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Abunada M, Nierobisch N, Ludovichetti R, Simmen C, Terziev R, Togni C, Michels L, Kulcsar Z, Hainc N. Autoimmune encephalitis: Early and late findings on serial MR imaging and correlation to treatment timepoints. Eur J Radiol Open 2024; 12:100552. [PMID: 38327544 PMCID: PMC10847996 DOI: 10.1016/j.ejro.2024.100552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/09/2024] Open
Abstract
Introduction MRI is negative in a large percentage of autoimmune encephalitis cases or lacks findings specific to an antibody. Even rarer is literature correlating the evolution of imaging findings with treatment timepoints. We aim to characterize imaging findings in autoimmune encephalitis at presentation and on follow up correlated with treatment timepoints for this rare disease. Methods A full-text radiological information system search was performed for "autoimmune encephalitis" between January 2012 and June 2022. Patients with laboratory-identified autoantibodies were included. MRI findings were assessed in correlation to treatment timepoints by two readers in consensus. For statistical analysis, cell-surface vs intracellular antibody groups were assessed for the presence of early limbic, early extralimbic, late limbic, and late extralimbic findings using the χ2 test. Results Thirty-seven patients (female n = 18, median age 58.8 years; range 25.7 to 82.7 years) with 15 different autoantibodies were included in the study. Twenty-three (62%) patients were MRI-negative at time of presentation; 5 of these developed MRI findings on short-term follow up. Of the 19 patients with early MRI findings, 9 (47%) demonstrated improvement upon treatment initiation (7/9 cell-surface group). There was a significant difference (p = 0.046) between the MRI spectrum of cell-surface vs intracellular antibody syndromes as cell-surface antibody syndromes demonstrated more early classic findings of limbic encephalitis and intracellular antibody syndromes demonstrated more late extralimbic abnormalities. Conclusion MRI can be used to help narrow the differential diagnosis in autoimmune encephalitis and can be used as a monitoring tool for certain subtypes of this rare disease.
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Affiliation(s)
- Mahmoud Abunada
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Nathalie Nierobisch
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Riccardo Ludovichetti
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Cyril Simmen
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Robert Terziev
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Claudio Togni
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Lars Michels
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Nicolin Hainc
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
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Helmstaedter C, Hansen N, Leelaarporn P, Schwing K, Oender D, Widman G, Racz A, Surges R, Becker A, Witt JA. Specific B- and T-cell populations are associated with cognition in patients with epilepsy and antibody positive and negative suspected limbic encephalitis. J Neurol 2021; 268:455-466. [PMID: 32816110 PMCID: PMC7880943 DOI: 10.1007/s00415-020-10158-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/30/2020] [Accepted: 08/10/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Neuropsychological impairments are major symptoms of autoimmune limbic encephalitis (LE) epilepsy patients. In LE epilepsy patients with an autoimmune response against intracellular antigens as well as in antibody-negative patients, the antibody findings and magnetic resonance imaging pathology correspond poorly to the clinical features. Here, we evaluated whether T- and B-cells are linked to cognitive impairment in these groups. METHODS In this cross-sectional, observational, case-controlled study, we evaluated 106 patients with adult-onset epilepsies with a suspected autoimmune etiology. We assessed verbal and visual memory, executive function, and mood in relation to the presence or absence of known auto-antibodies, and regarding T- and B-cell activity as indicated by flow cytometry (fluorescence-activated cell sorting = FACS, peripheral blood = PB and cerebrospinal fluid = CSF). RESULTS 56% of the patients were antibody-negative. In the other patients, auto-antibodies were directed against intracellular antigens (GAD65, paraneoplastic: 38%), or cellular surface antigens (LGI1/CASPR2/NMDA-R: 6%). Excluding LGI1/CASPR2/NMDA-R, the groups with and without antibodies did not differ in disease features, cognition, or mood. CD4+ T-cells and CD8+ T-cells in blood and CD4+ T-cells in CSF were prominent in the auto-antibody positive group. Regression analyses indicated the role education, drug load, amygdala and/or hippocampal pathology, and CD4+ T-cells play in verbal memory and executive function. Depressed mood revealed no relation to flow cytometry results. CONCLUSION Our results indicate a link between T- and B-cell activity and cognition in epilepsy patients with suspected limbic encephalitis, thus suggesting that flow cytometry results can provide an understanding of cognitive impairment in LE patients with autoantibodies against intracellular antigens.
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Affiliation(s)
- Christoph Helmstaedter
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Niels Hansen
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Von-Siebold-Str. 5, 37075, Göttingen, Germany
| | - Pitshaporn Leelaarporn
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
| | - Kerstin Schwing
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
| | - Demet Oender
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
| | - Guido Widman
- SEIN Epilepsy Center, Hemsteede, The Netherlands
| | - Attila Racz
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
| | - Albert Becker
- Department of Neuropathology, University Hospital, Bonn, Germany
| | - Juri-Alexander Witt
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
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Endres D, Prüss H, Dressing A, Schneider J, Feige B, Schweizer T, Venhoff N, Nickel K, Meixensberger S, Matysik M, Maier SJ, Domschke K, Urbach H, Meyer PT, Tebartz van Elst L. Psychiatric Manifestation of Anti-LGI1 Encephalitis. Brain Sci 2020; 10:brainsci10060375. [PMID: 32560097 PMCID: PMC7348933 DOI: 10.3390/brainsci10060375] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 12/20/2022] Open
Abstract
Background: Anti-leucine-rich glioma-inactivated 1 (LGI1) encephalitis is typically characterized by limbic encephalitis, faciobrachial dystonic seizures and hyponatremia. The frequency with which milder forms of anti-LGI1 encephalitis mimic isolated psychiatric syndromes, such as psychoses, or may lead to dementia if untreated, is largely unknown. Case presentation: Here, the authors present a 50-year-old patient who had suffered from neurocognitive deficits and predominant delusions for over one and a half years. He reported a pronounced feeling of thirst, although he was drinking 10–20 liters of water each day, and he was absolutely convinced that he would die of thirst. Due to insomnia in the last five years, the patient took Z-drugs; later, he also abused alcohol. Two years prior to admission, he developed a status epilepticus which had been interpreted as a withdrawal seizure. In his serum, anti-LGI1 antibodies were repeatedly detected by different independent laboratories. Cerebrospinal fluid analyses revealed slightly increased white blood cell counts and evidence for blood–brain-barrier dysfunction. Magnetic resonance imaging showed hyperintensities mesio-temporally and in the right amygdala. In addition, there was a slight grey–white matter blurring. A cerebral [18F] fluorodeoxyglucose positron emission tomography (FDG-PET) examination of his brain showed moderate hypometabolism of the bilateral rostral mesial to medial frontal cortices. Treatment attempts with various psychotropic drugs remained unsuccessful in terms of symptom relief. After the diagnosis of probable chronified anti-LGI1 encephalitis was made, two glucocorticoid pulse treatments were performed, which led to a slight improvement of mood and neurocognitive deficits. Further therapy was not desired by the patient and his legally authorized parents. Conclusion: This case study describes a patient with anti-LGI1 encephalitis in the chronified stage and a predominant long-lasting psychiatric course with atypical symptoms of psychosis and typical neurocognitive deficits. The patient’s poor response to anti-inflammatory drugs was probably due to the delayed start of treatment. This delay in diagnosis and treatment may also have led to the FDG-PET findings, which were compatible with frontotemporal dementia (“state of damage”). In similar future cases, newly occurring epileptic seizures associated with psychiatric symptoms should trigger investigations for possible autoimmune encephalitis, even in patients with addiction or other pre-existing psychiatric conditions. This should in turn result in rapid organic clarification and—in positive cases—to anti-inflammatory treatment. Early treatment of anti-LGI1 encephalitis during the “inflammatory activity state” is crucial for overall prognosis and may avoid the development of dementia in some cases. Based on this case, the authors advocate the concept—long established in many chronic inflammatory diseases in rheumatology—of distinguishing between an “acute inflammatory state” and a “state of organ damage” in autoimmune psychosis resembling neurodegenerative mechanisms.
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Affiliation(s)
- Dominique Endres
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
- Correspondence: ; Tel.: +49-761-270-66360; Fax: +49-761-270-69390
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité, Universitätsmedizin Berlin, 10117 Berlin, Germany;
- German Center for Neurodegenerative Diseases (DZNE) Berlin, 10117 Berlin, Germany
| | - Andrea Dressing
- Clinic of Neurology and Neurophysiology, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Johanna Schneider
- Renal Division, Department of Medicine, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Bernd Feige
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
| | - Tina Schweizer
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Kathrin Nickel
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
| | - Sophie Meixensberger
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
| | - Miriam Matysik
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
| | - Simon J. Maier
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
- Center for Basics in Neuromodulation, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Philipp T. Meyer
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Ludger Tebartz van Elst
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
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18F-FDG-PET/MRI in the diagnostic work-up of limbic encephalitis. PLoS One 2020; 15:e0227906. [PMID: 31951636 PMCID: PMC6968877 DOI: 10.1371/journal.pone.0227906] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 01/02/2020] [Indexed: 01/18/2023] Open
Abstract
Introduction Limbic encephalitis (LE) is an immune-related, sometimes paraneoplastic process of the central nervous system. Initial diagnosis and treatment are based on the clinical presentation as well as antibody profiles and MRI. This study investigated the diagnostic value of integrated 18F-FDG-PET/MRI in the diagnostic work-up of patients with LE for a cerebral and whole-body imaging concept. Material and methods Twenty patients with suspected LE were enrolled in this prospective study. All patients underwent a dedicated PET/MRI protocol of the brain as well as the whole-body. Two neuroradiologists, one body radiologist and one nuclear medicine physician performed blinded consensus readings of each corresponding MRI and PET/MRI dataset of the brain and whole-body. Diagnostic confidence was evaluated on a Likert scale. Results Based on integrated PET/MRI 19 / 20 patients were found to show morphologic and / or metabolic changes indicative of LE, whereas sole MRI enabled correct identification in 16 / 20 patients. Three patients with negative MRI showed metabolic changes of the limbic system or extra-limbic regions, shifting the diagnosis from (negative) MRI to positive for LE in PET/MRI. Whole-body staging revealed suspected lesions in 2/20 patients, identified by MRI and PET, one confirmed as malignant and one false positive. Diagnostic confidence for cerebral and whole-body imaging reached higher scores for PET/MRI (cerebral: 2.7 and whole body: 4.8) compared to MRI alone (cerebral: 2.4 and whole body: 4.5). Conclusion LE diagnosis remains challenging for imaging as it shows only subtle imaging findings in most patients. Nevertheless, based on the simultaneous and combined analysis of morphologic and metabolic data, integrated PET/MRI may enable a dual platform for improved diagnostic confidence and overall detection of LE as well as whole-body imaging for exclusion of paraneoplastic LE.
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Ernst L, David B, Gaubatz J, Domínguez-Narciso I, Lüchters G, Becker AJ, Weber B, Hattingen E, Elger CE, Rüber T. Volumetry of Mesiotemporal Structures Reflects Serostatus in Patients with Limbic Encephalitis. AJNR Am J Neuroradiol 2019; 40:2081-2089. [PMID: 31727746 DOI: 10.3174/ajnr.a6289] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 09/11/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND PURPOSE Limbic encephalitis is an autoimmune disease. A variety of autoantibodies have been associated with different subtypes of limbic encephalitis, whereas its MR imaging signature is uniformly characterized by mesiotemporal abnormalities across subtypes. Here, we hypothesized that patients with limbic encephalitis would show subtype-specific mesiotemporal structural correlates, which could be classified by supervised machine learning on an individual level. MATERIALS AND METHODS T1WI MPRAGE scans from 46 patients with antibodies against glutamic acid decarboxylase and 34 patients with antibodies against the voltage-gated potassium channel complex (including 10 patients with leucine-rich glioma-inactivated 1 autoantibodies) and 48 healthy controls were retrospectively ascertained. Parcellation of the amygdala, hippocampus, and hippocampal subfields was performed using FreeSurfer. Volumes were extracted and compared between groups using unpaired, 2-tailed t tests. The volumes of hippocampal subfields were analyzed using a multivariate linear model and a binary decision tree classifier. RESULTS Temporomesial volume alterations were most pronounced in an early stage and in the affected hemispheric side of patients. Statistical analysis revealed antibody-specific hippocampal fingerprints with a higher volume of CA1 in patients with glutamic acid decarboxylase-associated limbic encephalitis (P = .02), compared with controls, whereas CA1 did not differ from that in controls in patients with voltage-gated potassium channel complex autoantibodies. The classifier could successfully distinguish between patients with autoantibodies against leucine-rich glioma-inactivated 1 and glutamic acid decarboxylase with a specificity of 87% and a sensitivity of 80%. CONCLUSIONS Our results suggest stage-, side- and antibody-specific structural correlates of limbic encephalitis; thus, they create a perspective toward an MR imaging-based diagnosis.
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Affiliation(s)
- L Ernst
- From the Department of Epileptology (L.E., B.D., J.G., I.D.-N., C.E.E., T.R.)
| | - B David
- From the Department of Epileptology (L.E., B.D., J.G., I.D.-N., C.E.E., T.R.)
| | - J Gaubatz
- From the Department of Epileptology (L.E., B.D., J.G., I.D.-N., C.E.E., T.R.)
| | - I Domínguez-Narciso
- From the Department of Epileptology (L.E., B.D., J.G., I.D.-N., C.E.E., T.R.)
| | - G Lüchters
- Center for Development Research (G.L.), University of Bonn, Bonn, Germany
| | | | - B Weber
- Institute for Experimental Epileptology and Cognition Research (B.W.)
| | - E Hattingen
- Department of Radiology (E.H.), University of Bonn Medical Center, Bonn, Germany
- Department of Neuroradiology (E.H.), Goethe University Frankfurt, Frankfurt, Germany
| | - C E Elger
- From the Department of Epileptology (L.E., B.D., J.G., I.D.-N., C.E.E., T.R.)
| | - T Rüber
- From the Department of Epileptology (L.E., B.D., J.G., I.D.-N., C.E.E., T.R.)
- Epilepsy Center Frankfurt Rhine-Main (T.R.)
- Department of Neurology, and Center for Personalized Translational Epilepsy Research (T.R.), Goethe-University Frankfurt, Frankfurt am Main, Germany
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Zoccarato M, Valeggia S, Zuliani L, Gastaldi M, Mariotto S, Franciotta D, Ferrari S, Lombardi G, Zagonel V, De Gaspari P, Ermani M, Signori A, Pichiecchio A, Giometto B, Manara R. Conventional brain MRI features distinguishing limbic encephalitis from mesial temporal glioma. Neuroradiology 2019; 61:853-860. [PMID: 31028423 DOI: 10.1007/s00234-019-02212-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 04/04/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE Radiological hallmark of autoimmune limbic encephalitis (LE) is a hyperintense signal in MRI T2-weighted images of mesial temporal structures. We aimed to identify conventional magnetic resonance imaging (MRI) features that can help distinguish LE from temporal glioma. METHODS Brain MRIs of 25 patients affected by antibody-positive autoimmune LE, 24 patients affected by temporal glioma (tumor group), and 5 negative controls were retrospectively blindly evaluated in random order. RESULTS Ten brain MRIs from the LE group were correctly recognized; one additional patient with mesial temporal hyperintensity with anti-AK5 abs LE was wrongly diagnosed as having a tumor. The brain MRIs of the remaining 14 of the 25 patients with LE were judged negative or, in three cases, showed features not typical for LE. In the tumor group, all MRIs showed pathological alterations diagnosed as tumors in 22/24 cases and as LE in two (2/22, 9%). Unilateral lesions were more common in tumors than in neuroradiologically abnormal LE (96% vs. 18%, p < 0.001). T2/FLAIR hyperintensity of the parahippocampal gyrus was associated more with tumor than with LE (71% vs. 18%) (p = 0,009), as T2/FLAIR hyperintensity of extralimbic structures (p = 0.015), edema (p = 0.041), and mass effect (p = 0.015). Maintenance of gray/white matter distinction was strongly associated with LE (91% vs. 17%, p < 0.001). CONCLUSION Conventional brain MRI is a fundamental tool in the differential diagnosis between LE and glioma. Bilateral involvement and maintenance of gray/white matter distinction at the cortical/subcortical interface are highly suggestive of LE.
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Affiliation(s)
- Marco Zoccarato
- Neurology Unit, AULSS 6 Euganea, Padua, Italy. .,Neuroimmunology Group, Istituto di Ricerca Pediatrica, Padua, Italy.
| | | | - Luigi Zuliani
- Neuroimmunology Group, Istituto di Ricerca Pediatrica, Padua, Italy.,Department of Neurology, Ospedale San Bortolo, AULSS 8 Berica, Vicenza, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory, IRCSS Mondino Foundation, Pavia, Italy
| | - Sara Mariotto
- Neurology Unit, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Diego Franciotta
- Neuroimmunology Laboratory, IRCSS Mondino Foundation, Pavia, Italy
| | - Sergio Ferrari
- Neurology Unit, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Giuseppe Lombardi
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Vittorina Zagonel
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Piera De Gaspari
- Neuroimmunology Group, Istituto di Ricerca Pediatrica, Padua, Italy
| | - Mario Ermani
- Department of Neurosciences (DNS), Statistic and Informatics Unit, School of Medicine, University of Padua, Padua, Italy
| | - Alessio Signori
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Anna Pichiecchio
- Department of Neuroradiology, IRCSS Mondino Foundation, Pavia, Italy
| | - Bruno Giometto
- Department of Neurology, Ospedale Santa Chiara, Trento, Italy
| | - Renzo Manara
- Neuroradiology, Department of Medicine and Surgery, Sezione di Neuroscienze, University of Salerno, Salerno, Italy
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Sato M, Kishida D, Miyazaki D, Sekijima Y. A Patient with Limbic Encephalitis Associated with Anti-leucine-rich Glioma-inactivated 1 (LGI1) Antibody Presenting with Slowly Progressive Cognitive Impairment and Fluctuating Striatal Lesions. Intern Med 2019; 58:287-291. [PMID: 30146575 PMCID: PMC6378158 DOI: 10.2169/internalmedicine.1082-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
We herein report the case of a 59-year-old man with anti-leucine-rich glioma-inactivated 1 (LGI1) antibody encephalitis who presented with slowly progressive cognitive impairment mimicking dementia for over 3 years and then developed seizures. Unique brain magnetic resonance imaging (MRI) findings of fluctuating striatal lesions were observed during the disease course. He was treated with intravenous methylprednisolone pulse therapy followed by oral prednisolone, which dramatically improved his neurological function. Taken together, these findings indicate that anti-LGI1 encephalitis may present as slowly progressive cognitive impairment mimicking dementia and that fluctuating MRI striatal lesions may be a characteristic radiological finding of this disorder.
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Affiliation(s)
- Mitsuto Sato
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
| | - Dai Kishida
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
| | - Daigo Miyazaki
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
- Institute for Biomedical Sciences, Shinshu University, Japan
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Geschwind MD, Murray K. Differential diagnosis with other rapid progressive dementias in human prion diseases. HANDBOOK OF CLINICAL NEUROLOGY 2018; 153:371-397. [PMID: 29887146 DOI: 10.1016/b978-0-444-63945-5.00020-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Prion diseases are unique in medicine as in humans they occur in sporadic, genetic, and acquired forms. The most common human prion disease is sporadic Creutzfeldt-Jakob disease (CJD), which commonly presents as a rapidly progressive dementia (RPD) with behavioral, cerebellar, extrapyramidal, and some pyramidal features, with the median survival from symptom onset to death of just a few months. Because human prion diseases, as well as other RPDs, are relatively rare, they can be difficult to diagnose, as most clinicians have seen few, if any, cases. Not only can prion diseases mimic many other conditions that present as RPD, but some of those conditions can present similarly to prion disease. In this article, the authors discuss the different etiologic categories of conditions that often present as RPD and also present RPDs that had been misdiagnosed clinically as CJD. Etiologic categories of conditions are presented in order of the mnemonic used for remembering the various categories of RPDs: VITAMINS-D, for vascular, infectious, toxic-metabolic, autoimmune, mitochondrial/metastases, iatrogenic, neurodegenerative, system/seizures/sarcoid, and demyelinating. When relevant, clinical, imaging, or other features of an RPD that overlap with those of CJD are presented.
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Affiliation(s)
- Michael D Geschwind
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, CA, United States.
| | - Katy Murray
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, United Kingdom
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Tröscher AR, Klang A, French M, Quemada-Garrido L, Kneissl SM, Bien CG, Pákozdy Á, Bauer J. Selective Limbic Blood-Brain Barrier Breakdown in a Feline Model of Limbic Encephalitis with LGI1 Antibodies. Front Immunol 2017; 8:1364. [PMID: 29093718 PMCID: PMC5651237 DOI: 10.3389/fimmu.2017.01364] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 10/05/2017] [Indexed: 12/30/2022] Open
Abstract
Human leucine-rich glioma-inactivated protein 1 encephalitis (LGI1) is an autoimmune limbic encephalitis in which serum and cerebrospinal fluid contain antibodies targeting LGI1, a protein of the voltage gated potassium channel (VGKC) complex. Recently, we showed that a feline model of limbic encephalitis with LGI1 antibodies, called feline complex partial seizures with orofacial involvement (FEPSO), is highly comparable to human LGI1 encephalitis. In human LGI1 encephalitis, neuropathological investigations are difficult because very little material is available. Taking advantage of this natural animal model to study pathological mechanisms will, therefore, contribute to a better understanding of its human counterpart. Here, we present a brain-wide histopathological analysis of FEPSO. We discovered that blood–brain barrier (BBB) leakage was present not only in all regions of the hippocampus but also in other limbic structures such as the subiculum, amygdale, and piriform lobe. However, in other regions, such as the cerebellum, no leakage was observed. In addition, this brain-region-specific immunoglobulin leakage was associated with the breakdown of endothelial tight junctions. Brain areas affected by BBB dysfunction also revealed immunoglobulin and complement deposition as well as neuronal cell death. These neuropathological findings were supported by magnetic resonance imaging showing signal and volume increase in the amygdala and the piriform lobe. Importantly, we could show that BBB disturbance in LGI1 encephalitis does not depend on T cell infiltrates, which were present brain-wide. This finding points toward another, so far unknown, mechanism of opening the BBB. The limbic predilection sites of immunoglobulin antibody leakage into the brain may explain why most patients with LGI1 antibodies have a limbic phenotype even though LGI1, the target protein, is ubiquitously distributed across the central nervous system.
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Affiliation(s)
- Anna R Tröscher
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Andrea Klang
- Department for Pathobiology, Institute of Pathology and Forensic Veterinary Medicine, University of Veterinary Medicine, Vienna, Austria
| | - Maria French
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Lucía Quemada-Garrido
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Sibylle Maria Kneissl
- Diagnostic Imaging, Department for Companion Animals and Horses, University of Veterinary Medicine, Vienna, Austria
| | | | - Ákos Pákozdy
- Clinical Unit of Internal Medicine Small Animals, University of Veterinary Medicine, Vienna, Austria
| | - Jan Bauer
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
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10
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Grativvol RS, Simabukuro MM, Spera RR, Cavalcante WCP, Araújo HHS, Sakuno D, Lucato LT, Pinto LF, Castro LHM, Nitrini R. Imaging findings in faciobrachial dystonic seizures associated with LGI-1 antibodies. ARQUIVOS DE NEURO-PSIQUIATRIA 2016; 74:947. [PMID: 27901261 DOI: 10.1590/0004-282x20160146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 08/10/2016] [Indexed: 02/06/2023]
Affiliation(s)
- Ronnyson Susano Grativvol
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brasil
| | - Mateus Mistieri Simabukuro
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brasil
| | - Raphael Ribeiro Spera
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brasil
| | - Wagner Cid Palmeira Cavalcante
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brasil
| | - Hugo Henrique Soares Araújo
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brasil
| | - Daniel Sakuno
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Radiologia, São Paulo SP, Brasil
| | - Leandro Tavares Lucato
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Radiologia, São Paulo SP, Brasil
| | - Lécio Figueira Pinto
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brasil
| | - Luiz Henrique Martins Castro
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brasil
| | - Ricardo Nitrini
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brasil
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11
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van Sonderen A, Schreurs M, Wirtz P, Sillevis Smitt P, Titulaer M. From VGKC to LGI1 and Caspr2 encephalitis: The evolution of a disease entity over time. Autoimmun Rev 2016; 15:970-4. [DOI: 10.1016/j.autrev.2016.07.018] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 07/08/2016] [Indexed: 01/14/2023]
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12
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Sleep disturbances in voltage-gated potassium channel antibody syndrome. Sleep Med 2015; 21:171-3. [PMID: 26922624 DOI: 10.1016/j.sleep.2015.11.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 11/10/2015] [Accepted: 11/16/2015] [Indexed: 01/17/2023]
Abstract
Voltage-gated potassium channels (VGKCs) are a family of membrane proteins responsible for controlling cell membrane potential. The presence of antibodies (Ab) against neuronal VGKC complexes aids in the diagnosis of idiopathic and paraneoplastic autoimmune neurologic disorders. The diagnosis of VGKC Ab-associated encephalopathy (VCKC Ab syndrome) should be suspected in patients with subacute onset of disorientation, confusion, and memory loss in the presence of seizures or a movement disorder. VGKC Ab syndrome may present with sleep-related symptoms, and the purpose of this communication is to alert sleep and neurology clinicians of this still-under-recognized condition. In this case, we are presenting the VGKC Ab syndrome which improved after treatment with solumedrol. The prompt recognition and treatment of this condition may prevent the morbidity associated with cerebral atrophy and the mortality associated with intractable seizures and electrolyte disturbances.
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