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Yao Q, Fu M, Ren L, Lin C, Cao L. Inspiratory laryngeal stridor as the main feature of progressive encephalomyelitis with rigidity and myoclonus: a case report and literature review. BMC Neurol 2022; 22:42. [PMID: 35090404 PMCID: PMC8796497 DOI: 10.1186/s12883-022-02555-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 01/11/2022] [Indexed: 01/10/2023] Open
Abstract
Background Progressive encephalomyelitis with rigidity and myoclonus (PERM) is an acute, potentially life-threatening, yet curable neuro-immunological disease characterized by spasms, muscular rigidity, and brainstem and autonomic dysfunction. The clinical features of glycine receptor (GlyR) antibody-positive PERM may be overlooked, particularly with some unusual symptoms. Case presentation A 52-year-old man was admitted to the hospital for evaluation of tension headache for 20 days and mild dysarthria. These symptoms were followed by panic, profuse sweating, severe dysarthria, dizziness, unsteady gait, and paroxysmal muscle spasms. Brain magnetic resonance imaging and cerebrospinal fluid analysis were normal. The patient’s condition steadily deteriorated. He repeatedly presented with rigidity, panic attacks, severe anxiety, paroxysmal inspiratory laryngeal stridor, cyanosis of the lips, and intractable epilepsy. Electromyography showed multiple myoclonic seizures, a single generalized tonic-clonic seizure, and a single generalized tonic seizure. Screening for autoimmune encephalitis antibodies revealed anti-GlyR antibodies in his cerebrospinal fluid. Immunomodulatory pulse therapy with steroids and immunoglobulin resulted in expeditious improvement of the symptoms within 2 weeks, and a follow-up at 5 weeks showed consistent clinical improvement. Conclusion Our case highlights that inspiratory laryngeal stridor is an important symptom of PERM. Our observation widens the spectrum of the clinical presentation of anti-GlyR antibody-positive PERM, where early identification is a key to improving prognosis. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02555-y.
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Kitazaki Y, Ikawa M, Kishitani T, Kamisawa T, Nakane S, Nakamoto Y, Hamano T. Progressive Encephalomyelitis with Rigidity and Myoclonus (PERM)-like Symptoms Associated with Anti-ganglionic Acetylcholine Receptor Antibodies. Intern Med 2021; 60:2307-2313. [PMID: 33583893 PMCID: PMC8355408 DOI: 10.2169/internalmedicine.6419-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This report describes a 59-year-old woman who presented with progressive encephalomyelitis with rigidity and myoclonus (PERM)-like symptoms and severe dysautonomia, including orthostatic hypotension, sinus bradycardia, dysuria, and prolonged constipation. Her neurological symptoms improved after immunotherapy, but the dysautonomia persisted. Anti-ganglionic acetylcholine receptor (gAChR) α3 subunit antibodies, which are frequently identified in patients with autoimmune autonomic ganglionopathy, were detected in the pre-treatment serum. The central distribution of the nicotinic acetylcholine receptors, a target of anti-gAChR antibodies, and immunotherapeutic efficacy observed in this case indicate that anti-gAChR α3 subunit antibodies are associated with the PERM-like features accompanied by autonomic manifestations.
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Affiliation(s)
- Yuki Kitazaki
- Department of Neurology, Fukui-ken Saiseikai Hospital, Japan
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Masamichi Ikawa
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
- Department of Advanced Medicine for Community Healthcare, Faculty of Medical Sciences, University of Fukui, Japan
| | - Toru Kishitani
- Department of Neurology, Fukui-ken Saiseikai Hospital, Japan
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Tomoko Kamisawa
- Department of Neurology, Fukui-ken Saiseikai Hospital, Japan
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Shunya Nakane
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Yasunari Nakamoto
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Tadanori Hamano
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
- Department of Aging and Dementia, Faculty of Medical Sciences, University of Fukui, Japan
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Progressive encephalomyelitis with rigidity: A Taiwanese case and review of literature. Clin Neurol Neurosurg 2021; 208:106807. [PMID: 34325335 DOI: 10.1016/j.clineuro.2021.106807] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/26/2021] [Accepted: 06/28/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Progressive encephalomyelitis with rigidity and myoclonus (PERM) is a rare disorder. However, the outcome is still variable with different serological and tumor associations, and the elements to good response with less relapse is yet to be elucidated. METHOD We present a case and obtain a literature review of patients with PERM and make comparisons based on different serological groups. We also analyze patients with idiopathic PERM that had detailed medical records. RESULTS 81 patients were collected and analyzed. The largest group were glycine receptor-antibody (GlyR-Ab)-positive (70%), and the seropositive-GlyR-Ab-negative group had better response to immunotherapy. Malignancy can occur up to 2 years from the presentation of PERM. Among the 18 cases with detailed records, the patients who had good outcome initiate immunotherapy within 2 months from presentation. 9 of the 12 patients who experienced no relapse had non-steroid immunotherapy. The maximal interval time of relapse was 24 months. CONCLUSION We recommend tumor surveillance up to 2 years in patients with PERM and early administration of immunotherapies and maintain with non-steroid immunotherapy with or without oral corticosteroid for a minimum of 2 years to reduce the risk of relapse in GlyR-Ab-positive patients.
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Su Y, Cui L, Zhu M, Liang Y, Zhang Y. Progressive Encephalomyelitis With Rigidity and Myoclonus With Thymoma: A Case Report and Literature Review. Front Neurol 2020; 11:1017. [PMID: 33071929 PMCID: PMC7533529 DOI: 10.3389/fneur.2020.01017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 08/03/2020] [Indexed: 12/20/2022] Open
Abstract
Progressive encephalomyelitis with rigidity and myoclonus (PERM) is part of the variant type of the Stiff Person Syndrome (SPS) and is a rare neurological disease. We report here a patient with PERM who had thymoma and was positive for anti-glutamic acid decarboxylase (anti-GAD) antibodies. Her symptoms improved after treatment with hormones and gamma globulin. We also summarized the literature review of patients with PERM accompanied by tumors reported.
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Affiliation(s)
- Yana Su
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Li Cui
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Mingqin Zhu
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Yixuan Liang
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Ying Zhang
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
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5
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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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6
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Degeneffe A, Dagonnier M, D’hondt A, Elosegi JA. A case report of rigidity and recurrent lower limb myoclonus: progressive encephalomyelitis rigidity and myoclonus syndrome, a chameleon. BMC Neurol 2018; 18:173. [PMID: 30336789 PMCID: PMC6193294 DOI: 10.1186/s12883-018-1176-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 10/08/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Progressive encephalomyelitis with rigidity and myoclonus (PERM) syndrome is a rare neurological condition. Its clinical characteristics include axial and limb muscle rigidity, myoclonus, painful spasms and hyperekplexia. Diagnosis of this disease can be very challenging and optimal long-term treatment is unclear. CASE PRESENTATION We report a case of a 62 year old patient admitted for repetitive myoclonus and rigidity in the lower limbs progressing since 10 years, associated with a fluctuating encephalopathy requiring stays in Intensive Care Unit. Multiple diagnostics and treatment were proposed, unsuccessfully, before the diagnosis of PERM syndrome was established. In association with the clinical presentation, a strong positive result for GAD (glutamic acid decarboxylase) antibodies lead to the diagnosis of PERM syndrome. CONCLUSIONS PERM syndrome is a rare disease and its diagnosis is not easy. Once the diagnosis is established, the correct treatment should follow and could be lifesaving, regardless of a delayed diagnosis. Maintenance of long-term oral corticotherapy is suggested to prevent relapses.
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Affiliation(s)
- Aurélie Degeneffe
- Department of Neurology, CHU Ambroise Paré Hospital, Boulevard John Fitzgerald Kennedy 2, 7000 Mons, Belgium
| | - Marie Dagonnier
- Department of Neurology, CHU Ambroise Paré Hospital, Boulevard John Fitzgerald Kennedy 2, 7000 Mons, Belgium
| | - Alain D’hondt
- Intensive Care Unit, CHU Ambroise Paré Hospital, Mons, Belgium
| | - Jose Antonio Elosegi
- Department of Neurology, CHU Ambroise Paré Hospital, Boulevard John Fitzgerald Kennedy 2, 7000 Mons, Belgium
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7
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Swayne A, Tjoa L, Broadley S, Dionisio S, Gillis D, Jacobson L, Woodhall MR, McNabb A, Schweitzer D, Tsang B, Vincent A, Irani SR, Wong R, Waters P, Blum S. Antiglycine receptor antibody related disease: a case series and literature review. Eur J Neurol 2018; 25:1290-1298. [PMID: 29904974 PMCID: PMC6282944 DOI: 10.1111/ene.13721] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 05/23/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Antibodies to glycine receptors (GlyR-Abs) were first defined in progressive encephalopathy with rigidity and myoclonus (PERM) but were subsequently identified in other clinical presentations. Our aim was to assess the clinical associations of all patients identified with GlyR-Abs in Queensland, Australia, between April 2014 and May 2017 and to compare these to cases reported in the literature. METHODS A literature review identified the clinical features of all published GlyR-Ab-positive cases through online databases. A case series was undertaken via collection of clinical information from all patients diagnosed or known to immunology, pathology or neurological services in Queensland during the study period of 3 years. RESULTS In all, 187 GlyR-Ab-positive cases were identified in the literature. The majority (47.6%) had PERM, 22.4% had epilepsy, but the remaining 30% included mixed phenotypes consisting of cerebellar ataxia, movement disorders, demyelination and encephalitis/cognitive dysfunction. By contrast, in our series of 14 cases, eight had clinical presentations consistent with seizures and epilepsy and only three cases had classical features of PERM. There was one case each of global fatiguable weakness with sustained clonus, laryngeal dystonia and movement disorder with hemiballismus and tics. The rate of response to immune therapy was similar in all groups. CONCLUSION Antibodies to glycine receptors are linked to a spectrum of neurological disease. The results of the literature review and our case series suggest a greater relationship between GlyR-Abs and epilepsy than previously reported.
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Affiliation(s)
- A Swayne
- Princess Alexandra Hospital Brisbane Australia, Wooloongabba, QLD, Australia.,School of Medicine, University of Queensland, Herston, QLD, Australia.,Mater Centre for Neuroscience, South Brisbane, QLD, Australia
| | - L Tjoa
- Mater Centre for Neuroscience, South Brisbane, QLD, Australia
| | - S Broadley
- Gold Coast University Hospital, Griffith University Medical School, Griffith University, QLD, Australia
| | - S Dionisio
- Princess Alexandra Hospital Brisbane Australia, Wooloongabba, QLD, Australia.,Mater Centre for Neuroscience, South Brisbane, QLD, Australia
| | - D Gillis
- Pathology Queensland, Brisbane, QLD, Australia.,Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - L Jacobson
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - M R Woodhall
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - A McNabb
- Cairns Base Hospital, Cairns, QLD, Australia
| | - D Schweitzer
- Mater Centre for Neuroscience, South Brisbane, QLD, Australia
| | - B Tsang
- Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - A Vincent
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - S R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - R Wong
- Princess Alexandra Hospital Brisbane Australia, Wooloongabba, QLD, Australia.,Pathology Queensland, Brisbane, QLD, Australia
| | - P Waters
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - S Blum
- Princess Alexandra Hospital Brisbane Australia, Wooloongabba, QLD, Australia.,School of Medicine, University of Queensland, Herston, QLD, Australia.,Mater Centre for Neuroscience, South Brisbane, QLD, Australia
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8
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Kiziltan ME, Gunduz A, Tutuncu M, Ertan S, Apaydin H, Kiziltan G. Myoclonus in the elderly: A retrospective analysis of clinical and electrophysiological characteristics of patients referred to an electrophysiology laboratory. Parkinsonism Relat Disord 2018; 49:22-27. [PMID: 29326035 DOI: 10.1016/j.parkreldis.2017.12.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 12/09/2017] [Accepted: 12/22/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Late-onset myoclonus in the elderly is mainly related to dementia or systemic disease. In this report, we aimed to investigate the clinical and electrophysiological features of patients with late-onset myoclonus. PATIENTS AND METHOD We retrospectively assessed the medical records of patients who were referred to our electromyography laboratory. From these records, we included all patients who had myoclonus which started after the age of 60 years and in whom it was confirmed by polymyography. Demographic, clinical and electrophysiological findings were retrieved from the medical records. RESULTS There were 63 patients with myoclonus. Types of myoclonus were spinal segmental (n = 2), cortical (n = 25) and probable cortico-subcortical involving upper extremities (n = 36). The latter two types displayed reflex sensitivity. Four patients (one with multifocal cortical myoclonus and others with probable cortico-subcortical myoclonus) were diagnosed with probable CJD. Other diagnoses were Parkinsons's disease, Parkinson-plus or dementia syndromes, vascular parkinsonism, polyneuropathy, Celiac disease and post-hypoxic encephalopathy. Eleven patients did not have a specific diagnosis. CONCLUSIONS Myoclonus in our cohort was mostly associated with parkinsonism. Cortical myoclonus is not rare in the elderly age group. Myoclonus in polyneuropathy is irregular, tremor-like with electrophysiological characteristics similar to the cortical subtype.
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Affiliation(s)
- Meral E Kiziltan
- Department of Neurology, Cerrahpaşa School of Medicine, Istanbul University, Turkey
| | - Aysegul Gunduz
- Department of Neurology, Cerrahpaşa School of Medicine, Istanbul University, Turkey.
| | - Melih Tutuncu
- Department of Neurology, Cerrahpaşa School of Medicine, Istanbul University, Turkey
| | - Sibel Ertan
- Department of Neurology, Cerrahpaşa School of Medicine, Istanbul University, Turkey
| | - Hulya Apaydin
- Department of Neurology, Cerrahpaşa School of Medicine, Istanbul University, Turkey
| | - Gunes Kiziltan
- Department of Neurology, Cerrahpaşa School of Medicine, Istanbul University, Turkey
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9
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Lloyd-Smith Sequeira A, Rizzo JR, Rucker JC. Clinical Approach to Supranuclear Brainstem Saccadic Gaze Palsies. Front Neurol 2017; 8:429. [PMID: 28878733 PMCID: PMC5572401 DOI: 10.3389/fneur.2017.00429] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 08/08/2017] [Indexed: 12/14/2022] Open
Abstract
Failure of brainstem supranuclear centers for saccadic eye movements results in the clinical presence of a brainstem-mediated supranuclear saccadic gaze palsy (SGP), which is manifested as slowing of saccades with or without range of motion limitation of eye movements and as loss of quick phases of optokinetic nystagmus. Limitation in the range of motion of eye movements is typically worse with saccades than with smooth pursuit and is overcome with vestibular–ocular reflexive eye movements. The differential diagnosis of SGPs is broad, although acute-onset SGP is most often from brainstem infarction and chronic vertical SGP is most commonly caused by the neurodegenerative condition progressive supranuclear palsy. In this review, we discuss the brainstem anatomy and physiology of the brainstem saccade-generating network; we discuss the clinical features of SGPs, with an emphasis on insights from quantitative ocular motor recordings; and we consider the broad differential diagnosis of SGPs.
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Affiliation(s)
| | - John-Ross Rizzo
- Department of Neurology, New York University School of Medicine, New York, NY, United States.,Department of Physical Medicine and Rehabilitation, New York University School of Medicine, New York, NY, United States
| | - Janet C Rucker
- Department of Neurology, New York University School of Medicine, New York, NY, United States.,Department of Ophthalmology, New York University School of Medicine, New York, NY, United States
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10
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McKeon A, Tracy JA. GAD65 neurological autoimmunity. Muscle Nerve 2017; 56:15-27. [PMID: 28063151 DOI: 10.1002/mus.25565] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 01/04/2017] [Indexed: 12/11/2022]
Abstract
The glutamic acid decarboxylase 65-kilodalton isoform (GAD65) antibody is a biomarker of autoimmune central nervous system (CNS) disorders and, more commonly, nonneurological autoimmune diseases. Type 1 diabetes, autoimmune thyroid disease, and pernicious anemia are the most frequent GAD65 autoimmune associations. One or more of these disorders coexists in approximately 70% of patients with GAD65 neurological autoimmunity. Neurological phenotypes have CNS localization and include limbic encephalitis, epilepsy, cerebellar ataxia, and stiff-person syndrome (SPS), among others. Classic SPS is a disorder on the spectrum of CNS hyperexcitability which also includes phenotypes that are either more restricted (stiff-limb syndrome) or more widespread (progressive encephalomyelitis with rigidity and myoclonus). GAD65 antibody is not highly predictive of a paraneoplastic cause for neurological disorders, but diverse cancer types have been occasionally reported. For all phenotypes, responses to immunotherapy are variable (approximately 50% improve). GAD65 autoimmunity is important to recognize for both coexisting nonneurological autoimmune associations and potential immunotherapy-response. Muscle Nerve 56: 15-27, 2017.
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Affiliation(s)
- Andrew McKeon
- Department of Neurology, College of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota, 55905, USA.,Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jennifer A Tracy
- Department of Neurology, College of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota, 55905, USA
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11
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Abstract
Autoantibodies targeting proteins at the neuromuscular junction are known to cause several distinct myasthenic syndromes. Recently, autoantibodies targeting neurotransmitter receptors and associated proteins have also emerged as a cause of severe, but potentially treatable, diseases of the CNS. Here, we review the clinical evidence as well as in vitro and in vivo experimental evidence that autoantibodies account for myasthenic syndromes and autoimmune disorders of the CNS by disrupting the functional or structural integrity of synapses. Studying neurological and psychiatric diseases of autoimmune origin may provide new insights into the cellular and circuit mechanisms underlying a broad range of CNS disorders.
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Affiliation(s)
- Sarah J Crisp
- UCL Institute of Neurology, University College London, Queen Square House, Queen Square, London WC1N 3BG, UK
| | - Dimitri M Kullmann
- UCL Institute of Neurology, University College London, Queen Square House, Queen Square, London WC1N 3BG, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Level 6, West Wing, John Radcliffe Hospital, Oxford OX3 9DU, UK
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12
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Sarva H, Deik A, Ullah A, Severt WL. Clinical Spectrum of Stiff Person Syndrome: A Review of Recent Reports. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2016; 6:340. [PMID: 26989571 PMCID: PMC4790195 DOI: 10.7916/d85m65gd] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 12/22/2015] [Indexed: 12/11/2022]
Abstract
Background “Classic” stiff person syndrome (SPS) features stiffness, anti-glutamic acid decarboxylase (anti-GAD) antibodies, and other findings. Anti-GAD antibodies are also detected in some neurological syndromes (such as ataxia) in which stiffness is inconsistently present. Patients with otherwise “classic” SPS may either lack anti-GAD antibodies or be seropositive for others. Hence, SPS cases appear to fall within a clinical spectrum that includes conditions such as progressive encephalomyelitis with rigidity and myoclonus (PERM), which exhibits brainstem and autonomic features. We have compiled herein SPS-spectrum cases reported since 2010, and have segregated them on the basis of likely disease mechanism (autoimmune, paraneoplastic, or cryptogenic) for analysis. Methods The phrases “stiff person syndrome”, “PERM”, “anti-GAD antibody syndrome”, and “glycine receptor antibody neurological disorders” were searched for in PubMed in January 2015. The results were narrowed to 72 citations after excluding non-English and duplicate reports. Clinical descriptions, laboratory data, management, and outcomes were categorized, tabulated, and analyzed. Results Sixty-nine autoimmune, 19 paraneoplastic, and 13 cryptogenic SPS-spectrum cases were identified. SPS was the predominant diagnosis among the groups. Roughly two-thirds of autoimmune and paraneoplastic cases were female. Anti-GAD antibodies were most frequently identified, followed by anti-amphiphysin among paraneoplastic cases and by anti-glycine receptor antibodies among autoimmune cases. Benzodiazepines were the most commonly used medications. Prognosis seemed best for cryptogenic cases; malignancy worsened that of paraneoplastic cases. Discussion Grouping SPS-spectrum cases by pathophysiology provided insights into work-up, treatment, and prognosis. Ample phenotypic and serologic variations are present within the categories. Ruling out malignancy and autoimmunity is appropriate for suspected SPS-spectrum cases.
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Affiliation(s)
- Harini Sarva
- Department of Neurology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Andres Deik
- Parkinson Disease and Movement Disorders Center, Department of Neurology, University of Pennsylvania, PA, USA
| | - Aman Ullah
- Department of Neurology, Maimonides Medical Center, Brooklyn, NY, USA
| | - William L Severt
- Department of Neurology, Division of Movement Disorders, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel Medical Center, New York, NY, USA
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13
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Abstract
Autoimmune movement disorders encapsulate a large and diverse group of neurologic disorders occurring either in isolation or accompanying more diffuse autoimmune encephalitic illnesses. The full range of movement phenomena has been described and, as they often occur in adults, many of the presentations can mimic neurodegenerative disorders, such as Huntington disease. Disorders may be ataxic, hypokinetic (parkinsonism), or hyperkinetic (myoclonus, chorea, tics, and other dyskinetic disorders). The autoantibody targets are diverse and include neuronal surface proteins such as leucine-rich, glioma-inactivated 1 (LGI1) and glycine receptors, as well as antibodies (such as intracellular antigens) that are markers of a central nervous system process mediated by CD8+ cytotoxic T cells. However, there are two conditions, stiff-person syndrome (also known as stiff-man syndrome) and progressive encephalomyelitis with rigidity and myoclonus (PERM), that are always autoimmune movement disorders. In some instances (such as Purkinje cell cytoplasmic antibody-1 (PCA-1) autoimmunity), antibodies detected in serum and cerebrospinal fluid can be indicative of a paraneoplastic cause, and may direct the cancer search. In other instances (such as 65kDa isoform of glutamic acid decarboxylase (GAD65) autoimmunity), a paraneoplastic cause is very unlikely, and early treatment with immunotherapy may promote improvement or recovery. Here we describe the different types of movement disorder and the clinical features and antibodies associated with them, and discuss treatment.
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Affiliation(s)
- Andrew Mckeon
- Departments of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
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14
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Iizuka T, Tominaga N, Kaneko J. [Clinical spectrum of anti-glycine receptor antibody-associated disease]. Rinsho Shinkeigaku 2015; 53:1063-6. [PMID: 24291880 DOI: 10.5692/clinicalneurol.53.1063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Anti-glycine receptor (anti-GlyR) antibodies were first reported in 2008 in a case of progressive encephalomyelitis with myoclonus and rigidity (PERM), which is a variant of stiff-person syndrome (SPS). After that, the antibodies have been studied extensively. At least 40 patients have been reported or presented until May 2013. We reviewed 28 patients (median age 47 years, range 1 to 75 years), whose clinical data are available. Seventeen patients (60%) were male. We classified clinical phenotype into PERM (17), classic SPS (5), variant SPS (5), and others (1: progressive optic atrophy). Nine patients (32%) had ant-GAD antibodies. Accompanied diseases included thyroiditis (5), diabetes mellitus (3), thymoma (3), and Addison's disease (2). Twenty-one patients (75%) treated with immunotherapy or thymectomy improved, but two of six patients without immunotherapy died or developed cardiac arrest. The clinical features suggested that antibody-mediated inhibition of the GlyR on the brainstem nuclei or spinal inhibitory interneurons may cause continuous firing of α motor neurons and paroxysmal excessive response to a variety of afferent impulses, leading to increased stiffness, brainstem signs, trismus, myoclonus, painful spasms or hyperekplexia. Phenotype associated with the anti-GlyR antibodies may be broader than previously thought, but among those PERM is the most common phenotype.
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Affiliation(s)
- Takahiro Iizuka
- Department of Neurology, Kitasato University, School of Medicine
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15
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Abstract
Atypical parkinsonism comprises typically progressive supranuclear palsy, corticobasal degeneration, and mutilple system atrophy, which are distinct pathologic entities; despite ongoing research, their cause and pathophysiology are still unknown, and there are no biomarkers or effective treatments available. The expanding phenotypic spectrum of these disorders as well as the expanding pathologic spectrum of their classic phenotypes makes the early differential diagnosis challenging for the clinician. Here, clinical features and investigations that may help to diagnose these conditions and the existing limited treatment options are discussed.
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Affiliation(s)
- Maria Stamelou
- Second Department of Neurology, Attiko Hospital, University of Athens, Rimini 1, Athens 12462, Greece; Department of Neurology, Philipps Universität, Baldingerstrasse, Marburg 35039, Germany; Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK.
| | - Kailash P Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
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16
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Carvajal-González A, Leite MI, Waters P, Woodhall M, Coutinho E, Balint B, Lang B, Pettingill P, Carr A, Sheerin UM, Press R, Press R, Lunn MP, Lim M, Maddison P, Meinck HM, Vandenberghe W, Vincent A. Glycine receptor antibodies in PERM and related syndromes: characteristics, clinical features and outcomes. ACTA ACUST UNITED AC 2014; 137:2178-92. [PMID: 24951641 PMCID: PMC4107739 DOI: 10.1093/brain/awu142] [Citation(s) in RCA: 306] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
See Martinez-Martinez et al. (doi:10.1093/brain/awu153) for a scientific commentary on this article. Carvajal-González et al. describe the first prospective cohort of patients with glycine receptor antibodies. The majority have progressive encephalomyelitis with rigidity and myoclonus. The antibodies bind to extracellular determinants on glycine receptor-α1 and to glycine receptors on spinal cord and brainstem neurons. The patients make a good recovery with immunotherapies. The clinical associations of glycine receptor antibodies have not yet been described fully. We identified prospectively 52 antibody-positive patients and collated their clinical features, investigations and immunotherapy responses. Serum glycine receptor antibody endpoint titres ranged from 1:20 to 1:60 000. In 11 paired samples, serum levels were higher than (n = 10) or equal to (n = 1) cerebrospinal fluid levels; there was intrathecal synthesis of glycine receptor antibodies in each of the six pairs available for detailed study. Four patients also had high glutamic acid decarboxylase antibodies (>1000 U/ml), and one had high voltage-gated potassium channel-complex antibody (2442 pM). Seven patients with very low titres (<1:50) and unknown or alternative diagnoses were excluded from further study. Three of the remaining 45 patients had newly-identified thymomas and one had a lymphoma. Thirty-three patients were classified as progressive encephalomyelitis with rigidity and myoclonus, and two as stiff person syndrome; five had a limbic encephalitis or epileptic encephalopathy, two had brainstem features mainly, two had demyelinating optic neuropathies and one had an unclear diagnosis. Four patients (9%) died during the acute disease, but most showed marked improvement with immunotherapies. At most recent follow-up, (2–7 years, median 3 years, since first antibody detection), the median modified Rankin scale scores (excluding the four deaths) decreased from 5 at maximal severity to 1 (P < 0.0001), but relapses have occurred in five patients and a proportion are on reducing steroids or other maintenance immunotherapies as well as symptomatic treatments. The glycine receptor antibodies activated complement on glycine receptor-transfected human embryonic kidney cells at room temperature, and caused internalization and lysosomal degradation of the glycine receptors at 37°C. Immunoglobulin G antibodies bound to rodent spinal cord and brainstem co-localizing with monoclonal antibodies to glycine receptor-α1. Ten glycine receptor antibody positive samples were also identified in a retrospective cohort of 56 patients with stiff person syndrome and related syndromes. Glycine receptor antibodies are strongly associated with spinal and brainstem disorders, and the majority of patients have progressive encephalomyelitis with rigidity and myoclonus. The antibodies demonstrate in vitro evidence of pathogenicity and the patients respond well to immunotherapies, contrasting with earlier studies of this syndrome, which indicated a poor prognosis. The presence of glycine receptor antibodies should help to identify a disease that responds to immunotherapies, but these treatments may need to be sustained, relapses can occur and maintenance immunosuppression may be required.
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Affiliation(s)
| | - M Isabel Leite
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Patrick Waters
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Mark Woodhall
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Ester Coutinho
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Bettina Balint
- 2 Department of Neurology, INF 400, 69120 Heidelberg, Germany
| | - Bethan Lang
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Philippa Pettingill
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Aisling Carr
- 3 Department of Clinical Neurology, Royal Victoria Hospital, Belfast, Northern Ireland, BT12 6BA
| | - Una-Marie Sheerin
- 4 Department of Clinical Neurosciences, Charing Cross Hospital, Imperial College, London UK
| | | | - Raomand Press
- 5 Clinical Neuroscience, Karolinska Institute, Department of Neurology, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Michael P Lunn
- 6 Centre for Neuromuscular Disease, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Ming Lim
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Paul Maddison
- 7 Department of Clinical Neurology, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - H-M Meinck
- 2 Department of Neurology, INF 400, 69120 Heidelberg, Germany
| | - Wim Vandenberghe
- 8 Department of Neurology, University Hospitals Leuven; Department of Neurosciences, KU Leuven, Leuven, Belgium
| | - Angela Vincent
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
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van Coevorden-Hameete MH, de Graaff E, Titulaer MJ, Hoogenraad CC, Sillevis Smitt PAE. Molecular and cellular mechanisms underlying anti-neuronal antibody mediated disorders of the central nervous system. Autoimmun Rev 2014; 13:299-312. [PMID: 24225076 DOI: 10.1016/j.autrev.2013.10.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 10/30/2013] [Indexed: 12/31/2022]
Abstract
Over the last decade multiple autoantigens located on the plasma membrane of neurons have been identified. Neuronal surface antigens include molecules directly involved in neurotransmission and excitability. Binding of the antibody to the antigen may directly alter the target protein's function, resulting in neurological disorders. The often striking reversibility of symptoms following early aggressive immunotherapy supports a pathogenic role for autoantibodies to neuronal surface antigens. In order to better understand and treat these neurologic disorders it is important to gain insight in the underlying mechanisms of antibody pathogenicity. In this review we discuss the clinical, circumstantial, in vitro and in vivo evidence for neuronal surface antibody pathogenicity and the possible underlying cellular and molecular mechanisms. This review shows that antibodies to neuronal surface antigens are often directed at conformational epitopes located in the extracellular domain of the antigen. The conformation of the epitope can be affected by specific posttranslational modifications. This may explain the distinct clinical phenotypes that are seen in patients with antibodies to antigens that are expressed throughout the brain. Furthermore, it is likely that there is a heterogeneous antibody population, consisting of different IgG subtypes and directed at multiple epitopes located in an immunogenic region. Binding of these antibodies may result in different pathophysiological mechanisms occurring in the same patient, together contributing to the clinical syndrome. Unraveling the predominant mechanism in each distinct antigen could provide clues for therapeutic interventions.
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Affiliation(s)
- M H van Coevorden-Hameete
- Department of Biology, Division of Cell Biology, Utrecht University, Padualaan 8, 3584 CH, Utrecht, The Netherlands.
| | - E de Graaff
- Department of Biology, Division of Cell Biology, Utrecht University, Padualaan 8, 3584 CH, Utrecht, The Netherlands.
| | - M J Titulaer
- Department of Neurology, Erasmus MC, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands.
| | - C C Hoogenraad
- Department of Biology, Division of Cell Biology, Utrecht University, Padualaan 8, 3584 CH, Utrecht, The Netherlands.
| | - P A E Sillevis Smitt
- Department of Neurology, Erasmus MC, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands.
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