,000 population. The median age at onset was 51 years (range, 26-83 years), and 23 (76%) were female. Of these, 70% had classic SPS, and 30% had stiff-limb syndrome. The median time from symptom onset to diagnosis was significantly longer in the high-titer GAD65 antibody group than in the low-titer group (13 months vs 2.5 months, p = 0.01). The median modified Rankin Scale (mRS) at baseline was 4, and the median mRS at the last follow-up was 2. Among the 29 GAD65-positive patients with ≥1 year follow-up, 7 received only symptomatic treatment, 9 underwent immunotherapy without long-term immunotherapy, and 13 received long-term immunotherapy such as oral prednisolone. The coexistence of type 1 diabetes mellitus and the lack of long-term immunotherapy were independent risk factors for poor outcome (mRS ≥3) in the GAD65-positive patients (odds ratio, 15.0; 95% CI 2.6-131.6; p = 0.001; odds ratio, 19.8; 95% CI 3.2-191.5; p = 0.001, respectively). DISCUSSION This study provides the current epidemiologic and clinical status of SPS in Japan. The symptom onset to the diagnosis of SPS was longer in patients with high-titer GAD65 antibodies than in those with low-titer GAD65 antibodies. The outcome of patients with SPS was generally favorable, but more aggressive immunotherapies are necessary for GAD65-positive patients with SPS.
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Affiliation(s)
- Naoko Matsui
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Keiko Tanaka
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Mitsuyo Ishida
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Yohei Yamamoto
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Yuri Matsubara
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Reiko Saika
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Takahiro Iizuka
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Koshi Nakamura
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Nagato Kuriyama
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Makoto Matsui
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Kokichi Arisawa
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Yosikazu Nakamura
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Ryuji Kaji
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Satoshi Kuwabara
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Yuishin Izumi
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
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Peng Y, Yang H, Xue YH, Chen Q, Jin H, Liu S, Yao SY, Du MQ. An update on malignant tumor-related stiff person syndrome spectrum disorders: clinical mechanism, treatment, and outcomes. Front Neurol 2023; 14:1209302. [PMID: 37859648 PMCID: PMC10582361 DOI: 10.3389/fneur.2023.1209302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/01/2023] [Indexed: 10/21/2023] Open
Abstract
Stiff person syndrome (SPS) is a rare central nervous system disorder associated with malignancies. In this review, we retrieved information from PubMed, up until August 2023, using various search terms and their combinations, including SPS, stiff person syndrome spectrum disorders (SPSSDs), paraneoplastic, cancer, and malignant tumor. Data from peer-reviewed journals printed in English were organized to explain the possible relationships between different carcinomas and SPSSD subtypes, as well as related autoantigens. From literature searching, it was revealed that breast cancer was the most prevalent carcinoma linked to SPSSDs, followed by lung cancer and lymphoma. Furthermore, classic SPS was the most common SPSSD subtype, followed by stiff limb syndrome and progressive encephalomyelitis with rigidity and myoclonus. GAD65 was the most common autoantigen in patients with cancer and SPSSDs, followed by amphiphysin and GlyR. Patients with cancer subtypes might have multiple SPSSD subtypes, and conversely, patients with SPSSD subtypes might have multiple carcinoma subtypes. The first aim of this review was to highlight the complex nature of the relationships among cancers, autoantigens, and SPSSDs as new information in this field continues to be generated globally. The adoption of an open-minded approach to updating information on new cancer subtypes, autoantigens, and SPSSDs is recommended to renew our database. The second aim of this review was to discuss SPS animal models, which will help us to understand the mechanisms underlying the pathogenesis of SPS. In future, elucidating the relationship among cancers, autoantigens, and SPSSDs is critical for the early prediction of cancer and discovery of new therapeutic modalities.
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Affiliation(s)
- Yong Peng
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ya-hui Xue
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Quan Chen
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Hong Jin
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Shu Liu
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Shun-yu Yao
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Miao-qiao Du
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
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12
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Vittayawacharin P, Sy MY, Isfahani SA, Karnes WE, Kongtim P, Ciurea SO. Autologous hematopoietic stem cell transplantation for a patient with multiple autoimmune diseases. Am J Hematol 2023; 98:1659-1662. [PMID: 37676996 DOI: 10.1002/ajh.27011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 09/09/2023]
Abstract
Level of autoantibodies after autologous hematopoietic stem cell transplantation. AGA, antigliadin antibody; AHSCT, autologous hematopoietic stem cell transplantation; Anti-GAD65, Ab anti-glutamic acid decarboxylase epitope 65 antibody; Anti-TPO, anti-thyroid peroxidase antibody; CU, chemiluminescent unit.
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Affiliation(s)
- Pongthep Vittayawacharin
- Hematopoietic Stem Cell Transplantation and Cellular Therapy Program, Division of Hematology/Oncology, Department of Medicine, University of California Irvine, California, USA
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - Michael Y Sy
- Department of Neurology, University of California Irvine Health, Orange, California, USA
| | | | - William E Karnes
- Division of Gastroenterology & Hepatology, Department of Medicine, University of California Irvine Health, Orange, California, USA
| | - Piyanuch Kongtim
- Hematopoietic Stem Cell Transplantation and Cellular Therapy Program, Division of Hematology/Oncology, Department of Medicine, University of California Irvine, California, USA
| | - Stefan O Ciurea
- Hematopoietic Stem Cell Transplantation and Cellular Therapy Program, Division of Hematology/Oncology, Department of Medicine, University of California Irvine, California, USA
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Lim TT, Por CY, Beh YY, Schee JP, Tan AH. Treatment of startle and related disorders. Clin Park Relat Disord 2023; 9:100218. [PMID: 37808566 PMCID: PMC10556813 DOI: 10.1016/j.prdoa.2023.100218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/04/2023] [Accepted: 09/15/2023] [Indexed: 10/10/2023] Open
Affiliation(s)
| | - Chia Yin Por
- Department of Medicine, Penang General Hospital, Penang, Malaysia
| | - Yuan Ye Beh
- Department of Medicine, Penang General Hospital, Penang, Malaysia
| | - Jie Ping Schee
- Faculty of Medicine (Divisions of Neurology), University of Malaya, Malaysia
| | - Ai Huey Tan
- Faculty of Medicine (Divisions of Neurology), University of Malaya, Malaysia
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Vlad B, Wang Y, Newsome SD, Balint B. Stiff Person Spectrum Disorders-An Update and Outlook on Clinical, Pathophysiological and Treatment Perspectives. Biomedicines 2023; 11:2500. [PMID: 37760941 PMCID: PMC10525659 DOI: 10.3390/biomedicines11092500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Stiff person spectrum disorders (SPSD) are paradigm autoimmune movement disorders characterized by stiffness, spasms and hyperekplexia. Though rare, SPSD represent a not-to-miss diagnosis because of the associated disease burden and treatment implications. After decades as an enigmatic orphan disease, major advances in our understanding of the evolving spectrum of diseases have been made along with the identification of multiple associated autoantibodies. However, the most important recent developments relate to the recognition of a wider affection, beyond the classic core motor symptoms, and to further insights into immunomodulatory and symptomatic therapies. In this review, we summarize the recent literature on the clinical and paraclinical spectrum, current pathophysiological understanding, as well as current and possibly future therapeutic strategies.
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Affiliation(s)
- Benjamin Vlad
- Department of Neurology, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Yujie Wang
- Department of Neurology, University of Washington, Seattle, WA 98195, USA
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Scott D. Newsome
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Bettina Balint
- Department of Neurology, University Hospital Zurich, 8091 Zurich, Switzerland;
- Faculty of Medicine, University of Zurich, 8091 Zurich, Switzerland
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Mercure-Corriveau N, Roy S, Hu C, Crowe EP, Zhu X, Obando D, Patel EU, Tobian AAR, Wang Y, Bloch EM, Newsome SD. Therapeutic plasma exchange in the management of stiff person syndrome spectrum disorders: a case series and review of the literature. Ther Adv Neurol Disord 2023; 16:17562864231180736. [PMID: 37529719 PMCID: PMC10387686 DOI: 10.1177/17562864231180736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 05/11/2023] [Indexed: 08/03/2023] Open
Abstract
Background Stiff person syndrome spectrum disorders (SPSD) are a rare group of disabling neuroimmunological disorders. SPSD often requires immune therapies, especially in the setting of inadequate response to symptomatic treatments. The safety and efficacy of therapeutic plasma exchange (TPE) in SPSD remains uncertain. Objectives To describe the safety, tolerability, and efficacy of TPE in patients with SPSD. Design A retrospective observational study. Methods A retrospective review of SPSD patients seen at Johns Hopkins Hospital (JHH) from 1997 to 2021 was performed. Patient demographics/history, examination/diagnostic findings, treatment response, and TPE-related complications were recorded. Assessment for any associations between clinical characteristics, including age, sex, clinical phenotype, and time on immunotherapy, and response to TPE 3 months after treatment was performed. A subgroup of 18 patients treated with TPE at JHH and 6 patients treated with TPE at outside institutions were evaluated for any change in usage of symptomatic medications 3 months after the TPE treatment. Literature review of SPSD and TPE was also conducted. Results Thirty-nine SPSD patients were treated with TPE (21 at JHH and 18 at outside institutions); median age 48 years, 77% female, median modified Rankin Scale 3; mean initial anti-GAD65 antibody titer was 23,508 U/mL. Twenty-four patients (62%) had classic SPS, 10 (26%) had SPS-plus, 2 (5%) had progressive encephalomyelitis with rigidity and myoclonus, and 3 (8%) had pure cerebellar ataxia. All patients were on symptomatic treatments, 30 (77%) previously received IVIg, and 3 (8%) previously received rituximab. Four patients (10%) had a TPE-related adverse event. One developed asymptomatic hypotension, another had both line thrombosis and infection, and two had non-life-threatening bleeding events. Twenty-three (59%) patients reported improvement in symptoms after TPE. Of the subgroup of 24 patients evaluated for any change in usage of symptomatic medications 3 months after the TPE treatment, 14 (58%) required fewer GABAergic symptomatic medications. Literature review identified 57 additional patients with SPSD; 43 (75%) reported temporary improvement after TPE. Conclusion The majority of patients treated with TPE had improvement. Moreover, most patients evaluated for any change in usage of symptomatic medications after the TPE treatment no longer required as much symptomatic medications months after TPE. TPE appears safe and well-tolerated in SPSD. Further studies are needed to assess the long-term efficacy of TPE in SPSD and identify which patients may benefit the most from TPE.
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Affiliation(s)
- Nicolas Mercure-Corriveau
- Division of Transfusion Medicine, Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Shuvro Roy
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Chen Hu
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Elizabeth P. Crowe
- Division of Transfusion Medicine, Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Xianming Zhu
- Division of Transfusion Medicine, Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Danielle Obando
- Department of Neurology, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Eshan U. Patel
- Division of Transfusion Medicine, Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Aaron A. R. Tobian
- Division of Transfusion Medicine, Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Yujie Wang
- Department of Neurology, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Evan M. Bloch
- Division of Transfusion Medicine, Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Scott D. Newsome
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins University, School of Medicine, 600 North Wolfe Street, Pathology 627, Baltimore, MD 21287, USA
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Hou JY, Liu HU, Kuo CY, Liu YH, Lin JJ, Hsieh MY, Hung PC, Cheng YT, Su IC, Wang HS, Chou IJ, Lin KL. The clinical relevance of anti-glutamic acid decarboxylase antibodies in children with encephalitis/encephalopathy. Front Neurosci 2023; 16:1081580. [PMID: 36817097 PMCID: PMC9932768 DOI: 10.3389/fnins.2022.1081580] [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: 10/27/2022] [Accepted: 12/31/2022] [Indexed: 02/05/2023] Open
Abstract
Anti-glutamic acid decarboxylase (anti-GAD) antibodies are associated with different types of syndromes. However, few studies have investigated the correlation between anti-GAD antibody titers with clinical severity and outcomes in children with encephalitis/encephalopathy. In this single-center retrospective cohort study, we consecutively enrolled hospitalized children who had encephalitis and/or encephalopathy with positive anti-GAD antibodies in serum and/or cerebrospinal fluid (CSF) from February 2010 to October 2021. Thirty-seven patients were included and divided into high-titer and low-titer groups. The patients with high anti-GAD antibody titers were associated with initial symptoms of language difficulty and ataxia. The level of titers was not associated with severity or outcomes. Anti-GAD antibody titers decreased after immunotherapy, however, the clinical response to immunotherapy was variable. A transient elevation in anti-GAD antibody titers during immunotherapy was noted. Further studies are warranted to investigate the role of anti-GAD antibodies in the pathogenesis and immune mechanisms of encephalitis/encephalopathy.
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Affiliation(s)
- Ju-Yin Hou
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Hsin-Uei Liu
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Cheng-Yen Kuo
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Yi-Hsuan Liu
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Jainn-Jim Lin
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan,Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Meng-Ying Hsieh
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Po-Cheng Hung
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Yi-Ting Cheng
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - I-Chen Su
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Huei-Shyong Wang
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - I-Jun Chou
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan,College of Medicine, Chang Gung University, Taoyuan City, Taiwan,I-Jun Chou,
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan,College of Medicine, Chang Gung University, Taoyuan City, Taiwan,*Correspondence: Kuang-Lin Lin,
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Muscle Tonus Evaluation in Patients with Neurological Disorders: A Scoping Review. J Med Biol Eng 2023. [DOI: 10.1007/s40846-023-00773-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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18
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Li Z, Han D, Chen T, Zhang L, Wang Y, Liu Y, Zhang X. Paraneoplastic stiff-person syndrome with lung cancer: a case report and literature review. Am J Transl Res 2023; 15:330-335. [PMID: 36777868 PMCID: PMC9908479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 11/29/2022] [Indexed: 02/14/2023]
Abstract
Stiff person syndrome is a rare autoimmune disease of the central nervous system that manifests as stiffness and painful spasms of the trunk axis and lower limb muscles. Benzodiazepines are the first choice for the clinical treatment of the disease. We reported a case of SPS. The patient presented with stiffness and convulsions of lower limbs, weakness after convulsions, falling off easily, abdominal muscle stiffness, and painful spasms lasting for several minutes and alleviating spontaneously. This was caused or aggravated by fatigue or mental stimulation. Left stiffness and weakness of the muscle after relief was present. A chest-enhanced computed tomography scan (CT) suggested two large ground glass nodules in the upper lobe of the left lung. Biopsy pathology indicated the nodules as adenocarcinoma in situ. The patient's symptoms were significantly relieved after treatment with clonazepam and diazepam combined with pregabalin. The clinical manifestations of SPS vary among patients. The symptoms of the disease are mild or severe. Early identification and treatment can improve the prognoses of these patients.
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Affiliation(s)
- Zhao Li
- Department of General Practice, Affiliated Hospital of Qingdao UniversityQingdao, Shandong, China
| | - Di Han
- Department of General Practice, Affiliated Hospital of Qingdao UniversityQingdao, Shandong, China
| | - Tong Chen
- Department of General Practice, Affiliated Hospital of Qingdao UniversityQingdao, Shandong, China
| | - Lifang Zhang
- Department of General Practice, Affiliated Hospital of Qingdao UniversityQingdao, Shandong, China
| | - Yan Wang
- Department of General Practice, Affiliated Hospital of Qingdao UniversityQingdao, Shandong, China
| | - Yixuan Liu
- Department of Pathology, Affiliated Hospital of Qingdao UniversityQingdao, Shandong, China
| | - Xuejuan Zhang
- Department of General Practice, Affiliated Hospital of Qingdao UniversityQingdao, Shandong, China
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Bai L, Ren H, Liang M, Lu Q, Lin N, Liu M, Fan S, Cui R, Guan H. Neurological disorders associated with glutamic acid decarboxylase 65 antibodies: Clinical spectrum and prognosis of a cohort from China. Front Neurol 2022; 13:990553. [PMID: 36277926 PMCID: PMC9581312 DOI: 10.3389/fneur.2022.990553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
Objective To describe clinical phenotypes and prognosis of neurological autoimmunity related to glutamic acid decarboxylase 65 (GAD65) antibodies in China. Method In this retrospective observational study from Peking Union Medical College Hospital, we identified patients with neurological disorders related to GAD65 antibodies (cell-based assay) from May 2015 to September 2021. Clinical manifestations, immunotherapy responsiveness, and outcomes were collected after obtaining informed consent from all patients. Results Fifty-five patients were included: 40 (72.73%) were women and initial neurological symptoms developed at 42(34-55) years of age. The median time to the nadir of the disease was 5 months (range from 1 day to 48 months). The clinical syndromes included limbic encephalitis (LE) or epilepsy (Ep) (n = 34, 61.82%), stiff-person syndromes (SPS) (n = 18, 32.73%), autoimmune cerebellar ataxia (ACA) (n = 11, 20%), and overlap syndrome in eight (14.55%) patients. Thirty-two (58.2%) patients had comorbidities of other autoimmune diseases, including Hashimoto thyroiditis (n = 17, 53.13%), T1DM (n = 11, 34.78%), vitiligo (n = 6, 18.75%), and others (n=5, 15.63%). Two (3.64%) patients had tumors, including thymoma and small cell lung cancer. Fifty-one (92.7%) patients received first-line immunotherapy (glucocorticoids and/or IV immunoglobulin), and 4 (7.3%) received second-line immunotherapy (rituximab). Long-term immunotherapy (mycophenolate mofetil) was administered to 23 (41.8%) patients. At the median time of 15 months (IQR 6–33.75 month, range 3–96 month) of follow-up, the patients' median modified Rankin Score (mRS) had declined from 2 to 1. Thirty-eight (70.4%) patients experienced clinical improvement (mRS declined ≥1), 47 (87%) had favorable clinical outcomes (mRS ≤2), and nine were symptom-free (16.7%). The sustained response to immunotherapy ranged from 7/15 (63.63%) in ACA patients and 22/34 (64.7%) in LE/Ep patients to 14/17 (82.35%) in SPS patients. Conclusions LE/Ep was the most common neurological phenotype of GAD65 antibody neurological autoimmunity in our cohort. Most patients had comorbidities of other autoimmune diseases, but underlying tumors were rare. Most patients responded to immunotherapy. However, the long-term prognosis varied among different clinical phenotypes.
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Affiliation(s)
- Lin Bai
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Menglin Liang
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Qiang Lu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Nan Lin
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Mange Liu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ruixue Cui
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Hongzhi Guan
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Yi J, Dalakas MC. Long-term Effectiveness of IVIg Maintenance Therapy in 36 Patients With GAD Antibody–Positive Stiff-Person Syndrome. NEUROLOGY - NEUROIMMUNOLOGY NEUROINFLAMMATION 2022; 9:9/5/e200011. [PMID: 35798561 PMCID: PMC9262284 DOI: 10.1212/nxi.0000000000200011] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 05/10/2022] [Indexed: 11/18/2022]
Abstract
Background and Objectives IVIg has been the preferred immunotherapy in stiff-person syndrome (SPS) based on a 3-month controlled trial, but whether it is also effective in inducing long-term benefits or arresting disease progression is unknown. The information is needed because SPS is a progressively disabling disease and IVIg is liberally used as chronic therapy without efficacy data. The present study explores the long-term effects of IVIg in the largest cohort of well-characterized patients with SPS followed by the same clinicians over 10 years. Methods Data of 36 patients (32 glutamic acid decarboxylase [GAD] positive), diagnosed and treated with monthly maintenance IVIg by the same neurologists, were analyzed. Response was assessed by physician-observed changes, patients' reports of symptom improvement, modified Rankin Scale (mRS) scores, and dependency trials evaluating symptom recurrence after stopping IVIg, prolonging infusion frequency, decreasing monthly dose, or wearing-off effects in between doses. Clinically meaningful long-term response was defined by improved mRS scores, improvement in physician-assessed stiffness, balance and gait, and functional decline with dependency trials. Results Twenty-four of 36 (67%) patients had clinically meaningful response over a median 40-month period. Patients with improved mRS scores by 1–2 points manifested improved gait, posture, balance and decreased stiffness, spasms, and startle response; some patients using a wheelchair and those ambulating with devices walked unassisted. In 25% of responders, treatment benefit was sustained for a 40-month median period, but in 29.1%, it declined over a 39-month period; 12.5% exhibited a conditioning effect. Three of 5 patients with cerebellar GAD-SPS variant also improved over time. The 12 patients who did not respond the first 3 months remained unresponsive even if IVIg continued for several months. Discussion This is a large study in 36 patients with SPS demonstrating that monthly maintenance IVIg therapy offers long-term benefits in 67% of patients for a median 3.3-year period. Because 29.1% experienced diminishing benefit over time due to disease progression, the study highlights the need for more effective therapies.
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Affiliation(s)
- Jessica Yi
- From the Department of Neurology (J.Y., M.C.D.), Thomas Jefferson University, Philadelphia, PA; and National and Kapodistrian University of Athens (M.C.D.)
| | - Marinos C Dalakas
- From the Department of Neurology (J.Y., M.C.D.), Thomas Jefferson University, Philadelphia, PA; and National and Kapodistrian University of Athens (M.C.D.). marinos.dalakas@jefferson
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21
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Newsome SD, Johnson T. Stiff person syndrome spectrum disorders; more than meets the eye. J Neuroimmunol 2022; 369:577915. [PMID: 35717735 PMCID: PMC9274902 DOI: 10.1016/j.jneuroim.2022.577915] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 05/21/2022] [Accepted: 06/07/2022] [Indexed: 10/18/2022]
Abstract
Stiff person syndrome spectrum disorders (SPSD) are a group of rare neuroimmunological disorders that often include painful spasms and rigidity. However, patients have highly heterogeneous signs and symptoms which may reflect different mechanistic disease processes. Understanding subsets of patients based on clinical phenotype may be important for prognosis and guiding treatment. The goal of this review is to provide updates on SPSD and its expanding clinical spectrum, prognostic markers, and treatment considerations. Further, we describe the current understanding in immunopathogenesis and highlight gaps in our knowledge appropriate for future research directions. Examples of revised diagnostic criteria for SPSD based on phenotype are also presented.
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Affiliation(s)
- Scott D Newsome
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Tory Johnson
- Johns Hopkins University School of Medicine, Baltimore, MD, USA; Section of Infections of the Nervous System, NINDS, NIH, Bethesda, MD, USA
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22
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Dalakas MC. Stiff-person Syndrome and GAD Antibody-spectrum Disorders: GABAergic Neuronal Excitability, Immunopathogenesis and Update on Antibody Therapies. Neurotherapeutics 2022; 19:832-847. [PMID: 35084720 PMCID: PMC9294130 DOI: 10.1007/s13311-022-01188-w] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2022] [Indexed: 01/10/2023] Open
Abstract
Although antibodies against Glutamic Acid Decarboxylase (GAD) were originally associated with Stiff Person Syndrome (SPS), they now denote the "GAD antibody-spectrum disorders (GAD-SD)" that include Cerebellar Ataxia, Autoimmune Epilepsy, Limbic Encephalitis, PERM and eye movement disorder. In spite of the unique clinical phenotype that each of these disorders has, there is significant overlapping symptomatology characterized by autoimmune neuronal excitability. In addition to GAD, three other autoantibodies, against glycine receptors, amphiphysin and gephyrin, are less frequently or rarely associated with SPS-SD. Very high serum anti-GAD antibody titers are a key diagnostic feature for all GAD-SD, commonly associated with the presence of GAD antibodies in the CSF, a reduced CSF GABA level and increased anti-GAD-specific IgG intrathecal synthesis denoting stimulation of B-cell clones in the CNS. Because anti-GAD antibodies from the various hyperexcitability syndromes recognize the same dominant GAD epitope, the clinical heterogeneity among GAD-SD patients remains unexplained. The paper highlights the biologic basis of autoimmune hyperexcitability connected with the phenomenon of reciprocal inhibition as the fundamental mechanism of the patients' muscle stiffness and spasms; addresses the importance of high-GAD antibody titers in diagnosis, pinpointing the diagnostic challenges in patients with low-GAD titers or their distinction from functional disorders; and discusses whether high GAD-antibodies are disease markers or pathogenic in the context of their association with reduced GABA level in the brain and CSF. Finally, it focuses on therapies providing details on symptomatic GABA-enhancing drugs and the currently available immunotherapies in a step-by-step approach. The prospects of future immunotherapeutic options with antibody therapies are also summarized.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit National and Kapodistrian University of Athens Medical School, Athens, Greece.
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Macher S, Bsteh G, Berger T, Höftberger R. Diagnostic approach and treatment regimens in adult patients suffering from antibody-mediated or paraneoplastic encephalitis. Curr Pharm Des 2022; 28:454-467. [PMID: 35100954 DOI: 10.2174/1381612828666220131093259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 12/17/2021] [Indexed: 11/22/2022]
Abstract
Identification of patients with antibody-mediated encephalitis poses a diagnostic challenge and any delay in that respect will increase the interval until initiation of immunotherapy and may negatively affect the patient´s clinical outcome. Within this review we focus on therapeutic strategies in antibody-mediated encephalitis and propose how to proceed with patients, who are suspected to have encephalitis of unknown origin. We further briefly outline differences in treatment of paraneoplastic and antibody-mediated encephalitis according to its pathomechanisms.
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Affiliation(s)
- Stefan Macher
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
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One in a Million: A Case Report of Stiff Person Syndrome. Case Rep Rheumatol 2022; 2022:7741545. [PMID: 35070465 PMCID: PMC8776484 DOI: 10.1155/2022/7741545] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 12/23/2021] [Indexed: 11/18/2022] Open
Abstract
Stiff person syndrome (SPS) is a rare autoimmune disease caused by lack of inhibition to excitatory neurotransmitters in the central nervous system (CNS) leading to inappropriate motor unit firing. The pathophysiology is incompletely understood; however, high titers of antiglutamic acid decarboxylase antibody (anti-GAD Ab) are strongly associated with this disease. We present a 50-year-old woman with a history of ongoing gait and balance issues for 5 years with multiple negative workups. She recently had an acute exacerbation which left her bedbound, unable to move her legs or turn from side to side. After a negative workup at an outside hospital, the patient was discharged to a subacute rehabilitation facility. She then presented to our institution due to worsening of her condition and was ultimately diagnosed with SPS which was successfully treated. We review the case presentation and treatment options in the context of a severe disabling disease presentation.
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Treatment and Management of Disorders of Neuromuscular Hyperexcitability and Periodic Paralysis. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00018-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Thaler FS, Zimmermann L, Kammermeier S, Strippel C, Ringelstein M, Kraft A, Sühs KW, Wickel J, Geis C, Markewitz R, Urbanek C, Sommer C, Doppler K, Penner L, Lewerenz J, Rößling R, Finke C, Prüss H, Melzer N, Wandinger KP, Leypoldt F, Kümpfel T. Rituximab Treatment and Long-term Outcome of Patients With Autoimmune Encephalitis: Real-world Evidence From the GENERATE Registry. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:e1088. [PMID: 34599001 PMCID: PMC8488759 DOI: 10.1212/nxi.0000000000001088] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 08/23/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND OBJECTIVES To determine the real-world use of rituximab in autoimmune encephalitis (AE) and to correlate rituximab treatment with the long-term outcome. METHODS Patients with NMDA receptor (NMDAR)-AE, leucine-rich glioma-inactivated-1 (LGI1)- AE, contactin-associated protein-like-2 (CASPR2)-AE, or glutamic acid decarboxylase 65 (GAD65) disease from the GErman Network for Research on AuToimmune Encephalitis who had received at least 1 rituximab dose and a control cohort of non-rituximab-treated patients were analyzed retrospectively. RESULTS Of the 358 patients, 163 (46%) received rituximab (NMDAR-AE: 57%, CASPR2-AE: 44%, LGI1-AE: 43%, and GAD65 disease: 37%). Rituximab treatment was initiated significantly earlier in NMDAR- and LGI1-AE (median: 54 and 155 days from disease onset) compared with CASPR2-AE or GAD65 disease (median: 632 and 1,209 days). Modified Rankin Scale (mRS) scores improved significantly in patients with NMDAR-AE, both with and without rituximab treatment. Although being more severely affected at baseline, rituximab-treated patients with NMDAR-AE more frequently reached independent living (mRS score ≤2) (94% vs 88%). In LGI1-AE, rituximab-treated and nontreated patients improved, whereas in CASPR2-AE, only rituximab-treated patients improved significantly. No improvement was observed in patients with GAD65 disease. A significant reduction of the relapse rate was observed in rituximab-treated patients (5% vs 13%). Detection of NMDAR antibodies was significantly associated with mRS score improvement. A favorable outcome was also observed with early treatment initiation. DISCUSSION We provide real-world data on immunosuppressive treatments with a focus on rituximab treatment for patients with AE in Germany. We suggest that early and short-term rituximab therapy might be an effective and safe treatment option in most patients with NMDAR-, LGI1-, and CASPR2-AE. CLASS OF EVIDENCE This study provides Class IV evidence that rituximab is an effective treatment for some types of AE.
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Affiliation(s)
- Franziska S. Thaler
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Luise Zimmermann
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Stefan Kammermeier
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Christine Strippel
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Marius Ringelstein
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Andrea Kraft
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Kurt-Wolfram Sühs
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Jonathan Wickel
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Christian Geis
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Robert Markewitz
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Christian Urbanek
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Claudia Sommer
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Kathrin Doppler
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Loana Penner
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Jan Lewerenz
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Rosa Rößling
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Carsten Finke
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Harald Prüss
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Nico Melzer
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Klaus-Peter Wandinger
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Frank Leypoldt
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Tania Kümpfel
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - on behalf of the German Network for Research on Autoimmune Encephalitis (GENERATE)
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
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Lin BC, Johal J, Sivakumar K, Romano AE, Yacoub HA. Stiff-person syndrome: an atypical presentation and a review of the literature. Hosp Pract (1995) 2021; 49:384-390. [PMID: 34313523 DOI: 10.1080/21548331.2021.1961456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: Stiff-person syndrome (SPS) is a rare autoimmune neurological disorder associated with muscle rigidity and spasms. A number of antibodies have been associated with disorder, including anti-glutamic acid decarboxylase and anti-amphiphysin.Case report; In this report, we present a rare case of a 79-year-old woman who presented with bilateral lower extremity weakness who was ultimately diagnosed with stiff-limb syndrome, a rare variant of SPS. Extensive laboratory and CSF studies were unrevealing. Electromyography showed significant peroneal motor neuropathy and complex repetitive discharges in the left tibialis anterior muscle. Antibodies to glutamic acid decarboxylase were significantly elevated at 124 units/mL. She was subsequently started on oral diazepam with significant improvement in her symptoms.Conclusion: The presentation of SPS can vary based on epidemiologic factors, clinical symptoms, and associated disorders. These forms can have overlapping features which may make the categorization of patients into one of these forms challenging.
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Affiliation(s)
- Benjamin C Lin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jaspreet Johal
- Department of Neurology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Keithan Sivakumar
- Division of Neurology, Sunnybrook Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Alissa E Romano
- Department of Neurology, Lehigh Valley Health Network, Allentown, PA, USA.,Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Hussam A Yacoub
- Department of Neurology, Lehigh Valley Health Network, Allentown, PA, USA.,Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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Olszewska DA, Bhowmick SS, Lang AE. Exacerbation of Stiff Person Syndrome by Selective Serotonin Reuptake Inhibitors. Mov Disord Clin Pract 2021; 8:772-774. [PMID: 34307751 DOI: 10.1002/mdc3.13199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/12/2021] [Accepted: 03/15/2021] [Indexed: 11/07/2022] Open
Affiliation(s)
- Diana A Olszewska
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic Toronto Western Hospital Toronto Ontario Canada
| | - Suvorit S Bhowmick
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic Toronto Western Hospital Toronto Ontario Canada
| | - Anthony E Lang
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic Toronto Western Hospital Toronto Ontario Canada
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Abstract
Autoimmune neurogenic dysphagia refers to manifestation of dysphagia due to autoimmune diseases affecting muscle, neuromuscular junction, nerves, roots, brainstem, or cortex. Dysphagia is either part of the evolving clinical symptomatology of an underlying neurological autoimmunity or occurs as a sole manifestation, acutely or insidiously. This opinion article reviews the autoimmune neurological causes of dysphagia, highlights clinical clues and laboratory testing that facilitate early diagnosis, especially when dysphagia is the presenting symptom, and outlines the most effective immunotherapeutic approaches. Dysphagia is common in inflammatory myopathies, most prominently in inclusion body myositis, and is frequent in myasthenia gravis, occurring early in bulbar-onset disease or during the course of progressive, generalized disease. Acute-onset dysphagia is often seen in Guillain–Barre syndrome variants and slowly progressive dysphagia in paraneoplastic neuropathies highlighted by the presence of specific autoantibodies. The most common causes of CNS autoimmune dysphagia are demyelinating and inflammatory lesions in the brainstem, occurring in patients with multiple sclerosis and neuromyelitis optica spectrum disorders. Less common, but often overlooked, is dysphagia in stiff-person syndrome especially in conjunction with cerebellar ataxia and high anti-GAD autoantibodies, and in gastrointestinal dysmotility syndromes associated with autoantibodies against the ganglionic acetyl-choline receptor. In the setting of many neurological autoimmunities, acute-onset or progressive dysphagia is a potentially treatable condition, requiring increased awareness for prompt diagnosis and early immunotherapy initiation.
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Liu J, Zhao G, Niu Y, Gan T, Yan Z, Zhang Y. Effect of electro-acupuncture therapy on limb spasm and excitability of motor neurons in stroke rats. Zhejiang Da Xue Xue Bao Yi Xue Ban 2021; 50:361-368. [PMID: 34402251 PMCID: PMC8710936 DOI: 10.3724/zdxbyxb-2021-0007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 11/30/2020] [Indexed: 11/25/2022]
Abstract
To investigate the effect of electro-acupuncture therapy on limb spasm and excitability of motor neurons in stroke rats. Ischemic stroke model was induced with middle cerebral artery embolization in SD rats. Thirty-three modeled rats were randomly divided into model group, electro-acupuncture group, and baclofen group with 11 rats in each group, and another 10 rats were taken as sham operation group. The electro-acupuncture group and the baclofen group were treated with electro-acupuncture and baclofen tablets respectively. The model group and the sham operation group had no intervention. The neural function was evaluated with Bederson's scale and balance beam test; the muscle tension was measured with electrophysiography; the pathological changes of brain tissue was examined with HE staining; the content of glutamic acid (Glu) and γ-aminobutyric acid (GABA) in rat cerebral cortex was analyze with enzyme linked immunosorbent assay (ELISA) method, the expression of metabotropic glutamate receptor 1a () and γ-aminobutyric acid type B receptor subunit 1 () mRNA were detected with RT-qPCR. Compared with the model group, the neurological function scores of the electro-acupuncture group and the baclofen group showed a downward trend at d7 after operation (all >0.05), and the neurological function scores of the electro-acupuncture group and the baclofen group were significantly decreased at d12 after the operation (all <0.05). Compared with sham operation group, the electrophysiological results of model group, electro-acupuncture group and baclofen group were significantly lower (all <0.05), and there was no statistical difference in the electrophysiological results of the model group, electro-acupuncture group and baclofen group at d7 after operation (all >0.05). Compared with the model group, the electrophysiological results of the electro-acupuncture group and baclofen group were significantly increased after operation (all <0.05). The results of HE staining showed that there was no cell edema and degeneration in the sham operation group, no pyknosis of the nucleus, and no bleeding in the interstitium. Cell edema and degeneration and mesenchymal congestion appeared in the model group. Compared with the model group, the cytoplasmic edema and degeneration and the interstitial bleeding in the electroacupuncture group and the baclofen group were reduced. Compared with sham operation group, the Glu content and the relative expression of mRNA was increased in the model group, electro-acupuncture group and baclofen group, while the GABA content and the relative expression of mRNA decreased (all <0.05). Compared with model group, the Glu content and the relative expression of mRNA in the electro-acupuncture group and baclofen group decreased, and the GABA content and relative expression of mRNA increased (all <0.05). Electro-acupuncture may improve limb spasm after stroke through regulating the expression of Glu and GABA in the cerebral cortex and the excitability of motor neurons in rats.
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Affiliation(s)
- Junxia Liu
- Rehabilitation of Traditional Chinese Medicine
| | - Guigui Zhao
- Rehabilitation of Traditional Chinese Medicine
| | - Yan Niu
- Rehabilitation of Traditional Chinese Medicine
| | - Ting Gan
- Rehabilitation of Traditional Chinese Medicine
| | - Zhenyu Yan
- Rehabilitation of Traditional Chinese Medicine
| | - Yasu Zhang
- Rehabilitation of Traditional Chinese Medicine
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31
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Bose S, Thompson JP, Sadalage G, Karim A, Jacob S. Quantitative Assessment of Response to Long-Term Treatment with Intravenous Immunoglobulin in Patients with Stiff Person Syndrome. Mov Disord Clin Pract 2021; 8:868-874. [PMID: 34401404 PMCID: PMC8354084 DOI: 10.1002/mdc3.13261] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 04/11/2021] [Accepted: 04/28/2021] [Indexed: 11/11/2022] Open
Abstract
Background Stiff person syndrome (SPS) is an autoimmune condition involving antibodies against several components of the inhibitory synapse in the spinal cord, with glutamic acid decarboxylase antibodies being the predominant immune marker. SPS affects approximately 1 patient per million population per year. The effect of intravenous immunoglobulin (IVIG) has been established, but studies on the long-term efficacy of regular IVIG are limited. Objectives To review clinical details and long-term treatment response using a patient-reported questionnaire in SPS and related syndromes. Methods Patients were identified from a tertiary neuroimmunology clinic based on classical clinical symptoms, autoimmune profiles, and neurophysiological changes (Dalakas criteria). They were followed up after treatment to assess the response to IVIG. Results A total of 23 patients fulfilled the selection criteria. Patients' demographic profiles and clinical presentations were akin to that reported in literature. There was significant improvement in the functional ability (assessed by the modified Rankin scale [mRS]) and quality of life (QoL) following treatment with IVIG within 4 to 10 weeks (pre-mRS vs. post-mRS, P < 0.0001; pre-QoL vs. post-QoL, P = 0.0003) and sustained after 5 years of treatment (pre-mRS vs. present mRS, P = 0.0003; pre-QoL vs. present QoL, P = 0.0002). Conclusions This article describes one of the largest single-center experiences of 23 patients with SPS and related syndromes and is the first to establish the long-term efficacy of regular IVIG using a patient-reported scoring system (Birmingham Response to Immunomodulatory Therapy [BRIT]). Consistent improvement in QoL and functional scores were seen over nearly 5 years after regular use of IVIG. It is recommended to use BRIT scores to assess the initial response as well as to monitor continued improvement to immunomodulation in SPS.
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Affiliation(s)
- Smriti Bose
- Department of Neurology University Hospitals Birmingham Birmingham United Kingdom
| | - Joseph P Thompson
- Department of Neurology University Hospitals Birmingham Birmingham United Kingdom
| | - Girija Sadalage
- Department of Neurology University Hospitals Birmingham Birmingham United Kingdom
| | - Abid Karim
- Clinical Immunology Service University of Birmingham Birmingham United Kingdom
| | - Saiju Jacob
- Department of Neurology University Hospitals Birmingham Birmingham United Kingdom.,Institute of Immunology and Immunotherapy University of Birmingham Birmingham United Kingdom
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Tsiortou P, Alexopoulos H, Dalakas MC. GAD antibody-spectrum disorders: progress in clinical phenotypes, immunopathogenesis and therapeutic interventions. Ther Adv Neurol Disord 2021; 14:17562864211003486. [PMID: 33854562 PMCID: PMC8013924 DOI: 10.1177/17562864211003486] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 02/27/2021] [Indexed: 12/14/2022] Open
Abstract
Antibodies against glutamic acid decarboxylase (GAD), originally linked to stiff person syndrome (SPS), now denote the "GAD antibody-spectrum disorders" (GAD-SD) that also include autoimmune epilepsy, limbic encephalitis, cerebellar ataxia and nystagmus with overlapping symptomatology highlighting autoimmune neuronal excitability disorders. The reasons for the clinical heterogeneity among GAD-antibody associated syndromes remain still unsettled, implicating variable susceptibility of GABAergic neurons to anti-GAD or other still unidentified autoantibodies. Although anti-GAD antibody titers do not correlate with clinical severity, very high serum titers, often associated with intrathecal synthesis of anti-GAD-specific IgG, point to in-situ effects of GAD or related autoantibodies within the central nervous system. It remains, however, uncertain what drives these antibodies, why they persist and whether they are disease markers or have pathogenic potential. The review, focused on these concerns, describes the widened clinical manifestations and overlapping features of all GAD-SD; addresses the importance of GAD antibody titers and potential significance of GAD epitopes; summarizes the biologic basis of autoimmune hyperexcitability; highlights the electrophysiological basis of reciprocal inhibition in muscle stiffness; and provides practical guidelines on symptomatic therapies with gamma-aminobutyric acid-enhancing drugs or various immunotherapies.
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Affiliation(s)
- Popianna Tsiortou
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Philadelphia, PA 19107, USA; Neuroimmunology Unit, National and Kapodistrian University of Athens, Athens, Greece
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Xie YY, Meng HM, Zhang FX, Maimaiti B, Jiang T, Yang Y. Involuntary movement in stiff-person syndrome with amphiphysin antibodies: A case report. Medicine (Baltimore) 2021; 100:e24312. [PMID: 33546061 PMCID: PMC7837982 DOI: 10.1097/md.0000000000024312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/24/2020] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Stiff-person syndrome (SPS) is a rare neurological immune disorder characterized by progressive axial and proximal limb muscle rigidity, stiffness, and painful muscle spasms. Amphiphysin antibodies are positive in approximately 5% of SPS patients. To date, there have been no relevant reports on involuntary movement in cases of SPS with amphiphysin antibodies. PATIENT CONCERNS We describe the case of a 69-year-old man with a 2-year history of progressive stiffness in the neck, bilateral shoulders, and chest muscles, and a more-than-a-year history of dyspnea accompanied by mandibular involuntary movement. The patient was a vegetarian and had good health in the past. The family's medical history was unremarkable. DIAGNOSES He was diagnosed with SPS based on the progressive muscle stiffness, the amphiphysin antibody seropositivity, the continuous motor activity on electromyography, and the effective treatment with benzodiazepines. INTERVENTIONS The patient was orally administered clonazepam and baclofen, and corticosteroid IV followed by prednisone orally. OUTCOMES In the hospital, after treatment with methylprednisolone, clonazepam, and baclofen, the patient's rigidity, stiffness, and dyspnea significantly improved. The involuntary movement of the mandible persisted throughout the treatment process. Currently, under oral treatment with baclofen and clonazepam, the patient's symptoms of muscle stiffness and dyspnea exist, and follow-up is continued. LESSONS We report a rare and novel case of involuntary movement in SPS with amphiphysin antibodies. The present report explores the relationship between SPS and involuntary movement and expands the spectrum of clinical manifestations of SPS.
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Affiliation(s)
| | | | | | | | | | - Yu Yang
- Department of Neurology and Neuroscience Center, First Hospital of Jilin University, Changchun, Jilin, China
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Burt RK, Balabanov R, Han X, Quigley K, Arnautovic I, Helenowski I, Rose J, Siddique T. Autologous Hematopoietic Stem Cell Transplantation for Stiff-Person Spectrum Disorder: A Clinical Trial. Neurology 2020; 96:e817-e830. [PMID: 33318163 DOI: 10.1212/wnl.0000000000011338] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 09/24/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To test the hypothesis that autologous nonmyeloablative hematopoietic stem cell transplantation (HSCT) is safe and shows efficacy in the treatment of stiff-person spectrum disorder (SPSD). METHODS Twenty-three participants were treated in a prospective open-label cohort study of safety and efficacy. After stem cell mobilization with cyclophosphamide (2 g/m2) and filgrastim (5-10 µg/kg/d), participants were treated with cyclophosphamide (200 mg/kg) divided as 50 mg/kg IV on day -5 to day -2; rabbit anti-thymocyte globulin (thymoglobulin) given intravenously at 0.5 mg/kg on day -5, 1 mg/kg on days -4 and -3, and 1.5 mg/kg on days -2, and -1 (total dose 5.5 mg/kg); and rituximab 500 mg IV on days -6 and +1. Unselected peripheral blood stem cells were infused on day 0. Safety was assessed by survival and National Cancer Institute common toxicity criteria for adverse events during HSCT. Outcome was assessed by ≥50% decrease or discontinuation of antispasmodic drugs and by quality of life instruments. RESULTS There was no treatment-related mortality. One participant died 1 year after transplantation of disease progression. Of the 74% of participants who responded, 47% have stayed in remission for a mean of 3.5 years; 26% did not respond. Compared to nonresponders, responders were more likely to have pretransplantation intermittent muscle spasms (16 of 17 vs 0 of 6), normal reflexes (12 of 17 vs 0 of 6), and positive CSF anti-glutamic acid decarboxylase serology (12 of 14 vs 2 of 6). Compared to responders, nonresponders were more likely to have lead pipe rigidity (4 of 6 vs 0 of 17) and EMG-documented simultaneous contraction of agonist/antagonist limb muscles (4 of 6 vs 1 of 17). Pre-HSCT use of prescription serotonin selective receptor inhibitor (SSRI) or serotonin and norepinephrine reuptake inhibitor (SNRI) was more common in those who relapsed or never responded (9 of 12) compared to those responders who never relapsed (0 of 11). CONCLUSION In this cohort, HSCT was safe, but the beneficial effect of HSCT was variable and confined predominately to participants with episodic spasms and normal tendon reflexes without simultaneous cocontraction of limb agonist/antagonist muscles who were not taking SSRI or SNRI antidepressants. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that, for a subset of people with SPSD, autologous nonmyeloablative HSCT improves outcomes. CLINICALTRIALSGOV IDENTIFIER NCT02282514.
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Affiliation(s)
- Richard K Burt
- From the Division of Immunotherapy (R.K.B., X.H., K.Q., I.A.), Department of Medicine, Department of Neurology (R.B., T.S.), Department of Preventive Medicine (I.H.), and Department of Pathology and Cell and Developmental Biology (T.S.), Northwestern University, Chicago, IL; and Department of Neurology (J.R.), University of Utah, Salt Lake City
| | - Roumen Balabanov
- From the Division of Immunotherapy (R.K.B., X.H., K.Q., I.A.), Department of Medicine, Department of Neurology (R.B., T.S.), Department of Preventive Medicine (I.H.), and Department of Pathology and Cell and Developmental Biology (T.S.), Northwestern University, Chicago, IL; and Department of Neurology (J.R.), University of Utah, Salt Lake City
| | - Xiaoqiang Han
- From the Division of Immunotherapy (R.K.B., X.H., K.Q., I.A.), Department of Medicine, Department of Neurology (R.B., T.S.), Department of Preventive Medicine (I.H.), and Department of Pathology and Cell and Developmental Biology (T.S.), Northwestern University, Chicago, IL; and Department of Neurology (J.R.), University of Utah, Salt Lake City
| | - Kathleen Quigley
- From the Division of Immunotherapy (R.K.B., X.H., K.Q., I.A.), Department of Medicine, Department of Neurology (R.B., T.S.), Department of Preventive Medicine (I.H.), and Department of Pathology and Cell and Developmental Biology (T.S.), Northwestern University, Chicago, IL; and Department of Neurology (J.R.), University of Utah, Salt Lake City
| | - Indira Arnautovic
- From the Division of Immunotherapy (R.K.B., X.H., K.Q., I.A.), Department of Medicine, Department of Neurology (R.B., T.S.), Department of Preventive Medicine (I.H.), and Department of Pathology and Cell and Developmental Biology (T.S.), Northwestern University, Chicago, IL; and Department of Neurology (J.R.), University of Utah, Salt Lake City
| | - Irene Helenowski
- From the Division of Immunotherapy (R.K.B., X.H., K.Q., I.A.), Department of Medicine, Department of Neurology (R.B., T.S.), Department of Preventive Medicine (I.H.), and Department of Pathology and Cell and Developmental Biology (T.S.), Northwestern University, Chicago, IL; and Department of Neurology (J.R.), University of Utah, Salt Lake City
| | - John Rose
- From the Division of Immunotherapy (R.K.B., X.H., K.Q., I.A.), Department of Medicine, Department of Neurology (R.B., T.S.), Department of Preventive Medicine (I.H.), and Department of Pathology and Cell and Developmental Biology (T.S.), Northwestern University, Chicago, IL; and Department of Neurology (J.R.), University of Utah, Salt Lake City
| | - Teepu Siddique
- From the Division of Immunotherapy (R.K.B., X.H., K.Q., I.A.), Department of Medicine, Department of Neurology (R.B., T.S.), Department of Preventive Medicine (I.H.), and Department of Pathology and Cell and Developmental Biology (T.S.), Northwestern University, Chicago, IL; and Department of Neurology (J.R.), University of Utah, Salt Lake City
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Dalakas MC. Limited Benefits Halt Enrollment in Hematopoietic Stem Cell Transplantation Trial for Stiff-Person Syndrome: Should There Be More to Come? Neurology 2020; 96:239-240. [PMID: 33318165 DOI: 10.1212/wnl.0000000000011349] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Marinos C Dalakas
- From the Department of Neurology, Thomas Jefferson University, Philadelphia, PA; and the Neuroimmunology Unit, National and Kapodistrian University of Athens Medical School, Greece.
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Ortiz JF, Ghani MR, Morillo Cox Á, Tambo W, Bashir F, Wirth M, Moya G. Stiff-Person Syndrome: A Treatment Update and New Directions. Cureus 2020; 12:e11995. [PMID: 33437550 PMCID: PMC7793517 DOI: 10.7759/cureus.11995] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Stiff-person syndrome (SPS) is a rare and disabling central nervous system disorder with no satisfactory treatment. Muscle rigidity, sporadic muscle spasms, and chronic muscle pain characterize SPS. SPS is strongly correlated with autoimmune diseases, and it is usual to find high titers of antibodies against acid decarboxylase (GAD65). Due to its highly disabling nature and complicated treatment, we aim to create a treatment protocol through a narrative review of currently available treatments that show efficacy. We expect to facilitate management based on treatment responses ranging from first-line medication to refractory medication. We conducted a medical subject heading (MeSH) strategy. We used the term SPS with the subheading treatment: "Stiff-Person Syndrome/Therapy" [MeSH]. An initial data gathering of 270 papers came out with the initial research. After using the inclusion criteria, we had 159 articles. We excluded 31 papers for being either systematic reviews, literature reviews, or meta-analysis. From the 128 remaining articles, we excluded another 104 papers because the extraction of the data was not possible or the study outcome did not meet our demands. There are two main treatments for SPS: GABAergic (gamma-aminobutyric acid) therapy and immunotherapy. For treatment, we suggest starting with benzodiazepines as first-line treatment. We recommend adding levetiracetam or pregabalin if symptoms persist. As second-line therapy, we recommend oral baclofen over rituximab and tacrolimus. We also suggest rituximab over tacrolimus. For patients with refractory treatment, we can use intrathecal baclofen, intravenous immunoglobulin (IVIG), or plasmapheresis. We conclude that intrathecal baclofen and IVIG are more effective than plasmapheresis in patients with refractory symptoms. Propofol may be used as a bridge - temporary therapy before initiating a permanent treatment.
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Affiliation(s)
- Juan Fernando Ortiz
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mohammad R Ghani
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | | | - Willians Tambo
- Neurology, Universidad San Francisco de Quito, Quito, ECU
| | - Farah Bashir
- Internal Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, PAK
| | - Martín Wirth
- Neurology, Universidad San Francisco de Quito, Quito, ECU
| | - Gustavo Moya
- Medicine, Carlos Andrade Marín Hospital, Quito, ECU
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Fileccia E, Rinaldi R, Minicuci G, D'Angelo R, Bartolomei L, Liguori R, Donadio V. Subcutaneous immunoglobulin for maintenance therapy in stiff-person syndrome: One-year follow-up in two patients. Neuromuscul Disord 2020; 30:921-924. [DOI: 10.1016/j.nmd.2020.09.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 10/23/2022]
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Das J, Sharrack B, Snowden JA. Autologous hematopoietic stem-cell transplantation in neurological disorders: current approach and future directions. Expert Rev Neurother 2020; 20:1299-1313. [PMID: 32893698 DOI: 10.1080/14737175.2020.1820325] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Autologous hematopoietic stem-cell transplantation (AHSCT) has become increasingly popular in recent years as an effective treatment of immune-mediated neurological diseases. Treatment-related mortality has significantly reduced primarily through better patient selection, optimization of transplant technique, and increased center experience. AREA COVERED Multiple sclerosis is the main indication, but people with neuromyelitis optica spectrum disorder, stiff-person spectrum disorder, chronic inflammatory demyelinating polyneuropathy, myasthenia gravis, and other immune-mediated neurological disorders also have been treated. The review herein discusses the use of AHSCT in these neurological disorders, the importance of patient selection and transplant technique optimization and future directions. EXPERT OPINION Phase II and III clinical trials have confirmed the safety and efficacy of AHSCT in multiple sclerosis and recent phase II clinical trials have also suggested its safety and efficacy in chronic inflammatory demyelinating polyneuropathy and neuromyelitis optica spectrum disorder, with the evidence in other neurological disorders limited to individual case reports, small case series, and registry data. Therefore, further randomized controlled clinical trials are required to assess its safety and efficacy in other neurological conditions. However, in rare neurological conditions, pragmatic treatment trials or registry-based studies may be more realistic options for gathering efficacy and safety data.
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Affiliation(s)
- Joyutpal Das
- Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust , Salford, UK.,Cardiovascular medicine, University of Manchester , Manchester, UK.,Department of Neuroscience, NIHR Translational Neuroscience BRC, Sheffield Teaching Hospitals NHS Foundation Trust, University of Sheffield , Sheffield, UK
| | - Basil Sharrack
- Department of Neuroscience, NIHR Translational Neuroscience BRC, Sheffield Teaching Hospitals NHS Foundation Trust, University of Sheffield , Sheffield, UK
| | - John A Snowden
- Department of Hematology, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield, UK
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Graus F, Saiz A, Dalmau J. GAD antibodies in neurological disorders — insights and challenges. Nat Rev Neurol 2020; 16:353-365. [DOI: 10.1038/s41582-020-0359-x] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2020] [Indexed: 01/07/2023]
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Dade M, Berzero G, Izquierdo C, Giry M, Benazra M, Delattre JY, Psimaras D, Alentorn A. Neurological Syndromes Associated with Anti-GAD Antibodies. Int J Mol Sci 2020; 21:E3701. [PMID: 32456344 PMCID: PMC7279468 DOI: 10.3390/ijms21103701] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 12/11/2022] Open
Abstract
Glutamic acid decarboxylase (GAD) is an intracellular enzyme whose physiologic function is the decarboxylation of glutamate to gamma-aminobutyric acid (GABA), the main inhibitory neurotransmitter within the central nervous system. GAD antibodies (Ab) have been associated with multiple neurological syndromes, including stiff-person syndrome, cerebellar ataxia, and limbic encephalitis, which are all considered to result from reduced GABAergic transmission. The pathogenic role of GAD Ab is still debated, and some evidence suggests that GAD autoimmunity might primarily be cell-mediated. Diagnosis relies on the detection of high titers of GAD Ab in serum and/or in the detection of GAD Ab in the cerebrospinal fluid. Due to the relative rarity of these syndromes, treatment schemes and predictors of response are poorly defined, highlighting the unmet need for multicentric prospective trials in this population. Here, we reviewed the main clinical characteristics of neurological syndromes associated with GAD Ab, focusing on pathophysiologic mechanisms.
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Affiliation(s)
- Maëlle Dade
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Giulia Berzero
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
- Neuroncology Unit, IRCCS Mondino Foundation, 27100 Pavia, Italy
| | - Cristina Izquierdo
- Department of Neuroscience, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, 08916 Badalona, Spain;
| | - Marine Giry
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Marion Benazra
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Jean-Yves Delattre
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Dimitri Psimaras
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Agusti Alentorn
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
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Muñoz-Lopetegi A, de Bruijn MAAM, Boukhrissi S, Bastiaansen AEM, Nagtzaam MMP, Hulsenboom ESP, Boon AJW, Neuteboom RF, de Vries JM, Sillevis Smitt PAE, Schreurs MWJ, Titulaer MJ. Neurologic syndromes related to anti-GAD65: Clinical and serologic response to treatment. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:e696. [PMID: 32123047 PMCID: PMC7136051 DOI: 10.1212/nxi.0000000000000696] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/13/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Antibodies against glutamic acid decarboxylase 65 (anti-GAD65) are associated with a number of neurologic syndromes. However, their pathogenic role is controversial. Our objective was to describe clinical and paraclinical characteristics of anti-GAD65 patients and analyze their response to immunotherapy. METHODS Retrospectively, we studied patients (n = 56) with positive anti-GAD65 and any neurologic symptom. We tested serum and CSF with ELISA, immunohistochemistry, and cell-based assay. Accordingly, we set a cutoff value of 10,000 IU/mL in serum by ELISA to group patients into high-concentration (n = 36) and low-concentration (n = 20) groups. We compared clinical and immunologic features and analyzed response to immunotherapy. RESULTS Classical anti-GAD65-associated syndromes were seen in 34/36 patients with high concentration (94%): stiff-person syndrome (7), cerebellar ataxia (3), chronic epilepsy (9), limbic encephalitis (9), or an overlap of 2 or more of the former (6). Patients with low concentrations had a broad, heterogeneous symptom spectrum. Immunotherapy was effective in 19/27 treated patients (70%), although none of them completely recovered. Antibody concentration reduction occurred in 15/17 patients with available pre- and post-treatment samples (median reduction 69%; range 27%-99%), of which 14 improved clinically. The 2 patients with unchanged concentrations showed no clinical improvement. No differences in treatment responses were observed between specific syndromes. CONCLUSION Most patients with high anti-GAD65 concentrations (>10,000 IU/mL) showed some improvement after immunotherapy, unfortunately without complete recovery. Serum antibody concentrations' course might be useful to monitor response. In patients with low anti-GAD65 concentrations, especially in those without typical clinical phenotypes, diagnostic alternatives are more likely.
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Affiliation(s)
- Amaia Muñoz-Lopetegi
- From the Department of Neurology (A.M.-L., M.A.A.M.d.B., A.E.M.B., M.M.P.N., E.S.P.H., A.J.W.B., R.F.N., J.M.d.V., P.A.E.S.S., M.J.T.) and Department of Immunology (S.B., M.W.J.S.), Erasmus MC University Medical Center; Department of Neurology (A.M.-L.), IDIBAPS, Barcelona, Spain; and Health Care Provider of the European Reference Network on Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) (M.J.T.), Rotterdam, the Netherlands
| | - Marienke A A M de Bruijn
- From the Department of Neurology (A.M.-L., M.A.A.M.d.B., A.E.M.B., M.M.P.N., E.S.P.H., A.J.W.B., R.F.N., J.M.d.V., P.A.E.S.S., M.J.T.) and Department of Immunology (S.B., M.W.J.S.), Erasmus MC University Medical Center; Department of Neurology (A.M.-L.), IDIBAPS, Barcelona, Spain; and Health Care Provider of the European Reference Network on Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) (M.J.T.), Rotterdam, the Netherlands
| | - Sanae Boukhrissi
- From the Department of Neurology (A.M.-L., M.A.A.M.d.B., A.E.M.B., M.M.P.N., E.S.P.H., A.J.W.B., R.F.N., J.M.d.V., P.A.E.S.S., M.J.T.) and Department of Immunology (S.B., M.W.J.S.), Erasmus MC University Medical Center; Department of Neurology (A.M.-L.), IDIBAPS, Barcelona, Spain; and Health Care Provider of the European Reference Network on Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) (M.J.T.), Rotterdam, the Netherlands
| | - Anna E M Bastiaansen
- From the Department of Neurology (A.M.-L., M.A.A.M.d.B., A.E.M.B., M.M.P.N., E.S.P.H., A.J.W.B., R.F.N., J.M.d.V., P.A.E.S.S., M.J.T.) and Department of Immunology (S.B., M.W.J.S.), Erasmus MC University Medical Center; Department of Neurology (A.M.-L.), IDIBAPS, Barcelona, Spain; and Health Care Provider of the European Reference Network on Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) (M.J.T.), Rotterdam, the Netherlands
| | - Mariska M P Nagtzaam
- From the Department of Neurology (A.M.-L., M.A.A.M.d.B., A.E.M.B., M.M.P.N., E.S.P.H., A.J.W.B., R.F.N., J.M.d.V., P.A.E.S.S., M.J.T.) and Department of Immunology (S.B., M.W.J.S.), Erasmus MC University Medical Center; Department of Neurology (A.M.-L.), IDIBAPS, Barcelona, Spain; and Health Care Provider of the European Reference Network on Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) (M.J.T.), Rotterdam, the Netherlands
| | - Esther S P Hulsenboom
- From the Department of Neurology (A.M.-L., M.A.A.M.d.B., A.E.M.B., M.M.P.N., E.S.P.H., A.J.W.B., R.F.N., J.M.d.V., P.A.E.S.S., M.J.T.) and Department of Immunology (S.B., M.W.J.S.), Erasmus MC University Medical Center; Department of Neurology (A.M.-L.), IDIBAPS, Barcelona, Spain; and Health Care Provider of the European Reference Network on Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) (M.J.T.), Rotterdam, the Netherlands
| | - Agnita J W Boon
- From the Department of Neurology (A.M.-L., M.A.A.M.d.B., A.E.M.B., M.M.P.N., E.S.P.H., A.J.W.B., R.F.N., J.M.d.V., P.A.E.S.S., M.J.T.) and Department of Immunology (S.B., M.W.J.S.), Erasmus MC University Medical Center; Department of Neurology (A.M.-L.), IDIBAPS, Barcelona, Spain; and Health Care Provider of the European Reference Network on Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) (M.J.T.), Rotterdam, the Netherlands
| | - Rinze F Neuteboom
- From the Department of Neurology (A.M.-L., M.A.A.M.d.B., A.E.M.B., M.M.P.N., E.S.P.H., A.J.W.B., R.F.N., J.M.d.V., P.A.E.S.S., M.J.T.) and Department of Immunology (S.B., M.W.J.S.), Erasmus MC University Medical Center; Department of Neurology (A.M.-L.), IDIBAPS, Barcelona, Spain; and Health Care Provider of the European Reference Network on Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) (M.J.T.), Rotterdam, the Netherlands
| | - Juna M de Vries
- From the Department of Neurology (A.M.-L., M.A.A.M.d.B., A.E.M.B., M.M.P.N., E.S.P.H., A.J.W.B., R.F.N., J.M.d.V., P.A.E.S.S., M.J.T.) and Department of Immunology (S.B., M.W.J.S.), Erasmus MC University Medical Center; Department of Neurology (A.M.-L.), IDIBAPS, Barcelona, Spain; and Health Care Provider of the European Reference Network on Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) (M.J.T.), Rotterdam, the Netherlands
| | - Peter A E Sillevis Smitt
- From the Department of Neurology (A.M.-L., M.A.A.M.d.B., A.E.M.B., M.M.P.N., E.S.P.H., A.J.W.B., R.F.N., J.M.d.V., P.A.E.S.S., M.J.T.) and Department of Immunology (S.B., M.W.J.S.), Erasmus MC University Medical Center; Department of Neurology (A.M.-L.), IDIBAPS, Barcelona, Spain; and Health Care Provider of the European Reference Network on Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) (M.J.T.), Rotterdam, the Netherlands
| | - Marco W J Schreurs
- From the Department of Neurology (A.M.-L., M.A.A.M.d.B., A.E.M.B., M.M.P.N., E.S.P.H., A.J.W.B., R.F.N., J.M.d.V., P.A.E.S.S., M.J.T.) and Department of Immunology (S.B., M.W.J.S.), Erasmus MC University Medical Center; Department of Neurology (A.M.-L.), IDIBAPS, Barcelona, Spain; and Health Care Provider of the European Reference Network on Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) (M.J.T.), Rotterdam, the Netherlands
| | - Maarten J Titulaer
- From the Department of Neurology (A.M.-L., M.A.A.M.d.B., A.E.M.B., M.M.P.N., E.S.P.H., A.J.W.B., R.F.N., J.M.d.V., P.A.E.S.S., M.J.T.) and Department of Immunology (S.B., M.W.J.S.), Erasmus MC University Medical Center; Department of Neurology (A.M.-L.), IDIBAPS, Barcelona, Spain; and Health Care Provider of the European Reference Network on Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) (M.J.T.), Rotterdam, the Netherlands.
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Lipton RB, Goadsby PJ, Smith J, Schaeffler BA, Biondi DM, Hirman J, Pederson S, Allan B, Cady R. Efficacy and safety of eptinezumab in patients with chronic migraine: PROMISE-2. Neurology 2020; 94:e1365-e1377. [PMID: 32209650 PMCID: PMC7274916 DOI: 10.1212/wnl.0000000000009169] [Citation(s) in RCA: 212] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 08/30/2019] [Indexed: 01/03/2023] Open
Abstract
Objective To evaluate the efficacy and safety of eptinezumab, a humanized anti–calcitonin gene-related peptide monoclonal antibody, in the preventive treatment of chronic migraine (CM). Methods The Prevention of Migraine via Intravenous ALD403 Safety and Efficacy–2 (PROMISE-2) study was a phase 3, multicenter, randomized, double-blind, placebo-controlled, parallel-group study. Adults with CM were randomly assigned to receive IV eptinezumab 100 mg, eptinezumab 300 mg, or placebo administered on day 0 and week 12. The primary endpoint was change from baseline in mean monthly migraine days (MMDs) over weeks 1 to 12. Results Among treated participants (n = 1,072), baseline mean number of MMDs was ≈16.1 across groups. Treatment with eptinezumab 100 and 300 mg was associated with significant reductions in MMDs across weeks 1 to 12 compared with placebo (placebo −5.6, 100 mg −7.7, p < 0.0001 vs placebo; 300 mg −8.2, p < 0.0001 vs placebo). Treatment-emergent adverse events (TEAEs) were reported by 43.5% (100 mg), 52.0% (300 mg), and 46.7% (placebo) of patients. Nasopharyngitis was the only TEAE reported for >2% of eptinezumab-treated patients at an incidence of >2% over placebo; it occurred in the 300 mg eptinezumab arm (eptinezumab 9.4%, placebo 6.0%). Conclusion In patients with CM, eptinezumab 100 and 300 mg was associated with a significant reduction in MMDs from the day after IV administration through week 12, was well tolerated, and demonstrated an acceptable safety profile. Classification of evidence This study provides Class I evidence that for patients with CM, a single dose of eptinezumab reduces MMDs over 12 weeks of treatment. ClinicalTrials.gov identifier NCT02974153.
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Affiliation(s)
- Richard B Lipton
- From the Montefiore Headache Center (R.B.L.); Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; NIHR-Wellcome Trust King's Clinical Research Facility (P.J.G.), SLaM Biomedical Research Centre, King's College London, UK; Alder BioPharmaceuticals, Ltd (J.S.), Dublin, Ireland; Lundbeck Seattle BioPharmaceuticals, Inc (B.A.S., D.M.B., S.P., B.A., R.C.), Bothell, WA; and Pacific Northwest Statistical Consulting, Inc (J.H.), Woodinville, WA. Dr. Biondi is now at Cohen Veterans Bioscience, Cambridge, MA. Dr. Allan is now at Global Safety Docs, Paradise Valley, AZ.
| | - Peter J Goadsby
- From the Montefiore Headache Center (R.B.L.); Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; NIHR-Wellcome Trust King's Clinical Research Facility (P.J.G.), SLaM Biomedical Research Centre, King's College London, UK; Alder BioPharmaceuticals, Ltd (J.S.), Dublin, Ireland; Lundbeck Seattle BioPharmaceuticals, Inc (B.A.S., D.M.B., S.P., B.A., R.C.), Bothell, WA; and Pacific Northwest Statistical Consulting, Inc (J.H.), Woodinville, WA. Dr. Biondi is now at Cohen Veterans Bioscience, Cambridge, MA. Dr. Allan is now at Global Safety Docs, Paradise Valley, AZ
| | - Jeff Smith
- From the Montefiore Headache Center (R.B.L.); Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; NIHR-Wellcome Trust King's Clinical Research Facility (P.J.G.), SLaM Biomedical Research Centre, King's College London, UK; Alder BioPharmaceuticals, Ltd (J.S.), Dublin, Ireland; Lundbeck Seattle BioPharmaceuticals, Inc (B.A.S., D.M.B., S.P., B.A., R.C.), Bothell, WA; and Pacific Northwest Statistical Consulting, Inc (J.H.), Woodinville, WA. Dr. Biondi is now at Cohen Veterans Bioscience, Cambridge, MA. Dr. Allan is now at Global Safety Docs, Paradise Valley, AZ
| | - Barbara A Schaeffler
- From the Montefiore Headache Center (R.B.L.); Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; NIHR-Wellcome Trust King's Clinical Research Facility (P.J.G.), SLaM Biomedical Research Centre, King's College London, UK; Alder BioPharmaceuticals, Ltd (J.S.), Dublin, Ireland; Lundbeck Seattle BioPharmaceuticals, Inc (B.A.S., D.M.B., S.P., B.A., R.C.), Bothell, WA; and Pacific Northwest Statistical Consulting, Inc (J.H.), Woodinville, WA. Dr. Biondi is now at Cohen Veterans Bioscience, Cambridge, MA. Dr. Allan is now at Global Safety Docs, Paradise Valley, AZ
| | - David M Biondi
- From the Montefiore Headache Center (R.B.L.); Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; NIHR-Wellcome Trust King's Clinical Research Facility (P.J.G.), SLaM Biomedical Research Centre, King's College London, UK; Alder BioPharmaceuticals, Ltd (J.S.), Dublin, Ireland; Lundbeck Seattle BioPharmaceuticals, Inc (B.A.S., D.M.B., S.P., B.A., R.C.), Bothell, WA; and Pacific Northwest Statistical Consulting, Inc (J.H.), Woodinville, WA. Dr. Biondi is now at Cohen Veterans Bioscience, Cambridge, MA. Dr. Allan is now at Global Safety Docs, Paradise Valley, AZ
| | - Joe Hirman
- From the Montefiore Headache Center (R.B.L.); Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; NIHR-Wellcome Trust King's Clinical Research Facility (P.J.G.), SLaM Biomedical Research Centre, King's College London, UK; Alder BioPharmaceuticals, Ltd (J.S.), Dublin, Ireland; Lundbeck Seattle BioPharmaceuticals, Inc (B.A.S., D.M.B., S.P., B.A., R.C.), Bothell, WA; and Pacific Northwest Statistical Consulting, Inc (J.H.), Woodinville, WA. Dr. Biondi is now at Cohen Veterans Bioscience, Cambridge, MA. Dr. Allan is now at Global Safety Docs, Paradise Valley, AZ
| | - Susan Pederson
- From the Montefiore Headache Center (R.B.L.); Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; NIHR-Wellcome Trust King's Clinical Research Facility (P.J.G.), SLaM Biomedical Research Centre, King's College London, UK; Alder BioPharmaceuticals, Ltd (J.S.), Dublin, Ireland; Lundbeck Seattle BioPharmaceuticals, Inc (B.A.S., D.M.B., S.P., B.A., R.C.), Bothell, WA; and Pacific Northwest Statistical Consulting, Inc (J.H.), Woodinville, WA. Dr. Biondi is now at Cohen Veterans Bioscience, Cambridge, MA. Dr. Allan is now at Global Safety Docs, Paradise Valley, AZ
| | - Brent Allan
- From the Montefiore Headache Center (R.B.L.); Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; NIHR-Wellcome Trust King's Clinical Research Facility (P.J.G.), SLaM Biomedical Research Centre, King's College London, UK; Alder BioPharmaceuticals, Ltd (J.S.), Dublin, Ireland; Lundbeck Seattle BioPharmaceuticals, Inc (B.A.S., D.M.B., S.P., B.A., R.C.), Bothell, WA; and Pacific Northwest Statistical Consulting, Inc (J.H.), Woodinville, WA. Dr. Biondi is now at Cohen Veterans Bioscience, Cambridge, MA. Dr. Allan is now at Global Safety Docs, Paradise Valley, AZ
| | - Roger Cady
- From the Montefiore Headache Center (R.B.L.); Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; NIHR-Wellcome Trust King's Clinical Research Facility (P.J.G.), SLaM Biomedical Research Centre, King's College London, UK; Alder BioPharmaceuticals, Ltd (J.S.), Dublin, Ireland; Lundbeck Seattle BioPharmaceuticals, Inc (B.A.S., D.M.B., S.P., B.A., R.C.), Bothell, WA; and Pacific Northwest Statistical Consulting, Inc (J.H.), Woodinville, WA. Dr. Biondi is now at Cohen Veterans Bioscience, Cambridge, MA. Dr. Allan is now at Global Safety Docs, Paradise Valley, AZ
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Cerebellar Ataxia Followed by Stiff Person Syndrome in a Patient with Anti-GAD Antibodies. Case Reports Immunol 2020; 2020:8454532. [PMID: 32089910 PMCID: PMC7031724 DOI: 10.1155/2020/8454532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 01/18/2020] [Indexed: 11/24/2022] Open
Abstract
Anti-GAD antibody syndrome is a result of the production of antibodies against glutamic acid decarboxylase (GAD), the main enzyme responsible for the production of gamma-aminobutyric acid (GABA). Several neurological manifestations including cerebellar ataxia and stiff person syndrome have been reported in association with anti-GAD antibodies. In this paper, we present a case of a young woman with anti-GAD antibodies who initially presented with cerebellar ataxia followed by stiff person syndrome three and a half years later. Having both cerebellar ataxia and stiff person syndrome is a rare occurrence in anti-GAD antibody syndrome. We emphasise the importance of long-term follow-up of patients with anti-GAD antibody syndrome, as delayed neurological manifestations can occur.
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Ashina M, Saper J, Cady R, Schaeffler BA, Biondi DM, Hirman J, Pederson S, Allan B, Smith J. Eptinezumab in episodic migraine: A randomized, double-blind, placebo-controlled study (PROMISE-1). Cephalalgia 2020; 40:241-254. [PMID: 32075406 PMCID: PMC7066477 DOI: 10.1177/0333102420905132] [Citation(s) in RCA: 210] [Impact Index Per Article: 52.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of eptinezumab, a humanized anti-calcitonin gene-related peptide monoclonal antibody, in the preventive treatment of episodic migraine. METHODS The PRevention Of Migraine via Intravenous ALD403 Safety and Efficacy-1 (PROMISE-1) study was a phase 3, multicenter, randomized, double-blind, placebo-controlled, parallel-group study. Adults with episodic migraine were randomized to eptinezumab 30 mg, 100 mg, 300 mg, or placebo for up to four intravenous (IV) doses administered every 12 weeks. The primary endpoint was change from baseline in monthly migraine days (MMDs) over weeks 1-12. RESULTS A total of 888 patients received treatment across 84 study sites. Mean MMDs at baseline was ∼8.6 across treatment groups. Eptinezumab 100 mg and 300 mg met the primary endpoint, significantly reducing MMDs across weeks 1-12 compared with placebo (30 mg, -4.0; 100 mg, -3.9, p = 0.0182; 300 mg, -4.3; placebo, -3.2, p = 0.0001). Treatment-emergent adverse events were reported by 58.4% (30 mg), 63.2% (100 mg), 57.6% (300 mg), and 59.5% (placebo) of patients. Treatment-emergent adverse events reported by ≥2% of eptinezumab-treated patients at an incidence greater than placebo included: upper respiratory tract infection (30 mg, 11.4%; 100 mg, 9.9%; 300 mg, 10.3%; placebo, 7.2%), and fatigue (30 mg, 2.3%; 100 mg, 3.6%; 300 mg, 3.6%; placebo, <1%). CONCLUSION Eptinezumab (100 mg or 300 mg) significantly reduced migraine frequency, was well tolerated, and had an acceptable safety profile when used for the preventive treatment of migraine in adults with episodic migraine. ClinicalTrials.gov identifier: NCT02559895.
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Affiliation(s)
- Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Joel Saper
- Michigan Headache & Neurological Institute, Ann Arbor, MI, USA
| | - Roger Cady
- Lundbeck Seattle BioPharmaceuticals, Inc., Bothell, WA, USA
| | | | | | - Joe Hirman
- Pacific Northwest Statistical Consulting, Inc., Woodinville, WA, USA
| | - Susan Pederson
- Lundbeck Seattle BioPharmaceuticals, Inc., Bothell, WA, USA
| | - Brent Allan
- Alder BioPharmaceuticals, Inc., Bothell, WA, USA
| | - Jeff Smith
- Lundbeck Seattle BioPharmaceuticals, Inc., Bothell, WA, USA
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Kodama S, Tokushige SI, Sugiyama Y, Sato K, Otsuka J, Shirota Y, Hamada M, Iwata A, Toda T, Tsuji S, Terao Y. Rituximab improves not only back stiffness but also "stiff eyes" in stiff person syndrome: Implications for immune-mediated treatment. J Neurol Sci 2019; 408:116506. [PMID: 31734550 DOI: 10.1016/j.jns.2019.116506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 08/29/2019] [Accepted: 09/19/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Stiff person syndrome (SPS) is usually characterized by truncal muscle rigidity and episodic painful spasms, but it sometimes appears with ocular symptoms called "stiff eyes". We recorded saccade movements in an SPS patient manifesting with "stiff eyes" conditions with slow saccade velocity and evaluated the effect of immunotherapy including rituximab on saccade parameters. METHODS We repeatedly conducted saccade eye recordings using video-based eye tracking system on a 42-year-old male SPS patient with slow saccade. The velocity and onset latency of visual guided saccades (VGS) were measured at each recording. Because VGS velocity is affected by saccade amplitude, estimated peak velocity (Vmax) was also calculated by taking the relationship between the velocity and the amplitude of saccade into account. RESULTS The mean VGS velocity improved significantly after two courses of rituximab administration compared with its lowest value. The estimated Vmax decreased as the clinical manifestations worsened, but it increased after rituximab administration. Other neurological symptoms in this patient such as muscle rigidity and gait instability also improved after the treatment. CONCLUSION Slow saccade in a "stiff eyes" patient improved after rituximab administration. Our study also indicated that the saccade eye recording is useful for evaluating the clinical condition of SPS when it is complicated with ocular symptoms.
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Affiliation(s)
- Satoshi Kodama
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
| | - Shin-Ichi Tokushige
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan; Department of Neurology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, Japan
| | - Yusuke Sugiyama
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Kazuya Sato
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Juuri Otsuka
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Yuichiro Shirota
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Masashi Hamada
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Atsushi Iwata
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Tatsushi Toda
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Shoji Tsuji
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Yasuo Terao
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan; Department of Cell Physiology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, Japan
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Abstract
PURPOSE OF REVIEW Induction of lymphocyte depletion is increasingly used as a therapeutic strategy for central and peripheral neuroinflammatory disease. However, there is also a growing recognition of the treatment-related complication of secondary antibody deficiency (SAD). Although the occurrence of hypogammaglobulinaemia is a recognized phenomenon during immunomodulation, robust data on the coexistence of impaired responses to immunization, and significant and/or atypical infections is scarce. Here we review the literature on SAD in anti-CD20 therapy. RECENT FINDINGS Several factors that may increase the incidence of SAD have now been identified, including low levels of immunoglobulins prior to the commencement of B-cell ablation therapy, duration of maintenance therapy, and concurrent or prior use of other immunosuppressing agents such as cyclophosphamide and steroids. Measurement of disease-specific antibodies and vaccine response are likely to be helpful adjuncts to measurement of serum immunoglobulin levels during B-cell depleting therapy. Supportive treatment may include amending the treatment schedule to limit cumulative dose. SUMMARY B-cell depleting agents offer considerable therapeutic benefit in neurology. We propose modifications in current practice that include risk stratification and early identification of SAD, with the aim of minimising morbidity and mortality related to this underappreciated condition.
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El-Abassi R, Soliman MY, Villemarette-Pittman N, England JD. SPS: Understanding the complexity. J Neurol Sci 2019; 404:137-149. [PMID: 31377632 DOI: 10.1016/j.jns.2019.06.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 05/31/2019] [Accepted: 06/17/2019] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Stiff-person syndrome (SPS), first described in 1956 by Moersch and Woltman, is a progressive autoimmune disorder with core features of chronic fluctuating progressive truncal and limb rigidity and painful muscle spasms leading to gait difficulties, falls and an appearance that resembles tin soldiers. The syndrome is a rare, highly disabling disorder of the central nervous and frequently results in significant disability. Understanding of the etiology, clinical spectrum, diagnostic workup and therapeutic modalities for this painful and disabling disorder has vastly evolved over the past few years with more confidence in classifying and treating the patients. The purpose of this review is to increase the awareness, early detection, and treatment of this disabling disease. METHOD PubMed was searched, all date inclusive, using the following phrases: stiff person syndrome,anti-Glutamic acid decarboxylase (Anti-GAD) antibody syndrome, Progressive encephalomyelitis with rigidity and myoclonus (PERM), and Paraneoplastic Stiff Person syndrome. No filters or restrictions were used. A total of 888 articles were identified. RESULTS The results were narrowed to 190 citations after excluding non-English and duplicate reports. Clinical presentation, laboratory testing, treatment, and prognosis were categorized and summarized. DISCUSSION In this article we will discuss the epidemiology, presentation and classification. Explain the pathophysiology of SPS and the autoimmune mechanisms involved. Discuss the diagnostic approach and treatments available, as well as, the prognosis and outcome.
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Affiliation(s)
- Rima El-Abassi
- Department of Neurology, Louisiana State University School of medicine, New Orleans, USA.
| | - Michael Y Soliman
- Department of Neurology, Louisiana State University School of medicine, New Orleans, USA
| | | | - John D England
- Department of Neurology, Louisiana State University School of medicine, New Orleans, USA
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Baizabal-Carvallo JF. The neurological syndromes associated with glutamic acid decarboxylase antibodies. J Autoimmun 2019; 101:35-47. [DOI: 10.1016/j.jaut.2019.04.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/07/2019] [Accepted: 04/08/2019] [Indexed: 12/12/2022]
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Anti-glutamic acid decarboxylase (GAD) positive cerebellar Ataxia with transitioning to progressive encephalomyelitis with rigidity and myoclonus (PERM), responsive to immunotherapy: A case report and review of literature. J Neuroimmunol 2019; 332:135-137. [PMID: 31015081 DOI: 10.1016/j.jneuroim.2019.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/05/2019] [Accepted: 04/03/2019] [Indexed: 01/14/2023]
Abstract
We present a case of a 65-year-old African American male, immunosuppressed on Tacrolimus, who initially presented with cerebellar ataxia and rapidly developed Progressive Encephalomyelitis with Rigidity and Myoclonus (PERM) with positive anti-glutamic acid decarboxylase (GAD65) antibodies, no underlying malignancy, and normal neuroimaging. PERM is a rare spectrum of Stiff Person Syndrome (SPS), which is strongly associated with anti-GAD antibodies and characterized by flare-ups and remissions of encephalopathy, myelopathy and rigidity with myoclonus. PERM is diagnosed clinically and has been successfully treated with both Intravenous Immunoglobulin (IVIg) and plasmapheresis. Our patient was successfully treated with IVIg. On day 14 after starting IVIg treatment, his neurological symptoms started to improve and ultimately returned to baseline.
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Whittam DH, Tallantyre EC, Jolles S, Huda S, Moots RJ, Kim HJ, Robertson NP, Cree BAC, Jacob A. Rituximab in neurological disease: principles, evidence and practice. Pract Neurol 2019; 19:5-20. [PMID: 30498056 DOI: 10.1136/practneurol-2018-001899] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Rituximab is a widely used B-cell-depleting monoclonal antibody. It is unlicensed for use in neurological disorders and there are no treatment guidelines. However, as a rapidly acting, targeted therapy with growing evidence of efficacy and tolerability in several neuroinflammatory disorders, it is an attractive alternative to conventional immunomodulatory medications. This practical review aims to explain the basic principles of B-cell depletion with therapeutic monoclonal antibodies. We present the evidence for using rituximab in neurological diseases, and describe the practical aspects of prescribing, including dosing, monitoring, safety, treatment failure and its use in special circumstances such as coexisting viral hepatitis, pregnancy and lactation. We provide an administration guide, checklist and patient information leaflet, which can be adapted for local use. Finally, we review the safety data of rituximab and ocrelizumab (a newer and recently licensed B-cell-depleting therapy for multiple sclerosis) and suggest monitoring and risk reduction strategies.
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Affiliation(s)
- Daniel H Whittam
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Emma C Tallantyre
- Helen Durham Centre for Neuroinflammation, University Hospital or Wales, Cardiff, UK
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
- School of Medicine, Cardiff University, Cardiff, UK
| | - Saif Huda
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Robert J Moots
- Department of Musculoskeletal Diseases, Institute of Ageing and Chronic Diseases, University of Liverpool, Liverpool, UK
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, South Korea
| | - Neil P Robertson
- Helen Durham Centre for Neuroinflammation, University Hospital or Wales, Cardiff, UK
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Bruce A C Cree
- Weill Institute for Neurosciences, University of California, San Francisco, California, USA
| | - Anu Jacob
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
- School of Medicine, University of Liverpool, Liverpool, UK
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