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Shi K, Zhao H, Li Y, Li X, Chen W. Anti-metabolic glutamate receptor 5 encephalitis with gangliocytoma: a case and review of the literature. BMC Neurol 2024; 24:27. [PMID: 38218780 PMCID: PMC10787404 DOI: 10.1186/s12883-024-03528-z] [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: 08/04/2023] [Accepted: 01/04/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND There are very limited reports on anti-metabolic glutamate receptor5 (mGluR5) encephalitis, especially lacking of pediatric research. The disease was mostly accompanied by tumors, mainly Hodgkin's lymphoma. No reports of other tumors, such as gangliocytoma have been reported to associate with anti-mGluR5 encephalitis so far. CASE PRESENTATION AND LITERATURE REVIEWS We reported a case of a 12-year-old boy with anti-mGluR5 encephalitis complicated with gangliocytoma. The patient suffered from mental disorders including auditory hallucination, and sleep disorders. His cranial magnetic resonance imaging (MRI) showed an abnormality in the right insular lobe. Autoimmune encephalitis antibodies testing was positive for mGluR5 IgG antibody both in cerebrospinal fluid and serum (1:3.2, 1:100 respectively). Abdominal CT indicated a mass in left retroperitoneal confirmed with gangliocytoma via pathology. The patient underwent resection of gangliocytoma. After first-line immunotherapy (glucocorticoid, gamma globulin), his condition was improved. Furthermore, we provide a summary of 6 pediatric cases of Anti-mGluR5 encephalitis. Most of them complicated with Hodgkin's lymphoma, except the case currently reported comorbid with gangliocytoma. The curative effect is satisfactory. CONCLUSIONS We report the first patient with anti-mGlur5 encephalitis complicated with gangliocytoma. It suggests that in addition to paying attention to the common lymphoma associated with anti-mGlur5 encephalitis, we should also screen the possibility of other tumors for early detection of the cause, active treatment and prevention of recurrence.
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Affiliation(s)
- Kaili Shi
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou, 510623, China
| | - Huimin Zhao
- Department of Pediatrics, People's Hospital of Pidu, Sichuan, 611730, China
| | - Ying Li
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou, 510623, China
| | - Xiaojing Li
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou, 510623, China.
| | - Wenxiong Chen
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou, 510623, China.
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Abstract
PURPOSE OF REVIEW To systematically review the clinical features, diagnosis, and management of anti-gamma-aminobutyric acid receptor Type A (GABAA) autoimmune encephalitis with a focus on recent data. RECENT FINDINGS In a review of published reports, we identified 50 cases of anti-GABAA receptor encephalitis with clinical features reported. The median age at presentation was 47 years old (range, 2.5 months-88 years old), 64% were adults, 36% were children and it occurred in both males and females. Eight-two percent (41/50) presented with seizures, 72% (36/50) with encephalopathy, and 58% (29/50) with both. Of those presenting with seizures, 42% developed status epilepticus during their disease course. Ninety-six percent (48/50) had MRI results reported, with 83% of these cases having abnormal findings, most commonly multifocal/diffuse cortical and subcortical T2/FLAIR hyperintense lesions without associated gadolinium enhancement. Almost one-third, 28% (14/50), had an associated malignancy detected by the time of diagnosis, 64% (9/14) of which was thymoma. Of 44 patients with outcomes reported, 80% had partial or complete recovery, whereas 20% had poor outcomes including 11% (5/44) who died. Of the 42 patients with type of treatment(s) and outcomes reported, 54% (23/42) received only first-line immunotherapy and 31% (13/42) received first-line and second-line immunotherapy. Receiving a combination of first-line and second-line immunotherapy may be associated with higher likelihood of complete recovery. When follow-up MRIs were reported, all showed improvement, and sometimes complete resolution, of T2/FLAIR hyperintensities. SUMMARY Anti-GABAA receptor encephalitis can present across the age spectrum and should be considered in patients who present with rapidly progressive encephalopathy and/or seizures. Brain MRI often shows a distinctive pattern of multifocal cortical and subcortical T2/FLAIR hyperintense lesions, generally not typical of other known central nervous system autoantibody associated encephalitis syndromes. High clinical suspicion and early diagnosis are important given the potential for clinical improvement with immunotherapy.
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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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Management of Autoimmune Encephalitis in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Glutamate Receptor Antibodies in Autoimmune Central Nervous System Disease: Basic Mechanisms, Clinical Features, and Antibody Detection. Methods Mol Biol 2019. [PMID: 30707437 DOI: 10.1007/978-1-4939-9077-1_15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Immune-mediated inflammation of the brain has been recognized for more than 50 years, although the initial descriptions were mainly thought to be secondary to an underlying neoplasm. Some of these paraneoplastic encephalitides express serum antibodies, but these were not thought to be pathogenic but instead have a T-cell-mediated pathophysiology. Over the last two decades, several pathogenic antibodies against neuronal surface antigens have been described in autoimmune encephalitis, which are amenable to immunotherapy. Several of these antibodies are directed against glutamate receptors (GluRs). NMDAR encephalitis (NMDARE) is the most common of these antibodies, and patients often present with psychosis, hallucinations, and reduced consciousness. Patients often progress on to develop confusion, seizures, movement disorders, autonomic instability, and respiratory depression. Although initially described as exclusively occurring secondary to ovarian teratoma (and later other tumors), non-paraneoplastic forms are increasingly common, and other triggers like viral infections are now well recognized. AMPAR encephalitis is relatively less common than NMDARE but is more likely to paraneoplastic. AMPAR antibodies typically cause limbic encephalitis, with patients presenting with confusion, disorientation, memory loss, and often seizures. The syndromes associated with the metabotropic receptor antibodies are much rarer and often can be paraneoplastic-mGluR1 (cerebellar degeneration) and mGluR5 (Ophelia syndrome) being the ones described in literature.With the advance in molecular biology techniques, it is now possible to detect these antibodies using cell-based assays with high sensitivity and specificity, especially when coupled with brain tissue immunohistochemistry and binding to live cell-based neurons. The rapid and reliable identification of these antibodies aids in the timely treatment (either in the form of identifying/removing the underlying tumor or instituting immunomodulatory therapy) and has significantly improved clinical outcome in this otherwise devastating group of conditions.
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Phillips OR, Joshi SH, Narr KL, Shattuck DW, Singh M, Di Paola M, Ploner CJ, Prüss H, Paul F, Finke C. Superficial white matter damage in anti-NMDA receptor encephalitis. J Neurol Neurosurg Psychiatry 2018; 89:518-525. [PMID: 29101253 PMCID: PMC5899027 DOI: 10.1136/jnnp-2017-316822] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/09/2017] [Accepted: 10/19/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Clinical brain MRI is normal in the majority of patients with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. However, extensive deep white matter damage wasrecently identifiedin these patients using diffusion weighted imaging. Here, our aim was to study a particularly vulnerable brain compartment, the late myelinating superficial white matter. METHODS Forty-six patients with anti-NMDAR encephalitis were included. Ten out of these were considered neurologically recovered (modified Rankin scale of zero), while 36 patients were non-recovered. In addition, 30 healthy controls were studied. MRI data were collected from all subjects and superficial white matter mean diffusivity derived from diffusion tensor imaging was compared between groups in whole brain, lobar and vertex-based analyses. Patients underwent comprehensive cognitive testing, and correlation analyses were performed between cognitive performance and superficial white matter integrity. RESULTS Non-recovered patients showed widespread superficial white matter damage in comparison to recovered patients and healthy controls. Vertex-based analyses revealed that damage predominated in frontal and temporal lobes. In contrast, the superficial white matter was intact in recovered patients. Importantly, persistent cognitive impairments in working memory, verbal memory, visuospatial memory and attention significantly correlated with damage of the superficial white matter in patients. CONCLUSIONS Anti-NMDAR encephalitis is associated with extensive superficial white matter damage in patients with incomplete recovery. The strong association with impairment in several cognitive domains highlights the clinical relevance of white matter damage in this disorder and warrants investigations of the underlying pathophysiological mechanisms.
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Affiliation(s)
- Owen Robert Phillips
- Department of Psychiatry, Division of Child and Adolescent Psychiatry, Stanford University School of Medicine, Stanford, California, USA
| | - Shantanu H Joshi
- Department of Neurology, Ahmanson Lovelace Brain Mapping Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Katherine L Narr
- Department of Neurology, Ahmanson Lovelace Brain Mapping Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - David W Shattuck
- Department of Neurology, Ahmanson Lovelace Brain Mapping Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Manpreet Singh
- Department of Psychiatry, Division of Child and Adolescent Psychiatry, Stanford University School of Medicine, Stanford, California, USA
| | - Margherita Di Paola
- Department of Mental Health, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia.,Department of Clinical and Behavioral Neurology, IRCCS Santa Lucia Foundation, Rome, Italy
| | - Christoph J Ploner
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Harald Prüss
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany
| | - Friedemann Paul
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Berlin, Germany.,Experimental and Clinical Research Center, Charité Universitätsmedizin, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, Berlin, Germany
| | - Carsten Finke
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany.,Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
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Lynch DR, Rattelle A, Dong YN, Roslin K, Gleichman AJ, Panzer JA. Anti-NMDA Receptor Encephalitis: Clinical Features and Basic Mechanisms. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2017; 82:235-260. [PMID: 29413523 DOI: 10.1016/bs.apha.2017.08.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In slightly more than 10 years, anti-NMDA receptor (NMDAR) encephalitis has changed from a rare paraneoplastic syndrome to the most common cause of nonviral encephalitis. It presents fulminantly with progressive psychosis, seizures, and autonomic dysfunction, leading to death if untreated. However, rapid recognition and treatment can lead to survival and a return to baseline levels of functioning in many patients. While initially associated with ovarian teratomas, it is now associated with other tumors and can reflect a postviral event. The antibodies to the NMDAR made in this syndrome are pathogenic and are directed at the extracellular domain of the GluN1 subunit. Such antibodies lead to internalization of NMDARs in model systems, leading to a physiological state characterized by NMDAR hypofunction. Analogous disorders, characterized by antibodies to other synaptic receptors, present with neurological and psychiatric dysfunction and also appear to reflect antibody-induced internalization of receptors. However, this simple pathophysiology may be too simplistic to reflect the complexity of events in anti-NMDAR encephalitis. Future scientific investigations may allow a more complete understanding of this disorder and improve treatment of anti-NMDAR encephalitis.
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Affiliation(s)
- David R Lynch
- Children's Hospital of Philadelphia, Philadelphia, PA, United States; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Amy Rattelle
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Yi Na Dong
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Kylie Roslin
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Amy J Gleichman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Jessica A Panzer
- Children's Hospital of Philadelphia, Philadelphia, PA, United States; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Yeo T, Chen Z, Chai J, Tan K. Detection of LGI1 and CASPR2 antibodies with a commercial cell-based assay in patients with very high VGKC-complex antibody levels. J Neurol Sci 2017; 378:85-90. [DOI: 10.1016/j.jns.2017.04.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 03/26/2017] [Accepted: 04/25/2017] [Indexed: 01/17/2023]
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van Coevorden-Hameete MH, Titulaer MJ, Schreurs MWJ, de Graaff E, Sillevis Smitt PAE, Hoogenraad CC. Detection and Characterization of Autoantibodies to Neuronal Cell-Surface Antigens in the Central Nervous System. Front Mol Neurosci 2016; 9:37. [PMID: 27303263 PMCID: PMC4885853 DOI: 10.3389/fnmol.2016.00037] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 05/09/2016] [Indexed: 01/07/2023] Open
Abstract
Autoimmune encephalitis (AIE) is a group of disorders in which autoantibodies directed at antigens located on the plasma membrane of neurons induce severe neurological symptoms. In contrast to classical paraneoplastic disorders, AIE patients respond well to immunotherapy. The detection of neuronal surface autoantibodies in patients' serum or CSF therefore has serious consequences for the patients' treatment and follow-up and requires the availability of sensitive and specific diagnostic tests. This mini-review provides a guideline for both diagnostic and research laboratories that work on the detection of known surface autoantibodies and/or the identification of novel surface antigens. We discuss the strengths and pitfalls of different techniques for anti-neuronal antibody detection: (1) Immunohistochemistry (IHC) and immunofluorescence on rat/primate brain sections; (2) Immunocytochemistry (ICC) of living cultured hippocampal neurons; and (3) Cell Based Assay (CBA). In addition, we discuss the use of immunoprecipitation and mass spectrometry analysis for the detection of novel neuronal surface antigens, which is a crucial step in further disease classification and the development of novel CBAs.
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Affiliation(s)
- Marleen H. van Coevorden-Hameete
- Department of Biology, Division of Cell Biology, Faculty of Science, Utrecht UniversityUtrecht, Netherlands
- Department of Neurology, Erasmus Medical CenterRotterdam, Netherlands
| | | | | | - Esther de Graaff
- Department of Biology, Division of Cell Biology, Faculty of Science, Utrecht UniversityUtrecht, Netherlands
| | | | - Casper C. Hoogenraad
- Department of Biology, Division of Cell Biology, Faculty of Science, Utrecht UniversityUtrecht, Netherlands
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