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Qiao S, Zhang WY, Xie YF, Li HY, Cui CS, Tao SX, Xin T, Liu QJ. Diagnostic signatures and immune cell infiltration characteristics in anti-GABA BR encephalitis. J Neuroimmunol 2024; 388:578296. [PMID: 38309225 DOI: 10.1016/j.jneuroim.2024.578296] [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: 05/28/2023] [Revised: 08/16/2023] [Accepted: 01/23/2024] [Indexed: 02/05/2024]
Abstract
PURPOSE Anti-gamma-aminobutyric acid B receptor (GABABR) encephalitis is an uncommon form of autoimmune encephalitis associated with a poor prognosis and a high fatality rate. We aim to find diagnostic markers for anti- GABABR encephalitis as well as the effects of immune cell infiltration on this pathology. METHODS For quantitative proteomic analysis, isobaric tags for relative and absolute quantitation were used in conjunction with LC-MS/MS analysis. To conduct functional correlation analyses, differentially expressed proteins (DEPs) were identified. Following that, we used bioinformatics analysis to screen for and determine the diagnostic signatures of anti- GABABR encephalitis. ROC curves were used to evaluate the diagnostic values. To assess the inflammatory status of anti- GABABR encephalitis, we used cell-type identification by estimating relative subsets of the RNA transcript (CIBERSORT) and explored the link between diagnostic markers and infiltrating immune cells. RESULTS Overall, 108 robust DEPs (47 upregulated and 61 downregulated) were identified, of which 11 were immune related. The most impressively enriched pathways were complemented and coagulation cascades, actin cytoskeleton regulation, and cholesterol metabolism; GSEA revealed that the enriched pathways were considerably differentially connected to immune modulation. Eleven immune-related DEPs were chosen for further investigation. We developed a novel diagnostic model based on CSF1R and AZGP1 serum levels using ROC analysis (area under the ROC curve = 1). M1 macrophages and activated natural killer cells are likely to play a role in course of anti- GABABR encephalitis. CONCLUSION We identified CSF1R and AZGP1 are possible anti-GABABR encephalitis diagnostic indicators, and immune cell infiltration may have a significant impact on the development and occurrence of anti- GABABR encephalitis.
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Affiliation(s)
- Shan Qiao
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China; Key Laboratory for Experimental Teratology, Ministry of Education and Department of Medical Genetics, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
| | - Wen-Yu Zhang
- Department of Clinical Research, Central Hospital Affiliated to Shandong First Medical University, Jinan 250013, China
| | - Yun-Fang Xie
- Key Laboratory for Experimental Teratology, Ministry of Education and Department of Medical Genetics, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
| | - Hai-Yun Li
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Cai-San Cui
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, China
| | - Shu-Xin Tao
- Department of Neurology, Liaocheng People's Hospital, Liaocheng, Shandong, China
| | - Tao Xin
- Department of Neurosurgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China; Medical Science and Technology Innovation Center, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China.
| | - Qi-Ji Liu
- Key Laboratory for Experimental Teratology, Ministry of Education and Department of Medical Genetics, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China.
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Yang JH, Liu EN, Nguyen L, Dunn-Pirio A, Graves JS. Survival Analysis of Immunotherapy Effects on Relapse Rate in Pediatric and Adult Autoimmune Encephalitis. Neurology 2023; 101:e2300-e2313. [PMID: 37827848 PMCID: PMC10727225 DOI: 10.1212/wnl.0000000000207746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/01/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Prior observational studies for autoimmune encephalitis (AE) have mostly focused on outcomes after acute immunotherapies with better outcomes associated with earlier immunotherapy use. However, the impact of long-term immunotherapy and its association with clinical relapse is not well known. METHODS We conducted a retrospective study of consecutive patients meeting published clinical criteria for AE evaluated at UC San Diego and Rady Children's Hospital from January 2007 to November 2021. Survival analysis and Cox multivariable regression models were used to evaluate relapse risk using rituximab exposure as a time-dependent variable. Pooled and age-stratified analyses were performed. RESULTS A total of 204 pediatric and 380 adult participants were screened of which 30 pediatric and 75 adult participants were included. The most common antibody subtype in both cohorts was anti-NMDA receptor (76% in pediatric, 34% in adult). Relapses occurred in 31% of pediatric antibody-positive, 40% of adult antibody-positive, and 20% of adult antibody-negative cases. Times to first relapse (TTFR) were 10.6 ± 7.4 months (pediatric antibody-positive), 13.1 ± 24.5 months (adult antibody-positive), and 6.9 ± 3.8 months (adult antibody-negative). Rituximab was the most common second-line immunotherapy used. Combining pediatric and adult data, rituximab use was associated with a 71% lower hazard for time to first relapse (hazard ratio [HR] 0.29, 95% CI 0.09-0.85) and 51% lower hazard for recurring relapses (HR 0.49, 95% CI 0.9-1.26). The HR for TTFR with rituximab use in children was 0.30 (95% CI 0.05-1.69), 0.29 (95% CI 0.07-1.29) in adults, 0.32 in non-NMDA antibody-positive encephalitis (95% CI 0.07-1.39), and 0.42 (95% CI 0.07-2.67) for anti-NMDAR. DISCUSSION Relapses are common in pediatric and adult patients with AE, although less frequently in anti-NMDARE. Using a rigorous survival model, we demonstrate a substantial benefit of rituximab use for reducing relapse rates in AE, especially for the adult population. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that rituximab is associated with a lower hazard to relapse in patients with AE.
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Affiliation(s)
- Jennifer H Yang
- From the Department of Neurosciences (J.H.Y., L.N., A.D.-P., J.S.G.), University of California, San Diego; Rady Children's Hospital San Diego (J.H.Y., L.N., J.S.G.); and School of Medicine (E.N.L.), University of California, San Diego.
| | - Emilie N Liu
- From the Department of Neurosciences (J.H.Y., L.N., A.D.-P., J.S.G.), University of California, San Diego; Rady Children's Hospital San Diego (J.H.Y., L.N., J.S.G.); and School of Medicine (E.N.L.), University of California, San Diego
| | - Linda Nguyen
- From the Department of Neurosciences (J.H.Y., L.N., A.D.-P., J.S.G.), University of California, San Diego; Rady Children's Hospital San Diego (J.H.Y., L.N., J.S.G.); and School of Medicine (E.N.L.), University of California, San Diego
| | - Anastasie Dunn-Pirio
- From the Department of Neurosciences (J.H.Y., L.N., A.D.-P., J.S.G.), University of California, San Diego; Rady Children's Hospital San Diego (J.H.Y., L.N., J.S.G.); and School of Medicine (E.N.L.), University of California, San Diego
| | - Jennifer S Graves
- From the Department of Neurosciences (J.H.Y., L.N., A.D.-P., J.S.G.), University of California, San Diego; Rady Children's Hospital San Diego (J.H.Y., L.N., J.S.G.); and School of Medicine (E.N.L.), University of California, San Diego
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Yang F, Ma J, Zhu D, Wang Z, Li Y, He X, Zhang G, Kang X. The Role of S100A6 in Human Diseases: Molecular Mechanisms and Therapeutic Potential. Biomolecules 2023; 13:1139. [PMID: 37509175 PMCID: PMC10377078 DOI: 10.3390/biom13071139] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/11/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
S100A6, also known as calcyclin, is a low-molecular-weight Ca2+-binding protein from the S100 family that contains two EF-hands. S100A6 is expressed in a variety of mammalian cells and tissues. It is also expressed in lung, colorectal, pancreatic, and liver cancers, as well as other cancers such as melanoma. S100A6 has many molecular functions related to cell proliferation, the cell cycle, cell differentiation, and the cytoskeleton. It is not only involved in tumor invasion, proliferation, and migration, but also the pathogenesis of other non-neoplastic diseases. In this review, we focus on the molecular mechanisms and potential therapeutic targets of S100A6 in tumors, nervous system diseases, leukemia, endometriosis, cardiovascular disease, osteoarthritis, and other related diseases.
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Affiliation(s)
- Fengguang Yang
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou 730030, China; (F.Y.); (X.H.); (G.Z.)
- The Second Clinical Medical College, Lanzhou University, Lanzhou 730030, China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Jinglin Ma
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou 730030, China; (F.Y.); (X.H.); (G.Z.)
- The Second Clinical Medical College, Lanzhou University, Lanzhou 730030, China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou 730030, China
- School of Petrochemical Engineering, Lanzhou University of Technology, Lanzhou 730050, China
| | - Daxue Zhu
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou 730030, China; (F.Y.); (X.H.); (G.Z.)
- The Second Clinical Medical College, Lanzhou University, Lanzhou 730030, China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Zhaoheng Wang
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou 730030, China; (F.Y.); (X.H.); (G.Z.)
- The Second Clinical Medical College, Lanzhou University, Lanzhou 730030, China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Yanhu Li
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou 730030, China; (F.Y.); (X.H.); (G.Z.)
- The Second Clinical Medical College, Lanzhou University, Lanzhou 730030, China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Xuegang He
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou 730030, China; (F.Y.); (X.H.); (G.Z.)
- The Second Clinical Medical College, Lanzhou University, Lanzhou 730030, China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Guangzhi Zhang
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou 730030, China; (F.Y.); (X.H.); (G.Z.)
- The Second Clinical Medical College, Lanzhou University, Lanzhou 730030, China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Xuewen Kang
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou 730030, China; (F.Y.); (X.H.); (G.Z.)
- The Second Clinical Medical College, Lanzhou University, Lanzhou 730030, China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou 730030, China
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Cho JH, Kim SJ, Park KW. Anti-LGI1 Encephalitis Presented With Prominent Psychosis Without Loss of Consciousness. Dement Neurocogn Disord 2023; 22:78-80. [PMID: 37179694 PMCID: PMC10166675 DOI: 10.12779/dnd.2023.22.2.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 04/10/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023] Open
Affiliation(s)
- Ja Hyeon Cho
- Department of Neurology, Dong-A University Hospital, Busan, Korea
| | - Sun Jung Kim
- Department of Neurology, Dong-A University Hospital, Busan, Korea
| | - Kyung Won Park
- Department of Neurology, Dong-A University Hospital, Busan, Korea
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
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Kong DL. Anti-leucine-rich glioma inactivated protein 1 encephalitis with sleep disturbance as the first symptom: A case report and review of literature. World J Clin Cases 2023; 11:408-416. [PMID: 36686352 PMCID: PMC9850984 DOI: 10.12998/wjcc.v11.i2.408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 11/20/2022] [Accepted: 12/05/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Anti-leucine-rich glioma inactivated protein 1 (anti-LGI1) encephalitis is an infrequent type of autoimmune encephalitis (AE) characterized by acute or subacute cognitive and psychiatric disturbance, facio-brachial dystonic seizures (FBDSs), and hyponatremia. Anti-LGI1 AE has increasingly been considered a primary form of AE. Early identification and treatment of this disease are clearly very important.
CASE SUMMARY Here, we report that a male patient developed severe anti-LGI1 encephalitis, which was initially misdiagnosed as a sleep disturbance. He was hospitalized for epileptic seizures and typical FBDSs half a month after he developed sleep disturbances. LGI1 antibodies were detected in his cerebrospinal fluid and serum (1:100 and 1:3.2, respectively), which led to the diagnosis of classic anti-LGI1 AE. No obvious abnormality was observed on brain computed tomography images. T2-weighted fluid-attenuated inversion recovery and T2-weighted scans of brain magnetic resonance imaging (MRI) showed slightly elevated signals within the left basal ganglia area. No tumor was detected within the brain of this patient using MRI. After hormone and antiepileptic drug treatment, the patient’s symptoms improved significantly.
CONCLUSION Anti-LGI1 antibody-associated encephalitis has characteristic clinical manifestations, such as cognitive impairment, psychiatric symptoms, seizures, sleep disorders, hyponatremia, and FBDSs. LGI1 antibodies are present in the serum and/or cerebrospinal fluid, but their production is sensitive to immunosuppressants, and this disease has a relatively good prognosis. In particular, we should be aware of the possibility of anti-LGI1 antibody-associated encephalitis in adolescents with sleep disorders to avoid missed diagnoses and misdiagnoses.
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Affiliation(s)
- De-Lian Kong
- Department of Neurology, The Affiliated Jiangning Hospital with Nanjing Medical University, Nanjing 211000, Jiangsu Province, China
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Muacevic A, Adler JR, Jumaah O, Abubakar M, Landau D. Important Clues for the Diagnosis of Anti-LGI1-Antibody Autoimmune Encephalitis: A Case Report. Cureus 2023; 15:e34222. [PMID: 36852369 PMCID: PMC9960044 DOI: 10.7759/cureus.34222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2023] [Indexed: 01/27/2023] Open
Abstract
Anti-leucine-rich-glioma-inactivated 1 (LGI1) antibody autoimmune encephalitis is a rare autoimmune encephalitis. We present a 68-year-old female patient who initially presented with episodic confusion, hallucinations, behavioral changes, and unexplained hyponatremia. History was also remarkable for intermittent abnormal movement affecting the left upper extremity and face. She was initially thought to be suffering from dementia and was discharged home. However, progressive symptoms led to her second admission, where evidence of autonomic dysfunction with episodic bradycardia and persistent symptomatic orthostatic hypotension were evident. Generalized cortical hyperexcitability and subclinical seizures were seen. Diagnosis of LGI1 encephalitis was confirmed with a positive Anti-LGI1 antibody in the cerebrospinal fluid, and treatment with intravenous immunoglobulin and steroids improved her cognitive function. This case helps to highlight important features that should raise early clinical suspicion of LGI1 encephalitis, including unexplained progressive hyponatremia, autonomic dysfunction, and frequent refractory seizures. This can lead to earlier recognition of this condition, where earlier implementation of immunosuppressive therapy is linked to better clinical outcomes and brain structural preservation.
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Lai QL, Cai MT, Zheng Y, Fang GL, Du BQ, Shen CH, Wang JJ, Weng QJ, Zhang YX. Evaluation of CSF albumin quotient in neuronal surface antibody-associated autoimmune encephalitis. Fluids Barriers CNS 2022; 19:93. [DOI: 10.1186/s12987-022-00392-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 11/11/2022] [Indexed: 11/25/2022] Open
Abstract
Abstract
Background and Objectives
Disruption of brain barriers is considered to be involved in the pathogenesis of neuronal surface antibody-associated autoimmune encephalitis (NSAE), but few studies have focused on their relationship. We aimed to explore the association between the integrity of brain barriers and clinical and paraclinical characteristics in patients with NSAE.
Methods
This retrospective study consecutively recruited patients with NSAE. The cerebrospinal fluid (CSF) / serum albumin quotient (Qalb) was used to evaluate the function of brain barriers. The data on demographic information, clinical manifestations, magnetic resonance imaging (MRI), CSF findings and prognosis were collected and analyzed.
Results
Of the 93 patients included, 33 (35.5%) patients were assigned to the elevated Qalb group and 60 (64.5%) patients to the normal Qalb group. Males and prodromal symptoms were more common in elevated Qalb group (both P < 0.05). The CSF white blood cell, protein, immunoglobulin G and albumin were significantly higher in elevated Qalb group (all P < 0.05). Patients with elevated Qalb were more likely to have brain lesions on MRI (60.6% versus 33.3%, P = 0.011). The modified Rankin Scale (mRS) scores at discharge and at last follow-up were significantly higher in patients with elevated Qalb than those with normal Qalb (both P < 0.05). After univariate and multivariate analyses, Qalb elevation (adjusted odds ratio = 3.96, 95% confidence interval = 1.15–13.59, P = 0.029) was demonstrated as the only independent risk factor for a poor prognosis.
Discussion
Males, prodromal symptoms, brain lesions on MRI, CSF pleocytosis, and elevated CSF protein were more common in NSAE patients with increased Qalb. Qalb elevation was an independent prognostic indicator for a poor prognosis in NSAE.
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李 宇, 蒋 莉. Recent research on immunotherapy for anti-N-methyl-D-aspartate receptor encephalitis. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:948-953. [PMID: 36036136 PMCID: PMC9425858 DOI: 10.7499/j.issn.1008-8830.2204021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/03/2022] [Indexed: 01/24/2023]
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a central nervous system disease characterized by neurological and psychiatric symptoms. Immunotherapy is the basic treatment for this disease, including first- and second-line therapies for the acute stage and the long-course therapy for the chronic stage. Anti-NMDAR encephalitis often has a good prognosis, but some patients may still have neurological dysfunction due to poor response to current immunotherapy. In addition, the adverse reactions and economic burden of drugs are practical problems in clinical practice. To solve the above problems, continuous improvements have been made in immunotherapy regimens in terms of dose, route of administration, and course of treatment, and some new immunotherapy drugs have emerged. This article reviews the recent research on immunotherapy for anti-NMDAR encephalitis.
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Goecke SC, Griffin CM, Miller M. A Challenging Case of Treatment-Resistant Autoimmune N-methyl-D-aspartate Receptor Encephalitis Induced Delirium. Psychiatr Ann 2022. [DOI: 10.3928/00485713-20220514-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Huang X, Fan C, Gao L, Li L, Ye J, Shen H. Clinical Features, Immunotherapy, and Outcomes of Anti-Leucine-Rich Glioma-Inactivated-1 Encephalitis. J Neuropsychiatry Clin Neurosci 2022; 34:141-148. [PMID: 34794327 DOI: 10.1176/appi.neuropsych.20120303] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The investigators aimed to explore the clinical characteristics, immunotherapy, and outcomes of patients with antileucine-rich glioma-inactivated-1 (anti-LGI1) encephalitis. METHODS Data on participants' clinical characteristics, laboratory findings, radiological and electroencephalogram (EEG) features, treatment, and outcomes from January 2012 to December 2016 were collected. Statistical analysis was conducted to assess the factors associated with patient functional outcome. Forty-three patients were enrolled in the study, with a predominance of males (65.1%). The median age at onset was 57 years (interquartile range [IQR]: 44.0-65.0). The median time from onset to diagnosis was 60 days (IQR: 37.0-127.0). RESULTS The main clinical manifestations included epilepsy (100%), faciobrachial dystonic seizures (FBDS; 44.2%), cognitive dysfunction (95.3%), neuropsychiatric disturbances (76.7%), sleep disorders (58.1%), and disturbance of consciousness (48.8%). Twenty-two patients (51.2%) had hyponatremia, 31 (72.1%) had abnormal EEG results, and 30 (69.8%) had abnormal brain MRI scans, mainly involving the hippocampus (76.7%) or temporal lobe (40%). Twenty of 34 patients (58.8%) in a follow-up MRI examination exhibited hippocampal atrophy. Twenty-five patients (58.2%) were administered corticosteroids and intravenous immunoglobulin, whereas 17 patients were treated only with corticosteroids. Forty-one patients (95.3%) had favorable outcomes after a median of 21.5 months (IQR: 7-43) of follow-up. Serum sodium level was a factor associated with a disabled status (odds ratio=0.81, 95% CI=0.66, 0.98, p=0.03). Anti-LGI1 encephalitis patients were characterized by seizures, FBDS, cognitive deficits, neuropsychiatric disturbances, and hyponatremia. CONCLUSIONS Most patients with anti-LGI1 encephalitis are nonparaneoplastic, have low recurrence rates, and have favorable prognostic outcomes. Rapid evaluation, prompt immunotherapy, and long-term follow-up are essential in the care of anti-LGI1 encephalitis patients.
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Affiliation(s)
- Xiaoqin Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing
| | - Chunqiu Fan
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing
| | - Lehong Gao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing
| | - Liping Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing
| | - Jing Ye
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing
| | - Huixin Shen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing
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Höppner-Buchmann J, Seidel D, Block F, Briedigkeit L, Tietke M, Nürnberger J, Frank B. [Creutzfeldt-Jakob Disease Versus Anti-NMDA Receptor Encephalitis A Case Report]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2022; 90:163-168. [PMID: 34986490 DOI: 10.1055/a-1682-7197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Clinically differentiating between autoimmune and neurodegenerative disorders can often pose a diagnostic challenge. The differential diagnosis of rapidly progressing neurological and cognitive symptoms includes central nervous system tumours, cerebral vasculitis, and inflammatory, autoimmune, or paraneoplastic encephalopathies. Rarer neurodegenerative diseases such as Creutzfeldt-Jakob disease should also be considered. Detection of treatable causes, such as autoimmune disorders, remains important when potentially occurring in conjunction with Creutzfeldt-Jakob disease. The following report describes a rare case in which autoimmune encephalopathy and prion disease were considered as possible comorbidities.
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Affiliation(s)
| | - Desiree Seidel
- Klinik für Psychiatrie und Psychotherapie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Frank Block
- Klinik für Neurologie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Lutz Briedigkeit
- Institut für Laboratoriums- und Transfusionsmedizin, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Marc Tietke
- Institut für Radiologie, Kinder- und Neuroradiologie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Jens Nürnberger
- Klinik für Nephrologie und Dialyse, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Bernd Frank
- Akutklinik für Frührehabilitation und interdisziplinäres Rehabilitationszentrum, HELIOS Klinik Leezen GmbH, Leezen, Deutschland
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Reyes NGD, Espiritu AI, Agabao JF, Abejero JEE, Salonga-Quimpo RAM, Cabral-Lim LI, Jamora RDG, Pascual V JLR, Fernandez MLL, Gosiengfiao KTP. Autoimmune encephalitis in a tertiary hospital in the Philippines. J Clin Neurosci 2021; 90:191-198. [PMID: 34275548 DOI: 10.1016/j.jocn.2021.05.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/08/2020] [Accepted: 05/23/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Autoimmune encephalitis (AE) is an emerging disorder in adults and children. Due to its potentially reversible nature, prompt recognition and intervention are of utmost importance. OBJECTIVE To describe the clinical and paraclinical features, as well as treatment outcomes of patients with AE admitted in a Philippine tertiary hospital. METHODS Retrospective case series of patients with definite AE. RESULTS Eighteen (18) patients were included (12 adults, 6 children), majority of whom had anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis. The median age of onset was 32 (IQR: 10.8) years old and 13 (IQR: 4.8) years old in the adult and pediatric population, respectively. In both age groups, most presented with psychiatric symptoms and normal imaging findings. Cerebrospinal fluid (CSF) pleocytosis was detected in 8/12 (66.7%) adults and 2/6 (33.3%) children, while CSF protein elevation was only seen in 6/12 (50%) adults. Most patients presented with seizures, and the most frequent electroencephalography (EEG) abnormality detected was slow activity (70.5%). A high proportion of patients received high dose steroids, alone (35.3%) or in combination with intravenous immunoglobulin (IVIG, 52.9%). Overall, 66.7% had improved outcomes, mostly seen in the pediatric population. CONCLUSION This study highlighted the broad clinical phenotype, as well as the similarities and differences of AE manifestations in adults and children. It demonstrated the limited but supportive role of laboratory investigations in the diagnosis of AE. It also underscored the importance of early intervention in AE and highlighted factors influencing treatment practices and discharge outcomes in the local setting.
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Affiliation(s)
- Nikolai Gil D Reyes
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines.
| | - Adrian I Espiritu
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines; Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Manila, Philippines.
| | - Jerson F Agabao
- Division of Pediatric Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Joshua Emmanuel E Abejero
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Rhea Angela M Salonga-Quimpo
- Division of Pediatric Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Leonor I Cabral-Lim
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Roland Dominic G Jamora
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines.
| | - Jose Leonard R Pascual V
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Marc Laurence L Fernandez
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Katerina Tanya P Gosiengfiao
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
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13
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Devine MF, St Louis EK. Sleep Disturbances Associated with Neurological Autoimmunity. Neurotherapeutics 2021; 18:181-201. [PMID: 33786802 PMCID: PMC8116412 DOI: 10.1007/s13311-021-01020-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 12/29/2022] Open
Abstract
Associations between sleep disorders and neurological autoimmunity have been notably expanding recently. Potential immune-mediated etiopathogenesis has been proposed for various sleep disorders including narcolepsy, Kleine-Levin syndrome, and Morvan syndrome. Sleep manifestations are also common in various autoimmune neurological syndromes, but may be underestimated as overriding presenting (and potentially dangerous) neurological symptoms often require more urgent attention. Even so, sleep dysfunction has been described with various neural-specific antibody biomarkers, including IgLON5; leucine-rich, glioma-inactivated protein 1 (LGI1); contactin-associated protein 2 (CASPR2); N-methyl-D-aspartate (NMDA)-receptor; Ma2; dipeptidyl-peptidase-like protein-6 (DPPX); alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPA-R); anti-neuronal nuclear antibody type-1 (ANNA-1, i.e., Hu); anti-neuronal nuclear antibody type-2 (ANNA-2, i.e., Ri); gamma-aminobutyric acid (GABA)-B-receptor (GABA-B-R); metabotropic glutamate receptor 5 (mGluR5); and aquaporin-4 (AQP-4). Given potentially distinctive findings, it is possible that sleep testing could potentially provide objective biomarkers (polysomnography, quantitative muscle activity during REM sleep, cerebrospinal fluid hypocretin-1) to support an autoimmune diagnosis, monitor therapeutic response, or disease progression/relapse. However, more comprehensive characterization of sleep manifestations is needed to better understand the underlying sleep disruption with neurological autoimmunity.
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Affiliation(s)
- Michelle F Devine
- Mayo Clinic Center for Sleep Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
- Department of Medicine (Division of Pulmonary, Critical Care, and Sleep Medicine), Rochester, MN, USA.
- Department of Neurology, Mayo Clinic Health System Southwest Wisconsin-La Crosse, Mayo Clinic and Foundation, Rochester, MN, USA.
- Olmsted Medical Center, MN, Rochester, USA.
- Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - Erik K St Louis
- Mayo Clinic Center for Sleep Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
- Mayo Sleep Behavior and Neurophysiology Research Laboratory, Rochester, MN, USA
- Department of Medicine (Division of Pulmonary, Critical Care, and Sleep Medicine), Rochester, MN, USA
- Department of Neurology, Mayo Clinic Health System Southwest Wisconsin-La Crosse, Mayo Clinic and Foundation, Rochester, MN, USA
- Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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14
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Impact of predictive, preventive and precision medicine strategies in epilepsy. Nat Rev Neurol 2020; 16:674-688. [PMID: 33077944 DOI: 10.1038/s41582-020-0409-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 12/15/2022]
Abstract
Over the last decade, advances in genetics, neuroimaging and EEG have enabled the aetiology of epilepsy to be identified earlier in the disease course than ever before. At the same time, progress in the study of experimental models of epilepsy has provided a better understanding of the mechanisms underlying the condition and has enabled the identification of therapies that target specific aetiologies. We are now witnessing the impact of these advances in our daily clinical practice. Thus, now is the time for a paradigm shift in epilepsy treatment from a reactive attitude, treating patients after the onset of epilepsy and the initiation of seizures, to a proactive attitude that is more broadly integrated into a 'P4 medicine' approach. This P4 approach, which is personalized, predictive, preventive and participatory, puts patients at the centre of their own care and, ultimately, aims to prevent the onset of epilepsy. This aim will be achieved by adapting epilepsy treatments not only to a given syndrome but also to a given patient and moving from the usual anti-seizure treatments to personalized treatments designed to target specific aetiologies. In this Review, we present the current state of this ongoing revolution, emphasizing the impact on clinical practice.
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15
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Gillespie LE, Dave A, Goldstein A. A Tale of Two Brothers: Familial Voltage-Gated Potassium Channel Autoimmune Encephalitis. Cureus 2020; 12:e8723. [PMID: 32699718 PMCID: PMC7372199 DOI: 10.7759/cureus.8723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
This is the first reported case of familial voltage-gated potassium channel (VGKC) autoimmune encephalitis. The symptoms of autoimmune encephalitis can mimic infectious encephalitis with headache, fatigue, and neuropsychiatric symptoms. Autoimmunity is emerging as a distinct cause of encephalitis in the children. Prompt recognition, diagnosis, and treatment are important to prevent brain damage. Two brothers presented two years apart with different symptoms. The explanation for their distinct symptoms lies in the multifactorial development of autoimmunity. The presentation of autoimmune encephalitis can depend on the offending antibodies. The most common are antibodies against the N-methyl-D-aspartic acid (NMDA) receptor and the VGKC complex. Antibodies to the VGKC complex are divided into three different groups depending on their antigenic target: leucine-rich glioma-inactivated protein 1 (LGI1), contactin-associated protein-like 2 (CASPR2), or neither. Anti-VGKC antibodies in children are associated with neuroinflammation and encephalitis. Autoimmunity to LGI1 and CASPR2 antigens is associated with distinct human leukocyte antigen (HLA) alleles. Different HLA isotypes are involved in antigen processing and presentation and can lead to a genetic predisposition to autoimmunity. VGKC autoimmune encephalitis can present with memory changes, psychiatric symptoms, and motor abnormalities. Both brothers presented with these symptoms in their own unique way. Efficient diagnosis and immunosuppression helped improve their outcomes.
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Affiliation(s)
| | - Amanda Dave
- Pediatrics, University of Nebraska Medical Center, Omaha, USA
| | - Amy Goldstein
- Pediatrics, University of Nebraska Medical Center, Omaha, USA
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16
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Roberts C, McEachern M, Mounsey A. CSF studies which ultimately led to the possible diagnosis of anti-NMDAR encephalitis. BMJ Case Rep 2020; 13:13/5/e233489. [DOI: 10.1136/bcr-2019-233489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 17-year-old man with no significant medical history presented with new-onset seizure activity and altered mental status manifesting as bizarre behaviour, which included rapid pressured and tangential speech, psychomotor agitation, insomnia and delusions. He also had autonomic dysregulation, manifested in labile blood pressures. He had been recently discharged from his first psychiatric hospitalisation. Many studies were performed, including electroencephalogram (EEG), head CT, laboratory work, urine drug screen and lumbar puncture with cerebral spinal fluid studies, which ultimately led to the diagnosis of anti-N-methyl-D-aspartate receptor (NMDAR) autoimmune encephalitis. He was treated with five rounds of plasmapheresis with complete resolution of his altered mental status. This case highlights the importance of being familiar with the presentation of anti-NMDAR autoimmune encephalitis, especially in cases of new-onset mental status changes with psychotic like symptoms, seizure-like activity and autonomic dysregulation as early detection and treatment improves chances of good prognosis with return to baseline cognitive function.
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17
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Cordani R, Micalizzi C, Giacomini T, Gastaldi M, Franciotta D, Fioredda F, Buratti S, Morana G, Pirlo D, Renna S, Castagnola E, Risso M, Lanteri P, Vari MS, Mancardi MM. Bortezomib-Responsive Refractory Anti-N-Methyl-d-Aspartate Receptor Encephalitis. Pediatr Neurol 2020; 103:61-64. [PMID: 31759783 DOI: 10.1016/j.pediatrneurol.2019.09.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/23/2019] [Accepted: 09/09/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Anti-N-methyl-d-aspartate receptor encephalitis is a central nervous system inflammatory autoimmune disease affecting adults and children. The use of first- and second-line immunotherapies is supported. Recent reports suggest the efficacy of bortezomib in severe anti-N-methyl-d-aspartate encephalitis in adult patients not responsive to second-line treatment; there are no data about pediatric patients. PATIENT DESCRIPTION We describe an eight-year-old child with anti-N-methyl-d-aspartate encephalitis not responsive to first- and second-line treatments who experienced marked clinical improvement after bortezomib administration. DISCUSSION Bortezomib is a selective and reversible inhibitor of the 26S proteasome, which is used to treat oncologic and rare autoimmune disorders in pediatric patients. As observed in adult patients, bortezomib administration induced anti-N-methyl-d-aspartate antibody titer decline and clinical improvement with an acceptable risk profile. CONCLUSION This is the first report of the use of bortezomib in children with anti-N-methyl-d-aspartate encephalitis; it could be a useful therapeutic option in children with refractory anti-N-methyl-d-aspartate encephalitis.
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Affiliation(s)
- Ramona Cordani
- Unit of Child Neuropsichiatry, Department of Neuroscience, Ophthalmology Genetics and Maternal Infantile Sciences (DINOGMI), University of Genoa, IRCCS Giannina Gaslini, Genova, Italy
| | | | - Thea Giacomini
- Unit of Child Neuropsichiatry, Department of Neuroscience, Ophthalmology Genetics and Maternal Infantile Sciences (DINOGMI), University of Genoa, IRCCS Giannina Gaslini, Genova, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | - Diego Franciotta
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | | | - Silvia Buratti
- Neonatal and Pediatric Intensive Care Unit, IRCCS Giannina Gaslini, Genova, Italy
| | - Giovanni Morana
- Unit of Neuroradiology, IRCCS Giannina Gaslini, Genova, Italy
| | - Daniela Pirlo
- Department of Emergency, IRCCS Giannina Gaslini, Genova, Italy
| | - Salvatore Renna
- Department of Emergency, IRCCS Giannina Gaslini, Genova, Italy
| | - Elio Castagnola
- Unit of Infectious Diseases, IRCCS Giannina Gaslini, Genova, Italy
| | - Marco Risso
- Unit of Immunology and Transfusional Medicine, IRCCS Giannina Gaslini, Genova, Italy
| | - Paola Lanteri
- Unit of Neurophysiology, IRCCS Giannina Gaslini, Genova, Italy
| | - Maria Stella Vari
- Unit of Pediatric Neurology and Neurogenerative Diseases, IRCCS Giannina Gaslini, Genova, Italy
| | - Maria Margherita Mancardi
- Unit of Child Neuropsichiatry, Department of Clinical and Surgical Neurosciences and Rehabilitation, IRCCS Giannina Gaslini, Genova, Italy.
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18
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Gastaldi M, Zardini E, Scaranzin S, Uccelli A, Andreetta F, Baggi F, Franciotta D. Autoantibody Diagnostics in Neuroimmunology: Experience From the 2018 Italian Neuroimmunology Association External Quality Assessment Program. Front Neurol 2020; 10:1385. [PMID: 32010046 PMCID: PMC6971200 DOI: 10.3389/fneur.2019.01385] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 12/16/2019] [Indexed: 12/31/2022] Open
Abstract
Background: Neuroimmunology has impressively expanded in the past decade. Novel assays, especially cell-based assays (CBAs) can detect conformational antibodies (Abs) recognizing antigens in their native conformation. Generally, the availability of in-house and of commercial tests has improved the diagnostics, but introduced demanding laboratory tasks. Hence, standardization and quality controls represent a key step to promote accuracy. We report on the results of the 2018 external quality assessment program (EQAP) organized by the Italian Neuroimmunology Association. Methods: EQAP regarded 10 schemes, including oligoclonal bands (OCBs), intracellular-neuronal (ICN)-Abs, neuronal-surface (NS)-Abs, aquaporin-4 (AQP4)-Abs, myelin oligodendrocyte glycoprotein (MOG)-Abs, myelin-associated glycoprotein (MAG)-Abs, ganglioside-Abs, acetylcholine-receptor (AChR)-Abs, and muscle-specific-kinase (MuSK)-Abs, and 34 laboratories. Assays were classified as tissue-based assays (TBAs), solid-phase assays (SPAs), liquid-phase assays (LPAs), and CBAs. Thirty-three samples were provided. Results: Three-quarter of the tests were commercial. Median accuracy for the laboratories was 75% (range 50–100). In 8/10 schemes, at least one sample provided discrepant results. Inter-laboratory “substantial agreement” was found in 6/10 schemes (AChR, MuSK, MAG, AQP4, MOG, and NS-Abs), whereas the worst agreements regarded OCBs and ganglioside-Abs. Both commercial and in-house assays performed better in experienced laboratories. Conclusions: Assays could be divided in (a) robust commercial tests with substantial inter-laboratory agreement (MAG-Abs; AChR- and MuSK-Abs); commercial/“in-house” tests with (b) partial inter-laboratory agreement (AQP4-Abs, MOG-Abs, NS-Abs, ICN-Abs), and (c) with large inter-laboratory disagreement (OCBs, ganglioside-Abs). This real-life snapshot of the neuroimmunology test performances highlights shortcomings attributable to technician-dependent performances, assay structural limitations, and errors in test interpretations.
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Affiliation(s)
- Matteo Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | - Elisabetta Zardini
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Science, University of Pavia, Pavia, Italy
| | - Silvia Scaranzin
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | - Antonio Uccelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy.,Ospedale Policlinico San Martino - IRCCS, Genoa, Italy
| | - Francesca Andreetta
- UO Neurology IV, IRCCS Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Fulvio Baggi
- UO Neurology IV, IRCCS Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Diego Franciotta
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
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19
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Liu R, Zhang M, Liu L, Chen G, Hou Y, Wang M, Li J. Neuronal Surface Antibody Syndrome: A Review of the Characteristics of the Disease and Its Association with Autoantibodies. Neuroimmunomodulation 2020; 27:1-8. [PMID: 32554968 DOI: 10.1159/000507448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 03/21/2020] [Indexed: 01/17/2023] Open
Abstract
Several studies have certified that autoantibodies play an important role in the manifestation of neuromuscular diseases. Scientists have discovered specific neuronal tumor antibodies in patients with typical paraneoplastic neurological disorders. But in some clinical cases, it is not useful to cure this disease with common treatments unless the autoantibodies are addressed. In addition, recent studies have shown a close relationship between certain antibodies and neuronal surface proteins in some special cases. These antibodies, which act on the surface of neurons, mainly include voltage-gated calcium channel (VGKC) antibodies. VGKC antibodies are further divided into several types including anti-leucine-rich glioma inactivated 1 (LGI1), anti-contactin-associated protein-like 2 (Caspr2), anti-N-methyl-D-aspartate receptor (NMDAR), anti-α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR), anti-γ-aminobutyric acid receptor (GABAR), and glycine receptor. For the purpose of this review, cases of clinical studies of autoantibody-associated encephalitis were collected, the key points regarding the pathogenesis were summarized, the clinical manifestation was discussed, and all this information was organized as this review in order to introduce the relationship between autoantibodies and autoimmune encephalitis. Furthermore, it is hoped that it can effectively direct the development of diagnostic and therapeutic approach in the future.
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Affiliation(s)
- Rui Liu
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, China
| | - Mingkai Zhang
- Department of Neurology, Binzhou Medical University Hospital, Binzhou, China
| | - Lingling Liu
- Department of Neurology, Liaocheng People's Hospital, Liaocheng, China
| | - Gang Chen
- Department of Neurology, Binzhou Medical University Hospital, Binzhou, China
| | - Yiwei Hou
- Department of Neurology, Binzhou Medical University Hospital, Binzhou, China
| | - Meiling Wang
- Department of Neurology, Binzhou Medical University Hospital, Binzhou, China,
| | - Jianmin Li
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, China
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20
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Minicucci F, Ferlisi M, Brigo F, Mecarelli O, Meletti S, Aguglia U, Michelucci R, Mastrangelo M, Specchio N, Sartori S, Tinuper P. Management of status epilepticus in adults. Position paper of the Italian League against Epilepsy. Epilepsy Behav 2020; 102:106675. [PMID: 31766004 DOI: 10.1016/j.yebeh.2019.106675] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/30/2019] [Accepted: 10/30/2019] [Indexed: 01/15/2023]
Abstract
Since the publication of the Italian League Against Epilepsy guidelines for the treatment of status epilepticus in 2006, advances in the field have ushered in improvements in the therapeutic arsenal. The present position paper provides neurologists, epileptologists, neurointensive care specialists, and emergency physicians with updated recommendations for the treatment of adult patients with status epilepticus. The aim is to standardize treatment recommendations in the care of this patient population.
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Affiliation(s)
- Fabio Minicucci
- Epilepsy Center, Unit of Neurophysiology, Neurological Department, IRCCS San Raffaele Hospital, Milan, Italy.
| | - Monica Ferlisi
- Division of Neurology A, Azienda Ospedaliera Universitaria Integrata, Verona, Italy.
| | - Francesco Brigo
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, Italy; Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy
| | - Oriano Mecarelli
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy.
| | - Stefano Meletti
- Department of Biomedical, Metabolic and Neural Sciences, Center for Neurosciences and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, OCB Hospital, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy.
| | - Umberto Aguglia
- Epilepsy Center, Department of Medical and Surgical Sciences Regional, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Roberto Michelucci
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Unit of Neurology, Bellaria Hospital, Bologna, Italy.
| | - Massimo Mastrangelo
- Pediatric Neurology Unit, "V. Buzzi" Children's Hospital, Pediatrics Department, ASST Fatebenefratelli Sacco, Milan, Italy.
| | - Nicola Specchio
- Department of Neuroscience, IRCCS Bambino Gesù Children's Hospital, Rome, Italy.
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy.
| | - Paolo Tinuper
- IRCCS Istituto delle Scienze Neurologiche, Bellaria Hospital, Bologna, Italy; Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy.
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21
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Ernst L, David B, Gaubatz J, Domínguez-Narciso I, Lüchters G, Becker AJ, Weber B, Hattingen E, Elger CE, Rüber T. Volumetry of Mesiotemporal Structures Reflects Serostatus in Patients with Limbic Encephalitis. AJNR Am J Neuroradiol 2019; 40:2081-2089. [PMID: 31727746 DOI: 10.3174/ajnr.a6289] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 09/11/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND PURPOSE Limbic encephalitis is an autoimmune disease. A variety of autoantibodies have been associated with different subtypes of limbic encephalitis, whereas its MR imaging signature is uniformly characterized by mesiotemporal abnormalities across subtypes. Here, we hypothesized that patients with limbic encephalitis would show subtype-specific mesiotemporal structural correlates, which could be classified by supervised machine learning on an individual level. MATERIALS AND METHODS T1WI MPRAGE scans from 46 patients with antibodies against glutamic acid decarboxylase and 34 patients with antibodies against the voltage-gated potassium channel complex (including 10 patients with leucine-rich glioma-inactivated 1 autoantibodies) and 48 healthy controls were retrospectively ascertained. Parcellation of the amygdala, hippocampus, and hippocampal subfields was performed using FreeSurfer. Volumes were extracted and compared between groups using unpaired, 2-tailed t tests. The volumes of hippocampal subfields were analyzed using a multivariate linear model and a binary decision tree classifier. RESULTS Temporomesial volume alterations were most pronounced in an early stage and in the affected hemispheric side of patients. Statistical analysis revealed antibody-specific hippocampal fingerprints with a higher volume of CA1 in patients with glutamic acid decarboxylase-associated limbic encephalitis (P = .02), compared with controls, whereas CA1 did not differ from that in controls in patients with voltage-gated potassium channel complex autoantibodies. The classifier could successfully distinguish between patients with autoantibodies against leucine-rich glioma-inactivated 1 and glutamic acid decarboxylase with a specificity of 87% and a sensitivity of 80%. CONCLUSIONS Our results suggest stage-, side- and antibody-specific structural correlates of limbic encephalitis; thus, they create a perspective toward an MR imaging-based diagnosis.
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Affiliation(s)
- L Ernst
- From the Department of Epileptology (L.E., B.D., J.G., I.D.-N., C.E.E., T.R.)
| | - B David
- From the Department of Epileptology (L.E., B.D., J.G., I.D.-N., C.E.E., T.R.)
| | - J Gaubatz
- From the Department of Epileptology (L.E., B.D., J.G., I.D.-N., C.E.E., T.R.)
| | - I Domínguez-Narciso
- From the Department of Epileptology (L.E., B.D., J.G., I.D.-N., C.E.E., T.R.)
| | - G Lüchters
- Center for Development Research (G.L.), University of Bonn, Bonn, Germany
| | | | - B Weber
- Institute for Experimental Epileptology and Cognition Research (B.W.)
| | - E Hattingen
- Department of Radiology (E.H.), University of Bonn Medical Center, Bonn, Germany
- Department of Neuroradiology (E.H.), Goethe University Frankfurt, Frankfurt, Germany
| | - C E Elger
- From the Department of Epileptology (L.E., B.D., J.G., I.D.-N., C.E.E., T.R.)
| | - T Rüber
- From the Department of Epileptology (L.E., B.D., J.G., I.D.-N., C.E.E., T.R.)
- Epilepsy Center Frankfurt Rhine-Main (T.R.)
- Department of Neurology, and Center for Personalized Translational Epilepsy Research (T.R.), Goethe-University Frankfurt, Frankfurt am Main, Germany
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22
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Longo R, Wagner M, Savenkoff B, de Castaing MC, Desiro G, Tubail Z, Hennequin L, Mahmoud SB, Marcon N, Quetin P, Campitiello M, Plastino F. A paraneoplastic limbic encephalitis from an anorectal small cell neuroendocrine carcinoma: a case report. BMC Neurol 2019; 19:304. [PMID: 31783737 PMCID: PMC6884799 DOI: 10.1186/s12883-019-1542-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 11/25/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Paraneoplastic limbic encephalitis (PLE) is a rare autoimmune neurological syndrome observed in cancer patients. PLE is difficult to diagnose and presents a variable response to treatment, depending on the characteristics of the tumor and neuronal autoantibodies. CASE PRESENTATION A 64-year-old, Caucasian, non-smoker man presented with a rapidly developing cognitive impairment, personality change, spatial disorientation, and short-term memory loss associated with anorexia and cervical and inguinal lymph nodes. The 18F-FDG PET scan documented intensely hypermetabolic lymph nodes, which histologically corresponded to a metastasis from a small cell neuroendocrine carcinoma. The brain MRI revealed a high T2-weighted FLAIR signal of the hippocamps, consisted with a PLE. The presence of anti-neuronal Hu antibodies confirmed the diagnosis. The patient underwent plasmapheresis, associated to a systemic chemotherapy resulting in a partial and temporary improvement of the neurological symptoms. Four cycles of intravenous immunoglobulins were also necessary. After six cures of chemotherapy, the lymph node metastases regressed. However, a new anorectal lesion was detected and was histologically confirmed as a primary small cell neuroendocrine carcinoma, which was treated with concomitant chemoradiotherapy. At the end of this treatment, the patient showed a rapid tumor progression leading to his death. CONCLUSIONS This case highlights the rare entity, PLE, which is difficult to diagnose and manage. In addition, this is the first published case of PLE associated with an anorectal small cell neuroendocrine carcinoma, which appeared after completion of systemic chemotherapy.
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Affiliation(s)
- Raffaele Longo
- Division of Medical Oncology, "CHR Metz-Thionville", 1 Allée du Château, 57085, Ars-Laquenexy, France.
| | - Marc Wagner
- Division of Neurology, "CHR Metz-Thionville", 1 Allée du Château, 57085, Ars-Laquenexy, France
| | - Benjamin Savenkoff
- Division of Nephrology, "CHR Metz-Thionville", 1 Allée du Château, 57085, Ars-Laquenexy, France
| | | | - Guillaume Desiro
- Division of Medical Oncology, "CHR Metz-Thionville", 1 Allée du Château, 57085, Ars-Laquenexy, France
| | - Zead Tubail
- Division of Nephrology, "CHR Metz-Thionville", 1 Allée du Château, 57085, Ars-Laquenexy, France
| | - Laurent Hennequin
- Division of Radiology, "CHR Metz-Thionville", 1 Allée du Château, 57085, Ars-Laquenexy, France
| | - Sinan Ben Mahmoud
- Division of Nuclear Medecine, "CHR Metz-Thionville", 1 Allée du Château, 57085, Ars-Laquenexy, France
| | - Nathalie Marcon
- Division of Pathology, "CHR Metz-Thionville", 1 Allée du Château, 57085, Ars-Laquenexy, France
| | - Philippe Quetin
- Division of Radiotherapy, "CHR Metz-Thionville", 1 Allée du Château, 57085, Ars-Laquenexy, France
| | - Marco Campitiello
- Division of Medical Oncology, "CHR Metz-Thionville", 1 Allée du Château, 57085, Ars-Laquenexy, France
| | - Francesca Plastino
- Division of Medical Oncology, "CHR Metz-Thionville", 1 Allée du Château, 57085, Ars-Laquenexy, France
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23
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Tsai MH, Lin CH, Tsai KW, Lin MH, Ho CJ, Lu YT, Weng KP, Lin Y, Lin PH, Li SC. S100A6 Promotes B Lymphocyte Penetration Through the Blood-Brain Barrier in Autoimmune Encephalitis. Front Genet 2019; 10:1188. [PMID: 31850060 PMCID: PMC6901080 DOI: 10.3389/fgene.2019.01188] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 10/28/2019] [Indexed: 12/12/2022] Open
Abstract
Autoimmune encephalitis (AE) is a severe neurological disease. The brain of the AE patient is attacked by a dysregulated immune system, which is caused by the excessive production of autoantibodies against neuronal receptors and synaptic proteins. AE is also characterized by the uncontrolled B lymphocyte infiltration through the blood–brain barrier (BBB) layer, and the investigation of the underlying mechanism involved in this infiltration may facilitate the discovery of novel therapies for AE. However, few AE-related studies have focused on this issue. In this study, we aimed to identify the factors involved in B lymphocyte infiltration in AE. For this purpose, we first enrolled four healthy control and five AE subjects, collecting their serum and/or total white blood cell samples. The white blood cell samples were further used for collecting RNA and DNA. Then, we simulated the in vivo B lymphocyte infiltration with an in vitro leukocyte transendothelial migration model. It turned out that AE serum treatment significantly and specifically promoted B cells to penetrate the BBB endothelial layer without affecting neutrophils. Next, through genome-wide DNA methylation assays on bisulfite-conversion DNA samples, we identified S100A6 and S100A11 as potential hypo-methylated disease genes in the AE samples. Further qPCR assays demonstrated their upregulation in AE samples, reflecting the negative correlations between gene expression and DNA methylation. Finally, recombinant S100A6 protein treatment significantly increased B lymphocyte infiltration through the BBB endothelial layer, which partially recapitulated the effect of AE serum. In summary, by using an in vitro leukocyte transendothelial migration model, we confirmed that S100A6 promoted B lymphocyte to penetrate the BBB endothelial layer, which is similar to the in vivo clinical manifestations of AE. Therefore, further studies on how the S100A6 protein facilitates B lymphocyte infiltration and on whether other factors in serum also contribute to this phenomenon are likely to improve our understanding of AE and hopefully to reveal novel therapeutic targets for this emerging treatable neurological disorder.
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Affiliation(s)
- Meng-Han Tsai
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Hsiang Lin
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kuo-Wang Tsai
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ming-Hong Lin
- Department of Microbiology and Immunology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Research Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chen-Jui Ho
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yan-Ting Lu
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ken-Pen Weng
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Department of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Nursing, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan
| | - Yuyu Lin
- Genomics and Proteomics Core Laboratory, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Pei-Hsien Lin
- Genomics and Proteomics Core Laboratory, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Sung-Chou Li
- Genomics and Proteomics Core Laboratory, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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24
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Sveinsson O, Piehl F, Aspegren O, Hietala MA. Successful combined treatment with thymectomy, rituximab and tocilizumab for severe thymoma-associated multi autoimmune syndrome. J Neuroimmunol 2019; 336:577028. [PMID: 31472400 DOI: 10.1016/j.jneuroim.2019.577028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 08/21/2019] [Accepted: 08/22/2019] [Indexed: 12/25/2022]
Abstract
We present a 53-year-old woman who presented simultaneously with acute inflammatory demyelinating polyneuropathy, Graves' disease, leukocytoclastic vasculitis, elevated acetylcholine antibody receptor antibodies and a mediastinal mass. Thymectomy was performed and revealed a type A thymoma and the clinical picture and paraclinical findings were consistent with a thymoma-associated multi-autoimmune syndrome (TAMA). Beside prednisolone and plasmapheresis, the patient was treated with tocilizumab and rituximab. After surgical and immunomodulatory treatment with tocilizumab and rituximab the patient's condition slowly started to improve. TAMA is associated with a spectrum of autoantibodies and immune-mediated damage to multiple organs. Even if thymectomy is crucial for long term prognosis, aggressive immunomodulation should be considered early in the disease course, especially in cases showing involvement of the peripheral and/or central nervous system.
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Affiliation(s)
- Olafur Sveinsson
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical 7 Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Fredrik Piehl
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical 7 Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Oskar Aspegren
- Department of Pathology, Karolinska University Hospital, Stockholm, Sweden; Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Max Albert Hietala
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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25
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Ayzenberg I, Faissner S, Tomaske L, Richter D, Behrendt V, Gold R. General principles and escalation options of immunotherapy in autoantibody-associated disorders of the CNS. Neurol Res Pract 2019; 1:32. [PMID: 33324898 PMCID: PMC7650108 DOI: 10.1186/s42466-019-0037-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/05/2019] [Indexed: 12/18/2022] Open
Abstract
Autoimmune diseases associated with antineuronal and antiglial autoantibodies (Abs) is one of the most rapidly expanding research fields in clinical neuroimmunology, with more than 30 autoantibodies described so far. Being associated with a wide range of clinical presentations these syndromes can be diagnostically challenging. Surface or intracellular antigen localizations are crucial for the treatment response and outcome. In the latter Abs are mostly of paraneoplastic cause and tumor management should be performed as soon as possible in order to stop peripheral antigen stimulation. Immunotherapy should be started early in both groups, before irreversible neuronal loss occurs. Despite serious prognosis, aggressive therapeutic approaches can be effective in many cases. In this article we review main pathogenic mechanisms leading to Abs-related syndromes and describe standard as well as emerging strategies of immunotherapy, including tocilizumab and bortezomib. Several special therapeutic approaches will be illustrated by clinical cases recently treated in our department.
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Affiliation(s)
- Ilya Ayzenberg
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany.,Department of Neurology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Simon Faissner
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Laura Tomaske
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Daniel Richter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Volker Behrendt
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
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26
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Gibbs E, Silverman JM, Zhao B, Peng X, Wang J, Wellington CL, Mackenzie IR, Plotkin SS, Kaplan JM, Cashman NR. A Rationally Designed Humanized Antibody Selective for Amyloid Beta Oligomers in Alzheimer's Disease. Sci Rep 2019; 9:9870. [PMID: 31285517 PMCID: PMC6614461 DOI: 10.1038/s41598-019-46306-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 06/25/2019] [Indexed: 11/29/2022] Open
Abstract
Advances in the understanding of Alzheimer’s disease (AD) suggest that pathogenesis is not directly related to plaque burden, but rather to soluble toxic amyloid-beta oligomers (AßO). Therapeutic antibodies targeting Aß monomers and/or plaque have shown limited efficacy and dose-limiting adverse events in clinical trials. These findings suggest that antibodies capable of selectively neutralizing toxic AßO may achieve improved efficacy and safety. To this end, we generated monoclonal antibodies against a conformational Aß epitope predicted by computational modeling to be presented on toxic AßO but not monomers or fibrils. The resulting lead antibody, PMN310, showed the desired AßO-selective binding profile. In vitro, PMN310 inhibited AßO propagation and toxicity. In vivo, PMN310 prevented AßO-induced loss of memory formation and reduced synaptic loss and inflammation. A humanized version (huPMN310) compared favorably to other Aß-directed antibodies showing a lack of adverse event-associated binding to Aß deposits in AD brains, and greater selective binding to AßO-enriched AD brain fractions that contain synaptotoxic Aß species. Systemic administration of huPMN310 in mice resulted in brain exposure and kinetics comparable to those of other therapeutic human monoclonal antibodies. Greater selectivity for AßO and the potential to safely administer high doses of huPMN310 are expected to result in enhanced safety and therapeutic potency.
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Affiliation(s)
- Ebrima Gibbs
- University of British Columbia, Djavad Mowafaghian Centre for Brain Health, Vancouver, BC, V6T 2B5, Canada
| | - Judith M Silverman
- University of British Columbia, Djavad Mowafaghian Centre for Brain Health, Vancouver, BC, V6T 2B5, Canada
| | - Beibei Zhao
- University of British Columbia, Djavad Mowafaghian Centre for Brain Health, Vancouver, BC, V6T 2B5, Canada
| | - Xubiao Peng
- University of British Columbia, Department of Physics and Astronomy, Vancouver, BC, V6T 1Z1, Canada
| | - Jing Wang
- University of British Columbia, Djavad Mowafaghian Centre for Brain Health, Vancouver, BC, V6T 2B5, Canada
| | - Cheryl L Wellington
- University of British Columbia, Djavad Mowafaghian Centre for Brain Health, Vancouver, BC, V6T 2B5, Canada
| | - Ian R Mackenzie
- University of British Columbia, Djavad Mowafaghian Centre for Brain Health, Vancouver, BC, V6T 2B5, Canada
| | - Steven S Plotkin
- University of British Columbia, Department of Physics and Astronomy and Genome Sciences and Technology Program, Vancouver, BC, V6T 1Z1, Canada.,ProMIS Neurosciences, Cambridge, MA, 02142, USA
| | | | - Neil R Cashman
- University of British Columbia, Djavad Mowafaghian Centre for Brain Health, Vancouver, BC, V6T 2B5, Canada. .,ProMIS Neurosciences, Cambridge, MA, 02142, USA.
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27
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Management of antibody-mediated autoimmune encephalitis in adults and children: literature review and consensus-based practical recommendations. Neurol Sci 2019; 40:2017-2030. [PMID: 31161339 DOI: 10.1007/s10072-019-03930-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 05/09/2019] [Indexed: 12/24/2022]
Abstract
Autoimmune encephalitis associated with antibodies against neuronal surface targets (NSAE) are rare but still underrecognized conditions that affect adult and pediatric patients. Clinical guidelines have recently been published with the aim of providing diagnostic clues regardless of antibody status. These syndromes are potentially treatable but the choice of treatment and its timing, as well as differential diagnoses, long-term management, and clinical and paraclinical follow-up, remain major challenges. In the absence of evidence-based guidelines, management of these conditions is commonly based on single-center expertise.Taking into account different published expert recommendations in addition to the multicenter experience of the Italian Working Group on Autoimmune Encephalitis, both widely accepted and critical aspects of diagnosis, management and particularly of immunotherapy for NSAE have been reviewed and are discussed.Finally, we provide consensus-based practical advice for managing hospitalization and follow-up of patients with NSAE.
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28
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Chin G, Allsup S, Fratalia L. Autoimmune encephalitis presenting with cognitive decline and hyponatraemia. Br J Hosp Med (Lond) 2019; 80:350-351. [PMID: 31180781 DOI: 10.12968/hmed.2019.80.6.350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Gillian Chin
- Foundation Year 2 Doctor, Department for Older People, Whiston Hospital, Prescot L35 5DR
| | - Stephen Allsup
- Consultant in Geriatrics and General Medicine, Department for Older People, Whiston Hospital, Prescot
| | - Lauren Fratalia
- Consultant Neurologist, Department of Neurology, The Walton Centre, Liverpool
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29
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Deng B, Yu H, Liu X, Yu X, Zhang X, Li X, Yang W, Dong S, Qiu Y, Chen X. Reduced dosage rituximab in the treatment of anti-N-methyl-d-aspartate receptor encephalitis: An observation study in Chinese patients. J Neuroimmunol 2019; 330:81-86. [PMID: 30851542 DOI: 10.1016/j.jneuroim.2019.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/17/2019] [Accepted: 02/17/2019] [Indexed: 11/18/2022]
Abstract
The aim of this study was to observe the treatment effect and investigate the possible mechanism of reduced dosage (600 mg) rituximab treatment on anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis. The median modified Rankin Scale of ten enrolled patients decreased from 4 (range 2-4) before rituximab infusion to 0 (range 0-2) after a mean follow-up time of 24.3 ± 8.7 months. One patient relapsed 9 months after treatment. No severe adverse event was observed. The proportion of total B cells in lymphocytes was depleted from 13.4 ± 6.7% to 0.6 ± 0.8% one day after treatment. B cells started to regeneration at 3 months and reached 9.4 ± 3.7% at 12 months after treatment. At this time point, proportion of regulatory B cells (Breg) in reconstituted B cells was significantly higher than that before treatment (15.3 ± 12.1% vs. 0.5 ± 0.6%, p = 0.006), while proportion of memory B cells (Bmem) was significantly lower than baseline level (8.0 ± 4.5% vs. 30.2 ± 12.6%, p < 0.001). Our results supported that reduced dosage rituximab was effective and safe in treating anti-NMDAR encephalitis. B cell depletion and rebalance of Breg and Bmem might be involved in the treatment mechanism of this therapy.
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Affiliation(s)
- Bo Deng
- Department of Neurology, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China
| | - Hai Yu
- Department of Neurology, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China
| | - Xiaoni Liu
- Institute of Neurology, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China
| | - Xue Yu
- Department of Neurology, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China
| | - Xiang Zhang
- Department of Neurology, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China; Institute of Neurology, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China
| | - Xiang Li
- Department of Neurology, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China
| | - Wenbo Yang
- Department of Neurology, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China
| | - Siqi Dong
- Department of Neurology, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China
| | - Yue Qiu
- Department of Neurology, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China
| | - Xiangjun Chen
- Department of Neurology, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China; Institute of Neurology, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China.
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30
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Risk of Neurological Toxicities Following the Use of Different Immune Checkpoint Inhibitor Regimens in Solid Tumors. Neurologist 2019; 24:75-83. [DOI: 10.1097/nrl.0000000000000230] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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31
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Jiang Y, Tian X, Gu Y, Li F, Wang X. Application of Plasma Exchange in Steroid-Responsive Encephalopathy. Front Immunol 2019; 10:324. [PMID: 30873174 PMCID: PMC6400967 DOI: 10.3389/fimmu.2019.00324] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/07/2019] [Indexed: 12/18/2022] Open
Abstract
Plasma exchange has been widely used in autoimmune neurological diseases and is the standard treatment for myasthenia gravis crisis and Guillain-Barre syndrome. A growing body of research suggests that, in the clinical application of steroid-responsive encephalopathy, such as for Hashimoto's encephalopathy, limbic encephalitis, systemic lupus erythematosus encephalopathy, ANCA-associated vasculitis encephalopathy, and acute disseminated encephalomyelitis, plasma exchange is a safe, and effective option when steroids or other immunosuppressive therapies are ineffective in the short term or when contraindications are present. Additionally, plasma exchange can also be used alone or in combination with steroids, immunoglobulins, or other immunosuppressive agents to treat steroid-responsive encephalopathy. This paper reviews the clinical application of plasma exchange in steroid-responsive encephalopathy, including its indications, onset time, course, curative effects, and side effects.
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Affiliation(s)
- Yuting Jiang
- Chongqing Key Laboratory of Neurology, Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xin Tian
- Chongqing Key Laboratory of Neurology, Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yixue Gu
- Chongqing Key Laboratory of Neurology, Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Feng Li
- Chongqing Key Laboratory of Neurology, Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xuefeng Wang
- Chongqing Key Laboratory of Neurology, Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
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32
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Sveinsson O, Al Nimer F, Piehl F. Morvan's syndrome treated successfully with rituximab and lacosamide. BMJ Case Rep 2019; 12:12/2/e226832. [PMID: 30765442 DOI: 10.1136/bcr-2018-226832] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
We describe a woman with both central and peripheral nervous system symptoms consistent with Morvan's syndrome who was successfully treated with immunosuppression including rituximab and the new antiepileptic drug lacosamide against peripheral nerve hyperexcitability. Despite being over 8 months in hospital and 4 months in an intensive care unit she recovered fully. It is also the first case where cerebrospinal fluid neurofilament-light (NfL) levels were followed during the disease course. The clinical course resembled that of anti-NMDA receptor encephalitis, where patients often recover surprisingly well despite severe symptoms and an extensive time in intensive care. A possible explanation is the comparatively low levels of NfL, indicating disease processes that are not characterised by extensive neuroaxonal degeneration.
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Affiliation(s)
- Olafur Sveinsson
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Faiez Al Nimer
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Center for Neurology, Academic Specialist Center, Stockholm Health Services, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Center for Neurology, Academic Specialist Center, Stockholm Health Services, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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33
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Mycophenolate mofetil, azathioprine and methotrexate usage in paediatric anti-NMDAR encephalitis: A systematic literature review. Eur J Paediatr Neurol 2019; 23:7-18. [PMID: 30318435 DOI: 10.1016/j.ejpn.2018.09.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/12/2018] [Accepted: 09/23/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Available data on mycophenolate mofetil (MMF), azathioprine (AZA) and methotrexate (MTX) for paediatric-onset anti-N-methyl-d-aspartate receptor encephalitis (anti-NMDARE) is limited. METHODS Systematic literature review on patients treated with MMF/AZA/MTX for paediatric-onset anti-NMDARE, with focus on modes of use, efficacy and safety. RESULTS 87 patients were included (age at onset median 11 years, range 0.8-18 years; 69% females). 46% had a relapsing course. 52% received MMF, 27% AZA, 15% MTX, and 6% a combination of MMF/AZA/MTX (7 patients received intrathecal MTX). Before MMF/AZA/MTX, 100% patients received steroids, 83% intravenous immunoglobulin and 45% plasma exchange, and 50% received second-line treatments (rituximab/cyclophosphamide). MMF/AZA/MTX were administered >6 months from onset in 51%, and only after relapse in 40%. Worst mRS before MMF/AZA/MTX was median 4.5 (range 3-5). At last follow-up (median 2 years, range 0.2-8.6), median mRS was 1 (range 0-6). Median annualised relapse rate was 0.4 (range 0-6.7) pre-MMF/AZA/MTX (excluding first events), and 0 on MMF/AZA/MTX (mean 0.03, range 0-0.8). 7% patients relapsed on MMF/AZA/MTX. These relapsing patients had low rate of second-line treatments before MMF/AZA/MTX (25%), long median time between onset and MMF/AZA/MTX usage (18 months), and frequently they were started on MMF/AZA/MTX only after relapse (75%). Relapse rate was lower among patients who received first immune therapy ≤30 days (25%) than later (64%), who received second-line treatments at first event (14%) rather than not (64%), who were started on MMF/AZA/MTX after the first (12%) rather than subsequent events (17%), and who were started on MMF/AZA/MTX ≤3 months from onset (33%) rather than later (53%). Adverse reactions to MMF/AZA/MTX occurred in 2 cases (cytomegalovirus colitis and respiratory infection), of grade 3 Common Terminology Criteria for Adverse Events v4.0. DISCUSSION Our literature review disclosed heterogeneity in the use of MMF/AZA/MTX in paediatric-onset anti-NMDARE. MMF/AZA/MTX usage is mostly restricted to retrospective cohort descriptions. These agents may reduce risk of relapse, and have a reasonable safety profile, however data on larger cohorts are required to definitively determine effect.
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34
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Giannoccaro MP, Crisp SJ, Vincent A. Antibody-mediated central nervous system diseases. Brain Neurosci Adv 2018; 2:2398212818817497. [PMID: 32166168 PMCID: PMC7058213 DOI: 10.1177/2398212818817497] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Indexed: 01/02/2023] Open
Abstract
Antibody-mediated central nervous system diseases are a relatively new area of clinical neuroscience with growing impact. Their recognition has challenged the dogma of the blood–brain barrier preventing antibody access into the central nervous system. The antibodies discovered so far are mainly against neurotransmitter receptors (e.g. N-methyl-d-aspartate and glycine receptors) and ion channel–associated proteins (leucine-rich glioma inactivated protein 1 and contactin-associated protein 2) and are expressed on the surface of neuronal synapses and elsewhere. The disorders are reversible with immunotherapies that reduce antibody levels. Although rare, the identification of these disorders in clinical practice has made central nervous system autoimmune diseases a consideration in the differential diagnoses of many clinical presentations. There is still much to learn about the aetiology of the diseases and the mechanisms by which the antibodies act, the neuronal and glial changes that follow antibody-attack, and the compensatory changes that may be required to ensure good recovery.
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Affiliation(s)
- Maria Pia Giannoccaro
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Sarah J Crisp
- Kullmann Lab, Institute of Neurology, University College London, London, UK.,Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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35
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Shahmohammadi S, Doosti R, Shahmohammadi A, Mohammadianinejad SE, Sahraian MA, Azimi AR, Harirchian MH, Asgari N, Naser Moghadasi A. Autoimmune diseases associated with Neuromyelitis Optica Spectrum Disorders: A literature review. Mult Scler Relat Disord 2018; 27:350-363. [PMID: 30476871 DOI: 10.1016/j.msard.2018.11.008] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 11/06/2018] [Accepted: 11/10/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Neuromyelitis Optica (NMO) is an autoimmune inflammatory demyelinating disease of the central nervous system (CNS) which predominantly involves optic nerves and spinal cord. Since the introduction of Neuromyelitis Optica Spectrum Disorders (NMOSD) as a separate entity, there have been many reports on its association with other disorders including systemic and organ-specific autoimmune diseases. Here, we reviewed other immune-mediated diseases associated with NMOSD and tried to categorize them. METHODS The present review was conducted using the PUBMED database based on papers from 1976 (i.e., since the first NMO comorbidity with SLE was reported) to 2017. We included all articles published in English. The keywords utilized included Neuromyelitis optica, Neuromyelitis Optica Spectrum Disorders, Devic's disease, in combination with comorbidity or comorbidities. RESULTS Diseases with immune-based pathogenesis are the most frequently reported co-morbidities associated with NMOSD, most of which are antibody-mediated diseases. According to literature, Sjogren's Syndrome (SS) and Systemic Lupus Erythematosus (SLE) are the most frequently reported diseases associated with NMOSD among systemic autoimmune diseases. Further, myasthenia gravis in neurological and autoimmune thyroid diseases in non-neurological organ-specific autoimmune diseases are the most reported comorbidities associated with NMOSD in the literature. CONCLUSIONS NMOSD may be associated with a variety of different types of autoimmune diseases. Therefore, systemic or laboratory signs which are not typical for NMOSD should be properly investigated to exclude other associated comorbidities. These comorbidities may affect the treatment strategy and may improve the patients' care and management.
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Affiliation(s)
- Sareh Shahmohammadi
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Rozita Doosti
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Abootorab Shahmohammadi
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mohammad Ali Sahraian
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Reza Azimi
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Hossein Harirchian
- Iranian center for neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasrin Asgari
- Owens-gruppen Næstved/Slagelse/Ringsted Sygehuse, Region Sjælland J.B. Winsløws Vej 9, indgang B, 1. Sal 5000, Odense C, Denmark
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Morano A, Iannone L, Palleria C, Fanella M, Giallonardo AT, De Sarro G, Russo E, Di Bonaventura C. Pharmacology of new and developing intravenous therapies for the management of seizures and epilepsy. Expert Opin Pharmacother 2018; 20:25-39. [PMID: 30403892 DOI: 10.1080/14656566.2018.1541349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Antiepileptic drugs (AEDs) are administered orally for chronic use. Parenteral formulations might be necessary when the oral route is not feasible (e.g. an impairment of consciousness, trauma, dysphagia, gastrointestinal illness) or for treatment of seizure emergencies. At present, few intravenous (IV) formulations are available on the market. AREAS COVERED The purpose of this review is to summarize the pharmacological characteristics and clinical applications of IV medications that have been recently introduced to the armamentarium of epilepsy therapy or are currently being developed. Apart from AEDs, other compounds belonging to different pharmacological classes (e.g. diuretics, anesthetics), which have shown potential effectiveness in seizure control, are taken into consideration, and the pathophysiological premises supporting their use for epilepsy treatment are illustrated. The authors give particular focus to immunomodulatory and immunosuppressive agents, which have become the therapeutic cornerstones for immune-mediated epilepsies, despite regulatory obstacles. EXPERT OPINION In several circumstances, especially in the case of seizure-related emergencies, clinical practice seems not match literature-based evidence, and several IV AEDs are still used off-label. Strong evidence derived from randomized clinical trials (RCTs) is needed to support the effectiveness and tolerability of any therapeutic approach, however common and "accepted' it may be, in order to guarantee patient safety and well-being.
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Affiliation(s)
- Alessandra Morano
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
| | - Luigi Iannone
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Caterina Palleria
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Martina Fanella
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
| | - Anna Teresa Giallonardo
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
| | - Giovambattista De Sarro
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Emilio Russo
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Carlo Di Bonaventura
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
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Li LH, Ma CC, Zhang HF, Lian YJ. Clinical and electrographic characteristics of seizures in LGI1-antibody encephalitis. Epilepsy Behav 2018; 88:277-282. [PMID: 30332659 DOI: 10.1016/j.yebeh.2018.08.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/13/2018] [Accepted: 08/15/2018] [Indexed: 01/12/2023]
Abstract
PURPOSE The purpose of this study was to analyze the clinical and electrographic characteristics of seizures in LGI1-antibody encephalitis. METHODS The methods utilized in this study were prospective analysis of the clinical manifestations, types of seizures, electroencephalogram (EEG), adjuvant examination, treatment and prognosis of 19 cases of LGI1-antibody encephalitis diagnosed from January 2017 to February 2018 in First Affiliated Hospital of Zhengzhou University, and reviewed related literatures. RESULTS The 15/19 (79%) patients were male, and the average onset age was 58 years (23-82). The following cases were observed: 17 (89%) with epilepsy seizures, 14 (73%) with mental disorders, and 13 (68%) with cognitive impairment. Types of epilepsy were including focal aware seizures, focal-impaired awareness seizures, focal to bilateral tonic-clonic seizures, and status epilepticus. The motor events were most commonly clonus or automatisms, and the sensory events were frequently body shuddering. The 13 patients had faciobrachial dystonic seizures (FBDS); the median frequency was 48 per day (range 5-180). In some video-EEGs, multifocal ictal epileptiform discharges from frontal, temporal, and apical regions, and interictal slow wave activity were observed in patients. Normal EEG appeared in all patients during FBDS. Five patients had hyponatremia, and brain magnetic resonance imaging (MRI) results of 5 cases were abnormal. All patients were treated with antiepileptic drugs and immunotherapy, and their clinical symptoms were improved. During the follow-up period, 13 patients recovered basically, and 6 patients relapsed. One patient died of status epilepticus after relapse. CONCLUSIONS Faciobrachial dystonic seizure and various types of epileptic seizures are characteristic manifestations of LGI1-antibody encephalitis, which can assist in early diagnosis. Once this has been diagnosed, antiepileptic drugs and immunotherapy should be given as soon as possible to the patient.
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Affiliation(s)
- Li-Hao Li
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, China
| | - Cong-Cong Ma
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, China
| | - Hai-Feng Zhang
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, China
| | - Ya-Jun Lian
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, China.
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Lapin WB, Lyons-Warren AM, Risen SR, Rathore N, Slone JS, Elghetany MT, Marcus M. A 14-Year-Old Boy With Fevers, Cytopenias, and Neurocognitive Decline. Pediatrics 2018; 142:peds.2017-3258. [PMID: 30072574 DOI: 10.1542/peds.2017-3258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2018] [Indexed: 11/24/2022] Open
Abstract
A 14-year-old boy presented to our institution with a 1-month history of neurocognitive decline and intermittent fevers. His history was significant for fevers, headaches, and a 10-lb weight loss. Previous examinations by multiple medical providers were significant only for bilateral cervical lymphadenopathy. Previous laboratory workup revealed leukopenia, neutropenia, and elevated inflammatory markers. Despite improvement in his laboratory values after his initial presentation, his fevers persisted, and he developed slowed and "jerky" movements, increased sleep, slurred speech, delusions, visual hallucinations, and deterioration in his school performance. A brain MRI performed at an outside hospital before admission at our institution was concerning for patchy, increased T2 and fluid-attenuated inversion recovery signal intensity in multiple areas, including the basal ganglia. After transfer to our institution and admission to the pediatric hospital medicine team, the patient had an acute decompensation. Our subspecialists will discuss the initial evaluation, workup, differential diagnosis, definitive diagnosis, and subsequent management of this patient.
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Affiliation(s)
| | | | | | - Nisha Rathore
- Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas; and
| | - Jeremy S Slone
- Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas; and
| | - M Tarek Elghetany
- Departments of Pathology and Immunology, and.,Pediatrics, Baylor College of Medicine, Houston, Texas
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Bing-Lei W, Jia-Hua Z, Yan L, Zan Y, Xin B, Jian-Hua S, Hui-Juan W. Three cases of antibody-LGI1 limbic encephalitis and review of literature. Int J Neurosci 2018; 129:642-648. [PMID: 30112956 DOI: 10.1080/00207454.2018.1512985] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE Antibody-LGI1 limbic encephalitis (LGI1-Ab LE) is an anti-neuronal surface antigen-related autoimmune encephalitis. we report three cases of LGI1-Ab LE, describe the characteristics of clinical manifestation, course of evolution, imaging manifestation and treatment outcomes. METHODS Data from patients diagnosed with LGI1-Ab LE in the Second Hospital, Hebei Medical University, from June 2016 to July 2017, were retrospectively collected and analyzed. We followed up the patients for 90 days. RESULTS Two of the three patients were females, the average age of onset is 53 years old. Epilepsy is the most common clinical manifestations, and one of patients developed faciobrachial dystonic seizures (FBDS), which was recently described as a characteristic feature of LGI1-Ab LE. All patients had cognitive impairment in different degrees and abnormal signal of hippocampus in cranial MRI. All serum LGI1 antibodies were positive, whereas one LGI1 antibodies of CSF were negative. All patients accepted first-line immune therapy and had a good outcome. CONCLUSION LGI1-Ab LE, which is an autoimmune disease, is rare clinically and mostly nonparaneoplastic. We suggest that LGI1-Ab LE be considered in any patient with acute or subacute onset, cognitive dysfunction , various types of seizures, accompanied by mental disorders and hyponatremia, MR showed the involvement of the limbic system. It is necessary to have LE-related antibodies tested. Early immunotherapy can significantly improve the patient's overall prognosis. At the same time, we should also pay attention to the possibility of potential tumors.
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Affiliation(s)
- Wang Bing-Lei
- a Department of Neurology , Second Hospital, Hebei Medical University , Shijiazhuang , Hebei , China
| | - Zheng Jia-Hua
- b Department of Reproduction Medicine , Second Hospital, Hebei Medical University , Shijiazhuang , Hebei , China
| | - Li Yan
- a Department of Neurology , Second Hospital, Hebei Medical University , Shijiazhuang , Hebei , China
| | - Yue Zan
- a Department of Neurology , Second Hospital, Hebei Medical University , Shijiazhuang , Hebei , China
| | - Bian Xin
- a Department of Neurology , Second Hospital, Hebei Medical University , Shijiazhuang , Hebei , China
| | - Shen Jian-Hua
- a Department of Neurology , Second Hospital, Hebei Medical University , Shijiazhuang , Hebei , China
| | - Wang Hui-Juan
- a Department of Neurology , Second Hospital, Hebei Medical University , Shijiazhuang , Hebei , China
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Haneche F, Demeret S, Psimaras D, Katlama C, Pourcher V. An anti-NMDA receptor encephalitis mimicking an HIV encephalitis. Clin Immunol 2018; 193:10-11. [DOI: 10.1016/j.clim.2018.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 05/12/2018] [Indexed: 11/26/2022]
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Clinical characteristics and short-term prognosis of LGI1 antibody encephalitis: a retrospective case study. BMC Neurol 2018; 18:96. [PMID: 29980179 PMCID: PMC6035422 DOI: 10.1186/s12883-018-1099-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 07/02/2018] [Indexed: 01/17/2023] Open
Abstract
Background Recently, most reports of Leucine-rich glioma-inactivated 1 (LGI1) antibody encephalitis are from Europe and the US, while the short term outcome and clinical characteristics of Chinese patients are rarely reported,we study the clinical manifestations, laboratory results and brain magnetic resonance images (MRI) of eight patients who were recently diagnosed with LGI1 antibody encephalitis in our hospital to improve the awareness and knowledge of this disease. Methods Eight patients (five males and three females; mean age, 63.4) with LGI1 antibody encephalitis who were diagnosed and treated in the Department of Neurology of Shengjing Hospital of China Medical University from September 2016 to June 2017 were recruited for the current study. Their general information, clinical manifestations, treatment regimens, and short-term prognoses were retrospectively analyzed, as were the results from MRI and laboratory findings. Results Overall, patient symptoms included cognitive impairment, which manifested primarily as memory deficits (8/8), seizures (including faciobrachial dystonic seizure, (FBDS)) (8/8), psychiatric and behavioral disorders (7/8), sleep disorders (4/8), and autonomic abnormalities (3/8). Five patients also had abnormal findings on brain MRI, mainly involving the hippocampus, basal ganglia and insula. Hyponatremia occurred in six cases. All patients tested positive for LGI1 antibodies in their serum/cerebrospinal fluid (CSF)and patients were negative for tumors. Symptoms rapidly improved after treatment with immunoglobulin and/or steroid therapy. The patients were followed up for 4–13 months after discharge, and two patients relapsed. Conclusion Primary symptoms of LGI1 antibody encephalitis include memory impairments, seizures, FBDS, and mental and behavioral abnormalities. Increased titers of LGI1 antibodies are also present in the serum/CSF of patients. Patients often have hyponatremia, and MRIs show abnormalities in various brain regions. Finally, immunotherapy shows good efficacy and positive benefits, although patients may relapse in the short-term.
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Autoimmune encephalitis associated with two antibodies. EPILEPSY & BEHAVIOR CASE REPORTS 2018; 10:44-46. [PMID: 29928585 PMCID: PMC6008288 DOI: 10.1016/j.ebcr.2018.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 03/28/2018] [Accepted: 04/02/2018] [Indexed: 01/17/2023]
Abstract
•In patients presenting with clinical manifestations of encephalitis without clinical or laboratory signs of infection, an autoimmune etiology should be suspected.•Antibodies for various neural antigens may coexist, thus a complete and clinically-guided autoimmune panel must be done in suspected cases of autoimmune encephalitis.•Tumor resection, if applicable, combined with high dose steroids and immunotherapy are effective treatment strategies for autoimmune encephalitis with coexisting antibodies.
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Smith-Cohn MA, Gill D, Voorhies BN, Agarwal N, Garrido-Laguna I. Case report: pembrolizumab-induced Type 1 diabetes in a patient with metastatic cholangiocarcinoma. Immunotherapy 2018; 9:797-804. [PMID: 28877632 DOI: 10.2217/imt-2017-0042] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitors are novel cancer therapies associated with numerous autoimmune toxicities, some of which are only now being appreciated. CASE PRESENTATION A 67-year old female with metastatic cholangiocarcinoma and no prior history of diabetes was treated with leucovorin, fluorouracil, oxaliplatin and pembrolizumab. After eight cycles, she developed new onset type 1 diabetes mellitus with positive glutamic acid decarboxylase antibody titers. Conclusions: To our knowledge, this is the first reported case of PD-1 inhibitor associated Type 1 diabetes mellitus in a patient with cholangiocarcinoma and supports others' experiences that PD-1 inhibition can cause a spectrum of autoimmune adverse events that require clinical monitoring and periodic screenings.
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Affiliation(s)
- Matthew A Smith-Cohn
- Department of Neurology, University of Utah, Salt Lake City, 175 North Medical Drive East, UT 84132, USA
| | - David Gill
- Department of Hematology and Oncology, University of Utah School of Medicine, Huntsman Cancer Institute, 2000 Circle of Hope, Salt Lake City, UT 84112, USA
| | - Benjamin N Voorhies
- Department of Hematology and Oncology, University of Utah School of Medicine, Huntsman Cancer Institute, 2000 Circle of Hope, Salt Lake City, UT 84112, USA
| | - Neeraj Agarwal
- Department of Hematology and Oncology, University of Utah School of Medicine, Huntsman Cancer Institute, 2000 Circle of Hope, Salt Lake City, UT 84112, USA
| | - Ignacio Garrido-Laguna
- Department of Hematology and Oncology, University of Utah School of Medicine, Huntsman Cancer Institute, 2000 Circle of Hope, Salt Lake City, UT 84112, USA
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Stingl C, Cardinale K, Van Mater H. An Update on the Treatment of Pediatric Autoimmune Encephalitis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2018; 4:14-28. [PMID: 29780690 PMCID: PMC5957495 DOI: 10.1007/s40674-018-0089-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW Autoimmune encephalitis (AE) is an increasingly recognized etiology for neuropsychiatric deficits that are highly responsive to immunotherapy. As a result, rheumatologists are often called upon to help with the diagnosis and treatment of these conditions. The purpose of this review is to provide an update on the pharmacologic treatment of AE. RECENT FINDINGS To date, there are no prospective randomized placebo-controlled trials to guide treatment recommendations for AE. First-line therapies include corticosteroids, intravenous immunoglobulin, and plasma exchange. Second-line therapies include rituximab and cyclophosphamide (CYC), as well as mycophenolate mofetil and azathioprine. For patients refractory to both first- and second-line therapy, there is emerging evidence for the interleukin-6 (IL-6) inhibitor tocilizumab, the proteasome inhibitor bortezomib, and low-dose IL-2. Early treatment initiation and treatment escalation in patients with refractory disease improve outcomes. Given the delayed time between dosing and treatment effects of second-line agents, continuing first-line treatment until the patients shows improvement is recommended. SUMMARY Although AE can present with dramatic, life-threatening neuropsychiatric deficits, the potential for recovery with prompt treatment is remarkable. First- and second-line therapies for AE lead to clinical improvement in the majority of patients, including full recoveries in many. Early treatment and escalation to second-line therapy in those with refractory disease improves patient outcomes. Novel treatments including IL-6 blockade and proteasome inhibitors have shown promising results in patients with refractory disease.
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Affiliation(s)
- Cory Stingl
- Division of Pediatric Rheumatology, Duke University, Durham, NC, USA
| | | | - Heather Van Mater
- Division of Pediatric Rheumatology, Duke University, Durham, NC, USA
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Becker AJ. Review: Animal models of acquired epilepsy: insights into mechanisms of human epileptogenesis. Neuropathol Appl Neurobiol 2018; 44:112-129. [DOI: 10.1111/nan.12451] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 10/27/2017] [Indexed: 02/06/2023]
Affiliation(s)
- A. J. Becker
- Section for Translational Epilepsy Research; Department of Neuropathology; University of Bonn Medical Center; Bonn Germany
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Gastaldi M, Nosadini M, Spatola M, Sartori S, Franciotta D. N-methyl-D-aspartate receptor encephalitis: laboratory diagnostics and comparative clinical features in adults and children. Expert Rev Mol Diagn 2018; 18:181-193. [DOI: 10.1080/14737159.2018.1431124] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Matteo Gastaldi
- Laboratory of Neuroimmunology and Department of Brain and Behavioral Sciences, IRCCS Mondino Foundation and University of Pavia, Pavia, Italy
| | - Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University Hospital of Padua, Padova, Italy
| | - Marianna Spatola
- Department of Clinical Neuroscience, University of Lausanne (UNIL), Switzerland and IDIBAPS (Institut d’Investigacions Biomèdiques August Pi i Sunyer) Barcelona, Spain, Barcelona, Spain
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University Hospital of Padua, Padova, Italy
| | - Diego Franciotta
- Laboratory of Neuroimmunology, IRCCS Mondino Foundation, Pavia, Italy
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Autoimmune and paraneoplastic movement disorders: An update. J Neurol Sci 2017; 385:175-184. [PMID: 29406902 DOI: 10.1016/j.jns.2017.12.035] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 12/28/2017] [Indexed: 12/18/2022]
Abstract
Movement disorders (MDs) are common in patients with autoimmune disorders affecting the central and peripheral nervous system. They may be observed in autoimmune disorders triggered by an infectious agent, such as streptococcus in Sydenham's chorea, or in basal ganglia encephalitis with antibodies against the dopamine-D2 receptors. In these patients chorea or dystonia are usually the most prominent hyperkinetic MDs. MDs are also observed in patients with diffuse or limbic encephalitis with antibodies directed against neuronal cell-surface antigens. Anti-NMDA receptor encephalitis is one of the most common and may present with a variety of MDs, including: chorea, stereotypies, dystonia and myorhythmia. The recognition of other abnormal motor phenomena such as "faciobrachial dystonic seizures" and neuromyotonia, observed in patients with LGI1 and Caspr-2 antibodies, is important because they may herald the onset of overt limbic encephalitis. Autoimmunity directed against the intracellular enzyme glutamic acid decarboxylase usually presents with MDs, most commonly stiff-person syndrome or cerebellar ataxia. Chorea may be observed in rheumatologic disorders such as systemic lupus erythematosus or antiphospholipid syndrome. Disorders with uncertain autoimmune mechanisms such as Hashimoto's encephalitis and idiopathic opsoclonus-myoclonus syndrome commonly present with tremor, myoclonus and ataxia. A rapid diagnosis of an autoimmune disorder, which typically presents with subacute onset, is critical as early therapeutic intervention improves long-term prognosis and may be life-saving. Treatment usually involves some form of immunotherapy and symptomatic therapy of the abnormal movements with dopamine depleters, dopamine receptor antagonists, or GABAergic drugs. Detection and removal of an underlying tumor is essential for optimal outcome.
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Oldham M. Autoimmune Encephalopathy for Psychiatrists: When to Suspect Autoimmunity and What to Do Next. PSYCHOSOMATICS 2017; 58:228-244. [DOI: 10.1016/j.psym.2017.02.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 02/22/2017] [Accepted: 02/22/2017] [Indexed: 12/18/2022]
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Biotherapy in Inflammatory Diseases of the CNS: Current Knowledge and Applications. Curr Treat Options Neurol 2017; 19:19. [DOI: 10.1007/s11940-017-0456-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Weissert R. Adaptive Immunity Is the Key to the Understanding of Autoimmune and Paraneoplastic Inflammatory Central Nervous System Disorders. Front Immunol 2017; 8:336. [PMID: 28386263 PMCID: PMC5362596 DOI: 10.3389/fimmu.2017.00336] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 03/08/2017] [Indexed: 12/25/2022] Open
Abstract
There are common aspects and mechanisms between different types of autoimmune diseases such as multiple sclerosis (MS), neuromyelitis optica spectrum disorders (NMOSDs), and autoimmune encephalitis (AE) as well as paraneoplastic inflammatory disorders of the central nervous system. To our present knowledge, depending on the disease, T and B cells as well as antibodies contribute to various aspects of the pathogenesis. Possibly the events leading to the breaking of tolerance between the different diseases are of great similarity and so far, only partially understood. Beside endogenous factors (genetics, genomics, epigenetics, malignancy) also exogenous factors (vitamin D, sun light exposure, smoking, gut microbiome, viral infections) contribute to susceptibility in such diseases. What differs between these disorders are the target molecules of the immune attack. For T cells, these target molecules are presented on major histocompatibility complex (MHC) molecules as MHC-bound ligands. B cells have an important role by amplifying the immune response of T cells by capturing antigen with their surface immunoglobulin and presenting it to T cells. Antibodies secreted by plasma cells that have differentiated from B cells are highly structure specific and can have important effector functions leading to functional impairment or/and lesion evolvement. In MS, the target molecules are mainly myelin- and neuron/axon-derived proteins; in NMOSD, mainly aquaporin-4 expressed on astrocytes; and in AE, various proteins that are expressed by neurons and axons.
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Affiliation(s)
- Robert Weissert
- Department of Neurology, Neuroimmunology, University of Regensburg , Regensburg , Germany
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