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Mahadeen AZ, Carlson AK, Cohen JA, Galioto R, Abbatemarco JR, Kunchok A. Review of the Longitudinal Management of Autoimmune Encephalitis, Potential Biomarkers, and Novel Therapeutics. Neurol Clin Pract 2024; 14:e200306. [PMID: 38831758 PMCID: PMC11145747 DOI: 10.1212/cpj.0000000000200306] [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: 03/25/2023] [Accepted: 02/08/2024] [Indexed: 06/05/2024]
Abstract
Purpose of Review Increasing awareness and earlier diagnosis of autoimmune encephalitis (AE) have led to a greater number of patients being cared for longitudinally by neurologists. Although many neurologists are now familiar with the general approach to diagnosis and acute immunosuppression, this review aims to provide neurologists with guidance related to management beyond the acute phase of disease, including long-term immunosuppression, monitoring, potential biomarkers of disease activity, outcome measures, and symptom management. Recent Findings Observational studies in AE have demonstrated that early diagnosis and treatment is associated with improved neurologic outcomes, particularly in AE with antibodies targeting neuronal cell surface/synaptic proteins. The literature regarding long-term management is evolving. In addition to traditional immunosuppressive approaches, there is emerging use of novel immunosuppressive therapies (ISTs) in case series, and several randomized controlled trials are planned. Novel biomarkers of disease activity and methods to measure outcomes and response to treatment are being explored. Furthermore, it is increasingly recognized that many individuals have chronic symptoms affecting quality of life including seizures, cognitive impairment, fatigue, sleep disorders, and mood disorders, and there are emerging data supporting the use of patient centered outcome measures and multidisciplinary symptom-based care. Summary This review aims to summarize recent literature and offer a practical approach to long-term management of adult patients with AE through a multidisciplinary approach. We summarize current knowledge on ISTs, potential biomarkers of disease activity, outcome measures, and long-term sequelae. Further research is needed to answer questions regarding optimal IST, biomarker validity, and sequelae of disease.
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Affiliation(s)
- Ahmad Z Mahadeen
- Department of Neurology (AZM), University of Mississippi Medical Center, Jackson; and Cleveland Clinic Mellen Center (AKC, JAC, RG, JRA, AK), OH
| | - Alise K Carlson
- Department of Neurology (AZM), University of Mississippi Medical Center, Jackson; and Cleveland Clinic Mellen Center (AKC, JAC, RG, JRA, AK), OH
| | - Jeffrey A Cohen
- Department of Neurology (AZM), University of Mississippi Medical Center, Jackson; and Cleveland Clinic Mellen Center (AKC, JAC, RG, JRA, AK), OH
| | - Rachel Galioto
- Department of Neurology (AZM), University of Mississippi Medical Center, Jackson; and Cleveland Clinic Mellen Center (AKC, JAC, RG, JRA, AK), OH
| | - Justin R Abbatemarco
- Department of Neurology (AZM), University of Mississippi Medical Center, Jackson; and Cleveland Clinic Mellen Center (AKC, JAC, RG, JRA, AK), OH
| | - Amy Kunchok
- Department of Neurology (AZM), University of Mississippi Medical Center, Jackson; and Cleveland Clinic Mellen Center (AKC, JAC, RG, JRA, AK), OH
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Balint B, Bhatia KP, Dalmau J. "Antibody of Unknown Significance" (AUS): The Issue of Interpreting Antibody Test Results. Mov Disord 2021; 36:1543-1547. [PMID: 33955060 DOI: 10.1002/mds.28597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/30/2021] [Accepted: 03/05/2021] [Indexed: 11/11/2022] Open
Affiliation(s)
- Bettina Balint
- Department of Neurology, University Hospital, Heidelberg, Germany.,Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
| | - Kailash P Bhatia
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
| | - Josep Dalmau
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.,Service of Neurology, Hospital Clinic de Barcelona, Barcelona, Spain.,Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Centro de Investigación Biomédica en Red de Enfermedades Raras, Barcelona, Spain.,Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
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Chakrabarty S, Govindaraj P, Sankaran BP, Nagappa M, Kabekkodu SP, Jayaram P, Mallya S, Deepha S, Ponmalar JNJ, Arivinda HR, Meena AK, Jha RK, Sinha S, Gayathri N, Taly AB, Thangaraj K, Satyamoorthy K. Contribution of nuclear and mitochondrial gene mutations in mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome. J Neurol 2021; 268:2192-2207. [PMID: 33484326 PMCID: PMC8179915 DOI: 10.1007/s00415-020-10390-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 11/30/2022]
Abstract
Background Mitochondrial disorders are clinically complex and have highly variable phenotypes among all inherited disorders. Mutations in mitochon
drial DNA (mtDNA) and nuclear genome or both have been reported in mitochondrial diseases suggesting common pathophysiological pathways. Considering the clinical heterogeneity of mitochondrial encephalopathy, lactic acidosis and stroke-like episodes (MELAS) phenotype including focal neurological deficits, it is important to look beyond mitochondrial gene mutation. Methods The clinical, histopathological, biochemical analysis for OXPHOS enzyme activity, and electron microscopic, and neuroimaging analysis was performed to diagnose 11 patients with MELAS syndrome with a multisystem presentation. In addition, whole exome sequencing (WES) and whole mitochondrial genome sequencing were performed to identify nuclear and mitochondrial mutations. Results Analysis of whole mtDNA sequence identified classical pathogenic mutation m.3243A > G in seven out of 11 patients. Exome sequencing identified pathogenic mutation in several nuclear genes associated with mitochondrial encephalopathy, sensorineural hearing loss, diabetes, epilepsy, seizure and cardiomyopathy (POLG, DGUOK, SUCLG2, TRNT1, LOXHD1, KCNQ1, KCNQ2, NEUROD1, MYH7) that may contribute to classical mitochondrial disease phenotype alone or in combination with m.3243A > G mutation. Conclusion Individuals with MELAS exhibit clinical phenotypes with varying degree of severity affecting multiple systems including auditory, visual, cardiovascular, endocrine, and nervous system. This is the first report to show that nuclear genetic factors influence the clinical outcomes/manifestations of MELAS subjects alone or in combination with m.3243A > G mutation. Electronic supplementary material The online version of this article (10.1007/s00415-020-10390-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sanjiban Chakrabarty
- Department of Cell and Molecular Biology, Manipal School of Life Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Periyasamy Govindaraj
- Department of Neuropathology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Neuromuscular Laboratory, Neurobiology Research Centre, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Institute of Bioinformatics, International Tech Park, Bangalore, India.,Manipal Academy of Higher Education, Manipal, India
| | - Bindu Parayil Sankaran
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Neuromuscular Laboratory, Neurobiology Research Centre, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Genetic Metabolic Disorders Service, Children's Hospital At Westmead, Sydney, NSW, Australia.,Discipline of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Madhu Nagappa
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Neuromuscular Laboratory, Neurobiology Research Centre, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Shama Prasada Kabekkodu
- Department of Cell and Molecular Biology, Manipal School of Life Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Pradyumna Jayaram
- Department of Cell and Molecular Biology, Manipal School of Life Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Sandeep Mallya
- Department of Bioinformatics, Manipal School of Life Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Sekar Deepha
- Department of Neuropathology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Neuromuscular Laboratory, Neurobiology Research Centre, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - J N Jessiena Ponmalar
- Neuromuscular Laboratory, Neurobiology Research Centre, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Hanumanthapura R Arivinda
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | | | - Rajan Kumar Jha
- CSIR-Centre for Cellular and Molecular Biology, Hyderabad, India
| | - Sanjib Sinha
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Narayanappa Gayathri
- Department of Neuropathology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Neuromuscular Laboratory, Neurobiology Research Centre, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Arun B Taly
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Neuromuscular Laboratory, Neurobiology Research Centre, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Kumarasamy Thangaraj
- CSIR-Centre for Cellular and Molecular Biology, Hyderabad, India.,Centre for DNA Fingerprinting and Diagnostics, Hyderabad, India
| | - Kapaettu Satyamoorthy
- Department of Cell and Molecular Biology, Manipal School of Life Sciences, Manipal Academy of Higher Education, Manipal, India.
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Fominykh VV, Frei EA, Brylev LV, Gulyaeva NV. Autoimmune Encephalitis: A Disease of the 21st Century at the Crossroads of Neurology and Psychiatry. NEUROCHEM J+ 2018. [DOI: 10.1134/s1819712418040037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Balint B, Vincent A, Meinck HM, Irani SR, Bhatia KP. Movement disorders with neuronal antibodies: syndromic approach, genetic parallels and pathophysiology. Brain 2018; 141:13-36. [PMID: 29053777 PMCID: PMC5888977 DOI: 10.1093/brain/awx189] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/10/2017] [Accepted: 06/13/2017] [Indexed: 01/17/2023] Open
Abstract
Movement disorders are a prominent and common feature in many autoantibody-associated neurological diseases, a group of potentially treatable conditions that can mimic infectious, metabolic or neurodegenerative disease. Certain movement disorders are likely to associate with certain autoantibodies; for example, the characteristic dyskinesias, chorea and dystonia associated with NMDAR antibodies, stiff person spectrum disorders with GAD, glycine receptor, amphiphysin or DPPX antibodies, specific paroxysmal dystonias with LGI1 antibodies, and cerebellar ataxia with various anti-neuronal antibodies. There are also less-recognized movement disorder presentations of antibody-related disease, and a considerable overlap between the clinical phenotypes and the associated antibody spectra. In this review, we first describe the antibodies associated with each syndrome, highlight distinctive clinical or radiological 'red flags', and suggest a syndromic approach based on the predominant movement disorder presentation, age, and associated features. We then examine the underlying immunopathophysiology, which may guide treatment decisions in these neuroimmunological disorders, and highlight the exceptional interface between neuronal antibodies and neurodegeneration, such as the tauopathy associated with IgLON5 antibodies. Moreover, we elaborate the emerging pathophysiological parallels between genetic movement disorders and immunological conditions, with proteins being either affected by mutations or targeted by autoantibodies. Hereditary hyperekplexia, for example, is caused by mutations of the alpha subunit of the glycine receptor leading to an infantile-onset disorder with exaggerated startle and stiffness, whereas antibodies targeting glycine receptors can induce acquired hyperekplexia. The spectrum of such immunological and genetic analogies also includes cerebellar ataxias and some encephalopathies. Lastly, we discuss how these pathophysiological considerations could reflect on possible future directions regarding antigen-specific immunotherapies or targeting the pathophysiological cascades downstream of the antibody effects.
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Affiliation(s)
- Bettina Balint
- Sobell Department of Motor Neuroscience and Movement Disorders UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
- Department of Neurology, University Hospital, Heidelberg, Germany
- Neuroimmunology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Angela Vincent
- Neuroimmunology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | | | - Sarosh R Irani
- Neuroimmunology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, 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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Feigal J, Lin C, Barrio G, Kranz PG, Preud׳Homme X. Anti−N-Methyl-d-Aspartate Receptor Encephalitis Presenting With Features of Kleine-Levin Syndrome and Demyelination. PSYCHOSOMATICS 2016; 57:310-4. [DOI: 10.1016/j.psym.2015.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 11/05/2015] [Accepted: 11/05/2015] [Indexed: 12/25/2022]
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Suleiman J, Wright S, Gill D, Brilot F, Waters P, Peacock K, Procopis P, Nibber A, Vincent A, Dale RC, Lang B. Autoantibodies to neuronal antigens in children with new-onset seizures classified according to the revised ILAE organization of seizures and epilepsies. Epilepsia 2013; 54:2091-100. [PMID: 24151870 DOI: 10.1111/epi.12405] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2013] [Indexed: 12/14/2022]
Abstract
PURPOSE Potentially pathogenic autoantibodies are found increasingly in adults with seizure disorders, including focal seizures and those of unknown cause. In this study, we investigated a cohort of children with new-onset seizures to see whether there were autoantibodies and the relationship to any specific seizure or epilepsy type. METHODS We prospectively recruited 114 children (2 months to 16 years) with new-onset seizures presenting between September 2009 and November 2011, as well as 65 controls. Patients were clinically assessed and classified according to the new International League Against Epilepsy (ILAE) organization of seizures and epilepsies classification system. Sera were tested for autoantibodies to a range of antigens, blind to the clinical and classification details. KEY FINDINGS Eleven (9.7%) of 114 patients were positive for one or more autoantibodies compared to 3 of 65 controls (4.6%, p = ns). Patients had antibodies to the voltage-gated potassium channel (VGKC) complex (n = 4), contactin-associated protein-like 2 (CASPR2) (n = 3), N-methyl-d-aspartate receptors (NMDARs) (n = 2), or VGKC-complex and NMDAR (n = 2). None had antibodies to glutamic acid decarboxylase, contactin-2, or to glycine, 2-amino-3-(3-hydroxy-5-methyl-4-isoxazolyl) propionic acid (AMPA), or γ-aminobutyric acid B receptors. Ten of these 11 patients were classified as having epilepsy according to the new ILAE organization of seizures and epilepsy. Although, there were no significant differences in the demographic and clinical features between antibody-positive and antibody-negative patients, the classification of "unknown cause" was higher in the antibody positive (7/10; 70%) compared with the antibody negative subjects (23/86; 26.7%; p = 0.0095, Fisher's exact test). Furthermore, four of these seven patients with epilepsy (57.1%) were classified as having predominantly focal seizures compared with 12 of the 86 antibody-negative patients (13.9%; p = 0.015). SIGNIFICANCE Because autoantibodies were more frequent in pediatric patients with new-onset epilepsy of "unknown cause," often with focal epilepsy features, this group of children may benefit most from autoantibody screening and consideration of immune therapy.
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Affiliation(s)
- Jehan Suleiman
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, The Children's Hospital at Westmead, University of Sydney, Sydney, New South Wales, Australia; T.Y. Nelson Department of Neurology, Children's Hospital at Westmead, University of Sydney, Sydney, New South Wales, Australia
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