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Zhang S, Mao C, Li X, Miao W, Teng J. Advances in Potential Cerebrospinal Fluid Biomarkers for Autoimmune Encephalitis: A Review. Front Neurol 2022; 13:746653. [PMID: 35937071 PMCID: PMC9355282 DOI: 10.3389/fneur.2022.746653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 06/20/2022] [Indexed: 12/24/2022] Open
Abstract
Autoimmune encephalitis (AE) is a severe inflammatory disease of the brain. Patients with AE demonstrate amnesia, seizures, and psychosis. Recent studies have identified numerous associated autoantibodies (e.g., against NMDA receptors (NMDARs), LGI1, etc.) involved in the pathogenesis of AE, and the levels of diagnosis and treatment are thus improved dramatically. However, there are drawbacks of clinical diagnosis and treatment based solely on antibody levels, and thus the application of additional biomarkers is urgently needed. Considering the important role of immune mechanisms in AE development, we summarize the relevant research progress in identifying cerebrospinal fluid (CSF) biomarkers with a focus on cytokines/chemokines, demyelination, and nerve damage.
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Chan F, O'Gorman C, Swayne A, Gillis D, Blum S, Warren N. Voltage-gated potassium channel blanket testing in first-episode psychosis: Diagnostic nihilism? Aust N Z J Psychiatry 2021; 55:817-823. [PMID: 33423505 DOI: 10.1177/0004867420983454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Voltage-gated potassium channel antibodies are implicated in limbic encephalitis and currently included in first-episode psychosis organic screening guidelines. Individuals with high-positive voltage-gated potassium channel titres most commonly present with neurological symptoms as well as sleep, cognitive, behaviour, psychosis and mood disturbance. The significance of low-positive voltage-gated potassium channel antibody titres in psychiatric patients is unclear and has not been previously examined. We aim to describe a statewide cohort of psychiatric patients with low- and high-positive voltage-gated potassium channel titres and explore if this finding influenced clinical management and patient outcomes. METHODS A retrospective review of all voltage-gated potassium channel antibodies testing performed in public psychiatric services in Queensland, Australia, with comparison of the clinical presentation and long-term outcomes of low- and high-positive voltage-gated potassium channel titre cases. Specific antigen targets (leucine-rich glioma-inactivated protein 1 and contactin-associated protein 2 antibodies) were also assessed. RESULTS The overall prevalence of voltage-gated potassium channel antibody positivity in Queensland, public, psychiatric service testing was 0.3% (14/4098), with 12 cases of low-positive voltage-gated potassium channel titre, 2 cases of high-positive (leucine-rich glioma-inactivated protein 1 antibody positive) cases and a voltage-gated potassium channel negative contactin-associated protein 2 antibody positive case. No low-positive case developed neurological abnormalities or had abnormal paraclinical investigations. In comparison, both high-positive voltage-gated potassium channel/leucine-rich glioma-inactivated protein 1 cases and the contactin-associated protein 2 antibody positive case rapidly developed neurological symptoms, had abnormal paraclinical testing and improved only with immunotherapy. There was no later development of encephalitic symptoms in the low-positive cases over an average of 1067 days follow-up. CONCLUSION Voltage-gated potassium channel antibody-associated limbic encephalitis was rare, and always associated with high antibody titres. Low-positive titres were not associated with the development of encephalitis over a long period of follow-up. The value of universal voltage-gated potassium channel antibody screening is unclear, and further prospective studies in first-episode psychosis populations are required.
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Affiliation(s)
- Fiona Chan
- Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Cullen O'Gorman
- Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Mater Centre for Neurosciences, Mater Hospital Brisbane, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Andrew Swayne
- Mater Centre for Neurosciences, Mater Hospital Brisbane, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - David Gillis
- Queensland Pathology, Brisbane, QLD, Australia.,Immunology Department, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Stefan Blum
- Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Mater Centre for Neurosciences, Mater Hospital Brisbane, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Nicola Warren
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Metro South Addiction and Mental Health, Princess Alexandra Hospital, Brisbane, QLD, Australia
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3
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Gastaldi M, Scaranzin S, Businaro P, Mobilia E, Benedetti L, Pesce G, Franciotta D. Improving laboratory diagnostics in myasthenia gravis. Expert Rev Mol Diagn 2021; 21:579-590. [PMID: 33970749 DOI: 10.1080/14737159.2021.1927715] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Myasthenia gravis (MG) is a prototypical autoimmune disease, characterized by pathogenic autoantibodies targeting structures of the neuromuscular junction. Radioimmunoprecipitation assays (RIPAs) represent the gold standard for their detection. However, new methods are emerging to complement, or overcome RIPAs, also with the perspective of eliminating the use of radioactive reagents.Areas covered: We discuss advances in laboratory methods, prompted especially by cell-based assays (CBAs), for the detection of the autoantibodies of MG diagnostics, above all those to the nicotinic acetylcholine receptor (AChR), muscle-specific kinase (MuSK), and low molecular-weight receptor-related low-density lipoprotein-4 (LRP4).Expert opinion: CBA technology makes AChRs aggregate on cell membranes, thus allowing to detect autoantibodies to clustered AChRs, with reduction of seronegative MG cases. The diagnostic relevance of RIPA/CBA-measurable LRP4 antibodies is still unclear, in Caucasian patients at least. Live CBAs for the detection of AChR, MuSK, and LRP4 antibodies might represent an alternative to RIPAs, but first require full validation. CBAs could be used as screening tests, limiting RIPAs for antibody quantification. To this end, ELISAs might be an alternative.Fixation procedures preserving enough degree of antigen conformationality could yield AChR and MuSK CBAs suitable for a wide use in clinical-chemistry laboratories.
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Affiliation(s)
- Matteo Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | - Silvia Scaranzin
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | - Pietro Businaro
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Emanuela Mobilia
- Autoimmunity Laboratory, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Luana Benedetti
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy; IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Giampaola Pesce
- Autoimmunity Laboratory, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine (Dimi), University of Genova, Genova, Italy
| | - Diego Franciotta
- Autoimmunity Laboratory, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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4
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Michael S, Waters P, Irani SR. Stop testing for autoantibodies to the VGKC-complex: only request LGI1 and CASPR2. Pract Neurol 2020; 20:377-384. [DOI: 10.1136/practneurol-2019-002494] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 04/16/2020] [Accepted: 04/30/2020] [Indexed: 12/16/2022]
Abstract
Autoantibodies to leucine-rich glioma-inactivated 1 (LGI1) and contactin-associated protein like-2 (CASPR2) are associated with clinically distinctive syndromes that are highly immunotherapy responsive, such as limbic encephalitis, faciobrachial dystonic seizures, Morvan’s syndrome and neuromyotonia. These autoantibodies target surface-exposed domains of LGI1 or CASPR2, and appear to be directly pathogenic. In contrast, voltage-gated potassium channel (VGKC) antibodies that lack LGI1 or CASPR2 reactivities (‘double-negative’) are common in healthy controls and have no consistent associations with distinct syndromes. These antibodies target intracellular epitopes and lack pathogenic potential. Moreover, the clinically important LGI1 and CASPR2 antibodies comprise only ~15% of VGKC-positive results, meaning that most VGKC-antibody positive results mislead rather than help. Further, initial VGKC testing misses some cases that have LGI1 and CASPR2 antibodies. These collective observations confirm that laboratories should stop testing for VGKC antibodies and instead, test only for LGI1 and CASPR2 antibodies. This change in practice will lead to significant patient benefit.
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5
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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.
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Autoimmune Limbic Encephalitis in a Patient with Acute Encephalopathy and Hyponatremia. Case Rep Med 2019; 2019:9051738. [PMID: 31687029 PMCID: PMC6800970 DOI: 10.1155/2019/9051738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 09/07/2019] [Accepted: 09/20/2019] [Indexed: 01/09/2023] Open
Abstract
Acute encephalopathy is a common clinical presentation for hospital admissions. Autoimmune encephalitis is a rare cause of encephalopathy which has increasingly been recognized over the last decade. The detection of various neuronal antibodies has helped diagnose these syndromes, but they have limited availability, mostly in the developed countries. We present a case of a middle-aged female presenting with memory impairment, gait disturbances, and hyponatremia. A clinical diagnosis of autoimmune limbic encephalitis was made based on faciobrachial dystonic seizures, SIADH, and MRI changes 10 days prior to autoantibody titer returned. Prompt treatment with steroids and intravenous immunoglobulin was started with improvement in her neurological symptoms. This case highlights the importance of considering autoimmune encephalitis syndromes in the differential diagnosis of patients with classical neurological presentations and prompt diagnosis and immunotherapy to improve neurological outcomes.
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Blinder T, Lewerenz J. Cerebrospinal Fluid Findings in Patients With Autoimmune Encephalitis-A Systematic Analysis. Front Neurol 2019; 10:804. [PMID: 31404257 PMCID: PMC6670288 DOI: 10.3389/fneur.2019.00804] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 07/11/2019] [Indexed: 01/15/2023] Open
Abstract
Autoimmune encephalitides (AIE) comprise a group of inflammatory diseases of the central nervous system (CNS), which can be further characterized by the presence of different antineuronal antibodies. Recently, a clinical approach for diagnostic criteria for the suspected diagnosis of AIE as well as definitive AIE were proposed. These are intended to guide physicians when to order the antineuronal antibody testing and/or facilitate early diagnosis even prior to the availability of the specific disease-confirming test results to facilitate prompt treatment. These diagnostic criteria also include the results of basic cerebrospinal fluid (CSF) analysis. However, the different antibody-defined AIE subtypes might be highly distinct with regard to their immune pathophysiology, e.g., the pre-dominance of specific IgG subclasses, IgG1, or IgG4, or frequency of paraneoplastic compared to idiopathic origin. Thus, it is conceivable that the results of basic CSF analysis might also be very different. However, this has not been explored systematically. Here, we systematically reviewed the literature about the 10 most important AIE subtypes, AIE with antibodies against NMDA, AMPA, glycine, GABAA, and GABAB receptors as well as DPPX, CASPR2, LGI1, IgLON5, or glutamate decarboxylase (GAD), with respect to the reported basic CSF findings comprising CSF leukocyte count, total protein, and the presence of oligoclonal bands (OCB) restricted to the CSF as a sensitive measure for intrathecal IgG synthesis. Our results indicate that these basic CSF findings are profoundly different among the 10 different AIE subtypes. Whereas, AIEs with antibodies against NMDA, GABAB, and AMPA receptors as well as DPPX show rather frequent inflammatory CSF changes, in AIEs with either CASPR2, LGI1, GABAA, or glycine receptor antibodies CSF findings were mostly normal. Two subtypes, AIEs defined by either GAD, or IgLON5 antibodies, did not fit into this general pattern. In AIE with GAD antibodies, positive OCBs in the absence of other changes were typical, while the CSF in IgLON5 antibody-positive AIE was characterized by elevated protein.
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Affiliation(s)
| | - Jan Lewerenz
- Department of Neurology, Ulm University, Ulm, Germany
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8
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Mané-Damas M, Hoffmann C, Zong S, Tan A, Molenaar PC, Losen M, Martinez-Martinez P. Autoimmunity in psychotic disorders. Where we stand, challenges and opportunities. Autoimmun Rev 2019; 18:102348. [PMID: 31323365 DOI: 10.1016/j.autrev.2019.102348] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 02/26/2019] [Indexed: 12/24/2022]
Abstract
Psychotic disorders are debilitating mental illnesses associated with abnormalities in various neurotransmitter systems. The development of disease-modifing therapies has been hampered by the mostly unknown etiologies and pathophysiologies. Autoantibodies against several neuronal antigens are responsible for autoimmune encephalitis. These autoantibodies disrupt neurotransmission within the brain, resulting in a wide range of psychiatric and neurologic manifestations, including psychosis. The overlap of symptoms of autoimmune encephalitis with psychotic disorders raised the question as to whether autoantibodies against a number of receptors, ion channel and associated proteins could ultimately be responsible for some forms of psychosis. Here we review our current knowledge, on antibody mediated autoimmunity in psychotic disorders, the different diagnostic methods and their limitations, as well as on varying therapeutic approaches targeting the immune system.
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Affiliation(s)
- Marina Mané-Damas
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Carolin Hoffmann
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Shenghua Zong
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Amanda Tan
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Peter C Molenaar
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Mario Losen
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Pilar Martinez-Martinez
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
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10
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Abstract
PURPOSE OF REVIEW This article provides a review of the clinical phenotypes and evaluation of peripheral nerve hyperexcitability syndromes. These rare diagnoses include cramp-fasciculation syndrome, Isaacs syndrome, and Morvan syndrome. Recent investigations have led to an understanding of the autoimmune underpinnings of these conditions and their specific associated antibodies. As the presentation of peripheral nerve hyperexcitability syndromes includes muscle stiffness, twitches, and spasms, which are also shared with certain central nervous system and myopathic conditions, the differential diagnosis of peripheral nerve hyperexcitability syndromes is reviewed. RECENT FINDINGS Peripheral nerve hyperexcitability syndromes share clinical and electrodiagnostic evidence of motor nerve instability; however, their clinical presentations are varied. Case reviews have helped us understand the spectrum of symptoms associated with the three peripheral nerve hyperexcitability syndromes reviewed here: cramp-fasciculation syndrome, Isaacs syndrome, and Morvan syndrome. More recently, research has focused on understanding the voltage-gated potassium channel complex antibodies as well as neoplasms associated with these conditions. SUMMARY The diagnosis of peripheral nerve hyperexcitability syndromes requires a high index of suspicion, support from the physical examination, familiarity with the spectrum of symptoms associated with peripheral nerve hyperexcitability syndromes, and recognition of diagnostic EMG features. Voltage-gated potassium channel complex antibodies are associated with these conditions. Optimum treatment and autoimmune pathogenesis remain areas of active research.
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11
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Fan Z, Feng X, Fan Z, Zhu X, Yin S. Immunotherapy by targeting of VGKC complex for seizure control and prevention of cognitive impairment in a mouse model of epilepsy. Mol Med Rep 2018; 18:169-178. [PMID: 29749462 PMCID: PMC6059666 DOI: 10.3892/mmr.2018.9004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 04/16/2018] [Indexed: 11/13/2022] Open
Abstract
Epilepsy is a type of refractory neurologic disorder mental disease, which is associated with cognitive impairments and memory dysfunction. However, the potential mechanisms of epilepsy are not well understood. Previous evidence has identified the voltage gated potassium channel complex (VGKC) as a target in various cohorts of patients with epilepsy. In the present study, the efficacy of an antibody against VGKC (anti-VGKC) for the treatment of epilepsy in mice was investigated. A mouse model of lithium-pilocarpine temporal lobe epilepsy was established and anti-VGKC treatment was administered for 30 days. Memory impairment, anxiety, visual attention, inhibitory control and neuronal loss were measured in the mouse model of lithium-pilocarpine temporal lobe epilepsy. The results revealed that epileptic mice treated with anti-VGKC were able to learn the task and presented attention impairment, even a tendency toward impulsivity and compulsivity. It was also exhibited that anti-VGKC treatment decreased neuronal loss in structures classically associated with attentional performance in hippocampus. Mice who received Anti-VGKC treatment had inhibited motor seizures and hippocampal damage as compared with control mice. In conclusion, these results indicated that anti-VGKC treatment may present benefits for improvements of the condition of motor attention impairment and cognitive competence, which suggests that VGKC may be a potential target for the treatment of epilepsy.
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Affiliation(s)
- Zhiliang Fan
- The Third Department of Neurology, Xingtai People's Hospital of Hebei Province, Xingtai, Hebei 054001, P.R. China
| | - Xiaojuan Feng
- Department of Ultrasound, Xingtai People's Hospital of Hebei Province, Xingtai, Hebei 054001, P.R. China
| | - Zhigang Fan
- Department of Ultrasound, Xingtai People's Hospital of Hebei Province, Xingtai, Hebei 054001, P.R. China
| | - Xingyuan Zhu
- The Third Department of Neurology, Xingtai People's Hospital of Hebei Province, Xingtai, Hebei 054001, P.R. China
| | - Shaohua Yin
- The Third Department of Neurology, Xingtai People's Hospital of Hebei Province, Xingtai, Hebei 054001, P.R. China
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Autoimmune encephalitis with anti-leucine-rich glioma-inactivated 1 or anti-contactin-associated protein-like 2 antibodies (formerly called voltage-gated potassium channel-complex antibodies). Curr Opin Neurol 2018; 30:302-309. [PMID: 28248701 DOI: 10.1097/wco.0000000000000444] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Twenty years since the discovery of voltage-gated potassium channel (VGKC)-related autoimmunity; it is currently known that the antibodies are not directed at the VGKC itself but to two closely associated proteins, anti-leucine-rich glioma-inactivated 1 (LGI1) and contactin-associated protein-like 2 (Caspr2). Antibodies to LGI1 and Caspr2 give well-described clinical phenotypes. Anti-LGI1 encephalitis patients mostly have limbic symptoms, and anti-Caspr2 patients have variable syndromes with both central and peripheral symptoms. A large group of patients with heterogeneous symptoms are VGKC positive but do not have antibodies against LGI1 or Caspr2. The clinical relevance of VGKC positivity in these 'double-negative' patients is questionable. This review focusses on these three essentially different subgroups. RECENT FINDINGS The clinical phenotypes of anti-LGI1 encephalitis and anti-Caspr2 encephalitis have been described in more detail including data on treatment and long-term follow-up. A specific human leukocyte antigen (HLA) association was found in nontumor anti-LGI1 encephalitis, but not clearly in those with tumors. There has been increasing interest in the VGKC patients without LGI1/Caspr2 antibodies questioning its relevance in clinical practice. SUMMARY Anti-LGI1 encephalitis and anti-Caspr2 encephalitis are separate clinical entities. Early recognition and treatment is necessary and rewarding. The term VGKC-complex antibodies, lumping patients with anti-LGI1, anti-Caspr2 antibodies or lacking both, should be considered obsolete.
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Jonuskaite D, Kalibatas P, Praninskiene R, Zalubiene A, Jucaite A, Cerkauskiene R. Adolescent with acute psychosis due to anti-N-methyl-D-aspartate receptor encephalitis: successful recovery. Scand J Child Adolesc Psychiatr Psychol 2017. [DOI: 10.21307/sjcapp-2017-012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Abstract
Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a relatively new autoimmune disorder of the central nervous system. We report the first case of anti-NMDAR autoimmune encephalitis combined with anti-voltage-gated potassium channel (anti-VGKC) antibodies in Lithuania in a 16-year-old girl. The patient was admitted to psychiatry unit because of an acute psychotic episode. She was unsuccessfully treated with antipsychotics, and electroconvulsive therapy was initiated because of her rapidly deteriorating condition. Electroconvulsive therapy improved the patient’s condition even before the initiation of immunomodulatory therapy. The abrupt onset, atypical and severe course of psychosis, poor response to antipsychotic treatment, and signs of flu-like prodromal period led to the search of non-psychiatric causes. Although with considerable delay, she was screened for an autoimmune encephalitis. Positive anti-NMDA receptor antibodies were found in the cerebrospinal fluid, but not in serum. In addition, serum was found positive for antinuclear antibodies and anti-VGKC antibodies but negative for CASPR2 and LGI1 antibodies. The girl was treated with intravenous immunoglobulin and methylprednisolone with satisfactory response, although infrequent orofacial movements, emotional lability, and learning deficits remained upon discharge. The reported case suggests that multiple antibodies could be present, and that electroconvulsive therapy may have a role in symptomatic treatment of autoimmune encephalitis.
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Affiliation(s)
- Dovile Jonuskaite
- Children’s Hospital, Affiliate of Vilnius University Hospital Santaros Klinikos , Vilnius , Lithuania
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University , Vilnius , Lithuania
| | - Paulius Kalibatas
- Children’s Hospital, Affiliate of Vilnius University Hospital Santaros Klinikos , Vilnius , Lithuania
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University , Vilnius , Lithuania
| | - Ruta Praninskiene
- Children’s Hospital, Affiliate of Vilnius University Hospital Santaros Klinikos , Vilnius , Lithuania
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University , Vilnius , Lithuania
| | - Asta Zalubiene
- University Dep. of Child and Adolescent Psychiatry, Republican Vilnius Psychiatry Hospital , Vilnius , Lithuania
| | - Aurelija Jucaite
- Dep. of Clinical Neuroscience, Karolinska Institutet , Stockholm , Sweden
| | - Rimante Cerkauskiene
- Children’s Hospital, Affiliate of Vilnius University Hospital Santaros Klinikos , Vilnius , Lithuania
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University , Vilnius , Lithuania
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Voltage-gated Potassium Channel Antibody Autoimmune Encephalopathy Presenting With Isolated Psychosis in an Adolescent. J Psychiatr Pract 2017; 23:441-445. [PMID: 29303952 DOI: 10.1097/pra.0000000000000265] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Antibody-mediated encephalopathies associated with serum or cerebrospinal fluid antibodies directed against neuronal structures may present with a multitude of neuropsychiatric syndromes. Although some of the antibody-driven conditions are now well recognized in adults (eg, N-methyl-D-aspartate receptor antibody encephalitis), the spectrum of neuropsychiatric manifestations in the pediatric population is less clear. Psychosis, confusion, catatonia, and additional behavioral changes, along with seizures, encephalopathy, and movement disorders, may be initial manifestations or concurrent features in all age groups. Psychosis, when present, is often part of a broader spectrum of neurological and neuropsychiatric symptoms for which the diagnosis of autoimmune encephalitis is considered. The authors present the case of an adolescent with an acute and isolated psychotic presentation of voltage-gated potassium channel antibody encephalitis, further expanding the phenotypic spectrum of this specific antibody-mediated disease and raising the possibility that specific immune-mediated processes may define a biological subgroup of psychoses.
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15
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Voltage-gated Potassium Channel Antibody Autoimmune Encephalopathy Presenting With Isolated Psychosis in an Adolescent. J Psychiatr Pract 2017; 23:441-445. [PMID: 29303953 DOI: 10.1097/pra.0000000000000266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Antibody-mediated encephalopathies associated with serum or cerebrospinal fluid antibodies directed against neuronal structures may present with a multitude of neuropsychiatric syndromes. Although some of the antibody-driven conditions are now well recognized in adults (eg, N-methyl-D-aspartate receptor antibody encephalitis), the spectrum of neuropsychiatric manifestations in the pediatric population is less clear. Psychosis, confusion, catatonia, and additional behavioral changes, along with seizures, encephalopathy, and movement disorders, may be initial manifestations or concurrent features in all age groups. Psychosis, when present, is often part of a broader spectrum of neurological and neuropsychiatric symptoms for which the diagnosis of autoimmune encephalitis is considered. The authors present the case of an adolescent with an acute and isolated psychotic presentation of voltage-gated potassium channel antibody encephalitis, further expanding the phenotypic spectrum of this specific antibody-mediated disease and raising the possibility that specific immune-mediated processes may define a biological subgroup of psychoses.
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Spiegel DR, Samaras A, Oldham CL, Kaloji M, Warren A, Maj S, Husain SR, Solomons JI, Le S. A Likely Case of Limbic Encephalitis in a Patient With Voltage-Gated Potassium Channel Complex Antibody, Without a Known Antigenic Target: A Review of the Disease State and Value of Antibody Titers. PSYCHOSOMATICS 2017; 58:669-675. [PMID: 28750836 DOI: 10.1016/j.psym.2017.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 05/24/2017] [Accepted: 05/30/2017] [Indexed: 11/17/2022]
Affiliation(s)
- David R Spiegel
- Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA.
| | - Anastasia Samaras
- Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA
| | - Cameron L Oldham
- Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA
| | - Meghana Kaloji
- Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA
| | - Alyssa Warren
- Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA
| | - Shannon Maj
- Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA
| | - Sharmeen R Husain
- Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA
| | - Jeremy I Solomons
- Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA
| | - Stephanie Le
- Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA
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von Podewils F, Suesse M, Geithner J, Gaida B, Wang ZI, Lange J, Dressel A, Grothe M, Kessler C, Langner S, Runge U, Bien CG. Prevalence and outcome of late-onset seizures due to autoimmune etiology: A prospective observational population-based cohort study. Epilepsia 2017; 58:1542-1550. [DOI: 10.1111/epi.13834] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2017] [Indexed: 01/17/2023]
Affiliation(s)
- Felix von Podewils
- Department of Neurology; Epilepsy Center; University Medicine Greifswald; Greifswald Germany
| | - Marie Suesse
- Department of Neurology; Epilepsy Center; University Medicine Greifswald; Greifswald Germany
| | | | - Bernadette Gaida
- Department of Neurology; Epilepsy Center; University Medicine Greifswald; Greifswald Germany
| | - Zhong I. Wang
- Epilepsy Center; Neurological Institute; Cleveland Clinic Foundation; Cleveland Ohio U.S.A
| | - Julia Lange
- Department of Neurology; Epilepsy Center; University Medicine Greifswald; Greifswald Germany
| | - Alexander Dressel
- Department of Neurology; Epilepsy Center; University Medicine Greifswald; Greifswald Germany
- Department of Neurology, Carl-Thiem-Hospital Cottbus; Cottbus Germany
| | - Matthias Grothe
- Department of Neurology; Epilepsy Center; University Medicine Greifswald; Greifswald Germany
| | - Christof Kessler
- Department of Neurology; Epilepsy Center; University Medicine Greifswald; Greifswald Germany
| | - Soenke Langner
- Center for Diagnostic Radiology and Neuroradiology; University Medicine Greifswald; Greifswald Germany
| | - Uwe Runge
- Department of Neurology; Epilepsy Center; University Medicine Greifswald; Greifswald Germany
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18
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Yeo T, Chen Z, Chai J, Tan K. Detection of LGI1 and CASPR2 antibodies with a commercial cell-based assay in patients with very high VGKC-complex antibody levels. J Neurol Sci 2017; 378:85-90. [DOI: 10.1016/j.jns.2017.04.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 03/26/2017] [Accepted: 04/25/2017] [Indexed: 01/17/2023]
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19
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van Sonderen A, Petit-Pedrol M, Dalmau J, Titulaer MJ. The value of LGI1, Caspr2 and voltage-gated potassium channel antibodies in encephalitis. Nat Rev Neurol 2017; 13:290-301. [DOI: 10.1038/nrneurol.2017.43] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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20
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Irani SR, Vincent A. Voltage-gated potassium channel-complex autoimmunity and associated clinical syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2017; 133:185-97. [PMID: 27112678 DOI: 10.1016/b978-0-444-63432-0.00011-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Voltage-gated potassium channel (VGKC)-complex antibodies are defined by the radioimmunoprecipitation of Kv1 potassium channel subunits from brain tissue extracts and were initially discovered in patients with peripheral nerve hyperexcitability (PNH). Subsequently, they were found in patients with PNH plus psychosis, insomnia, and dysautonomia, collectively termed Morvan's syndrome (MoS), and in a limbic encephalopathy (LE) with prominent amnesia and frequent seizures. Most recently, they have been described in patients with pure epilepsies, especially in patients with the novel and distinctive semiology termed faciobrachial dystonic seizures (FBDS). In each of these conditions, there is a close correlation between clinical measures and antibody levels. The VGKC-complex is a group of proteins that are strongly associated in situ and after extraction in mild detergent. Two major targets of the autoantibodies are leucine-rich glioma-inactivated 1 (LGI1) and contactin-associated protein 2 (CASPR2). The patients with PNH or MoS are most likely to have CASPR2 antibodies, whereas LGI1 antibodies are found characteristically in patients with FBDS and LE. Crucially, each of these conditions has a good response to immunotherapies, often corticosteroids and plasma exchange, although optimal regimes require further study. VGKC-complex antibodies have also been described in neuropathic pain syndromes, chronic epilepsies, a polyradiculopathy in porcine abattoir workers, and some children with status epilepticus. Increasingly, however, the antigenic targets in these patients are not defined and in some cases the antibodies may be secondary rather than the primary cause. Future serologic studies should define all the antigenic components of the VGKC-complex, and further inform mechanisms of antibody pathogenicity and related inflammation.
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Affiliation(s)
- Sarosh R Irani
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK.
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
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21
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Ogawa R, Nakashima I, Takahashi T, Kaneko K, Akaishi T, Takai Y, Sato DK, Nishiyama S, Misu T, Kuroda H, Aoki M, Fujihara K. MOG antibody-positive, benign, unilateral, cerebral cortical encephalitis with epilepsy. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2017; 4:e322. [PMID: 28105459 PMCID: PMC5241006 DOI: 10.1212/nxi.0000000000000322] [Citation(s) in RCA: 292] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 12/15/2016] [Indexed: 01/21/2023]
Abstract
Objective: To describe the features of adult patients with benign, unilateral cerebral cortical encephalitis positive for the myelin oligodendrocyte glycoprotein (MOG) antibody. Methods: In this retrospective, cross-sectional study, after we encountered an index case of MOG antibody–positive unilateral cortical encephalitis with epileptic seizure, we tested for MOG antibody using our in-house, cell-based assay in a cohort of 24 consecutive adult patients with steroid-responsive encephalitis of unknown etiology seen at Tohoku University Hospital (2008–2014). We then analyzed the findings in MOG antibody–positive cases. Results: Three more patients, as well as the index case, were MOG antibody–positive, and all were adult men (median age 37 years, range 23–39 years). The main symptom was generalized epileptic seizure with or without abnormal behavior or consciousness disturbance. Two patients also developed unilateral benign optic neuritis (before or after seizure). In all patients, brain MRI demonstrated unilateral cerebral cortical fluid-attenuated inversion recovery hyperintense lesions, which were swollen and corresponded to hyperperfusion on SPECT. CSF studies showed moderate mononuclear pleocytosis with some polymorphonuclear cells and mildly elevated total protein levels, but myelin basic protein was not elevated. A screening of encephalitis-associated autoantibodies, including aquaporin-4, glutamate receptor, and voltage-gated potassium channel antibodies, was negative. All patients received antiepilepsy drugs and fully recovered after high-dose methylprednisolone, and the unilateral cortical MRI lesions subsequently disappeared. No patient experienced relapse. Conclusions: These MOG antibody–positive cases represent unique benign unilateral cortical encephalitis with epileptic seizure. The pathology may be autoimmune, although the findings differ from MOG antibody–associated demyelination and Rasmussen and other known immune-mediated encephalitides.
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Affiliation(s)
- Ryo Ogawa
- Department of Neurology (R.O., I.N., T.T., K.K., T.A., Y.T., D.K.S., S.N., T.M., H.K., M.A., K.F.), Tohoku University Graduate School of Medicine, Sendai; Department of Neurology (T.T.), Yonezawa National Hospital, Yamagata, Japan; Brain Institute (D.K.S.), The Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University; and Multiple Sclerosis & Neuromyelitis Optica Center (K.F.), Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Ichiro Nakashima
- Department of Neurology (R.O., I.N., T.T., K.K., T.A., Y.T., D.K.S., S.N., T.M., H.K., M.A., K.F.), Tohoku University Graduate School of Medicine, Sendai; Department of Neurology (T.T.), Yonezawa National Hospital, Yamagata, Japan; Brain Institute (D.K.S.), The Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University; and Multiple Sclerosis & Neuromyelitis Optica Center (K.F.), Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Toshiyuki Takahashi
- Department of Neurology (R.O., I.N., T.T., K.K., T.A., Y.T., D.K.S., S.N., T.M., H.K., M.A., K.F.), Tohoku University Graduate School of Medicine, Sendai; Department of Neurology (T.T.), Yonezawa National Hospital, Yamagata, Japan; Brain Institute (D.K.S.), The Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University; and Multiple Sclerosis & Neuromyelitis Optica Center (K.F.), Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Kimihiko Kaneko
- Department of Neurology (R.O., I.N., T.T., K.K., T.A., Y.T., D.K.S., S.N., T.M., H.K., M.A., K.F.), Tohoku University Graduate School of Medicine, Sendai; Department of Neurology (T.T.), Yonezawa National Hospital, Yamagata, Japan; Brain Institute (D.K.S.), The Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University; and Multiple Sclerosis & Neuromyelitis Optica Center (K.F.), Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Tetsuya Akaishi
- Department of Neurology (R.O., I.N., T.T., K.K., T.A., Y.T., D.K.S., S.N., T.M., H.K., M.A., K.F.), Tohoku University Graduate School of Medicine, Sendai; Department of Neurology (T.T.), Yonezawa National Hospital, Yamagata, Japan; Brain Institute (D.K.S.), The Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University; and Multiple Sclerosis & Neuromyelitis Optica Center (K.F.), Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Yoshiki Takai
- Department of Neurology (R.O., I.N., T.T., K.K., T.A., Y.T., D.K.S., S.N., T.M., H.K., M.A., K.F.), Tohoku University Graduate School of Medicine, Sendai; Department of Neurology (T.T.), Yonezawa National Hospital, Yamagata, Japan; Brain Institute (D.K.S.), The Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University; and Multiple Sclerosis & Neuromyelitis Optica Center (K.F.), Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Douglas Kazutoshi Sato
- Department of Neurology (R.O., I.N., T.T., K.K., T.A., Y.T., D.K.S., S.N., T.M., H.K., M.A., K.F.), Tohoku University Graduate School of Medicine, Sendai; Department of Neurology (T.T.), Yonezawa National Hospital, Yamagata, Japan; Brain Institute (D.K.S.), The Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University; and Multiple Sclerosis & Neuromyelitis Optica Center (K.F.), Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Shuhei Nishiyama
- Department of Neurology (R.O., I.N., T.T., K.K., T.A., Y.T., D.K.S., S.N., T.M., H.K., M.A., K.F.), Tohoku University Graduate School of Medicine, Sendai; Department of Neurology (T.T.), Yonezawa National Hospital, Yamagata, Japan; Brain Institute (D.K.S.), The Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University; and Multiple Sclerosis & Neuromyelitis Optica Center (K.F.), Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Tatsuro Misu
- Department of Neurology (R.O., I.N., T.T., K.K., T.A., Y.T., D.K.S., S.N., T.M., H.K., M.A., K.F.), Tohoku University Graduate School of Medicine, Sendai; Department of Neurology (T.T.), Yonezawa National Hospital, Yamagata, Japan; Brain Institute (D.K.S.), The Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University; and Multiple Sclerosis & Neuromyelitis Optica Center (K.F.), Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Hiroshi Kuroda
- Department of Neurology (R.O., I.N., T.T., K.K., T.A., Y.T., D.K.S., S.N., T.M., H.K., M.A., K.F.), Tohoku University Graduate School of Medicine, Sendai; Department of Neurology (T.T.), Yonezawa National Hospital, Yamagata, Japan; Brain Institute (D.K.S.), The Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University; and Multiple Sclerosis & Neuromyelitis Optica Center (K.F.), Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Masashi Aoki
- Department of Neurology (R.O., I.N., T.T., K.K., T.A., Y.T., D.K.S., S.N., T.M., H.K., M.A., K.F.), Tohoku University Graduate School of Medicine, Sendai; Department of Neurology (T.T.), Yonezawa National Hospital, Yamagata, Japan; Brain Institute (D.K.S.), The Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University; and Multiple Sclerosis & Neuromyelitis Optica Center (K.F.), Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Kazuo Fujihara
- Department of Neurology (R.O., I.N., T.T., K.K., T.A., Y.T., D.K.S., S.N., T.M., H.K., M.A., K.F.), Tohoku University Graduate School of Medicine, Sendai; Department of Neurology (T.T.), Yonezawa National Hospital, Yamagata, Japan; Brain Institute (D.K.S.), The Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University; and Multiple Sclerosis & Neuromyelitis Optica Center (K.F.), Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
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Schou M, Sæther SG, Borowski K, Teegen B, Kondziella D, Stoecker W, Vaaler A, Reitan SK. Prevalence of serum anti-neuronal autoantibodies in patients admitted to acute psychiatric care. Psychol Med 2016; 46:3303-3313. [PMID: 27609625 DOI: 10.1017/s0033291716002038] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Autoimmune encephalitis associated with anti-neuronal antibodies may be challenging to distinguish from primary psychiatric disorders. The significance of anti-neuronal antibodies in psychiatric patients without clear evidence of autoimmune encephalitis is unknown. We investigated the serum prevalence of six anti-neuronal autoantibodies in a cohort of unselected patients admitted to acute psychiatric care. METHOD Serum was drawn from 925 patients admitted to acute psychiatric in-patient care. Psychiatric diagnoses were set according to International Classification of Diseases (ICD)-10 criteria. Antibody analysis was performed with an indirect immunofluorescence test for N-methyl d-aspartate receptor (NMDAR) antibodies and five other anti-neuronal autoantibodies of the immunoglobulin (Ig) classes IgA, IgG and IgM isotype. RESULTS Anti-neuronal autoantibodies were found in 11.6% of patients: NMDAR antibodies in 7.6%, contactin-associated protein-like 2 (CASPR2) antibodies in 2.5%, glutamic acid decarboxylase-65 (GAD65) antibodies in 1.9%, and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor antibodies in 0.1%. Leucine-rich glioma-inactivated protein-1 (LGI1) and γ-aminobutyric acid B (GABAB) receptor antibodies were not detected. NMDAR antibodies of class IgG were present in five patients only (0.5%). NMDAR antibodies of all Ig classes were equally prevalent in patients with and without psychosis. There were no significant differences in antibody prevalence in the different diagnostic categories, except for a higher odds ratio of being NMDAR antibody positive for patients without a specific psychiatric diagnosis. CONCLUSIONS NMDAR IgG autoantibodies, which are known to be strongly associated with anti-NMDAR encephalitis, were rarely found. CASPR2 and GAD65 antibodies were more frequently encountered in the present study than previously reported. Further research on the clinical significance of anti-neuronal autoantibodies in patients with acute psychiatric symptoms is needed.
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Affiliation(s)
- M Schou
- Department of Neuroscience,Norwegian University of Science and Technology,Trondheim,Norway
| | - S G Sæther
- Department of Neuroscience,Norwegian University of Science and Technology,Trondheim,Norway
| | - K Borowski
- Institute for Experimental Immunology,Euroimmun AG,Lübeck,Germany
| | - B Teegen
- Institute for Experimental Immunology,Euroimmun AG,Lübeck,Germany
| | - D Kondziella
- Department of Neuroscience,Norwegian University of Science and Technology,Trondheim,Norway
| | - W Stoecker
- Institute for Experimental Immunology,Euroimmun AG,Lübeck,Germany
| | - A Vaaler
- Department of Neuroscience,Norwegian University of Science and Technology,Trondheim,Norway
| | - S K Reitan
- Department of Neuroscience,Norwegian University of Science and Technology,Trondheim,Norway
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O’Sullivan B, Steele T, Ellul M, Kirby E, Duale A, Kier G, Crooks D, Jacob A, Solomon T, Michael B. When should we test for voltage-gated potassium channel complex antibodies? A retrospective case control study. J Clin Neurosci 2016; 33:198-204. [DOI: 10.1016/j.jocn.2016.04.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 04/12/2016] [Accepted: 04/20/2016] [Indexed: 12/22/2022]
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van Sonderen A, Schreurs M, Wirtz P, Sillevis Smitt P, Titulaer M. From VGKC to LGI1 and Caspr2 encephalitis: The evolution of a disease entity over time. Autoimmun Rev 2016; 15:970-4. [DOI: 10.1016/j.autrev.2016.07.018] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 07/08/2016] [Indexed: 01/14/2023]
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Bakpa OD, Reuber M, Irani SR. Antibody-associated epilepsies: Clinical features, evidence for immunotherapies and future research questions. Seizure 2016; 41:26-41. [PMID: 27450643 PMCID: PMC5042290 DOI: 10.1016/j.seizure.2016.07.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 07/05/2016] [Accepted: 07/08/2016] [Indexed: 01/11/2023] Open
Abstract
PURPOSE The growing recognition of epilepsies and encephalopathies associated with autoantibodies against surface neuronal proteins (LGI1, NMDAR, CASPR2, GABABR, and AMPAR) means that epileptologists are increasingly asking questions about mechanisms of antibody-mediated epileptogenesis, and about the use of immunotherapies. This review summarizes clinical and paraclinical observations related to autoimmune epilepsies, examines the current evidence for the effectiveness of immunotherapy, and makes epilepsy-specific recommendations for future research. METHOD Systematic literature search with summary and review of the identified publications. Studies describing the clinical characteristics of autoantibody-associated epilepsies and treatments are detailed in tables. RESULTS Literature describing the clinical manifestations and treatment of autoimmune epilepsies associated with neuronal cell-surface autoantibodies (NSAbs) is largely limited to retrospective case series. We systematically summarize the features of particular interest to epileptologists dividing patients into those with acute or subacute encephalopathies associated with epilepsy, and those with chronic epilepsy without encephalopathy. Available observational studies suggest that immunotherapies are effective in some clinical circumstances but outcome data collection methods require greater standardization. CONCLUSIONS The clinical experience captured suggests that clusters of clinical features associate well with specific NSAbs. Intensive and early immunotherapy is indicated when patients present with autoantibody-associated encephalopathies. It remains unclear how patients with chronic epilepsy and the same autoantibodies should be assessed and treated. Tables in this paper provide a comprehensive resource for systematic descriptions of both clinical features and treatments, and highlight limitations of current studies.
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Affiliation(s)
- Ochuko D Bakpa
- Academic Neurology Unit, Royal Hallamshire Hospital, University of Sheffield, Sheffield S10 2JF, UK
| | - Markus Reuber
- Academic Neurology Unit, Royal Hallamshire Hospital, University of Sheffield, Sheffield S10 2JF, UK
| | - Sarosh R Irani
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DS, UK.
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van Sonderen A, Ariño H, Petit-Pedrol M, Leypoldt F, Körtvélyessy P, Wandinger KP, Lancaster E, Wirtz PW, Schreurs MWJ, Sillevis Smitt PAE, Graus F, Dalmau J, Titulaer MJ. The clinical spectrum of Caspr2 antibody-associated disease. Neurology 2016; 87:521-8. [PMID: 27371488 DOI: 10.1212/wnl.0000000000002917] [Citation(s) in RCA: 262] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 04/25/2016] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE To report a large cohort of patients with antibodies against contactin-associated protein-like 2 (Caspr2) and provide the clinical spectrum of this disorder. METHODS Serum and CSF samples were assessed at 2 neuroimmunology centers in Barcelona and Rotterdam. Patients were included if Caspr2 antibodies were confirmed with 2 independent techniques, including brain immunohistochemistry and cell-based assay. Clinical information was obtained by the authors or provided by treating physicians after patients' informed consent. RESULTS Median age at symptom onset was 66 years. Of 38 patients, 34 were male. Median time to nadir of disease was 4 months (in 30% >1 year). The most frequent syndromes included limbic encephalitis (42%) and Morvan syndrome (29%). Seventy-seven percent of the patients had ≥3 of the following symptoms: encephalopathy (cognitive deficits/seizures), cerebellar dysfunction, peripheral nervous system hyperexcitability, dysautonomia, insomnia, neuropathic pain, or weight loss. A tumor, mostly thymoma, occurred in 19% of the patients. Immunoglobulin G4 subclass antibodies were present in all patients; 63% also had immunoglobulin G1 antibodies. Treatment response occurred in 93% of the patients and 25% had clinical relapses. CONCLUSIONS Caspr2 antibodies associate with a treatable disorder that predominantly affects elderly men. The resulting syndrome may vary among patients but it usually includes a set of well-established symptoms. Recognition of this spectrum of symptoms and consideration of the protracted clinical course are important for early diagnosis of this disorder. Prompt immunotherapy and tumor therapy (if needed) often result in improvement.
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Affiliation(s)
- Agnes van Sonderen
- From the Departments of Neurology (A.v.S., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S.), Erasmus University Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, the Hague, the Netherlands; Department of Neurology (H.A., F.G.), Hospital Clinic, University of Barcelona; Neuroimmunology Program (H.A., M.P.-P., F.G.) and Department of Neurology, Hospital Clinic (J.D.), Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Neuroimmunology (F.L.), Institute of Clinical Chemistry, Christian-Albrechts-University; Department of Neurology (F.L.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology (P.K.), University Hospital Magdeburg; Neuroimmunology (K.-P.W), Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein Campus Lübeck; Department of Neurology (K.-P.W), University of Lübeck, Germany; Department of Neurology (E.L.), University of Pennsylvania (J.D.), Philadelphia; and Department of Neurology (J.D.), Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Helena Ariño
- From the Departments of Neurology (A.v.S., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S.), Erasmus University Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, the Hague, the Netherlands; Department of Neurology (H.A., F.G.), Hospital Clinic, University of Barcelona; Neuroimmunology Program (H.A., M.P.-P., F.G.) and Department of Neurology, Hospital Clinic (J.D.), Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Neuroimmunology (F.L.), Institute of Clinical Chemistry, Christian-Albrechts-University; Department of Neurology (F.L.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology (P.K.), University Hospital Magdeburg; Neuroimmunology (K.-P.W), Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein Campus Lübeck; Department of Neurology (K.-P.W), University of Lübeck, Germany; Department of Neurology (E.L.), University of Pennsylvania (J.D.), Philadelphia; and Department of Neurology (J.D.), Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Mar Petit-Pedrol
- From the Departments of Neurology (A.v.S., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S.), Erasmus University Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, the Hague, the Netherlands; Department of Neurology (H.A., F.G.), Hospital Clinic, University of Barcelona; Neuroimmunology Program (H.A., M.P.-P., F.G.) and Department of Neurology, Hospital Clinic (J.D.), Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Neuroimmunology (F.L.), Institute of Clinical Chemistry, Christian-Albrechts-University; Department of Neurology (F.L.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology (P.K.), University Hospital Magdeburg; Neuroimmunology (K.-P.W), Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein Campus Lübeck; Department of Neurology (K.-P.W), University of Lübeck, Germany; Department of Neurology (E.L.), University of Pennsylvania (J.D.), Philadelphia; and Department of Neurology (J.D.), Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Frank Leypoldt
- From the Departments of Neurology (A.v.S., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S.), Erasmus University Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, the Hague, the Netherlands; Department of Neurology (H.A., F.G.), Hospital Clinic, University of Barcelona; Neuroimmunology Program (H.A., M.P.-P., F.G.) and Department of Neurology, Hospital Clinic (J.D.), Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Neuroimmunology (F.L.), Institute of Clinical Chemistry, Christian-Albrechts-University; Department of Neurology (F.L.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology (P.K.), University Hospital Magdeburg; Neuroimmunology (K.-P.W), Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein Campus Lübeck; Department of Neurology (K.-P.W), University of Lübeck, Germany; Department of Neurology (E.L.), University of Pennsylvania (J.D.), Philadelphia; and Department of Neurology (J.D.), Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Peter Körtvélyessy
- From the Departments of Neurology (A.v.S., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S.), Erasmus University Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, the Hague, the Netherlands; Department of Neurology (H.A., F.G.), Hospital Clinic, University of Barcelona; Neuroimmunology Program (H.A., M.P.-P., F.G.) and Department of Neurology, Hospital Clinic (J.D.), Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Neuroimmunology (F.L.), Institute of Clinical Chemistry, Christian-Albrechts-University; Department of Neurology (F.L.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology (P.K.), University Hospital Magdeburg; Neuroimmunology (K.-P.W), Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein Campus Lübeck; Department of Neurology (K.-P.W), University of Lübeck, Germany; Department of Neurology (E.L.), University of Pennsylvania (J.D.), Philadelphia; and Department of Neurology (J.D.), Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Klaus-Peter Wandinger
- From the Departments of Neurology (A.v.S., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S.), Erasmus University Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, the Hague, the Netherlands; Department of Neurology (H.A., F.G.), Hospital Clinic, University of Barcelona; Neuroimmunology Program (H.A., M.P.-P., F.G.) and Department of Neurology, Hospital Clinic (J.D.), Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Neuroimmunology (F.L.), Institute of Clinical Chemistry, Christian-Albrechts-University; Department of Neurology (F.L.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology (P.K.), University Hospital Magdeburg; Neuroimmunology (K.-P.W), Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein Campus Lübeck; Department of Neurology (K.-P.W), University of Lübeck, Germany; Department of Neurology (E.L.), University of Pennsylvania (J.D.), Philadelphia; and Department of Neurology (J.D.), Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Eric Lancaster
- From the Departments of Neurology (A.v.S., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S.), Erasmus University Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, the Hague, the Netherlands; Department of Neurology (H.A., F.G.), Hospital Clinic, University of Barcelona; Neuroimmunology Program (H.A., M.P.-P., F.G.) and Department of Neurology, Hospital Clinic (J.D.), Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Neuroimmunology (F.L.), Institute of Clinical Chemistry, Christian-Albrechts-University; Department of Neurology (F.L.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology (P.K.), University Hospital Magdeburg; Neuroimmunology (K.-P.W), Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein Campus Lübeck; Department of Neurology (K.-P.W), University of Lübeck, Germany; Department of Neurology (E.L.), University of Pennsylvania (J.D.), Philadelphia; and Department of Neurology (J.D.), Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Paul W Wirtz
- From the Departments of Neurology (A.v.S., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S.), Erasmus University Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, the Hague, the Netherlands; Department of Neurology (H.A., F.G.), Hospital Clinic, University of Barcelona; Neuroimmunology Program (H.A., M.P.-P., F.G.) and Department of Neurology, Hospital Clinic (J.D.), Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Neuroimmunology (F.L.), Institute of Clinical Chemistry, Christian-Albrechts-University; Department of Neurology (F.L.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology (P.K.), University Hospital Magdeburg; Neuroimmunology (K.-P.W), Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein Campus Lübeck; Department of Neurology (K.-P.W), University of Lübeck, Germany; Department of Neurology (E.L.), University of Pennsylvania (J.D.), Philadelphia; and Department of Neurology (J.D.), Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Marco W J Schreurs
- From the Departments of Neurology (A.v.S., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S.), Erasmus University Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, the Hague, the Netherlands; Department of Neurology (H.A., F.G.), Hospital Clinic, University of Barcelona; Neuroimmunology Program (H.A., M.P.-P., F.G.) and Department of Neurology, Hospital Clinic (J.D.), Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Neuroimmunology (F.L.), Institute of Clinical Chemistry, Christian-Albrechts-University; Department of Neurology (F.L.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology (P.K.), University Hospital Magdeburg; Neuroimmunology (K.-P.W), Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein Campus Lübeck; Department of Neurology (K.-P.W), University of Lübeck, Germany; Department of Neurology (E.L.), University of Pennsylvania (J.D.), Philadelphia; and Department of Neurology (J.D.), Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Peter A E Sillevis Smitt
- From the Departments of Neurology (A.v.S., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S.), Erasmus University Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, the Hague, the Netherlands; Department of Neurology (H.A., F.G.), Hospital Clinic, University of Barcelona; Neuroimmunology Program (H.A., M.P.-P., F.G.) and Department of Neurology, Hospital Clinic (J.D.), Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Neuroimmunology (F.L.), Institute of Clinical Chemistry, Christian-Albrechts-University; Department of Neurology (F.L.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology (P.K.), University Hospital Magdeburg; Neuroimmunology (K.-P.W), Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein Campus Lübeck; Department of Neurology (K.-P.W), University of Lübeck, Germany; Department of Neurology (E.L.), University of Pennsylvania (J.D.), Philadelphia; and Department of Neurology (J.D.), Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Francesc Graus
- From the Departments of Neurology (A.v.S., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S.), Erasmus University Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, the Hague, the Netherlands; Department of Neurology (H.A., F.G.), Hospital Clinic, University of Barcelona; Neuroimmunology Program (H.A., M.P.-P., F.G.) and Department of Neurology, Hospital Clinic (J.D.), Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Neuroimmunology (F.L.), Institute of Clinical Chemistry, Christian-Albrechts-University; Department of Neurology (F.L.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology (P.K.), University Hospital Magdeburg; Neuroimmunology (K.-P.W), Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein Campus Lübeck; Department of Neurology (K.-P.W), University of Lübeck, Germany; Department of Neurology (E.L.), University of Pennsylvania (J.D.), Philadelphia; and Department of Neurology (J.D.), Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Josep Dalmau
- From the Departments of Neurology (A.v.S., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S.), Erasmus University Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, the Hague, the Netherlands; Department of Neurology (H.A., F.G.), Hospital Clinic, University of Barcelona; Neuroimmunology Program (H.A., M.P.-P., F.G.) and Department of Neurology, Hospital Clinic (J.D.), Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Neuroimmunology (F.L.), Institute of Clinical Chemistry, Christian-Albrechts-University; Department of Neurology (F.L.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology (P.K.), University Hospital Magdeburg; Neuroimmunology (K.-P.W), Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein Campus Lübeck; Department of Neurology (K.-P.W), University of Lübeck, Germany; Department of Neurology (E.L.), University of Pennsylvania (J.D.), Philadelphia; and Department of Neurology (J.D.), Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Maarten J Titulaer
- From the Departments of Neurology (A.v.S., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S.), Erasmus University Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, the Hague, the Netherlands; Department of Neurology (H.A., F.G.), Hospital Clinic, University of Barcelona; Neuroimmunology Program (H.A., M.P.-P., F.G.) and Department of Neurology, Hospital Clinic (J.D.), Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Neuroimmunology (F.L.), Institute of Clinical Chemistry, Christian-Albrechts-University; Department of Neurology (F.L.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology (P.K.), University Hospital Magdeburg; Neuroimmunology (K.-P.W), Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein Campus Lübeck; Department of Neurology (K.-P.W), University of Lübeck, Germany; Department of Neurology (E.L.), University of Pennsylvania (J.D.), Philadelphia; and Department of Neurology (J.D.), Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain.
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Vanli-Yavuz EN, Erdag E, Tuzun E, Ekizoglu E, Baysal-Kirac L, Ulusoy C, Peach S, Gundogdu G, Sencer S, Sencer A, Kucukali CI, Bebek N, Gurses C, Gokyigit A, Baykan B. Neuronal autoantibodies in mesial temporal lobe epilepsy with hippocampal sclerosis. J Neurol Neurosurg Psychiatry 2016; 87:684-92. [PMID: 27151964 DOI: 10.1136/jnnp-2016-313146] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 04/12/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Our aim was to investigate the prevalence of neuronal autoantibodies (NAbs) in a large consecutive series with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) and to elucidate the clinical and laboratory clues for detection of NAbs in this prototype of frequent, drug-resistant epilepsy syndrome. METHODS Consecutive patients diagnosed with MTLE fulfilling the MRI criteria for HS were enrolled. The sera of patients and various control groups (80 subjects) were tested for eight NAbs after ethical approval and signed consents. Brain tissues obtained from surgical specimens were also investigated by immunohistochemical analysis for the presence of inflammatory infiltrates. The features of seropositive versus seronegative groups were compared and binary logistic regression analysis was performed to explore the differentiating variables. RESULTS We found antibodies against antigens, contactin-associated protein-like 2 in 11 patients, uncharacterised voltage-gated potassium channel (VGKC)-complex antigens in four patients, glycine receptor (GLY-R) in 5 patients, N-methyl-d-aspartate receptor in 4 patients and γ-aminobutyric acid receptor A in 1 patient of 111 patients with MTLE-HS and none of the control subjects. The history of status epilepticus, diagnosis of psychosis and positron emission tomography or single-photon emission CT findings in temporal plus extratemporal regions were found significantly more frequently in the seropositive group. Binary logistic regression analysis disclosed that status epilepticus, psychosis and cognitive dysfunction were statistically significant variables to differentiate between the VGKC-complex subgroup versus seronegative group. CONCLUSIONS This first systematic screening study of various NAbs showed 22.5% seropositivity belonging mostly to VGKC-complex antibodies in a large consecutive series of patients with MTLE-HS. Our results indicated a VGKC-complex autoimmunity-related subgroup in the syndrome of MTLE-HS.
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Affiliation(s)
- Ebru Nur Vanli-Yavuz
- Istanbul Faculty of Medicine, Departments of Neurology and Clinical Neurophysiology, Istanbul University, Istanbul, Turkey Department of Neurology, Koc University, School of Medicine, Istanbul, Turkey
| | - Ece Erdag
- Department of Neuroscience, Istanbul University, Institute of Experimental Medical Research, Istanbul, Turkey
| | - Erdem Tuzun
- Department of Neuroscience, Istanbul University, Institute of Experimental Medical Research, Istanbul, Turkey
| | - Esme Ekizoglu
- Istanbul Faculty of Medicine, Departments of Neurology and Clinical Neurophysiology, Istanbul University, Istanbul, Turkey Department of Neuroscience, Istanbul University, Institute of Experimental Medical Research, Istanbul, Turkey
| | - Leyla Baysal-Kirac
- Istanbul Faculty of Medicine, Departments of Neurology and Clinical Neurophysiology, Istanbul University, Istanbul, Turkey
| | - Canan Ulusoy
- Department of Neuroscience, Istanbul University, Institute of Experimental Medical Research, Istanbul, Turkey
| | - Sian Peach
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Gokcen Gundogdu
- Istanbul Faculty of Medicine, Department of Pathology, Istanbul University, Istanbul, Turkey
| | - Serra Sencer
- Istanbul Faculty of Medicine, Department of Neuroradiology, Istanbul University, Istanbul, Turkey
| | - Altay Sencer
- Istanbul Faculty of Medicine, Department of Neurosurgery, Istanbul University, Istanbul, Turkey
| | - Cem Ismail Kucukali
- Department of Neuroscience, Istanbul University, Institute of Experimental Medical Research, Istanbul, Turkey
| | - Nerses Bebek
- Istanbul Faculty of Medicine, Departments of Neurology and Clinical Neurophysiology, Istanbul University, Istanbul, Turkey
| | - Candan Gurses
- Istanbul Faculty of Medicine, Departments of Neurology and Clinical Neurophysiology, Istanbul University, Istanbul, Turkey
| | - Aysen Gokyigit
- Istanbul Faculty of Medicine, Departments of Neurology and Clinical Neurophysiology, Istanbul University, Istanbul, Turkey
| | - Betul Baykan
- Istanbul Faculty of Medicine, Departments of Neurology and Clinical Neurophysiology, Istanbul University, Istanbul, Turkey
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28
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Jammoul A, Shayya L, Mente K, Li J, Rae-Grant A, Li Y. Clinical utility of seropositive voltage-gated potassium channel-complex antibody. Neurol Clin Pract 2016; 6:409-418. [PMID: 27847683 DOI: 10.1212/cpj.0000000000000268] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Antibodies against voltage-gated potassium channel (VGKC)-complex are implicated in the pathogenesis of acquired neuromyotonia, limbic encephalitis, faciobrachial dystonic seizure, and Morvan syndrome. Outside these entities, the clinical value of VGKC-complex antibodies remains unclear. METHODS We conducted a single-center review of patients positive for VGKC-complex antibodies over an 8-year period. RESULTS Among 114 patients positive for VGKC-complex antibody, 11 (9.6%) carrying the diagnosis of limbic encephalitis (n = 9) or neuromyotonia (n = 2) constituted the classic group, and the remaining 103 cases of various neurologic and non-neurologic disorders comprised the nonclassic group. The median titer for the classic group was higher than the nonclassic group (p < 0.0001). A total of 90.9% of the patients in the classic and 21.4% in the nonclassic group possessed high (>0.25 nM) VGKC-complex antibody levels (p < 0.0001). A total of 75.0% of the patients in the high-level group had definite or probable autoimmune basis, while nonautoimmune disorders were seen in 75.6% of patients from the low-level group (p < 0.0001). A total of 26.3% of patients were found with active or remote solid organ or hematologic malignancy, but no antibody titer difference was observed among subgroups of absent, active, or remote malignancy. Compared to age-matched US national census, rates of active cancer in our cohort were higher in patients older than 45 years. CONCLUSIONS High VGKC-complex antibody titers are more likely found in patients with classically associated syndromes and other autoimmune conditions. Low-level VGKC-complex antibodies can be detected in nonspecific and mostly nonautoimmune disorders. The presence of VGKC-complex antibody, rather than its level, may serve as a marker of malignancy.
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Affiliation(s)
- Adham Jammoul
- Neurohospitalist Program (AJ), Aultman Hospital, Canton; and Department of Neurology (LS, KM, AR-G, YL) and Department of Quantitative Health Sciences, Lerner Research Institute (JL), Cleveland Clinic Foundation, OH
| | - Luay Shayya
- Neurohospitalist Program (AJ), Aultman Hospital, Canton; and Department of Neurology (LS, KM, AR-G, YL) and Department of Quantitative Health Sciences, Lerner Research Institute (JL), Cleveland Clinic Foundation, OH
| | - Karin Mente
- Neurohospitalist Program (AJ), Aultman Hospital, Canton; and Department of Neurology (LS, KM, AR-G, YL) and Department of Quantitative Health Sciences, Lerner Research Institute (JL), Cleveland Clinic Foundation, OH
| | - Jianbo Li
- Neurohospitalist Program (AJ), Aultman Hospital, Canton; and Department of Neurology (LS, KM, AR-G, YL) and Department of Quantitative Health Sciences, Lerner Research Institute (JL), Cleveland Clinic Foundation, OH
| | - Alexander Rae-Grant
- Neurohospitalist Program (AJ), Aultman Hospital, Canton; and Department of Neurology (LS, KM, AR-G, YL) and Department of Quantitative Health Sciences, Lerner Research Institute (JL), Cleveland Clinic Foundation, OH
| | - Yuebing Li
- Neurohospitalist Program (AJ), Aultman Hospital, Canton; and Department of Neurology (LS, KM, AR-G, YL) and Department of Quantitative Health Sciences, Lerner Research Institute (JL), Cleveland Clinic Foundation, OH
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29
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Graus F, Titulaer MJ, Balu R, Benseler S, Bien CG, Cellucci T, Cortese I, Dale RC, Gelfand JM, Geschwind M, Glaser CA, Honnorat J, Höftberger R, Iizuka T, Irani SR, Lancaster E, Leypoldt F, Prüss H, Rae-Grant A, Reindl M, Rosenfeld MR, Rostásy K, Saiz A, Venkatesan A, Vincent A, Wandinger KP, Waters P, Dalmau J. A clinical approach to diagnosis of autoimmune encephalitis. Lancet Neurol 2016; 15:391-404. [PMID: 26906964 PMCID: PMC5066574 DOI: 10.1016/s1474-4422(15)00401-9] [Citation(s) in RCA: 2318] [Impact Index Per Article: 289.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 12/08/2015] [Accepted: 12/16/2015] [Indexed: 12/18/2022]
Abstract
Encephalitis is a severe inflammatory disorder of the brain with many possible causes and a complex differential diagnosis. Advances in autoimmune encephalitis research in the past 10 years have led to the identification of new syndromes and biomarkers that have transformed the diagnostic approach to these disorders. However, existing criteria for autoimmune encephalitis are too reliant on antibody testing and response to immunotherapy, which might delay the diagnosis. We reviewed the literature and gathered the experience of a team of experts with the aims of developing a practical, syndrome-based diagnostic approach to autoimmune encephalitis and providing guidelines to navigate through the differential diagnosis. Because autoantibody test results and response to therapy are not available at disease onset, we based the initial diagnostic approach on neurological assessment and conventional tests that are accessible to most clinicians. Through logical differential diagnosis, levels of evidence for autoimmune encephalitis (possible, probable, or definite) are achieved, which can lead to prompt immunotherapy.
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Affiliation(s)
- Francesc Graus
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Service of Neurology, Hospital Clinic, Barcelona, Spain.
| | | | - Ramani Balu
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Susanne Benseler
- Department of Pediatrics, Alberta Children Hospital, Calgary, AB, Canada
| | | | - Tania Cellucci
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - Irene Cortese
- Neuroimmunology Clinic, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Russell C Dale
- Neuroimmunology Group, Children's Hospital at Westmead, University of Sydney, Sydney, NSW, Australia
| | - Jeffrey M Gelfand
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Michael Geschwind
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Carol A Glaser
- Division of Pediatric Infectious Diseases, Kaiser Permanente, Oakland Medical Center and University of California, San Francisco, CA, USA
| | - Jerome Honnorat
- French Reference Center on Paraneoplastic Neurological Syndrome, Hospices Civils De Lyon, Hôpital Neurologique, Inserm U1028, CNRS UMR 5292, Lyon's Neurosciences Research Center, Université Claude-Bernard Lyon-1, Lyon, France
| | - Romana Höftberger
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Takahiro Iizuka
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Sarosh R Irani
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Eric Lancaster
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Frank Leypoldt
- Neuroimmunology, Institute of Clinical Chemistry, and Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Harald Prüss
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany; German Center for Neurodegenerative Disorders Berlin, Berlin, Germany
| | | | - Markus Reindl
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Myrna R Rosenfeld
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Kevin Rostásy
- Department of Pediatric Neurology, Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany
| | - Albert Saiz
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Service of Neurology, Hospital Clinic, Barcelona, Spain
| | - Arun Venkatesan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Klaus-Peter Wandinger
- Institute of Clinical Chemistry and Department of Neurology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Patrick Waters
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Josep Dalmau
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA; Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain.
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30
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van Sonderen A, Schreurs MWJ, de Bruijn MAAM, Boukhrissi S, Nagtzaam MMP, Hulsenboom ESP, Enting RH, Thijs RD, Wirtz PW, Sillevis Smitt PAE, Titulaer MJ. The relevance of VGKC positivity in the absence of LGI1 and Caspr2 antibodies. Neurology 2016; 86:1692-9. [PMID: 27037230 DOI: 10.1212/wnl.0000000000002637] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 12/22/2015] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To assess the clinical relevance of a positive voltage-gated potassium channel (VGKC) test in patients lacking antibodies to LGI1 and Caspr2. METHODS VGKC-positive patients were tested for LGI1 and Caspr2 antibodies. Patients lacking both antibodies were matched (1:2) to VGKC-negative patients. Clinical and paraclinical criteria were used to blindly determine evidence for autoimmune inflammation in both groups. Patients with an inconclusive VGKC titer were analyzed in the same way. RESULTS A total of 1,455 patients were tested by VGKC radioimmunoassay. Fifty-six patients tested positive, 50 of whom were available to be included. Twenty-five patients had antibodies to LGI1 (n = 19) or Caspr2 (n = 6) and 25 patients lacked both antibodies. Evidence for autoimmune inflammation was present in 7 (28%) of the VGKC-positive patients lacking LGI1 and Caspr2, compared to 9 (18%) of the VGKC-negative controls (p = 0.38). Evidence for autoimmune inflammation was mainly found in patients with limbic encephalitis/encephalomyelitis (57%), but not in other clinical phenotypes (5%, p < 0.01). VGKC titers were significantly higher in patients with antibodies to LGI1 or Caspr2 (p < 0.001). However, antibodies to Caspr2 could also be detected in patients with inconclusive low VGKC titer, while many VGKC-positive patients had no evidence for autoimmune inflammation. CONCLUSIONS VGKC positivity in the absence of antibodies to LGI1 and Caspr2 is not a clear marker for autoimmune inflammation and seems not to contribute in clinical practice. No cutoff value for the VGKC titer was appropriate to discriminate between patients with and without autoimmune inflammation.
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Affiliation(s)
- Agnes van Sonderen
- From the Departments of Neurology (A.v.S., M.A.A.M.d.B., M.M.P.N., E.S.P.H., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S., S.B.), Erasmus Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, The Hague; Department of Neurology (R.H.E.), University Medical Center Groningen/Rijksuniversiteit Groningen; and Stichting Epilepsie Instellingen Nederland (SEIN) (R.D.T.), Heemstede, the Netherlands
| | - Marco W J Schreurs
- From the Departments of Neurology (A.v.S., M.A.A.M.d.B., M.M.P.N., E.S.P.H., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S., S.B.), Erasmus Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, The Hague; Department of Neurology (R.H.E.), University Medical Center Groningen/Rijksuniversiteit Groningen; and Stichting Epilepsie Instellingen Nederland (SEIN) (R.D.T.), Heemstede, the Netherlands
| | - Marienke A A M de Bruijn
- From the Departments of Neurology (A.v.S., M.A.A.M.d.B., M.M.P.N., E.S.P.H., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S., S.B.), Erasmus Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, The Hague; Department of Neurology (R.H.E.), University Medical Center Groningen/Rijksuniversiteit Groningen; and Stichting Epilepsie Instellingen Nederland (SEIN) (R.D.T.), Heemstede, the Netherlands
| | - Sanae Boukhrissi
- From the Departments of Neurology (A.v.S., M.A.A.M.d.B., M.M.P.N., E.S.P.H., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S., S.B.), Erasmus Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, The Hague; Department of Neurology (R.H.E.), University Medical Center Groningen/Rijksuniversiteit Groningen; and Stichting Epilepsie Instellingen Nederland (SEIN) (R.D.T.), Heemstede, the Netherlands
| | - Mariska M P Nagtzaam
- From the Departments of Neurology (A.v.S., M.A.A.M.d.B., M.M.P.N., E.S.P.H., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S., S.B.), Erasmus Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, The Hague; Department of Neurology (R.H.E.), University Medical Center Groningen/Rijksuniversiteit Groningen; and Stichting Epilepsie Instellingen Nederland (SEIN) (R.D.T.), Heemstede, the Netherlands
| | - Esther S P Hulsenboom
- From the Departments of Neurology (A.v.S., M.A.A.M.d.B., M.M.P.N., E.S.P.H., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S., S.B.), Erasmus Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, The Hague; Department of Neurology (R.H.E.), University Medical Center Groningen/Rijksuniversiteit Groningen; and Stichting Epilepsie Instellingen Nederland (SEIN) (R.D.T.), Heemstede, the Netherlands
| | - Roelien H Enting
- From the Departments of Neurology (A.v.S., M.A.A.M.d.B., M.M.P.N., E.S.P.H., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S., S.B.), Erasmus Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, The Hague; Department of Neurology (R.H.E.), University Medical Center Groningen/Rijksuniversiteit Groningen; and Stichting Epilepsie Instellingen Nederland (SEIN) (R.D.T.), Heemstede, the Netherlands
| | - Roland D Thijs
- From the Departments of Neurology (A.v.S., M.A.A.M.d.B., M.M.P.N., E.S.P.H., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S., S.B.), Erasmus Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, The Hague; Department of Neurology (R.H.E.), University Medical Center Groningen/Rijksuniversiteit Groningen; and Stichting Epilepsie Instellingen Nederland (SEIN) (R.D.T.), Heemstede, the Netherlands
| | - Paul W Wirtz
- From the Departments of Neurology (A.v.S., M.A.A.M.d.B., M.M.P.N., E.S.P.H., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S., S.B.), Erasmus Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, The Hague; Department of Neurology (R.H.E.), University Medical Center Groningen/Rijksuniversiteit Groningen; and Stichting Epilepsie Instellingen Nederland (SEIN) (R.D.T.), Heemstede, the Netherlands
| | - Peter A E Sillevis Smitt
- From the Departments of Neurology (A.v.S., M.A.A.M.d.B., M.M.P.N., E.S.P.H., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S., S.B.), Erasmus Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, The Hague; Department of Neurology (R.H.E.), University Medical Center Groningen/Rijksuniversiteit Groningen; and Stichting Epilepsie Instellingen Nederland (SEIN) (R.D.T.), Heemstede, the Netherlands
| | - Maarten J Titulaer
- From the Departments of Neurology (A.v.S., M.A.A.M.d.B., M.M.P.N., E.S.P.H., P.A.E.S.S., M.J.T.) and Immunology (M.W.J.S., S.B.), Erasmus Medical Center, Rotterdam; Department of Neurology (A.v.S., P.W.W.), Haga Teaching Hospital, The Hague; Department of Neurology (R.H.E.), University Medical Center Groningen/Rijksuniversiteit Groningen; and Stichting Epilepsie Instellingen Nederland (SEIN) (R.D.T.), Heemstede, the Netherlands.
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Donaldson R, Li J, Li Y. Clinical significance of cation channel antibodies in motor neuron disease. Muscle Nerve 2016; 54:228-31. [DOI: 10.1002/mus.25046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 01/07/2015] [Accepted: 01/12/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Rachel Donaldson
- Department of Neurology; Cleveland Clinic Foundation; 9500 Euclid Avenue Cleveland Ohio 44195 USA
| | - Jianbo Li
- Department of Quantitative Health Sciences; Learner Research Institute, Cleveland Clinic Foundation; Cleveland Ohio USA
| | - Yuebing Li
- Department of Neurology; Cleveland Clinic Foundation; 9500 Euclid Avenue Cleveland Ohio 44195 USA
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Maskery M, Chhetri SK, Dayanandan R, Gall C, Emsley HCA. Morvan Syndrome: A Case Report With Patient Narrative and Video. Neurohospitalist 2016; 6:32-5. [PMID: 26740856 DOI: 10.1177/1941874415580597] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A 74-year-old gentleman was admitted to the regional neurosciences center with encephalopathy, myokymia, and dysautonomia. Chest imaging had previously identified an incidental mass in the anterior mediastinum, consistent with a primary thymic tumor. Antivoltage-gated potassium channel (anti-VGKC) antibodies were positive (titer 1273 pmol/L) and he was hypokalemic. Electromyogram and nerve conduction studies were in keeping with peripheral nerve hyperexcitability syndrome, and an electroencephalogram was consistent with encephalopathy. A diagnosis of Morvan syndrome was made, for which he was initially treated with high-dose steroids, followed by a 5-day course of intravenous immunoglobulin (IVIG) therapy. He also underwent thymectomy, followed by a postexcision flare of his symptoms requiring intensive care management. Further steroids, plasmapheresis, and IVIG achieved stabilization of his clinical condition, enabling transfer for inpatient neurorehabilitation. He was commenced on azathioprine and a prolonged oral steroid taper. A subsequent presumed incipient relapse responded well to further IVIG treatment. This case report documents a thymoma-associated presentation of anti-VGKC-positive Morvan syndrome supplemented by patient and carer narrative and video, both of which provide valuable further insights into this rare disorder. There are a limited number of publications surrounding this rare condition available in the English literature. This, combined with the heterogenous presentation, association with underlying malignancy, response to treatment, and prognosis, provides a diagnostic challenge. However, the association with anti-VGKC antibody-associated complexes and 2 recent case series have provided some scope for both accurate diagnosis and management.
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Affiliation(s)
- Mark Maskery
- University of Manchester, Manchester, United Kingdom
| | - Suresh K Chhetri
- Department of Neurology, Royal Preston Hospital, Preston, United Kingdom
| | - Rejith Dayanandan
- Department of Neurology, Royal Preston Hospital, Preston, United Kingdom
| | - Claire Gall
- Department of Neurology, Royal Preston Hospital, Preston, United Kingdom
| | - Hedley C A Emsley
- University of Manchester, Manchester, United Kingdom; Department of Neurology, Royal Preston Hospital, Preston, United Kingdom
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Abstract
Over the last 15 years it has become clear that rare but highly recognizable diseases of the central nervous system (CNS), including newly identified forms of limbic encephalitis and other encephalopathies, are likely to be mediated by antibodies (Abs) to CNS proteins. The Abs are directed against membrane receptors and ion channel-associated proteins that are expressed on the surface of neurons in the CNS, such as N-methyl D-aspartate receptors and leucine-rich, glioma inactivated 1 protein and contactin-associated protein like 2, that are associated with voltage-gated potassium channels. The diseases are not invariably cancer-related and are therefore different from the classical paraneoplastic neurological diseases that are associated with, but not caused by, Abs to intracellular proteins. Most importantly, the new antibody-associated diseases almost invariably respond to immunotherapies with considerable and sometimes complete recovery, and there is convincing evidence of their pathogenicity in the relatively limited studies performed so far. Treatments include first-line steroids, intravenous immunoglobulins, and plasma exchange, and second-line rituximab and cyclophosphamide, followed in many cases by steroid-sparing agents in the long-term. This review focuses mainly on N-methyl D-aspartate receptor- and voltage-gated potassium channel complex-related Abs in adults, the clinical phenotypes, and treatment responses. Pediatric cases are referred to but not reviewed in detail. As there have been very few prospective studies, the conclusions regarding immunotherapies are based on retrospective studies.
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Affiliation(s)
- Matteo Gastaldi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
- University of Pavia, Pavia, Italy.
| | - Anaïs Thouin
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Hacohen Y, Singh R, Rossi M, Lang B, Hemingway C, Lim M, Vincent A. Clinical relevance of voltage-gated potassium channel–complex antibodies in children. Neurology 2015; 85:967-75. [PMID: 26296514 DOI: 10.1212/wnl.0000000000001922] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To assess the clinical and immunologic findings in children with voltage-gated potassium channel (VGKC)-complex antibodies (Abs). METHODS Thirty-nine of 363 sera, referred from 2 pediatric centers from 2007 to 2013, had been reported positive (.100 pM) for VGKC-complex Abs. Medical records were reviewed retrospectively and the patients’ condition was independently classified as inflammatory (n 5 159) or noninflammatory (n 5 204). Positive sera (.100 pM) were tested/retested for the VGKC complex Ab–positive complex proteins LGI1 and CASPR2, screened for binding to live hippocampal neurons, and 12 high-titer sera (.400 pM) tested by radioimmunoassay for binding to VGKC Kv1 subunits with or without intracellular postsynaptic density proteins. RESULTS VGKC-complex Abs were found in 39 children, including 20% of encephalopathies and 7.6% of other conditions (p 5 0.001). Thirty children had inflammatory conditions and 9 had noninflammatory etiologies but titers.400 pM (n512) were found only in inflammatory diseases (p , 0.0001). Four sera, including from 2 children with coexisting NMDA receptor Abs and one with Guillain-Barré syndrome and Abs to both LGI1 and CASPR2, bound to hippocampal neurons. None of the sera bound detectably to VGKC Kv1 subunits on live HEK cells, but 4 of 12 .400 pM sera immunoprecipitated VGKC Kv1 subunits, with or without postsynaptic densities, extracted from transfected cells. CONCLUSION Positive VGKC-complex Abs cannot be taken to indicate a specific clinical syndrome in children, but appear to be a nonspecific biomarker of inflammatory neurologic diseases, particularly of encephalopathy. Some of the Abs may bind to intracellular epitopes on the VGKC subunits, or to the intracellular interacting proteins, but in many the targets remain undefined.
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Nosadini M, Mohammad SS, Ramanathan S, Brilot F, Dale RC. Immune therapy in autoimmune encephalitis: a systematic review. Expert Rev Neurother 2015; 15:1391-419. [DOI: 10.1586/14737175.2015.1115720] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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