1
|
Melzer N, Weber K, Räuber S, Rosenow F. [(Auto)immunity in focal epilepsy: mechanisms of (auto‑)immune-inflammatory epileptogenic neurodegeneration]. DER NERVENARZT 2024:10.1007/s00115-024-01695-5. [PMID: 38953922 DOI: 10.1007/s00115-024-01695-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/07/2024] [Indexed: 07/04/2024]
Abstract
OBJECTIVE While the neuronal mechanisms of epileptic hyperexcitability (HE) have been studied in detail, recent findings suggest that extraneuronal, mainly immune-mediated inflammatory and vascular mechanisms play an important role in the development and progression of HE in epilepsy and the cognitive and behavioral comorbidities. MATERIAL AND METHODS Narrative review. RESULTS As in autoimmune (limbic) encephalitis (ALE/AIE) or Rasmussen's encephalitis (RE), the primary adaptive and innate immune responses and associated changes in the blood-brain barrier (BBB) and neurovascular unit (NVU) can cause acute cortical hyperexcitability (HE) and the development of hippocampal sclerosis (HS) and other structural cortical lesions with chronic HE. Cortical HE, which is associated with malformation of cortical development (MCD) and low-grade epilepsy-associated tumors (LEAT), for example, can be accompanied by secondary adaptive and innate immune responses and alterations in the BBB and NVU, potentially modulating the ictogenicity and epileptogenicity. These associations illustrate the influence of adaptive and innate immune mechanisms and associated changes in the BBB and NVU on cortical excitability and vice versa, suggesting a dynamic and complex interplay of these factors in the development and progression of epilepsy in general. DISCUSSION The described concept of a neuro-immune-vascular interaction in focal epilepsy opens up new possibilities for the pathogenetic understanding and thus also for the selective therapeutic intervention.
Collapse
Affiliation(s)
- Nico Melzer
- Klinik für Neurologie, Medizinische Fakultät und Universitätsklinikum, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
| | - Katharina Weber
- Neurologisches Institut (Edinger Institut), Universitätsklinikum Frankfurt, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
- Frankfurt Cancer Institute (FCI), Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
- Partnerstätte Frankfurt, Frankfurt am Main und Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Deutsches Konsortium für Translationale Krebsforschung (DKTK), Heidelberg, Deutschland
- Universitäres Centrum für Tumorerkrankungen Frankfurt (UCT), Universitätsklinikum Frankfurt, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
| | - Saskia Räuber
- Klinik für Neurologie, Medizinische Fakultät und Universitätsklinikum, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - Felix Rosenow
- Epilepsiezentrum Frankfurt Rhein-Main, Klinik für Neurologie, Zentrum für Neurologie und Neurochirurgie, Universitätsklinikum Frankfurt, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland.
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland.
| |
Collapse
|
2
|
Su M, Luo Q, Wu Z, Feng H, Zhou H. Thymoma-associated autoimmune encephalitis with myasthenia gravis: Case series and literature review. CNS Neurosci Ther 2024; 30:e14568. [PMID: 38421083 PMCID: PMC10850820 DOI: 10.1111/cns.14568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 11/20/2023] [Accepted: 12/02/2023] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVES This comprehensive review aimed to compile cases of patients with thymoma diagnosed with both autoimmune encephalitis (AE) and myasthenia gravis (MG), and describe their clinical characteristics. METHODS Clinical records of 3 AE patients in the first affiliated hospital of Sun Yat-sen University were reviewed. All of them were diagnosed with AE between 1 November 2021 and 1 March 2022, and clinical evidence about thymoma and MG was found. All published case reports were searched for comprehensive literature from January 1990 to June 2022. RESULTS A total of 18 cases diagnosed with thymoma-associated autoimmune encephalitis (TAAE) and thymoma-associated myasthenia gravis (TAMG) were included in this complication, wherein 3 cases were in the first affiliated hospital of Sun Yat-sen University and the other 15 were published case reports. 5/18 patients had alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor antibody (AMPAR-Ab) in their serum and cerebrospinal fluid (CSF). All of them had positive anti-acetylcholine receptor antibody (AChR-Ab). And 12/18 patients showed a positive response to thymectomy and immunotherapy. Besides, thymoma recurrences were detected because of AE onset. And the shortest interval between operation and AE onset was 2 years in patients with thymoma recurrence. CONCLUSIONS There was no significant difference in the clinical manifestations between these patients and others with only TAMG or TAAE. TAAE was commonly associated with AMPAR2-Ab. Significantly, AE more commonly heralded thymoma recurrences than MG onset. And the intervals of thymectomy and MG or AE onset had different meanings for thymoma recurrence and prognoses of patients.
Collapse
Affiliation(s)
- Miao Su
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Qiuyan Luo
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
- Department of NeurologyGuangzhou Women and Children's Medical CenterGuangzhouChina
| | - Zichao Wu
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Huiyu Feng
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Hongyan Zhou
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| |
Collapse
|
3
|
Casagrande S, Zuliani L, Grisold W. Paraneoplastic encephalitis. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:131-149. [PMID: 38494274 DOI: 10.1016/b978-0-12-823912-4.00019-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
The first reports of encephalitis associated with cancer date to the 1960s and were characterized by clinical and pathologic involvement of limbic areas. This specific association was called limbic encephalitis (LE). The subsequent discovery of several "onconeural" antibodies (Abs), i.e., Abs targeting an antigen shared by neurons and tumor cells, supported the hypothesis of an autoimmune paraneoplastic etiology of LE and other forms of rapidly progressive encephalopathy. Over the past 20 years, similar clinical pictures with different clinical courses have been described in association with novel Abs-binding neuronal membrane proteins and proved to be pathogenic. The most well-known encephalitis in this group was described in 2007 as an association of a complex neuro-psychiatric syndrome, N-methyl-d-aspartate (NMDA) receptor-Abs, and ovarian teratoma in young women. Later on, nonparaneoplastic cases of NMDA receptor encephalitis were also described. Since then, the historical concept of LE and Ab associated encephalitis has changed. Some of these occur in fact more commonly in the absence of a malignancy (e.g., anti-LG1 Abs). Lastly, seronegative cases were also described. The term paraneoplastic encephalitis nowadays encompasses different syndromes that may be triggered by occult tumors.
Collapse
Affiliation(s)
- Silvia Casagrande
- Neurology Unit, Rovereto Hospital, Trento, Italy; Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy.
| | - Luigi Zuliani
- Department of Neurology, San Bortolo Hospital, Azienda ULSS8 Berica, Vicenza, Italy
| | - Wolfgang Grisold
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
| |
Collapse
|
4
|
Raynowska J, Wu V, Kazer M, LaBuzetta JN, Ferrey D, Dunn‐Pirio A. COVID-19-associated AMPA-R and CRMP-5 autoimmune encephalitis in a patient with thymoma and myasthenia gravis. Clin Case Rep 2023; 11:e7064. [PMID: 36950670 PMCID: PMC10025254 DOI: 10.1002/ccr3.7064] [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: 08/01/2022] [Revised: 01/06/2023] [Accepted: 02/22/2023] [Indexed: 03/24/2023] Open
Abstract
Thymomas are associated with autoimmune disease, most commonly myasthenia gravis, and rarely with autoimmune encephalitis. More recently, viral triggers including COVID-19 have also been implicated in autoimmunity. We present a case of antibody-positive autoimmune encephalitis that developed in the setting of COVID-19 in a patient with thymomatous myasthenia gravis.
Collapse
Affiliation(s)
- Jenelle Raynowska
- Department of NeurosciencesUniversity of California, San DiegoLa JollaCaliforniaUSA
| | - Victoria Wu
- Department of NeurosciencesUniversity of California, San DiegoLa JollaCaliforniaUSA
| | - Max Kazer
- Department of NeurosciencesUniversity of California, San DiegoLa JollaCaliforniaUSA
| | | | - Dominic Ferrey
- Department of NeurosciencesUniversity of California, San DiegoLa JollaCaliforniaUSA
| | - Anastasie Dunn‐Pirio
- Department of NeurosciencesUniversity of California, San DiegoLa JollaCaliforniaUSA
| |
Collapse
|
5
|
Mueller C, Elben S, Day GS, Alves P, Hebert J, Tang-Wai DF, Holtmann O, Iorio R, Perani D, Titulaer MJ, Hansen N, Bartsch T, Johnen A, Illes Z, Borm L, Willison AG, Wiendl H, Meuth SG, Kovac S, Bölte J, Melzer N. Review and meta-analysis of neuropsychological findings in autoimmune limbic encephalitis with autoantibodies against LGI1, CASPR2, and GAD65 and their response to immunotherapy. Clin Neurol Neurosurg 2022; 224:107559. [PMID: 36549220 DOI: 10.1016/j.clineuro.2022.107559] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES It is assumed that autoimmune limbic encephalitis (ALE) demonstrates distinct neuropsychological manifestations with differential responses to immunotherapy according to which associated autoantibody (AAB), if any, is identified. Towards investigating whether this is the case, this study aims to summarize respective findings from the primary literature on ALE with AABs binding to cell surface neural antigens and ALE with AABs against intracellular neural antigens. METHODS We chose ALE with AABs against leucine-rich, glioma inactivated protein 1 (LGI1) and contactin-associated protein-like 2 (CASPR2) as the most frequent cell surface membrane antigens, and ALE with AABs to Embryonic Lethal, Abnormal Vision, Like 1 (ELAVL) proteins (anti-Hu) and glutamic acid decarboxylase 65 (GAD65) as the most frequent intracellular neural antigens. The PubMed and Scopus databases were searched on March 1st, 2021 for neuropsychological test and -screening data from patients with ALE of these AAB-types. Findings were reviewed according to AAB-type and immunotherapy status and are presented in a review section and are further statistically evaluated and presented in a meta-analysis section in this publication. RESULTS Of the 1304 initial hits, 32 studies on ALE with AABs against LGI1, CASPR2, and GAD65 reporting cognitive screening data could be included in a review. In ALE with AABs against LGI1, CASPR2 and GAD65, memory deficits are the most frequently reported deficits. However, deficits in attention and executive functions including working memory, fluency, and psychological function have also been reported. This review shows that ALE patients with AABs against both LGI1 and CASPR2 show higher percentages of neuropsychological deficits compared to ALE patients with AABs against GAD65 before and after initiation of immunotherapy. However, the methodologies used in these studies were heterogenous, and longitudinal studies were not comparable. Moreover, 21 studies including ALE patients with AABs against LGI1 and GAD65 were also suitable for meta-analysis. No suitable study on ALE with AABs against ELAVL proteins could be identified. Meta-Analyses could be executed for cognitive screening data and only partially, due to the small number of studies. However, in statistical analysis no consistent effect of AAB or immunotherapy on performance in cognitive screening tests could be found. CONCLUSION Currently, there is no definite evidence supporting the notion that different AAB-types of ALE exhibit distinct neuropsychological manifestations and respond differently to immunotherapy. Overall, we could not identify evidence for any effect of immunotherapy on cognition in ALE. More systematic, in-depth and longitudinal neuropsychological assessments of patients with different AAB-types of ALE are required in the future to investigate these aspects.
Collapse
Affiliation(s)
- Christoph Mueller
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Saskia Elben
- Department of Neurology, Medical Faculty, Heinrich-Heine University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.
| | - Gregory S Day
- Department of Neurology, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, United States.
| | - Pedro Alves
- Serviço de Neurologia, Departamento de Neurociências e Saúde Mental, Hospital de Santa Maria, CHULN, Lisboa, Portugal; Laboratório de Estudos de Linguagem, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Portugal.
| | - Julien Hebert
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Canada.
| | - David F Tang-Wai
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Canada; Memory Clinic, Toronto Western Hospital (University Health Network), Toronto, Canada.
| | - Olga Holtmann
- Institute of Medical Psychology and Systems Neuroscience, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Raffaele Iorio
- Neurology Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Daniela Perani
- Division of Neuroscience, University Vita-Salute San Raffaele, Via Olgettina, 58, 20132 Milano, MI, Italy.
| | - Maarten J Titulaer
- Department of Neurology, Neuropsychology and Immunology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
| | - Niels Hansen
- Department of Psychiatry and Psychotherapy, University of Göttingen, Von-Siebold-Str. 5, 37075 Göttingen, Germany.
| | - Thorsten Bartsch
- Department of Neurology, University Medical Center Schleswig-Holstein, Rosalind-Franklin-Straße 10, 24105 Kiel, Germany.
| | - Andreas Johnen
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Zslot Illes
- Department of Neurology with Institute of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 4, 5000 Odense, Denmark.
| | - Leah Borm
- Institute of Psychology, Westfälische Wilhelms-University of Münster, Fliednerstraße 21, 48149 Münster, Germany.
| | - Alice G Willison
- Department of Neurology, Medical Faculty, Heinrich-Heine University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany; Department of Neurology, Medical Faculty, Heinrich-Heine University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.
| | - Stjepana Kovac
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Jens Bölte
- Institute of Psychology, Westfälische Wilhelms-University of Münster, Fliednerstraße 21, 48149 Münster, Germany.
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany; Department of Neurology, Medical Faculty, Heinrich-Heine University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.
| |
Collapse
|
6
|
Neuronal and Neuroaxonal Damage Cerebrospinal Fluid Biomarkers in Autoimmune Encephalitis Associated or Not with the Presence of Tumor. Biomedicines 2022; 10:biomedicines10061262. [PMID: 35740284 PMCID: PMC9220160 DOI: 10.3390/biomedicines10061262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/17/2022] [Accepted: 05/20/2022] [Indexed: 02/05/2023] Open
Abstract
The aim of this study was to evaluate the association of neuronal damage biomarkers (neurofilament light chain (NFL) and total tau protein (T-tau)) in the CSF of patients with autoimmune encephalitis (AE) with the presence of an underlying malignancy and to determine correlations with patient characteristics. The study comprised 21 patients with encephalitis associated with antibodies against intracellular (n = 11) and surface/synaptic antigens (extracellular, n = 10) and non-inflammatory disease controls (n = 10). Patients with AE associated with intracellular antigens had increased CSF-NFL (p = 0.003) but not T-tau levels compared to controls. When adjusted for age, CSF-NFL but not CSF-T-tau was higher in patients with encephalitis associated with intracellular antigens as compared to those with encephalitis associated with extracellular antigens (p = 0.032). Total tau and NFL levels were not significantly altered in patients with encephalitis associated with extracellular antigens compared to controls. NFL in the total cohort correlated with neurological signs of cerebellar dysfunction, peripheral neuropathy, presence of CV2 positivity, presence of an underlying tumor and a more detrimental clinical outcome. AE patients with abnormal MRI findings displayed higher NFL levels compared to those without, albeit with no statistical significance (p = 0.07). Using receiver operating characteristic curve analysis, CSF-NFL levels with a cut-off value of 969 pg/mL had a sensitivity and specificity of 100% and 76.19%, respectively, regarding the detection of underlying malignancies. Our findings suggest that neuronal integrity is preserved in autoimmune encephalitis associated with extracellular antigens and without the presence of tumor. However, highly increased NFL is observed in AE associated with intracellular antigens and presence of an underlying tumor. CSF-NFL could potentially be used as a diagnostic biomarker of underlying malignancies in the clinical setting of AE.
Collapse
|
7
|
Wright MA, Trandafir CC, Nelson GR, Hersh AO, Inman CJ, Zielinski BA. Diagnosis and Management of Suspected Pediatric Autoimmune Encephalitis: A Comprehensive, Multidisciplinary Approach and Review of Literature. J Child Neurol 2022; 37:303-313. [PMID: 34927485 DOI: 10.1177/08830738211064673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Autoimmune encephalitis is an increasingly recognized entity in children. When treated promptly, favorable outcomes are seen in a majority of pediatric patients. However, recognition of autoimmune encephalitis in young patients is challenging. Once autoimmune encephalitis is suspected, additional difficulties exist regarding timing of treatment initiation and duration of treatment, as evidence to guide management of these patients is emerging. Here, we review available literature regarding pediatric autoimmune encephalitis and present our institution's comprehensive approach to the evaluation and management of the disease. These guidelines were developed through an iterative process involving both pediatric neurologists and rheumatologists.
Collapse
Affiliation(s)
- Melissa A Wright
- Division of Pediatric Neurology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA
| | - Cristina C Trandafir
- Division of Pediatric Neurology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA.,Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, 3989Baylor College of Medicine, Houston, TX, USA
| | - Gary R Nelson
- Division of Pediatric Neurology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA
| | - Aimee O Hersh
- Division of Pediatric Rheumatology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA
| | - C J Inman
- Division of Pediatric Rheumatology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA
| | - Brandon A Zielinski
- Division of Pediatric Neurology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA.,Department of Neurology, 14434University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
8
|
Cross-reactivity of a pathogenic autoantibody to a tumor antigen in GABA A receptor encephalitis. Proc Natl Acad Sci U S A 2021; 118:1916337118. [PMID: 33619082 DOI: 10.1073/pnas.1916337118] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Encephalitis associated with antibodies against the neuronal gamma-aminobutyric acid A receptor (GABAA-R) is a rare form of autoimmune encephalitis. The pathogenesis is still unknown but autoimmune mechanisms were surmised. Here we identified a strongly expanded B cell clone in the cerebrospinal fluid of a patient with GABAA-R encephalitis. We expressed the antibody produced by it and showed by enzyme-linked immunosorbent assay (ELISA) and immunohistochemistry that it recognizes the GABAA-R. Patch-clamp recordings revealed that it tones down inhibitory synaptic transmission and causes increased excitability of hippocampal CA1 pyramidal neurons. Thus, the antibody likely contributed to clinical disease symptoms. Hybridization to a protein array revealed the cross-reactive protein LIM-domain-only protein 5 (LMO5), which is related to cell-cycle regulation and tumor growth. We confirmed LMO5 recognition by immunoprecipitation and ELISA and showed that cerebrospinal fluid samples from two other patients with GABAA-R encephalitis also recognized LMO5. This suggests that cross-reactivity between GABAA-R and LMO5 is frequent in GABAA-R encephalitis and supports the hypothesis of a paraneoplastic etiology.
Collapse
|
9
|
Saini L, Sondhi V. CNS autoimmunity in children: An unwanted wrinkle in a smooth narrative. Med J Armed Forces India 2021; 77:138-146. [PMID: 33867628 DOI: 10.1016/j.mjafi.2021.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 03/13/2021] [Indexed: 11/25/2022] Open
Abstract
The emerging paradigm of childhood autoimmune neurological disorders has exploded in recent times due to reliable diagnostic methods and their ease of availability, well-defined diagnostic criteria, and universal awareness about these disorders. The most important aspect of these disorders is a considerable recovery in response to early targeted immunotherapy. If left untreated and/or ill-treated, these can lead to mortality or lifelong morbidity. Autoantibodies can target any part of the central nervous system (CNS), ranging from superficial structures like myelin to deep intracellular ion channels like voltage-gated potassium channels, resulting in contrasting and at times overlapping symptomatology. Though neuroimaging characteristics and serological tests confirm these disorders' diagnosis, it is essential to suspect them clinically and start management before the reports are available for minimizing morbidity and mortality. In the pediatric age group, several metabolic conditions, like mitochondrial disorders and enzyme deficiencies like HMG-CoA-lyase deficiency, can develop neuroimaging patterns similar to those seen in childhood CNS autoimmune disorders and may also show a favorable response to steroids in acute phases. Hence, the clinician must suspect and work up the index patient appropriately. Here, we briefly discuss the pathophysiology, clinical clues, and potential therapeutic targets related to pediatric CNS autoimmune disorders.
Collapse
Affiliation(s)
- Lokesh Saini
- Assistant Professor (Pediatrics), Pediatric Neurology Unit, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sondhi
- Associate Professor, Department of Pediatrics, Armed Forces Medical College, Pune, India
| |
Collapse
|
10
|
Kao YC, Lin MI, Weng WC, Lee WT. Neuropsychiatric Disorders Due to Limbic Encephalitis: Immunologic Aspect. Int J Mol Sci 2020; 22:ijms22010389. [PMID: 33396564 PMCID: PMC7795533 DOI: 10.3390/ijms22010389] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/26/2020] [Accepted: 12/28/2020] [Indexed: 12/16/2022] Open
Abstract
Limbic encephalitis (LE) is a rare cause of encephalitis presenting as an acute and subacute onset of neuropsychiatric manifestations, particularly with memory deficits and confusion as core features, along with seizure occurrence, movement disorders, or autonomic dysfunctions. LE is caused by neuronal antibodies targeting the cellular surface, synaptic, and intracellular antigens, which alter the synaptic transmission, especially in the limbic area. Immunologic mechanisms involve antibodies, complements, or T-cell-mediated immune responses in different degree according to different autoantibodies. Sensitive cerebrospinal fluid markers of LE are unavailable, and radiographic findings may not reveal a typical mesiotemporal involvement at neurologic presentations; therefore, a high clinical index of suspicions is pivotal, and a neuronal antibody testing is necessary to make early diagnosis. Some patients have concomitant tumors, causing paraneoplastic LE; therefore, tumor survey and treatment are required in addition to immunotherapy. In this study, a review on the molecular and immunologic aspects of LE was conducted to gain awareness of its peculiarity, which we found quite different from our knowledge on traditional psychiatric illness.
Collapse
Affiliation(s)
- Yu-Chia Kao
- Department of Pediatrics, E-Da Hospital, Kaohsiung 82445, Taiwan;
| | - Ming-I Lin
- Department of Pediatrics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 11101, Taiwan;
| | - Wen-Chin Weng
- Department of Pediatrics, National Taiwan University Hospital, Taipei 100226, Taiwan;
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei 100233, Taiwan
| | - Wang-Tso Lee
- Department of Pediatrics, National Taiwan University Hospital, Taipei 100226, Taiwan;
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei 100233, Taiwan
- Graduate Institute of Brain and Mind Sciences, National Taiwan University College of Medicine, Taipei 100233, Taiwan
- Correspondence: ; Tel.: +886-2-23123456 (ext. 71545); Fax: +886-2-23147450
| |
Collapse
|
11
|
Pilli D, Zou A, Dawes R, Lopez JA, Tea F, Liyanage G, Lee FX, Merheb V, Houston SD, Pillay A, Jones HF, Ramanathan S, Mohammad S, Kelleher AD, Alexander SI, Dale RC, Brilot F. Pro-inflammatory dopamine-2 receptor-specific T cells in paediatric movement and psychiatric disorders. Clin Transl Immunology 2020; 9:e1229. [PMID: 33425355 PMCID: PMC7780098 DOI: 10.1002/cti2.1229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/09/2020] [Accepted: 11/29/2020] [Indexed: 12/13/2022] Open
Abstract
Objectives A dysregulated inflammatory response against the dopamine‐2 receptor (D2R) has been implicated in movement and psychiatric disorders. D2R antibodies were previously reported in a subset of these patients; however, the role of T cells in these disorders remains unknown. Our objective was to identify and characterise pro‐inflammatory D2R‐specific T cells in movement and psychiatric disorders. Methods Blood from paediatric patients with movement and psychiatric disorders of suspected autoimmune and neurodevelopmental aetiology (n = 24) and controls (n = 16) was cultured in vitro with a human D2R peptide library, and D2R‐specific T cells were identified by flow cytometric quantification of CD4+CD25+CD134+ T cells. Cytokine secretion was analysed using a cytometric bead array and ELISA. HLA genotypes were examined in D2R‐specific T‐cell‐positive patients. D2R antibody seropositivity was determined using a flow cytometry live cell‐based assay. Results Three immunodominant regions of D2R, amino acid (aa)121–131, aa171–181 and aa396–416, specifically activated CD4+ T cells in 8/24 patients. Peptides corresponding to these regions were predicted to bind with high affinity to the HLA of the eight positive patients and had also elicited the secretion of pro‐inflammatory cytokines IL‐2, IFN‐ γ, TNF, IL‐6, IL‐17A and IL‐17F. All eight patients were seronegative for D2R antibodies. Conclusion Autoreactive D2R‐specific T cells and a pro‐inflammatory Th1 and Th17 cytokine profile characterise a subset of paediatric patients with movement and psychiatric disorders, further underpinning the theory of immune dysregulation in these disorders. These findings offer new perspectives into the neuroinflammatory mechanisms of movement and psychiatric disorders and can influence patient diagnosis and treatment.
Collapse
Affiliation(s)
- Deepti Pilli
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the 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
| | - Alicia Zou
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the 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
| | - Ruebena Dawes
- Discipline of Child and Adolescent Health Faculty of Medicine and Health The University of Sydney Sydney NSW Australia.,Genomic Medicine Group Kids Neuroscience Centre Kids Research at the Children's Hospital at Westmead Sydney NSW Australia
| | - Joseph A Lopez
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the 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
| | - Fiona Tea
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the 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
| | - Ganesha Liyanage
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the Children's Hospital at Westmead Sydney NSW Australia.,School of Medical Sciences Discipline of Applied Medical Science Faculty of Medicine and Health The University of Sydney Sydney NSW Australia
| | - Fiona Xz Lee
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the Children's Hospital at Westmead Sydney NSW Australia
| | - Vera Merheb
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the Children's Hospital at Westmead Sydney NSW Australia
| | - Samuel D Houston
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the Children's Hospital at Westmead Sydney NSW Australia.,School of Biomedical Engineering The University of Sydney Sydney NSW Australia
| | - Aleha Pillay
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the Children's Hospital at Westmead Sydney NSW Australia
| | - Hannah F Jones
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the 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
| | - Sudarshini Ramanathan
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the 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
| | - Shekeeb Mohammad
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the 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
| | | | - Stephen I Alexander
- Discipline of Child and Adolescent Health Faculty of Medicine and Health The University of Sydney Sydney NSW Australia.,Centre for Kidney Research Children's Hospital at Westmead Sydney NSW Australia
| | - Russell C Dale
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the 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.,Brain and Mind Centre The University of Sydney Sydney NSW Australia
| | - Fabienne Brilot
- Brain Autoimmunity Group Kids Neuroscience Centre Kids Research at the 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.,School of Medical Sciences Discipline of Applied Medical Science Faculty of Medicine and Health The University of Sydney Sydney NSW Australia.,Brain and Mind Centre The University of Sydney Sydney NSW Australia
| |
Collapse
|
12
|
Zhao XH, Yang X, Liu XW, Wang SJ. Clinical features and outcomes of Chinese patients with anti-γ-aminobutyric acid B receptor encephalitis. Exp Ther Med 2020; 20:617-622. [PMID: 32509023 PMCID: PMC7271726 DOI: 10.3892/etm.2020.8684] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 03/10/2020] [Indexed: 12/24/2022] Open
Abstract
Antibodies against γ-aminobutyric acid B (GABAB) receptor are associated with limbic encephalitis (LE). It is estimated that ~1/2 of patients with LE have small-cell lung cancer. The present study analyzed the specific GABAB receptor antibodies in serum and cerebrospinal fluid (CSF) samples of 12 patients. The clinical manifestations, therapy and outcome were retrospectively compared. The median onset age was 65.1 years and all patients presented with new-onset seizures. In total, 11 (91.6%) patients had memory deficits, 7 (58.3%) patients had psychiatric problems and 4 (33.3%) patients had a disturbance of consciousness. Furthermore, lung cancer was detected in 7 patients (58.3%) by CT scan. Lymphocytic pleocytosis and protein concentration elevation in CSF were detected in 3 (25%) and 4 (33.3%) patients, respectively. Furthermore, MRI scan results identified 4 (33.3%) patients with abnormalities in the mesial temporal region. The lung cancer tissues of 3 patients were positively stained for anti-GABAB receptor on immunohistochemistry. All patients received antiepileptic drugs and immunotherapy. In total, 3 patients with lung cancer were subjected to tumor resection. Those patients without cancer exhibited neurological improvement at the follow-up. The present results suggested that seizures and memory deficits were the major manifestations in Chinese patients with anti-GABAB receptor antibodies who were responsive to immunotherapy. The lung cancer tissues from patients with anti-GABAB receptor antibodies were positively stained for anti-GABAB receptor. Collectively, the present results suggested that patients with underlying lung cancer have a relatively poor prognosis.
Collapse
Affiliation(s)
- Xiu-He Zhao
- Department of Neurology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Xue Yang
- Department of Neurology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Xue-Wu Liu
- Department of Neurology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Sheng-Jun Wang
- Department of Neurology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| |
Collapse
|
13
|
S1 guidelines "lumbar puncture and cerebrospinal fluid analysis" (abridged and translated version). Neurol Res Pract 2020; 2:8. [PMID: 33324914 PMCID: PMC7650145 DOI: 10.1186/s42466-020-0051-z] [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: 12/31/2019] [Accepted: 02/03/2020] [Indexed: 12/12/2022] Open
Abstract
Introduction Cerebrospinal fluid (CSF) analysis is important for detecting inflammation of the nervous system and the meninges, bleeding in the area of the subarachnoid space that may not be visualized by imaging, and the spread of malignant diseases to the CSF space. In the diagnosis and differential diagnosis of neurodegenerative diseases, the importance of CSF analysis is increasing. Measuring the opening pressure of CSF in idiopathic intracranial hypertension and at spinal tap in normal pressure hydrocephalus constitute diagnostic examination procedures with therapeutic benefits.Recommendations (most important 3-5 recommendations on a glimpse): The indications and contraindications must be checked before lumbar puncture (LP) is performed, and sampling CSF requires the consent of the patient.Puncture with an atraumatic needle is associated with a lower incidence of postpuncture discomfort. The frequency of postpuncture syndrome correlates inversely with age and body mass index, and it is more common in women and patients with a history of headache. The sharp needle is preferably used in older or obese patients, also in punctures expected to be difficult.In order to avoid repeating LP, a sufficient quantity of CSF (at least 10 ml) should be collected. The CSF sample and the serum sample taken at the same time should be sent to a specialized laboratory immediately so that the emergency and basic CSF analysis program can be carried out within 2 h.The indication for LP in anticoagulant therapy should always be decided on an individual basis. The risk of interrupting anticoagulant therapy must be weighed against the increased bleeding risk of LP with anticoagulant therapy.As a quality assurance measure in CSF analysis, it is recommended that all cytological, clinical-chemical, and microbiological findings are combined in an integrated summary report and evaluated by an expert in CSF analysis. Conclusions In view of the importance and developments in CSF analysis, the S1 guideline "Lumbar puncture and cerebrospinal fluid analysis" was recently prepared by the German Society for CSF analysis and clinical neurochemistry (DGLN) and published in German in accordance with the guidelines of the AWMF (https://www.awmf.org). /uploads/tx_szleitlinien/030-141l_S1_Lumbalpunktion_und_Liquordiagnostik_2019-08.pdf). The present article is an abridged translation of the above cited guideline. The guideline has been jointly edited by the DGLN and DGN.
Collapse
|
14
|
Jia Y, Wang J, Xue L, Hou Y. Limbic encephalitis associated with AMPA receptor and CRMP5 antibodies: A case report and literature review. Brain Behav 2020; 10:e01528. [PMID: 31991060 PMCID: PMC7066334 DOI: 10.1002/brb3.1528] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 12/25/2022] Open
Abstract
AIMS AMPA receptor (AMPAR) and CRMP5 antibodies are relatively uncommon in limbic encephalitis, and patients with both antibodies are rare. We recently treated such a patient, but the patient died after active treatment. To further understand this disease, we conducted a case report and literature review. DISCUSSIONS To date, five encephalitis patients, including our patient, have been found to be positive for AMPAR and CRMP5 antibodies. The male-to-female ratio of the reported cases is 4:1, and the age range is 26 and 62 years old. All five patients presented with various neuropsychiatric symptoms, including insomnia, abnormal behavior, seizures, extrapyramidal symptoms, and autonomic dysfunction. Four patients had tumors (three invasive thymomas and one suspected lymphoma), and three cases died within a short period of time. No tumor was detected in one of the patients during the follow-up period; however, after active treatment, the outcome was poor, and the patient developed cachexia. One patient had good response to immunotherapy and tumor therapy and successfully returned to work. CONCLUSIONS The prognosis of encephalitis associated with AMPAR and CRMP5 antibodies is worse than that of the encephalitis associated with AMPAR antibodies alone. The most likely cause is that this encephalitis is more likely to be accompanied by malignant tumors, leading to a poor prognosis. In addition, it may also be due to some synergistic mechanisms between the two antibodies. Further studies aimed at the prognosis of this type of encephalitis are warranted.
Collapse
Affiliation(s)
- Yujuan Jia
- Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Jie Wang
- Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Lanping Xue
- Department of Neurology, Shanxi Bethune Hospital, Taiyuan, China
| | - Yuli Hou
- Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan, China
| |
Collapse
|
15
|
Neuroinflammation in CNS diseases: Molecular mechanisms and the therapeutic potential of plant derived bioactive molecules. PHARMANUTRITION 2020. [DOI: 10.1016/j.phanu.2020.100176] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
16
|
Bracher A, Alcalá C, Ferrer J, Melzer N, Hohlfeld R, Casanova B, Beltrán E, Dornmair K. An expanded parenchymal CD8+ T cell clone in GABA A receptor encephalitis. Ann Clin Transl Neurol 2020; 7:239-244. [PMID: 31943946 PMCID: PMC7034500 DOI: 10.1002/acn3.50974] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/12/2019] [Accepted: 12/05/2019] [Indexed: 12/28/2022] Open
Abstract
The role of T cells in autoimmune encephalitis syndromes with autoantibodies against cell surface antigens is still enigmatic. Here we analyzed the T cell receptor repertoires of CD8+ and CD4+ T cells in a patient with "idiopathic" gamma-aminobutyric-acid-A receptor (GABAA -R) encephalitis by next-generation sequencing and single-cell analyses. We identified a CD8+ T cell clone that was strongly expanded in the cerebrospinal fluid and in the hippocampus but not in the operculo-insular cortex. By contrast, CD4+ T cells were polyclonal in these tissues. Such a strong clonal expansion suggests that CD8+ T cells may play a significant role in the pathogenesis.
Collapse
Affiliation(s)
- Aline Bracher
- Institute of Clinical Neuroimmunology, Biomedical Center and Hospital of the Ludwig-Maximilians Universität München, Munich, Germany
| | - Carmen Alcalá
- Department of Neurology, Hospital Universitari i Politècnic la Fe, Valencia, Spain
| | - Jaime Ferrer
- Department of Pathology, Hospital Universitari i Politècnic la Fe, Valencia, Spain
| | - Nico Melzer
- Clinic of Neurology and Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, Biomedical Center and Hospital of the Ludwig-Maximilians Universität München, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Bonaventura Casanova
- Department of Neurology, Hospital Universitari i Politècnic la Fe, Valencia, Spain
| | - Eduardo Beltrán
- Institute of Clinical Neuroimmunology, Biomedical Center and Hospital of the Ludwig-Maximilians Universität München, Munich, Germany
| | - Klaus Dornmair
- Institute of Clinical Neuroimmunology, Biomedical Center and Hospital of the Ludwig-Maximilians Universität München, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| |
Collapse
|
17
|
Schumacher M, Rommel FR, Arneth B, Renz H, Stöcker W, Windhorst A, Hahn A, Neubauer BA. Encephalopathy Associated With Neurochondrin Autoantibodies. J Child Neurol 2019; 34:660-665. [PMID: 31138003 DOI: 10.1177/0883073819849773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We determined the prevalence of autoantibodies against an extended number of established and novel neural antigens in children and adolescents with suspected autoimmune encephalitis, epilepsy, single seizures, or marked epileptiform activity in electroencephalography (EEG). Prospectively, 103 patients were recruited aged between 0 and 18 years and 104 controls. A panel of 35 autoantibodies against neural cell-surface and intracellular antigens was screened. Sixteen of 103 patients (15.5%) showed a positive result for 1 or more autoantibodies, compared to 6 of 104 controls (5.8%, P = .02). Neurochondrin was identified as a possible new target of autoantibodies in 3 patients within this cohort, but none in controls. The patients showed severe behavioral disturbances, memory and cognitive impairment, episodes of reduced responsiveness, but no seizures, and normal MRI. Clinical findings, course, and treatment response of these 3 patients are presented.
Collapse
Affiliation(s)
- Myriam Schumacher
- 1 Department of Child Neurology, Justus-Liebig University Gießen, Gießen, Germany
| | - Frank Risto Rommel
- 1 Department of Child Neurology, Justus-Liebig University Gießen, Gießen, Germany
| | - Borros Arneth
- 2 Institute of Laboratory Medicine and Pathobiochemistry, Molecular Diagnostics, Justus-Liebig University Gießen, Gießen, Germany
| | - Harald Renz
- 2 Institute of Laboratory Medicine and Pathobiochemistry, Molecular Diagnostics, Justus-Liebig University Gießen, Gießen, Germany
| | - Winfried Stöcker
- 3 Institute of Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Anita Windhorst
- 4 Institute for Medical Informatics, Justus-Liebig-University, Giessen, Germany
| | - Andreas Hahn
- 1 Department of Child Neurology, Justus-Liebig University Gießen, Gießen, Germany
| | - Bernd Axel Neubauer
- 1 Department of Child Neurology, Justus-Liebig University Gießen, Gießen, Germany
| |
Collapse
|
18
|
Chiang S, Garg T, Hu A, Amin H, Davalos-Balderas A, Alfradique-Dunham I, Goldsmith CE. Pearls & Oy-sters: Relapse of anti-NMDA receptor encephalitis after prior first- and second-line immunotherapy. Neurology 2019; 90:936-939. [PMID: 29759996 DOI: 10.1212/wnl.0000000000005517] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Sharon Chiang
- From the School of Medicine (S.C.), Department of Neurology (T.G., H.A., A.D.-B., I.A.-D., C.E.G.), and Department of Internal Medicine (A.H.), Baylor College of Medicine, Houston, TX
| | - Tanu Garg
- From the School of Medicine (S.C.), Department of Neurology (T.G., H.A., A.D.-B., I.A.-D., C.E.G.), and Department of Internal Medicine (A.H.), Baylor College of Medicine, Houston, TX
| | - Austin Hu
- From the School of Medicine (S.C.), Department of Neurology (T.G., H.A., A.D.-B., I.A.-D., C.E.G.), and Department of Internal Medicine (A.H.), Baylor College of Medicine, Houston, TX
| | - Hitha Amin
- From the School of Medicine (S.C.), Department of Neurology (T.G., H.A., A.D.-B., I.A.-D., C.E.G.), and Department of Internal Medicine (A.H.), Baylor College of Medicine, Houston, TX
| | - Alfredo Davalos-Balderas
- From the School of Medicine (S.C.), Department of Neurology (T.G., H.A., A.D.-B., I.A.-D., C.E.G.), and Department of Internal Medicine (A.H.), Baylor College of Medicine, Houston, TX
| | - Isabel Alfradique-Dunham
- From the School of Medicine (S.C.), Department of Neurology (T.G., H.A., A.D.-B., I.A.-D., C.E.G.), and Department of Internal Medicine (A.H.), Baylor College of Medicine, Houston, TX
| | - Corey E Goldsmith
- From the School of Medicine (S.C.), Department of Neurology (T.G., H.A., A.D.-B., I.A.-D., C.E.G.), and Department of Internal Medicine (A.H.), Baylor College of Medicine, Houston, TX.
| |
Collapse
|
19
|
18F-Flurodeoxyglucose positron emission tomography with computed tomography (FDG PET/CT) findings in children with encephalitis and comparison to conventional imaging. Eur J Nucl Med Mol Imaging 2019; 46:1309-1324. [DOI: 10.1007/s00259-019-04302-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 02/28/2019] [Indexed: 12/24/2022]
|
20
|
Amedonu E, Brenker C, Barman S, Schreiber JA, Becker S, Peischard S, Strutz-Seebohm N, Strippel C, Dik A, Hartung HP, Budde T, Wiendl H, Strünker T, Wünsch B, Goebels N, Meuth SG, Seebohm G, Melzer N. An Assay to Determine Mechanisms of Rapid Autoantibody-Induced Neurotransmitter Receptor Endocytosis and Vesicular Trafficking in Autoimmune Encephalitis. Front Neurol 2019; 10:178. [PMID: 30881339 PMCID: PMC6405626 DOI: 10.3389/fneur.2019.00178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/11/2019] [Indexed: 02/01/2023] Open
Abstract
N-Methyl-D-aspartate (NMDA) receptors (NMDARs) are among the most important excitatory neurotransmitter receptors in the human brain. Autoantibodies to the human NMDAR cause the most frequent form of autoimmune encephalitis involving autoantibody-mediated receptor cross-linking and subsequent internalization of the antibody-receptor complex. This has been deemed to represent the predominant antibody effector mechanism depleting the NMDAR from the synaptic and extra-synaptic neuronal cell membrane. To assess in detail the molecular mechanisms of autoantibody-induced NMDAR endocytosis, vesicular trafficking, and exocytosis we transiently co-expressed rat GluN1-1a-EGFP and GluN2B-ECFP alone or together with scaffolding postsynaptic density protein 95 (PSD-95), wild-type (WT), or dominant-negative (DN) mutant Ras-related in brain (RAB) proteins (RAB5WT, RAB5DN, RAB11WT, RAB11DN) in HEK 293T cells. The cells were incubated with a pH-rhodamine-labeled human recombinant monoclonal GluN1 IgG1 autoantibody (GluN1-aAbpH−rhod) genetically engineered from clonally expanded intrathecal plasma cells from a patient with anti-NMDAR encephalitis, and the pH-rhodamine fluorescence was tracked over time. We show that due to the acidic luminal pH, internalization of the NMDAR-autoantibody complex into endosomes and lysosomes increases the pH-rhodamine fluorescence. The increase in fluorescence allows for mechanistic assessment of endocytosis, vesicular trafficking in these vesicular compartments, and exocytosis of the NMDAR-autoantibody complex under steady state conditions. Using this method, we demonstrate a role for PSD-95 in stabilization of NMDARs in the cell membrane in the presence of GluN1-aAbpH−rhod, while RAB proteins did not exert a significant effect on vertical trafficking of the internalized NMDAR autoantibody complex in this heterologous expression system. This novel assay allows to unravel molecular mechanisms of autoantibody-induced receptor internalization and to study novel small-scale specific molecular-based therapies for autoimmune encephalitis syndromes.
Collapse
Affiliation(s)
- Elsie Amedonu
- Myocellular Electrophysiology and Molecular Biology, Institute for Genetics of Heart Diseases, University of Muenster, Muenster, Germany.,Department of Neurology, University of Muenster, Muenster, Germany
| | - Christoph Brenker
- Centre of Reproductive Medicine and Andrology, University of Muenster, Muenster, Germany
| | - Sumanta Barman
- Department of Neurology, Universitätsklinikum and Center for Neurology and Neuropsychiatry LVR Klinikum, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Julian A Schreiber
- Myocellular Electrophysiology and Molecular Biology, Institute for Genetics of Heart Diseases, University of Muenster, Muenster, Germany
| | - Sebastian Becker
- Myocellular Electrophysiology and Molecular Biology, Institute for Genetics of Heart Diseases, University of Muenster, Muenster, Germany
| | - Stefan Peischard
- Myocellular Electrophysiology and Molecular Biology, Institute for Genetics of Heart Diseases, University of Muenster, Muenster, Germany
| | - Nathalie Strutz-Seebohm
- Myocellular Electrophysiology and Molecular Biology, Institute for Genetics of Heart Diseases, University of Muenster, Muenster, Germany
| | | | - Andre Dik
- Department of Neurology, University of Muenster, Muenster, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Universitätsklinikum and Center for Neurology and Neuropsychiatry LVR Klinikum, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Thomas Budde
- Institute for Physiology I, University of Muenster, Muenster, Germany
| | - Heinz Wiendl
- Department of Neurology, University of Muenster, Muenster, Germany
| | - Timo Strünker
- Centre of Reproductive Medicine and Andrology, University of Muenster, Muenster, Germany
| | - Bernhard Wünsch
- Institute for Pharmaceutical and Medical Chemistry, University of Muenster, Muenster, Germany
| | - Norbert Goebels
- Department of Neurology, Universitätsklinikum and Center for Neurology and Neuropsychiatry LVR Klinikum, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Sven G Meuth
- Department of Neurology, University of Muenster, Muenster, Germany
| | - Guiscard Seebohm
- Myocellular Electrophysiology and Molecular Biology, Institute for Genetics of Heart Diseases, University of Muenster, Muenster, Germany
| | - Nico Melzer
- Department of Neurology, University of Muenster, Muenster, Germany
| |
Collapse
|
21
|
Dik A, Strippel C, Mönig C, Golombeck KS, Schulte-Mecklenbeck A, Wiendl H, Meuth SG, Johnen A, Gross CC, Melzer N. Onconeural antigen spreading in paraneoplastic neurological disease due to small cell lung cancer. Oxf Med Case Reports 2018; 2018:omy034. [PMID: 30002861 PMCID: PMC6037119 DOI: 10.1093/omcr/omy034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 04/30/2018] [Indexed: 01/29/2023] Open
Abstract
Cellular and humoral immunity towards distinct onconeural antigens is the hallmark of paraneoplastic neurological diseases (PNDs). Stable formation of immunoglobulin (Ig) G antibodies to particular onconeural antigens occurs in the majority of cases, whereas persistent coexistence of antibodies specific for multiple onconeural antigens is a relatively rare phenomenon of certain malignant tumors like small cell lung cancer (SCLC). We here describe onconeural antigen spreading in a 70-year-old Caucasian male with PND due to SCLC. Onconeural antigen spreading may be promoted by two mutually non-exclusive mechanisms: (i) a switch of antigen expression pattern of the underlying tumor tissue as a result of a mutagenic process caused by the cancer itself and (ii) a self-propagated paraneoplastic immune response with persistent neuronal destruction, liberation, processing and presentation of intracellular neural antigens. This illustrates a potential dissociation between peripheral anti-tumoral immunity and central anti-neural immunity during the course of PND.
Collapse
Affiliation(s)
- Andre Dik
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Christine Strippel
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Constanze Mönig
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Kristin S Golombeck
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | | | - Heinz Wiendl
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Sven G Meuth
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Andreas Johnen
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Catharina C Gross
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Nico Melzer
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| |
Collapse
|
22
|
Fragoso DC, Gonçalves Filho ALDM, Pacheco FT, Barros BR, Aguiar Littig I, Nunes RH, Maia Júnior ACM, da Rocha AJ. Imaging of Creutzfeldt-Jakob Disease: Imaging Patterns and Their Differential Diagnosis. Radiographics 2017; 37:234-257. [PMID: 28076012 DOI: 10.1148/rg.2017160075] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Diagnosis of sporadic Creutzfeldt-Jakob disease (sCJD) remains a challenge because of the large variability of the clinical scenario, especially in its early stages, which may mimic several reversible or treatable disorders. The molecular basis of prion disease, as well as its brain propagation and the pathogenesis of the illness, have become better understood in recent decades. Several reports have listed recognizable clinical features and paraclinical tests to supplement the replicable diagnostic criteria in vivo. Nevertheless, we lack specific data about the differential diagnosis of CJD at imaging, mainly regarding those disorders evolving with similar clinical features (mimicking disorders). This review provides an update on the neuroimaging patterns of sCJD, emphasizing the relevance of magnetic resonance (MR) imaging, summarizing the clinical scenario and molecular basis of the disease, and highlighting clinical, genetic, and imaging correlations in different subtypes of prion diseases. A long list of differential diagnoses produces a comprehensive pictorial review, with the aim of enabling radiologists to identify typical and atypical patterns of sCJD. This review reinforces distinguishable imaging findings and confirms diffusion-weighted imaging (DWI) features as pivotal in the diagnostic workup of sCJD, as these findings enable radiologists to reliably recognize this rare but invariably lethal disease. A probable diagnosis is justified when expected MR imaging patterns are demonstrated and CJD-mimicking disorders are confidently ruled out. ©RSNA, 2017.
Collapse
Affiliation(s)
- Diego Cardoso Fragoso
- From the Division of Neuroradiology, Serviço de Diagnostico por Imagem, Santa Casa de Misericordia de Sao Paulo, Rua Dr. Cesario Motta Jr. 112, Vila Buarque, Sao Paulo-SP 01221-020, Brazil (D.C.F., A.L.d.M.G.F., F.T.P., B.R.B., I.A.L., R.H.N., A.C.M.M.J., A.J.d.R.); and Division of Neuroradiology, Fleury Medicina e Saúde, Sao Paulo, Brazil (D.C.F., A.L.d.M.G.F., F.T.P., I.A.L., R.H.N., A.C.M.M.J., A.J.d.R.)
| | - Augusto Lio da Mota Gonçalves Filho
- From the Division of Neuroradiology, Serviço de Diagnostico por Imagem, Santa Casa de Misericordia de Sao Paulo, Rua Dr. Cesario Motta Jr. 112, Vila Buarque, Sao Paulo-SP 01221-020, Brazil (D.C.F., A.L.d.M.G.F., F.T.P., B.R.B., I.A.L., R.H.N., A.C.M.M.J., A.J.d.R.); and Division of Neuroradiology, Fleury Medicina e Saúde, Sao Paulo, Brazil (D.C.F., A.L.d.M.G.F., F.T.P., I.A.L., R.H.N., A.C.M.M.J., A.J.d.R.)
| | - Felipe Torres Pacheco
- From the Division of Neuroradiology, Serviço de Diagnostico por Imagem, Santa Casa de Misericordia de Sao Paulo, Rua Dr. Cesario Motta Jr. 112, Vila Buarque, Sao Paulo-SP 01221-020, Brazil (D.C.F., A.L.d.M.G.F., F.T.P., B.R.B., I.A.L., R.H.N., A.C.M.M.J., A.J.d.R.); and Division of Neuroradiology, Fleury Medicina e Saúde, Sao Paulo, Brazil (D.C.F., A.L.d.M.G.F., F.T.P., I.A.L., R.H.N., A.C.M.M.J., A.J.d.R.)
| | - Bernardo Rodi Barros
- From the Division of Neuroradiology, Serviço de Diagnostico por Imagem, Santa Casa de Misericordia de Sao Paulo, Rua Dr. Cesario Motta Jr. 112, Vila Buarque, Sao Paulo-SP 01221-020, Brazil (D.C.F., A.L.d.M.G.F., F.T.P., B.R.B., I.A.L., R.H.N., A.C.M.M.J., A.J.d.R.); and Division of Neuroradiology, Fleury Medicina e Saúde, Sao Paulo, Brazil (D.C.F., A.L.d.M.G.F., F.T.P., I.A.L., R.H.N., A.C.M.M.J., A.J.d.R.)
| | - Ingrid Aguiar Littig
- From the Division of Neuroradiology, Serviço de Diagnostico por Imagem, Santa Casa de Misericordia de Sao Paulo, Rua Dr. Cesario Motta Jr. 112, Vila Buarque, Sao Paulo-SP 01221-020, Brazil (D.C.F., A.L.d.M.G.F., F.T.P., B.R.B., I.A.L., R.H.N., A.C.M.M.J., A.J.d.R.); and Division of Neuroradiology, Fleury Medicina e Saúde, Sao Paulo, Brazil (D.C.F., A.L.d.M.G.F., F.T.P., I.A.L., R.H.N., A.C.M.M.J., A.J.d.R.)
| | - Renato Hoffmann Nunes
- From the Division of Neuroradiology, Serviço de Diagnostico por Imagem, Santa Casa de Misericordia de Sao Paulo, Rua Dr. Cesario Motta Jr. 112, Vila Buarque, Sao Paulo-SP 01221-020, Brazil (D.C.F., A.L.d.M.G.F., F.T.P., B.R.B., I.A.L., R.H.N., A.C.M.M.J., A.J.d.R.); and Division of Neuroradiology, Fleury Medicina e Saúde, Sao Paulo, Brazil (D.C.F., A.L.d.M.G.F., F.T.P., I.A.L., R.H.N., A.C.M.M.J., A.J.d.R.)
| | - Antônio Carlos Martins Maia Júnior
- From the Division of Neuroradiology, Serviço de Diagnostico por Imagem, Santa Casa de Misericordia de Sao Paulo, Rua Dr. Cesario Motta Jr. 112, Vila Buarque, Sao Paulo-SP 01221-020, Brazil (D.C.F., A.L.d.M.G.F., F.T.P., B.R.B., I.A.L., R.H.N., A.C.M.M.J., A.J.d.R.); and Division of Neuroradiology, Fleury Medicina e Saúde, Sao Paulo, Brazil (D.C.F., A.L.d.M.G.F., F.T.P., I.A.L., R.H.N., A.C.M.M.J., A.J.d.R.)
| | - Antonio J da Rocha
- From the Division of Neuroradiology, Serviço de Diagnostico por Imagem, Santa Casa de Misericordia de Sao Paulo, Rua Dr. Cesario Motta Jr. 112, Vila Buarque, Sao Paulo-SP 01221-020, Brazil (D.C.F., A.L.d.M.G.F., F.T.P., B.R.B., I.A.L., R.H.N., A.C.M.M.J., A.J.d.R.); and Division of Neuroradiology, Fleury Medicina e Saúde, Sao Paulo, Brazil (D.C.F., A.L.d.M.G.F., F.T.P., I.A.L., R.H.N., A.C.M.M.J., A.J.d.R.)
| |
Collapse
|
23
|
Marcoux SV, Lam HN, Petrich CE, Ray NM. An Adult Man with Altered Mental Status, Bizarre Behavior, and Abnormal Limb Movements. Psychiatr Ann 2017. [DOI: 10.3928/00485713-20170731-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
24
|
Shin YW, Lee ST, Park KI, Jung KH, Jung KY, Lee SK, Chu K. Treatment strategies for autoimmune encephalitis. Ther Adv Neurol Disord 2017; 11:1756285617722347. [PMID: 29399043 PMCID: PMC5784571 DOI: 10.1177/1756285617722347] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 06/14/2017] [Indexed: 12/13/2022] Open
Abstract
Autoimmune encephalitis is one of the most rapidly growing research topics in neurology. Along with discoveries of novel antibodies associated with the disease, clinical experience and outcomes with diverse immunotherapeutic agents in the treatment of autoimmune encephalitis are accumulating. Retrospective observations indicate that early aggressive treatment is associated with better functional outcomes and fewer relapses. Immune response to first-line immunotherapeutic agents (corticosteroids, intravenous immunoglobulin, plasma exchange, and immunoadsorption) is fair, but approximately half or more of patients are administered second-line immunotherapy (rituximab and cyclophosphamide). A small but significant proportion of patients are refractory to all first- and second-line therapies and require further treatment. Although several investigations have shown promising alternatives, the low absolute number of patients involved necessitates more evidence to establish further treatment strategies. In this review, the agents used for first- and second-line immunotherapy are discussed and recent attempts at finding new treatment options are introduced.
Collapse
Affiliation(s)
- Yong-Won Shin
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea Yeongjusi Health Center, Gyeongsangbuk-do, South Korea
| | - Soon-Tae Lee
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung-Il Park
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Keun-Hwa Jung
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Ki-Young Jung
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Sang Kun Lee
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Kon Chu
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National niversity Hospital, 101, Daehangno, Jongno-gu, Seoul 110-744, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| |
Collapse
|
25
|
Pilli D, Zou A, Tea F, Dale RC, Brilot F. Expanding Role of T Cells in Human Autoimmune Diseases of the Central Nervous System. Front Immunol 2017. [PMID: 28638382 PMCID: PMC5461350 DOI: 10.3389/fimmu.2017.00652] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
It is being increasingly recognized that a dysregulation of the immune system plays a vital role in neurological disorders and shapes the treatment of the disease. Aberrant T cell responses, in particular, are key in driving autoimmunity and have been traditionally associated with multiple sclerosis. Yet, it is evident that there are other neurological diseases in which autoreactive T cells have an active role in pathogenesis. In this review, we report on the recent progress in profiling and assessing the functionality of autoreactive T cells in central nervous system (CNS) autoimmune disorders that are currently postulated to be primarily T cell driven. We also explore the autoreactive T cell response in a recently emerging group of syndromes characterized by autoantibodies against neuronal cell-surface proteins. Common methodology implemented in T cell biology is further considered as it is an important determinant in their detection and characterization. An improved understanding of the contribution of autoreactive T cells expands our knowledge of the autoimmune response in CNS disorders and can offer novel methods of therapeutic intervention.
Collapse
Affiliation(s)
- Deepti Pilli
- Brain Autoimmunity Group, Institute for Neuroscience and Muscle Research, The Kids Research Institute at The Children's Hospital at Westmead, University of Sydney, Sydney, NSW, Australia
| | - Alicia Zou
- Brain Autoimmunity Group, Institute for Neuroscience and Muscle Research, The Kids Research Institute at The Children's Hospital at Westmead, University of Sydney, Sydney, NSW, Australia
| | - Fiona Tea
- Brain Autoimmunity Group, Institute for Neuroscience and Muscle Research, The Kids Research Institute at The Children's Hospital at Westmead, University of Sydney, Sydney, NSW, Australia
| | - Russell C Dale
- Brain Autoimmunity Group, Institute for Neuroscience and Muscle Research, The Kids Research Institute at The Children's Hospital at Westmead, University of Sydney, Sydney, NSW, Australia.,Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia
| | - Fabienne Brilot
- Brain Autoimmunity Group, Institute for Neuroscience and Muscle Research, The Kids Research Institute at The Children's Hospital at Westmead, University of Sydney, Sydney, NSW, Australia.,Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
26
|
Golombeck KS, Bönte K, Mönig C, van Loo KM, Hartwig M, Schwindt W, Widman G, Lindenau M, Becker AJ, Glatzel M, Elger CE, Wiendl H, Meuth SG, Lohmann H, Gross CC, Melzer N. Evidence of a pathogenic role for CD8(+) T cells in anti-GABAB receptor limbic encephalitis. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2016; 3:e232. [PMID: 27213174 PMCID: PMC4853055 DOI: 10.1212/nxi.0000000000000232] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 03/17/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To characterize the cellular autoimmune response in patients with γ-aminobutyric acid (GABA)B receptor antibody-associated limbic encephalitis (GABAB-R LE). METHODS Patients underwent MRI, extensive neuropsychological assessment, and multiparameter flow cytometry of peripheral blood and CSF. RESULTS We identified a series of 3 cases of nonparaneoplastic GABAB-R LE and one case of paraneoplastic GABAB-R LE associated with small cell lung cancer. All patients exhibited temporal lobe epilepsy, neuropsychological deficits, and MRI findings typical of LE. Absolute numbers of CD19(+) B cells, CD138(+) CD19(+) plasma cells, CD4(+) T cells, activated HLADR(+) CD4(+) T cells, as well as CD8(+) T cells and HLADR(+) CD8(+) T cells did not differ in peripheral blood but were elevated in CSF of patients with GABAB-R LE compared to controls. Augmented absolute numbers of CD138(+) CD19(+) plasma cells and activated HLADR(+) CD8(+) T cells in CSF corresponded to higher overall neuropsychological and memory deficits in patients with GABAB-R LE. A histologic specimen of one patient following selective amygdalohippocampectomy revealed perivascular infiltrates of CD138(+) plasma cells and CD4(+) T cells, whereas cytotoxic CD8(+) T cells were detected within the brain parenchyma in close contact to neurons. CONCLUSION Our data suggest a pathogenic role for CD8(+) T cells in addition to the established role of plasma cell-derived autoantibodies in GABAB-R LE.
Collapse
Affiliation(s)
- Kristin S Golombeck
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Kathrin Bönte
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Constanze Mönig
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Karen M van Loo
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Marvin Hartwig
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Wolfram Schwindt
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Guido Widman
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Matthias Lindenau
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Albert J Becker
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Markus Glatzel
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Christian E Elger
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Heinz Wiendl
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Sven G Meuth
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Hubertus Lohmann
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Catharina C Gross
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| | - Nico Melzer
- Departments of Neurology (K.S.G., K.B., C.M., M.H., H.W., S.G.M., H.L., C.C.G., N.M.) and Clinical Radiology (W.S.), and Institute of Physiology I-Neuropathophysiology (S.G.M.), University of Münster; Departments of Epileptology (G.W., C.E.E.) and Neuropathology (K.M.v.L., A.J.B.), University of Bonn; Epilepsy Center Hamburg (M.L.), Evangelisches Krankenhaus Alsterdorf, Hamburg; and Department of Neuropathology (M.G.), University of Hamburg, Germany
| |
Collapse
|
27
|
CTLA-4+49 A/G polymorphism and antiglutamic acid decarboxylase antibody-associated encephalopathy in Taiwanese children. Brain Dev 2016; 38:419-26. [PMID: 26546236 DOI: 10.1016/j.braindev.2015.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 10/09/2015] [Accepted: 10/09/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND Anti-glutamic acid decarboxylase antibodies are associated with encephalopathy, an autoimmune central nervous system inflammatory disease. The cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4)+49 A/G polymorphism has been shown to confer genetic susceptibility to positive anti-glutamic acid decarboxylase antibodies in patients with type 1 diabetes mellitus in Japan. We aimed to investigate the association of the CTLA-4+49 A/G (rs231775) polymorphism in Taiwanese children with anti-glutamic acid decarboxylase antibody-associated encephalopathy. METHODS This was a case-control study from July 2011 to June 2012 performed at Chang Gung Children's Hospital in Taiwan. Genotyping of the CTLA-4+49 A/G polymorphism was performed by polymerase chain reaction-restriction fragment length polymorphism. RESULTS Seventeen patients with anti-glutamic acid decarboxylase antibody-associated encephalopathy and 97 controls were enrolled. The genotype, allele and carrier frequencies of the CTLA-4+49 A/G polymorphism were equally distributed in the patients and controls, with no significant differences between the two groups. In addition, we found a positive trend between the level of anti-glutamic acid decarboxylase antibodies and the G allele of the CTLA-4+49 A/G polymorphism, although this trend was not statistically significant. CONCLUSIONS Our results suggest that the CTLA-4+49 A/G (rs231775) polymorphism does not confer an increased susceptibility to anti-glutamic acid decarboxylase antibody-associated encephalopathy in Taiwanese children.
Collapse
|
28
|
Byun JI, Lee ST, Jung KH, Sunwoo JS, Moon J, Lim JA, Lee DY, Shin YW, Kim TJ, Lee KJ, Lee WJ, Lee HS, Jun J, Kim DY, Kim MY, Kim H, Kim HJ, Suh HI, Lee Y, Kim DW, Jeong JH, Choi WC, Bae DW, Shin JW, Jeon D, Park KI, Jung KY, Chu K, Lee SK. Effect of Immunotherapy on Seizure Outcome in Patients with Autoimmune Encephalitis: A Prospective Observational Registry Study. PLoS One 2016; 11:e0146455. [PMID: 26771547 PMCID: PMC4714908 DOI: 10.1371/journal.pone.0146455] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 12/17/2015] [Indexed: 01/03/2023] Open
Abstract
Objective To evaluate the seizure characteristics and outcome after immunotherapy in adult patients with autoimmune encephalitis (AE) and new-onset seizure. Methods Adult (age ≥18 years) patients with AE and new-onset seizure who underwent immunotherapy and were followed-up for at least 6 months were included. Seizure frequency was evaluated at 2–4 weeks and 6 months after the onset of the initial immunotherapy and was categorized as “seizure remission”, “> 50% seizure reduction”, or “no change” based on the degree of its decrease. Results Forty-one AE patients who presented with new-onset seizure were analysed. At 2–4 weeks after the initial immunotherapy, 51.2% of the patients were seizure free, and 24.4% had significant seizure reduction. At 6 months, seizure remission was observed in 73.2% of the patients, although four patients died during hospitalization. Rituximab was used as a second-line immunotherapy in 12 patients who continued to have seizures despite the initial immunotherapy, and additional seizure remission was achieved in 66.6% of them. In particular, those who exhibited partial response to the initial immunotherapy had a better seizure outcome after rituximab, with low adverse events. Conclusion AE frequently presented as seizure, but only 18.9% of the living patients suffered from seizure at 6 months after immunotherapy. Aggressive immunotherapy can improve seizure outcome in patients with AE.
Collapse
Affiliation(s)
- Jung-Ick Byun
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Soon-Tae Lee
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Keun-Hwa Jung
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Jun-Sang Sunwoo
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Jangsup Moon
- Department of Neurology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, South Korea
| | - Jung-Ah Lim
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Doo Young Lee
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Yong-Won Shin
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Tae-Joon Kim
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Keon-Joo Lee
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Woo-Jin Lee
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Han-Sang Lee
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Jinsun Jun
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong-Yub Kim
- Departments of Neurology, Samsung Medical Center, Seoul, South Korea
| | - Man-Young Kim
- Departments of Neurology, Chosun University Hospital, Gwangju, South Korea
| | - Hyunjin Kim
- Departments of Neurology, Asan medical center, Seoul, South Korea
| | - Hyeon Jin Kim
- Departments of Neurology, Ewha Woman’s University Hospital, Seoul, South Korea
| | - Hong Il Suh
- Departments of Neurology, Ajou University Medical Center, Suwon, South Korea
| | - Yoojin Lee
- Departments of Neurology, Asan medical center, Seoul, South Korea
| | - Dong Wook Kim
- Departments of Neurology, Konkuk University Medical Center, Seoul, South Korea
| | - Jin Ho Jeong
- Departments of Neurology, Inje University Busan Paik Hospital, Busan, South Korea
| | - Woo Chan Choi
- Departments of Neurology, Kyungpook National University Hospital, Daegu, South Korea
| | - Dae Woong Bae
- Departments of Neurology, St. Mary's Hospital, Seoul, South Korea
| | - Jung-Won Shin
- Departments of Neurology, Cha university, CHA Bundang Medical Center, Seongnam, South Korea
| | - Daejong Jeon
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Kyung-Il Park
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Ki-Young Jung
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Kon Chu
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
- * E-mail: (KC); (SKL)
| | - Sang Kun Lee
- Departments of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
- * E-mail: (KC); (SKL)
| |
Collapse
|
29
|
Schröder O, Schriewer E, Golombeck KS, Kürten J, Lohmann H, Schwindt W, Wiendl H, Bruchmann M, Melzer N, Straube T. Impaired Autonomic Responses to Emotional Stimuli in Autoimmune Limbic Encephalitis. Front Neurol 2015; 6:250. [PMID: 26648907 PMCID: PMC4663278 DOI: 10.3389/fneur.2015.00250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 11/13/2015] [Indexed: 12/19/2022] Open
Abstract
Limbic encephalitis (LE) is an autoimmune-mediated disorder that affects structures of the limbic system, in particular, the amygdala. The amygdala constitutes a brain area substantial for processing of emotional, especially fear-related signals. The amygdala is also involved in neuroendocrine and autonomic functions, including skin conductance responses (SCRs) to emotionally arousing stimuli. This study investigates behavioral and autonomic responses to discrete emotion evoking and neutral film clips in a patient suffering from LE associated with contactin-associated protein-2 (CASPR2) antibodies as compared to a healthy control group. Results show a lack of SCRs in the patient while watching the film clips, with significant differences compared to healthy controls in the case of fear-inducing videos. There was no comparable impairment in behavioral data (emotion report, valence, and arousal ratings). The results point to a defective modulation of sympathetic responses during emotional stimulation in patients with LE, probably due to impaired functioning of the amygdala.
Collapse
Affiliation(s)
- Olga Schröder
- Institute of Medical Psychology and Systems Neuroscience, University of Muenster , Muenster , Germany
| | - Elisabeth Schriewer
- Institute of Medical Psychology and Systems Neuroscience, University of Muenster , Muenster , Germany
| | | | - Julia Kürten
- Institute of Medical Psychology and Systems Neuroscience, University of Muenster , Muenster , Germany
| | - Hubertus Lohmann
- Department of Neurology, University of Muenster , Muenster , Germany
| | - Wolfram Schwindt
- Department of Clinical Radiology, University of Muenster , Muenster , Germany
| | - Heinz Wiendl
- Department of Neurology, University of Muenster , Muenster , Germany
| | - Maximilian Bruchmann
- Institute of Medical Psychology and Systems Neuroscience, University of Muenster , Muenster , Germany
| | - Nico Melzer
- Department of Neurology, University of Muenster , Muenster , Germany
| | - Thomas Straube
- Institute of Medical Psychology and Systems Neuroscience, University of Muenster , Muenster , Germany
| |
Collapse
|
30
|
Lazarev I, Shelef I, Refaely Y, Ariad S, Ifergane G. Two Paraneoplastic Autoimmune Syndromes: Limbic Encephalitis and Palmar Fasciitis in a Patient with Small Cell Lung Cancer. Rare Tumors 2015; 7:5721. [PMID: 26500723 PMCID: PMC4600985 DOI: 10.4081/rt.2015.5721] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 04/20/2015] [Accepted: 04/22/2015] [Indexed: 12/03/2022] Open
Abstract
Small cell lung cancer (SCLC) is characterized by a relatively high rate of autoimmune phenomena. Paraneoplastic limbic encephalitis (PLE) is an autoimmune syndrome in which a non-neural tumor containing an antigen normally present in the nervous system precipitates an antibody attack on neural tissues. Patients with PLE usually present with rapidly progressive short-term memory deficits, confusion or even dementia. Palmar fasciitis and polyarthritis syndrome (PFPAS) is another autoimmune syndrome characterized by rheumatologic manifestations, especially involving the palms of the hands. We report a case of a 59-year old woman who presented with worsening neurological symptoms of two-week duration, and later coma. The combined clinical, serological, and imaging studies suggested a diagnosis of PLE. A chest computed tomographic scan showed a 1.2 cm-diameter mass in the upper lobe of the left lung that was surgically removed and showed SCLC. Following surgery, neurological symptoms rapidly improved, allowing the patient to receive adjuvant chemotherapy. While in remission for both SCLC and PLE, the patient developed pain, soft-tissue swelling, and stiffness in both palms, suggesting the diagnosis of PFPAS. Five months following the diagnosis of palmar fasciitis, SCLC relapsed with mediastinal and cervical lymphadenopathy. This case report underlines the continuous interaction of SCLC with the immune system, expressed by coexistence of two rare paraneoplastic diseases, PLE, and PFPAS, in a patient with SCLC. While symptoms related to PLE preceded the initial diagnosis of SCLC, other symptoms related to PFPAS preceded relapse.
Collapse
Affiliation(s)
- Irina Lazarev
- Departments of Oncology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev , Beer Sheba, Israel
| | - Ilan Shelef
- Departments of Imaging, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev , Beer Sheba, Israel
| | - Yael Refaely
- Departments of Thoracic Surgery, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev , Beer Sheba, Israel
| | - Samuel Ariad
- Departments of Oncology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev , Beer Sheba, Israel
| | - Gal Ifergane
- Departments of Neurology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev , Beer Sheba, Israel
| |
Collapse
|
31
|
Ehling P, Melzer N, Budde T, Meuth SG. CD8(+) T Cell-Mediated Neuronal Dysfunction and Degeneration in Limbic Encephalitis. Front Neurol 2015; 6:163. [PMID: 26236280 PMCID: PMC4502349 DOI: 10.3389/fneur.2015.00163] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 07/02/2015] [Indexed: 12/31/2022] Open
Abstract
Autoimmune inflammation of the limbic gray matter structures of the human brain has recently been identified as major cause of mesial temporal lobe epilepsy with interictal temporal epileptiform activity and slowing of the electroencephalogram, progressive memory disturbances, as well as a variety of other behavioral, emotional, and cognitive changes. Magnetic resonance imaging exhibits volume and signal changes of the amygdala and hippocampus, and specific anti-neuronal antibodies binding to either intracellular or plasma membrane neuronal antigens can be detected in serum and cerebrospinal fluid. While effects of plasma cell-derived antibodies on neuronal function and integrity are increasingly becoming characterized, potentially contributing effects of T cell-mediated immune mechanisms remain poorly understood. CD8+ T cells are known to directly interact with major histocompatibility complex class I-expressing neurons in an antigen-specific manner. Here, we summarize current knowledge on how such direct CD8+ T cell–neuron interactions may impact neuronal excitability, plasticity, and integrity on a single cell and network level and provide an overview on methods to further corroborate the in vivo relevance of these mechanisms mainly obtained from in vitro studies.
Collapse
Affiliation(s)
- Petra Ehling
- Department of Neurology, Westfälische Wilhelms-University of Münster , Münster , Germany ; Institute of Physiology I - Neuropathophysiology, Westfälische Wilhelms-University , Münster , Germany
| | - Nico Melzer
- Department of Neurology, Westfälische Wilhelms-University of Münster , Münster , Germany
| | - Thomas Budde
- Institute of Physiology I, Westfälische Wilhelms-University , Münster , Germany
| | - Sven G Meuth
- Department of Neurology, Westfälische Wilhelms-University of Münster , Münster , Germany ; Institute of Physiology I - Neuropathophysiology, Westfälische Wilhelms-University , Münster , Germany
| |
Collapse
|
32
|
Witt JA, Vogt VL, Widman G, Langen KJ, Elger CE, Helmstaedter C. Loss of Autonoetic Awareness of Recent Autobiographical Episodes and Accelerated Long-Term Forgetting in a Patient with Previously Unrecognized Glutamic Acid Decarboxylase Antibody Related Limbic Encephalitis. Front Neurol 2015; 6:130. [PMID: 26106363 PMCID: PMC4460811 DOI: 10.3389/fneur.2015.00130] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 05/19/2015] [Indexed: 01/16/2023] Open
Abstract
We describe a 35-year-old male patient presenting with depressed mood and emotional instability, who complained about severe anterograde and retrograde memory deficits characterized by accelerated long-term forgetting and loss of autonoetic awareness regarding autobiographical memories of the last 3 years. Months before he had experienced two breakdowns of unknown etiology giving rise to the differential diagnosis of epileptic seizures after various practitioners and clinics had suggested different etiologies such as a psychosomatic condition, burnout, depression, or dissociative amnesia. Neuropsychological assessment indicated selectively impaired figural memory performance. Extended diagnostics confirmed accelerated forgetting of previously learned and retrievable verbal material. Structural imaging showed bilateral swelling and signal alterations of temporomesial structures (left >right). Video-EEG monitoring revealed a left temporal epileptic focus and subclincal seizure, but no overt seizures. Antibody tests in serum and liquor were positive for glutamic acid decarboxylase antibodies. These findings led to the diagnosis of glutamic acid decarboxylase antibody related limbic encephalitis. Monthly steroid pulses over 6 months led to recovery of subjective memory and to intermediate improvement but subsequent worsening of objective memory performance. During the course of treatment, the patient reported de novo paroxysmal non-responsive states. Thus, antiepileptic treatment was started and the patient finally became seizure free. At the last visit, vocational reintegration was successfully in progress. In conclusion, amygdala swelling, retrograde biographic memory impairment, accelerated long-term forgetting, and emotional instability may serve as indicators of limbic encephalitis, even in the absence of overt epileptic seizures. The monitoring of such patients calls for a standardized and concerted multilevel diagnostic approach with repeated assessments.
Collapse
Affiliation(s)
| | - Viola Lara Vogt
- Department of Epileptology, University of Bonn , Bonn , Germany
| | - Guido Widman
- Department of Epileptology, University of Bonn , Bonn , Germany
| | - Karl-Josef Langen
- Institute of Neuroscience and Medicine, Forschungszentrum Jülich , Jülich , Germany
| | | | | |
Collapse
|
33
|
|
34
|
Probst C, Saschenbrecker S, Stoecker W, Komorowski L. Anti-neuronal autoantibodies: Current diagnostic challenges. Mult Scler Relat Disord 2014; 3:303-20. [DOI: 10.1016/j.msard.2013.12.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 10/01/2013] [Accepted: 12/03/2013] [Indexed: 01/17/2023]
|
35
|
Autoimmune-mediated cognitive impairment: a case report. PSYCHOSOMATICS 2014; 55:698-702. [PMID: 24751115 DOI: 10.1016/j.psym.2013.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 12/26/2013] [Accepted: 12/27/2013] [Indexed: 11/20/2022]
|