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De Napoli G, Gastaldi M, Natali P, Bedin R, Simone AM, Santangelo M, Mariotto S, Vitetta F, Smolik K, Cardi M, Meletti S, Ferraro D. Kappa index in the diagnostic work-up of autoimmune encephalitis. J Neurol Sci 2024; 463:123146. [PMID: 39033735 DOI: 10.1016/j.jns.2024.123146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 07/03/2024] [Accepted: 07/16/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND The presence of inflammatory changes in the cerebrospinal fluid (CSF), including immunoglobulin intrathecal synthesis (IS), can support the diagnosis of autoimmune encephalitis (AE) and allow prompt treatment. The main aim of our study was to calculate the Kappa index as a marker of IS, in patients with AE. METHODS Charts of patients undergoing a diagnostic work-up for suspected AE between 2009 and 2023 were reviewed and the Graus criteria applied. CSF and serum kappa free light chains were determined using the Freelite assay (The Binding Site Group) and the turbidimetric Optilite analyzer. RESULTS We identified 34 patients with "definite" AE (9 anti-NMDAR AE and 25 limbic AE) and nine patients with "possible" AE. Five patients (15%) with definite AE had pleocytosis and twelve (34%) showed CSF-restricted oligoclonal bands (OCB) at isoelectric focusing. The Kappa index was >6 in 29.4% and > 3 in 50% of the definite AE patients. It was elevated (>3) in 36.4% of patients with definite AE who resulted negative to OCB testing and was the only altered parameter suggestive of an ongoing inflammatory process in the CNS in three definite AE patients with otherwise normal CSF findings (i.e. normal cell count and protein levels, no OCBs). In the possible AE group, one patient had a Kappa index >3 in the absence of OCB. CONCLUSIONS The Kappa index could be useful, as a more sensitive marker of IS and as a supportive marker of neuroinflammation, in the diagnostic work-up of suspected AE.
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Affiliation(s)
- Giulia De Napoli
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy; Department of Neurosciences, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | - Patrizia Natali
- Department of Laboratory Medicine, Azienda Ospedaliero-Universitaria and Azienda Unità Sanitaria Locale, Ospedale Civile di Baggiovara, Modena, Italy
| | - Roberta Bedin
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy
| | | | | | - Sara Mariotto
- Neurology Unit, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Francesca Vitetta
- Department of Neurosciences, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Krzysztof Smolik
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy; Department of Neurosciences, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Martina Cardi
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Meletti
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy; Department of Neurosciences, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Diana Ferraro
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy; Department of Neurosciences, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy.
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2
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Forcadela M, Birch K, Rocchi C, Campagna G, Jackson E, Chadwick C, Hamid S, Jacob A, Huda S. Do we still need OCBs in MS diagnosis and how many? Mult Scler Relat Disord 2023; 79:105035. [PMID: 37864992 DOI: 10.1016/j.msard.2023.105035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/24/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND CSF-specific oligoclonal bands (CSF-OCBs) can be used for dissemination in time (DIT) in the 2017 multiple sclerosis (MS) diagnostic criteria. A cut-off of ≥2 CSF-OCBs was recommended but studies have suggested ≥3 CSF-OCBs may be superior. OBJECTIVES To assess utility of ≥2 and ≥3 CSF-OCBs as a cut-off for MS diagnosis. METHODS Paired serum and CSF-OCBs sent to the Walton Centre, UK between July 2018 and June 2020 were included. CSF-OCBs were assessed using isoelectric focussing and reviewed by two blinded raters. Case records were reviewed. RESULTS Of 1334 paired serum and CSF-OCB requests, 945 cases had sufficient clinical information. More than 1 CSF-OCB was detected in 268/945(28%) cases. Of these, 252 had ≥2 and 230 had ≥3 CSF-OCBs. The sensitivity and specificity for MS with ≥2 and ≥3 CSF-OCBs were 91.7%, 91.2%, 90.2% and 93.8% respectively. Only 3/22 patients with 2 CSF-OCBs had MS. In 25% of patients, CSF-OCBs reduced time to MS diagnosis (median 437.5 days (28-1332)). CONCLUSION Although cut-offs of ≥2 or ≥3 CSF-OCBs performed similarly well, 2 CSF-OCBs were frequently seen with non-inflammatory pathology. Use of ≥3 CSF-OCBs for MS diagnosis should be considered. CSF analysis reduced time to MS diagnosis by approximately 14 months.
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Affiliation(s)
| | - Katherine Birch
- The Neuroscience laboratories, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | | | - Edward Jackson
- The Neuroscience laboratories, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Carrie Chadwick
- The Neuroscience laboratories, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Shahd Hamid
- The Walton Centre Foundation Trust, Liverpool, UK
| | - Anu Jacob
- The Walton Centre Foundation Trust, Liverpool, UK; Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Saif Huda
- The Walton Centre Foundation Trust, Liverpool, UK
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Higgins V, Beriault D, Mostafa A, Estey M, Agbor T, Ismail O, Parker ML. Variation in Processes and Reporting of Cerebrospinal Fluid Oligoclonal Banding and Associated Tests and Calculated Indices across Canadian Clinical Laboratories. Clin Biochem 2023; 116:105-112. [PMID: 37100108 DOI: 10.1016/j.clinbiochem.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVES Multiple sclerosis is diagnosed based on clinical and laboratory findings, including cerebrospinal fluid (CSF) oligoclonal banding (OCB) analysis. The lack of updated CSF OCB laboratory guidelines in Canada has likely led to variation in processes and reporting across clinical laboratories. As a first step to developing harmonized laboratory recommendations, we examined current CSF OCB processes, reporting, and interpretation across all Canadian clinical laboratories currently performing this test. DESIGN AND METHODS A survey of 39 questions was sent to clinical chemists at all 13 Canadian clinical laboratories performing CSF OCB analysis. The survey included questions regarding quality control processes, reporting practices for CSF gel electrophoresis pattern interpretation, and associated tests and calculated indices. RESULTS The survey response rate was 100%. Most (10/13) laboratories use ≥2 CSF-specific bands (2017 McDonald Criteria) as their CSF OCB positivity cut-off and only 2/13 report the number of bands with every report. Most (8/13 and 9/13) laboratories report an inflammatory response pattern and monoclonal gammopathy pattern, respectively. However, the process for reporting and/or confirming a monoclonal gammopathy varies widely. Variation was observed for reference intervals, units, and the panel of reported associated tests and calculated indices. The maximum acceptable time interval between paired CSF and serum collections varied from 24 hours to no limit. CONCLUSIONS Profound variation exists in processes, reporting, and interpretation of CSF OCB and associated tests and indices across Canadian clinical laboratories. Harmonization of CSF OCB analysis is required to ensure continuity and quality of patient care. Our detailed assessment of current practice variation highlights the need for clinical stakeholder engagement and further data analysis to support optimal interpretation and reporting practices, which will aid in developing harmonized laboratory recommendations.
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Affiliation(s)
- V Higgins
- DynaLIFE Medical Labs, Edmonton, AB, Canada; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada.
| | - D Beriault
- Department of Laboratory Medicine, St. Michael's Hospital, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada
| | - A Mostafa
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - M Estey
- DynaLIFE Medical Labs, Edmonton, AB, Canada; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - T Agbor
- DynaLIFE Medical Labs, Edmonton, AB, Canada; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - O Ismail
- DynaLIFE Medical Labs, Edmonton, AB, Canada; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - M L Parker
- DynaLIFE Medical Labs, Edmonton, AB, Canada; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
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Belimezi M, Kalliaropoulos A, Mentis AFA, Chrousos GP. Diagnostic significance of IgG and albumin indices versus oligoclonal band types in demyelinating disorders. J Clin Pathol 2023; 76:166-171. [PMID: 34526372 DOI: 10.1136/jclinpath-2021-207766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/29/2021] [Indexed: 11/04/2022]
Abstract
AIMS The laboratory diagnosis of demyelinating inflammatory disorders (DIDs) relies on both intrathecal oligoclonal band (OCB) positivity and IgG index. Although OCB typing remains the gold-standard test for DIDs, it can be laborious and ambiguous, complicating diagnostics, and unduly increasing diagnostic time. We examined whether serum or cerebrospinal fluid (CSF) parameters can classify OCB types and, thus, be used as a replacement test to standard OCB typing. METHODS We retrospectively analysed >1000 prospectively collected samples of patients with DIDs and quantified albumin and IgG levels in the CSF and serum. We determined OCB types by isoelectric focusing combined with immunofixation and evaluated the diagnostic accuracies of IgG and albumin indices in discriminating OCB types by receiver operating characteristic curves and multinomial regression. RESULTS An IgG index cut-off of 0.589 differentiated types 2/3 from types 1/4 (area under the curve 0.780, 95% CI 0.761 to 0.812, p<0.001; specificity: 71.10%, sensitivity: 73.45%). Albumin quotient cut-off values of 6.625 and of 6.707 discriminated type 1 from type 4 and type 2 from type 3, respectively (specificity: <55%, sensitivity: <75%). Female sex, age, IgG index, CSF IgG and serum albumin were associated with different OCB types. CONCLUSIONS Our study reveals that IgG and albumin index can differentiate OCB types with adequate accuracy, especially if refined by age and gender.
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Affiliation(s)
- Maria Belimezi
- Diagnostic Services Laboratory, Hellenic Pasteur Institute, Athens, Greece
| | | | - Alexios-Fotios A Mentis
- Diagnostic Services Laboratory, Hellenic Pasteur Institute, Athens, Greece .,University Research Institute of Maternal and Child Health and Precision Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - George P Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Evidence for an Intrathecal Immunoglobulin Synthesis by Kappa Free Light Chains in Neurological Patients with an Isolated Band in Isoelectric Focusing. Biomedicines 2022; 10:biomedicines10092202. [PMID: 36140302 PMCID: PMC9496576 DOI: 10.3390/biomedicines10092202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 09/02/2022] [Accepted: 09/03/2022] [Indexed: 11/17/2022] Open
Abstract
The gold standard for detecting intrathecal immunoglobulin synthesis is the determination of the oligoclonal band (OCB) in the cerebrospinal fluid (CSF) using isoelectric focusing (IEF). Controversy still exists regarding the significance of an isolated band in the CSF. A highly promising alternative method for the assessment of intrathecal inflammation is the quantification of kappa free light chains (k-FLC). Our aim was to evaluate the clinical significance of quantitative k-FLC in patients with an isolated band in the CSF. Using the Human Kappa Freelite Mx Kit on a turbidimetric Optilite®, we quantified the k-FLCs in paired CSF and serum samples in 47 patients with a single band in IEF. We classified patients into 27× inflammatory neurological disorders (IND), 2× peripheral inflammatory neurological disorders (PIND), 9× non-inflammatory neurological disorders (NIND) and 9× symptomatic controls (SC) based on their medical diagnosis. k-FLC were below the lower measurement limit of the analyser (LML) in all SC and PIND, as well as in 8 out of 9 NIND and 11 IND. Only 1 NIND and 16 IND were above the LML, and of these, only 14 IND were above the upper discrimination limit (Qlim). A neuroinflammatory nature of the diseases can be indicated in many cases by positive k-FLC in patients with an isolated band in IEF. The measurement of k-FLC can support the diagnosis of neurological diseases if they are included in the routine work-up.
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Carta S, Ferraro D, Ferrari S, Briani C, Mariotto S. Oligoclonal bands: clinical utility and interpretation cues. Crit Rev Clin Lab Sci 2022; 59:391-404. [DOI: 10.1080/10408363.2022.2039591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Sara Carta
- Department of Neurosciences, Biomedicine, and Movement Sciences, Neurology Unit, University of Verona, Verona, Italy
| | - Diana Ferraro
- Department of Biomedicine, Metabolic, and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Sergio Ferrari
- Department of Neurosciences, Biomedicine, and Movement Sciences, Neurology Unit, University of Verona, Verona, Italy
| | - Chiara Briani
- Department of Neurosciences, University of Padova, Padova, Italy
| | - Sara Mariotto
- Department of Neurosciences, Biomedicine, and Movement Sciences, Neurology Unit, University of Verona, Verona, Italy
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Jin Z, Bertholf RL, Yi X. Significance of Monoclonal Band in Cerebral Spinal Fluid. Clin Chem 2022; 68:276-281. [PMID: 35104857 DOI: 10.1093/clinchem/hvab258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/27/2021] [Indexed: 11/14/2022]
Affiliation(s)
- Zhicheng Jin
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Roger L Bertholf
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA.,Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Xin Yi
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA.,Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY, USA
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Ruiz M, Puthenparampil M, Campagnolo M, Castellani F, Salvalaggio A, Ruggero S, Toffanin E, Cacciavillani M, Gallo P, Franciotta D, Briani C. Oligoclonal IgG bands in chronic inflammatory polyradiculoneuropathies. J Neurol Neurosurg Psychiatry 2021; 92:969-974. [PMID: 33850000 DOI: 10.1136/jnnp-2020-325868] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/20/2021] [Accepted: 03/22/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) albumincytologic dissociation represents a supportive diagnostic criterion of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP).Few studies have investigated possible systemic or intrathecal humoral immune response activation in CIDP.Aim of our study was to investigate whether the search of oligoclonal IgG bands (OCBs) might provide additional data helpful in CIDP diagnostic work-up. METHODS Forty-eight consecutive patients with CIDP (34 men, mean age 59.4, range 16-83) were recruited. CSF analysis included nephelometric measurement of albumin and IgG concentrations, calculation of QALB, QAlbLIM and intrathecal IgG synthesis, and OCBs detection with isoelectric focusing. Data were compared with those from CSF and serum of 32 patients with Guillain-Barré syndrome (GBS), 18 patients with anti-myelin associated glycoprotein (MAG) antibody neuropathy, 4 patients with multifocal motor neuropathy and 32 patients with non-inflammatory neuropathies (NINPs). RESULTS Patients with CIDP and anti-MAG antibody neuropathy had significantly higher CSF albumin concentrations and QALB values than NINPs (p=0.0003 and p=0.0095, respectively). A total of 9 (19%) patients with CIDP presented identical serum and CSF OCBs ('mirror pattern') versus 3 patients (16.6%) with anti-MAG antibody neuropathy, 13 patients (40.6%) with GBS and 12.5% patients with NINPs. Only one patient with CIDP showed unique-to-CSF OCBs. First-line therapy was effective in 80.4% of patients with CIDP, irrespective of CSF findings. CONCLUSIONS Compared with NINP, CIDP, GBS and anti-MAG antibody neuropathies had a significantly increased CSF protein and blood-spinal nerve root barrier damage. Intrathecal humoral immune response is rare in our patients with CIDP. Systemic oligoclonal activation is more frequent, but not significantly different from what was detected in the control groups.
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Affiliation(s)
- Marta Ruiz
- Department of Neurosciences (DNS), University of Padova, Padova, Italy
| | | | - Marta Campagnolo
- Department of Neurosciences (DNS), University of Padova, Padova, Italy
| | | | - Alessandro Salvalaggio
- Department of Neurosciences (DNS), University of Padova, Padova, Italy.,Padova Neuroscience Center (PNC), Padova, Italy
| | - Susanna Ruggero
- Department of Neurosciences (DNS), University of Padova, Padova, Italy
| | | | | | - Paolo Gallo
- Department of Neurosciences (DNS), University of Padova, Padova, Italy
| | | | - Chiara Briani
- Department of Neurosciences (DNS), University of Padova, Padova, Italy
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Early multiple sclerosis: diagnostic challenges in clinically and radiologically isolated syndrome patients. Curr Opin Neurol 2021; 34:277-285. [PMID: 33661162 DOI: 10.1097/wco.0000000000000921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW With the introduction of new diagnostic criteria, the sensibility for multiple sclerosis (MS) diagnosis increased and the number of cases with the clinically isolated syndrome (CIS) decreased. Nevertheless, a misdiagnosis might always be around the corner, and the exclusion of a 'better explanation' is mandatory.There is a pressing need to provide an update on the main prognostic factors that increase the risk of conversion from CIS or from radiologically isolated syndrome (RIS) to MS, and on the potential 'red flags' to consider during the diagnostic workup. RECENT FINDINGS We discuss diagnostic challenges when facing patients presenting with a first demyelinating attack or with a RIS, with a focus on recently revised diagnostic criteria, on other neuroinflammatory conditions to be considered in the differential diagnosis and on factors distinguishing patients at risk of developing MS.A correct definition of a 'typical' demyelinating attack, as well as a correct interpretation of MRI findings, remains crucial in the diagnostic process. The cerebrospinal fluid examination is warmly recommended to confirm the dissemination in time of the demyelinating process and to increase the diagnostic accuracy. SUMMARY An early and accurate diagnosis of MS requires careful consideration of all clinical, paraclinical and radiological data, as well the reliable exclusion of other mimicking pathological conditions. This is advocated to promptly initiate an appropriate disease-modifying therapy, which can impact positively on the long-term outcome of the disease.
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Tusseau M, Cheli E, Marignier R, Poitevin F, Malcus C, Gossez M, Bancel J, Monneret G, Vukusic S. Clinical significance of a single cerebrospinal fluid immunoglobulin band: A retrospective study. Mult Scler 2020; 27:1451-1454. [PMID: 33295240 DOI: 10.1177/1352458520978222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND To demonstrate an inflammatory process in the central nervous system, the presence of at least two immunoglobulin (Ig) bands in the cerebrospinal fluid (CSF) is required. So far, the presence of a single abnormal Ig band is considered as negative. OBJECTIVE The objective was to assess retrospectively the significance of a single CSF Ig band in clinical practice. METHODS AND RESULTS Out of 10,286 CSF analyses, we retained 214 results with single Ig. An inflammatory neurological disorder was diagnosed in 41% of patients. CONCLUSION Despite a modest sensitivity, the presence of a single CSF Ig band may be a biomarker of an inflammatory mechanism and, as such, may prompt the clinician to repeat the analysis when the clinical context remains suggestive.
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Affiliation(s)
- Maud Tusseau
- Hospices Civils de Lyon, Laboratoire d'immunologie, Hôpital Édouard Herriot, Lyon, France
| | - Estelle Cheli
- Hospices Civils de Lyon, Laboratoire d'immunologie, Hôpital Édouard Herriot, Lyon, France
| | - Romain Marignier
- Hospices Civils de Lyon, service de neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, Centre de Ressources, Recherche et Compétence pour la Sclérose en Plaques (C2RC-SEP), Centre de Référence pour les Maladies Inflammatoires Rares du Cerveau et de la Moelle Epinière (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Lyon, France
| | - Françoise Poitevin
- Hospices Civils de Lyon, Laboratoire d'immunologie, Hôpital Édouard Herriot, Lyon, France
| | - Christophe Malcus
- Hospices Civils de Lyon, Laboratoire d'immunologie, Hôpital Édouard Herriot, Lyon, France
| | - Morgane Gossez
- Hospices Civils de Lyon, Laboratoire d'immunologie, Hôpital Édouard Herriot, Lyon, France
| | - Julien Bancel
- Hospices Civils de Lyon, Laboratoire d'immunologie, Hôpital Édouard Herriot, Lyon, France
| | - Guillaume Monneret
- Hospices Civils de Lyon, Laboratoire d'immunologie, Hôpital Édouard Herriot, Lyon, France
| | - Sandra Vukusic
- Hospices Civils de Lyon, service de neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, Centre de Ressources, Recherche et Compétence pour la Sclérose en Plaques (C2RC-SEP), Centre de Référence pour les Maladies Inflammatoires Rares du Cerveau et de la Moelle Epinière (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Lyon, France/CNRS UMR5292, Centre des Neurosciences de Lyon, Observatoire Français de la Sclérose en Plaques, INSERM 1028, Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
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Ferraro D, Bedin R, Natali P, Franciotta D, Smolik K, Santangelo M, Immovilli P, Camera V, Vitetta F, Gastaldi M, Trenti T, Meletti S, Sola P. Kappa Index Versus CSF Oligoclonal Bands in Predicting Multiple Sclerosis and Infectious/Inflammatory CNS Disorders. Diagnostics (Basel) 2020; 10:diagnostics10100856. [PMID: 33096861 PMCID: PMC7589948 DOI: 10.3390/diagnostics10100856] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/12/2020] [Accepted: 10/19/2020] [Indexed: 01/03/2023] Open
Abstract
Background: Cerebrospinal fluid (CSF) kappa free light chains (KFLC) are gaining increasing interest as markers of intrathecal immunoglobulin synthesis. The main aim of this study was to assess the diagnostic accuracy (AUC) of the kappa index (CSF/serum KFLC divided by the CSF/serum albumin ratio) compared to CSF oligoclonal IgG bands (OCB) in predicting Multiple Sclerosis (MS) or a central nervous system infectious/inflammatory disorder (CNSID). Methods: We enrolled patients who underwent a diagnostic spinal tap throughout two years. KFLC levels were determined using a Freelite assay (Binding Site) and the turbidimetric Optilite analyzer. Results: Of 540 included patients, 223 had a CNSID, and 84 had MS. The kappa index was more sensitive (0.89 versus 0.85) and less specific (0.84 versus 0.89), with the same AUC (0.87) as OCB for MS diagnosis (optimal cut-off: 6.2). Adding patients with a single CSF IgG band to the OCB-positive group slightly increased the AUC (0.88). Likewise, the kappa index (cut-off: 3.9) was more sensitive (0.67 versus 0.50) and less specific (0.81 versus 0.97), with the same AUC (0.74) as OCB, for a CNSID diagnosis. Conclusion: The kappa index and CSF OCB have comparable diagnostic accuracies for a MS or CNSID diagnosis and supply the clinician with useful, complementary information.
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Affiliation(s)
- Diana Ferraro
- Neurology Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy; (V.C.); (F.V.); (S.M.); (P.S.)
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, 41126 Modena, Italy; (R.B.); (K.S.)
- Correspondence: ; Tel.: +39-0593961678
| | - Roberta Bedin
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, 41126 Modena, Italy; (R.B.); (K.S.)
| | - Patrizia Natali
- Department of Laboratory Medicine, Azienda Ospedaliero-Universitaria and Azienda Unità Sanitaria Locale, Ospedale Civile, 41126 Modena, Italy; (P.N.); (T.T.)
| | - Diego Franciotta
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, 27100 Pavia, Italy; (D.F.); (M.G.)
| | - Krzysztof Smolik
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, 41126 Modena, Italy; (R.B.); (K.S.)
| | | | - Paolo Immovilli
- Neurology Unit, Ospedale G. da Saliceto, 29121 Piacenza, Italy;
| | - Valentina Camera
- Neurology Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy; (V.C.); (F.V.); (S.M.); (P.S.)
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, 41126 Modena, Italy; (R.B.); (K.S.)
| | - Francesca Vitetta
- Neurology Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy; (V.C.); (F.V.); (S.M.); (P.S.)
| | - Matteo Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, 27100 Pavia, Italy; (D.F.); (M.G.)
| | - Tommaso Trenti
- Department of Laboratory Medicine, Azienda Ospedaliero-Universitaria and Azienda Unità Sanitaria Locale, Ospedale Civile, 41126 Modena, Italy; (P.N.); (T.T.)
| | - Stefano Meletti
- Neurology Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy; (V.C.); (F.V.); (S.M.); (P.S.)
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, 41126 Modena, Italy; (R.B.); (K.S.)
| | - Patrizia Sola
- Neurology Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy; (V.C.); (F.V.); (S.M.); (P.S.)
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Mariotto S, Ferraro D, Soldani F, Alberti D, Bedin R, Sola P, Gastaldi M, Franciotta D, Ferrari S. Inter-center agreement in the interpretation of oligoclonal bands. Clin Chem Lab Med 2020; 59:e91-e94. [PMID: 32986610 DOI: 10.1515/cclm-2020-1037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/13/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Sara Mariotto
- Department of Neurosciences, Biomedicine and Movement Sciences, Neurology Unit, University of Verona, Verona, Italy
| | - Diana Ferraro
- Department of Biomedical, Metabolic and Neurosciences, Neurology Unit, University of Modena and Reggio Emilia, Nuovo Ospedale Civile Sant'Agostino Estense, Modena, Italy
| | - Fabio Soldani
- Department of Diagnostic and Public Health, Infectious Disease Section, University of Verona, Verona, Italy
| | - Daniela Alberti
- Department of Neurosciences, Biomedicine and Movement Sciences, Neurology Unit, University of Verona, Verona, Italy
| | - Roberta Bedin
- Department of Biomedical, Metabolic and Neurosciences, Neurology Unit, University of Modena and Reggio Emilia, Nuovo Ospedale Civile Sant'Agostino Estense, Modena, Italy
| | - Patrizia Sola
- Department of Biomedical, Metabolic and Neurosciences, Neurology Unit, University of Modena and Reggio Emilia, Nuovo Ospedale Civile Sant'Agostino Estense, Modena, Italy
| | - Matteo Gastaldi
- Laboratory of Neuroimmunology, National Neurological Institute, IRCCS, Mondino Foundation, Pavia, Italy
| | - Diego Franciotta
- Laboratory of Neuroimmunology, National Neurological Institute, IRCCS, Mondino Foundation, Pavia, Italy
| | - Sergio Ferrari
- Department of Neurosciences, Biomedicine and Movement Sciences, Neurology Unit, University of Verona, Verona, Italy
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Zeman D, Kušnierová P, Všianský F, Reguliová K, Škutová M, Woznicová I, Zapletalová O, Hradílek P. Cerebrospinal fluid oligoclonal IgM test in routine practice: Comparison with quantitative assessment of intrathecal IgM synthesis. Clin Chim Acta 2020; 508:137-145. [PMID: 32416174 DOI: 10.1016/j.cca.2020.05.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/11/2020] [Accepted: 05/11/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Intrathecal IgM synthesis demonstrated either as cerebrospinal fluid (CSF)-restricted oligoclonal (o-) IgM bands or calculated using various formulas has been linked to more aggressive multiple sclerosis (MS) course. However, the proportion of MS patients showing intrathecal IgM synthesis varies largely between studies. We aimed to explore the relation between different formulas and results of o-IgM, and to assess the frequency of o-IgM bands in an unselected series of samples. METHODS 432 samples were analyzed for o-IgM, o-IgG and quantitative measures of IgM and IgG synthesis. IgM index and formulas of Reiber, Auer and Öhman were compared to the result of the o-IgM test. RESULTS At the cut-off commonly used, the non-linear formulas for intrathecal synthesis were specific (>94%) but rather insensitive (<40% even at a cut-off of 4 CSF-restricted bands) compared to o-IgM. No significant difference was noted in the performance of different formulas. At a cut-off of 4 bands, 61% of MS patients, but none of the controls were positive for o-IgM. CONCLUSIONS Formulas for intrathecal IgM synthesis are insensitive compared to o-IgM. We propose to evaluate samples with 2 or 3 extra-CSF IgM bands as borderline and only samples with 4 or more as definitely positive.
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Affiliation(s)
- David Zeman
- Institute of Laboratory Diagnostics, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava, Czech Republic; Clinic of Neurology, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava, Czech Republic; Dept. of Biomedical Sciences, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic.
| | - Pavlína Kušnierová
- Institute of Laboratory Diagnostics, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava, Czech Republic; Dept. of Biomedical Sciences, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
| | - František Všianský
- Institute of Laboratory Diagnostics, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava, Czech Republic
| | - Katarína Reguliová
- Clinic of Neurology, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava, Czech Republic
| | - Monika Škutová
- Clinic of Neurology, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava, Czech Republic
| | - Ivana Woznicová
- Clinic of Neurology, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava, Czech Republic
| | - Olga Zapletalová
- Clinic of Neurology, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava, Czech Republic; Dept. of Neurology and Psychiatry, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
| | - Pavel Hradílek
- Clinic of Neurology, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava, Czech Republic
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Süße M, Feistner F, Holbe C, Grothe M, Nauck M, Dressel A, Hannich MJ. Diagnostic value of kappa free light chains in patients with one isolated band in isoelectric focusing. Clin Chim Acta 2020; 507:205-209. [PMID: 32353362 DOI: 10.1016/j.cca.2020.04.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/02/2020] [Accepted: 04/26/2020] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Oligoclonal band (OCB) determination in cerebrospinal fluid (CSF) is the gold standard to detect intrathecal inflammation. However, there is uncertainty about the significance of one isolated band in CSF. Free light chains kappa (FLC-k) are gaining interest as a complementary method to detect intrathecal inflammation. The aim of this study was to investigate the performance of an additive measurement of FLC-k in patients with one isolated band in CSF. MATERIALS & METHODS FLC-k were analyzed using the nephelometric Siemens FLC-k kit in paired samples of CSF and sera (n = 56) in patients with one isolated band in isoelectric focusing. According to medical diagnosis, samples were subdivided in inflammatory neurological disease, non-inflammatory neurological disease controls and symptomatic controls. Intrathecal fraction of FLC-k was plotted in a FLC-k quotient diagram. OCB interpretation was done blinded by three experienced raters. RESULTS Of 6695 OCB analyses, 91 (1.4%) had one isolated band in CSF. After exclusion of patient samples due to unclear OCB pattern after reevaluation and sample availability, 56 patient samples were included in the study. All patients with an inflammatory origin of disease (n = 13) had FLC-k values above the upper discrimination line (Qlim) in the FLC-k quotient diagram, resulting in a sensitivity of 100% with a positive predictive value of 52% and a negative predictive value of 100%. Fourteen patients (36%) with a non-inflammatory origin of disease (n = 39) had FLC-k values above Qlim. CONCLUSIONS In patients with one isolated band in CSF, a lack of intrathecal fraction of FLC-k strongly favors a non-inflammatory orgin of disease. Implementation of FLC-k measurement can help the clinician in the diagnostic process of neurological diseases.
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Affiliation(s)
- Marie Süße
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany.
| | - Fritz Feistner
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Christine Holbe
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Matthias Grothe
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Matthias Nauck
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
| | | | - Malte Johannes Hannich
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
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15
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Ferraro D, Trovati A, Bedin R, Natali P, Franciotta D, Santangelo M, Camera V, Vitetta F, Varani M, Trenti T, Gastaldi M, De Biasi S, Nasi M, Pinti M, Meletti S, Sola P. Cerebrospinal fluid kappa and lambda free light chains in oligoclonal band‐negative patients with suspected multiple sclerosis. Eur J Neurol 2019; 27:461-467. [DOI: 10.1111/ene.14121] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 11/04/2019] [Indexed: 12/20/2022]
Affiliation(s)
- D. Ferraro
- Neurology Unit Azienda Ospedaliero‐Universitaria of Modena Modena
- Department of Biomedical, Metabolic and Neurosciences University of Modena and Reggio Emilia Modena
| | - A. Trovati
- Neurology Unit Azienda Ospedaliero‐Universitaria of Modena Modena
| | - R. Bedin
- Department of Biomedical, Metabolic and Neurosciences University of Modena and Reggio Emilia Modena
| | - P. Natali
- Department of Laboratory Medicine Azienda Ospedaliero‐Universitaria and Azienda Unità Sanitaria Locale Modena
| | - D. Franciotta
- Neuroimmunology Laboratory IRCCS Mondino Foundation Pavia
| | | | - V. Camera
- Department of Biomedical, Metabolic and Neurosciences University of Modena and Reggio Emilia Modena
| | - F. Vitetta
- Neurology Unit Azienda Ospedaliero‐Universitaria of Modena Modena
| | - M. Varani
- Department of Laboratory Medicine Azienda Ospedaliero‐Universitaria and Azienda Unità Sanitaria Locale Modena
| | - T. Trenti
- Department of Laboratory Medicine Azienda Ospedaliero‐Universitaria and Azienda Unità Sanitaria Locale Modena
| | - M. Gastaldi
- Neuroimmunology Laboratory IRCCS Mondino Foundation Pavia
| | - S. De Biasi
- Department of Life Sciences University of Modena and Reggio Emilia Modena
| | - M. Nasi
- Department of Surgery, Medicine Dentistry and Morphological Sciences University of Modena and Reggio Emilia Modena Italy
| | - M. Pinti
- Department of Life Sciences University of Modena and Reggio Emilia Modena
| | - S. Meletti
- Neurology Unit Azienda Ospedaliero‐Universitaria of Modena Modena
- Department of Biomedical, Metabolic and Neurosciences University of Modena and Reggio Emilia Modena
| | - P. Sola
- Neurology Unit Azienda Ospedaliero‐Universitaria of Modena Modena
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Hegen H, Zinganell A, Auer M, Deisenhammer F. The clinical significance of single or double bands in cerebrospinal fluid isoelectric focusing. A retrospective study and systematic review. PLoS One 2019; 14:e0215410. [PMID: 30986255 PMCID: PMC6464233 DOI: 10.1371/journal.pone.0215410] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/01/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The presence of ≥3 oligoclonal bands (OCB) in the cerebrospinal fluid (CSF) without corresponding bands in serum represents a definite pathological pattern, whereas the clinical significance of 1-2 CSF bands (borderline pattern) is poorly investigated. METHODS We screened 1986 consecutive CSF and serum samples which were collected over a four-year time period and had results of isoelectric focusing (IEF) available. Of patients with borderline OCB we reviewed individual medical charts for assessment of clinical diagnoses. Where feasible, IEF was replicated and results of follow-up samples were obtained. IEF was performed using polyacrylamide gel followed by immunoblotting and IgG-specific antibody staining. Additionally, we performed a systematic literature review of the diagnostic specificity of OCB using different cut-offs for CSF-restricted bands. RESULTS Out of 253 patients with borderline OCB, 21.7% had an inflammatory neurological disease (IND) of the central nervous system, comprising 4% multiple sclerosis patients, and 14.2% had a peripheral IND, whereas the remaining 64.1% of patients showed non-inflammatory diseases. Frequency of one or two CSF bands without corresponding serum bands did not differ between the disease groups. In a subgroup of 100 patients IEF was repeated. Of those, 73% were OCB negative, while no sample was positive. In 26 patients IEF results were available of a follow-up sample collected after a median of 27 months. Of those, 4 (15.4%) turned positive. Systematic literature review revealed a diagnostic specificity of OCB of 97% and 92% using a cut-off ≥3 and ≥2 CSF bands in patients with mainly non-inflammatory neurological diseases. CONCLUSION The clinical significance of one or two CSF-restricted bands is moderate and, hence, indicates a possible but not reliable proof of intrathecal B-cell activity. Sample re-testing, introduction of an additional diagnostic category, e.g. "possible intrathecal IgG synthesis", and follow-up lumbar puncture might be possible options to address this scenario.
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Affiliation(s)
- Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Anne Zinganell
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Menéndez-Valladares P, García-Sánchez MI, Adorna Martínez M, García De Veas Silva JL, Bermudo Guitarte C, Izquierdo Ayuso G. Validation and meta-analysis of kappa index biomarker in multiple sclerosis diagnosis. Autoimmun Rev 2019; 18:43-49. [DOI: 10.1016/j.autrev.2018.07.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 07/19/2018] [Indexed: 01/23/2023]
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18
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Gastaldi M, Zardini E, Leante R, Ruggieri M, Costa G, Cocco E, De Luca G, Cataldo I, Biagioli T, Ballerini C, Castellazzi M, Fainardi E, Pettini P, Zaffaroni M, Giunti D, Capello E, Bernardi G, Ciusani E, Giannotta C, Nobile-Orazio E, Bazzigaluppi E, Passerini G, Bedin R, Sola P, Brivio R, Cavaletti G, Sala A, Bertolotto A, Desina G, Leone MA, Mariotto S, Ferrari S, Paternoster A, Giavarina D, Lolli F, Franciotta D. Cerebrospinal fluid analysis and the determination of oligoclonal bands. Neurol Sci 2018; 38:217-224. [PMID: 29030765 DOI: 10.1007/s10072-017-3034-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This document presents the guidelines for the cerebrospinal fluid (CSF) analysis and the determination of oligoclonal bands (OCBs) as pivotal tests in neuroinflammatory pathologies of the central nervous system. The guidelines have been developed following a consensus process built on questionnaire-based surveys, internet contacts, and discussions at workshops of the sponsoring Italian Association of Neuroimmunology (AINI) congresses. Essential clinical information on the pathologies in which the CSF analysis is indicated, and, particularly, on those characterized by the presence of OCBs in the intrathecal compartment, indications and limits of CSF analysis and OCB determination, instructions for result interpretation, and agreed laboratory protocols (Appendix) are reported for the communicative community of neurologists and clinical pathologists.
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Affiliation(s)
- Matteo Gastaldi
- C. Mondino National Neurological Institute, University of Pavia, Pavia, Italy
| | - Elisabetta Zardini
- C. Mondino National Neurological Institute, University of Pavia, Pavia, Italy
| | | | | | | | | | | | | | | | - Clara Ballerini
- Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
| | | | - Enrico Fainardi
- Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
| | - Paola Pettini
- Ospedale di Gallarate ASST Valle Olona, Gallarate, Italy
| | | | - Debora Giunti
- Ospedale Policlinico San Martino IRCCS, University of Genova, Genoa, Italy
| | - Elisabetta Capello
- Ospedale Policlinico San Martino IRCCS, University of Genova, Genoa, Italy
| | | | | | | | | | | | | | - Roberta Bedin
- Ospedale Civile Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Patrizia Sola
- Ospedale Civile Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | | | - Guido Cavaletti
- Expersimental Neurology Unit, University of Milano-Bicocca, Monza, Italy
| | | | | | - Gaetano Desina
- IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Maurizio A Leone
- IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Sara Mariotto
- Department of Neuroscience, Biomedicine and Movement, University of Verona, Verona, Italy
| | - Sergio Ferrari
- Department of Neuroscience, Biomedicine and Movement, University of Verona, Verona, Italy
| | | | | | - Francesco Lolli
- Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
| | - Diego Franciotta
- Laboratory of Neuroimmunology, C. Mondino National Neurological Institute, Via Mondino 2, 27100, Pavia, Italy.
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