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Hagbohm C, Ouellette R, Flanagan EP, Jonsson DI, Piehl F, Banwell B, Wickström R, Iacobaeus E, Granberg T, Ineichen BV. Clinical and neuroimaging phenotypes of autoimmune glial fibrillary acidic protein astrocytopathy: A systematic review and meta-analysis. Eur J Neurol 2024; 31:e16284. [PMID: 38506182 DOI: 10.1111/ene.16284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/13/2024] [Accepted: 03/05/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVE This study was undertaken to provide a comprehensive review of neuroimaging characteristics and corresponding clinical phenotypes of autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A), a rare but severe neuroinflammatory disorder, to facilitate early diagnosis and appropriate treatment. METHODS A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis)-conforming systematic review and meta-analysis was performed on all available data from January 2016 to June 2023. Clinical and neuroimaging phenotypes were extracted for both adult and paediatric forms. RESULTS A total of 93 studies with 681 cases (55% males; median age = 46, range = 1-103 years) were included. Of these, 13 studies with a total of 535 cases were eligible for the meta-analysis. Clinically, GFAP-A was often preceded by a viral prodromal state (45% of cases) and manifested as meningitis, encephalitis, and/or myelitis. The most common symptoms were headache, fever, and movement disturbances. Coexisting autoantibodies (45%) and neoplasms (18%) were relatively frequent. Corticosteroid treatment resulted in partial/complete remission in a majority of cases (83%). Neuroimaging often revealed T2/fluid-attenuated inversion recovery (FLAIR) hyperintensities (74%) as well as perivascular (45%) and/or leptomeningeal (30%) enhancement. Spinal cord abnormalities were also frequent (49%), most commonly manifesting as longitudinally extensive myelitis. There were 88 paediatric cases; they had less prominent neuroimaging findings with lower frequencies of both T2/FLAIR hyperintensities (38%) and contrast enhancement (19%). CONCLUSIONS This systematic review and meta-analysis provide high-level evidence for clinical and imaging phenotypes of GFAP-A, which will benefit the identification and clinical workup of suspected cases. Differential diagnostic cues to distinguish GFAP-A from common clinical and imaging mimics are provided as well as suitable magnetic resonance imaging protocol recommendations.
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Affiliation(s)
- Caroline Hagbohm
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Russell Ouellette
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Eoin P Flanagan
- Department of Neurology, Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Dagur I Jonsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurophysiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Centre for Neurology, Academic Specialist Centre, Karolinska University Hospital, Stockholm, Sweden
| | - Brenda Banwell
- Division of Child Neurology, Children's Hospital of Philadelphia, Department of Neurology and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ronny Wickström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Ellen Iacobaeus
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Tobias Granberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Benjamin V Ineichen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Reproducible Science, University of Zürich, Zürich, Switzerland
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Ohashi N, Kamijima S, Watanabe R, Tazawa KI. [Peripheral neuropathy associated with severe glial fibrillary acidic protein (GFAP) astrocytopathy: a case report]. Rinsho Shinkeigaku 2024; 64:403-407. [PMID: 38797687 DOI: 10.5692/clinicalneurol.cn-001940] [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] [Indexed: 05/29/2024]
Abstract
A 44-year-old man was admitted due to a fever. He developed unconsciousness and respiratory failure, necessitating mechanical ventilation. After the administration of methylprednisolone and intravenous immunoglobulin for suspected autoimmune encephalitis, his consciousness and respiratory state improved. However, he exhibited pronounced tetraparalysis and impaired sensation below the neck. A spinal MRI revealed swelling of the entire spinal cord, indicating myelitis. Deep tendon reflexes were diminished in all extremities, and a nerve conduction study confirmed motor-dominant axonal polyneuropathy. Subsequently, he developed a fever and headache. Brain MRI demonstrated FLAIR hyperintensities in the basal ganglia and brain stem. CSF analysis for anti-glial fibrillary acidic protein (GFAP) antibody turned out positive, leading to the diagnosis of GFAP astrocytopathy. Although the steroid re-administration improved muscle strength in his upper limbs and reduced the range of diminished sensation, severe hemiparalysis remained. Severe GFAP astrocytopathy can be involved with polyneuropathy. Early detection and therapeutic intervention for this condition may lead to a better prognosis.
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Affiliation(s)
| | | | - Rie Watanabe
- Department of Neurology, Nagano Red Cross Hospital
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Ng CC, Poh MQW, Lim SA, Swaminathan SK, Yeo T. Headache and optic disc oedema revealing autoimmune GFAP-astrocytopathy. QJM 2024; 117:375-377. [PMID: 38229263 DOI: 10.1093/qjmed/hcae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Indexed: 01/18/2024] Open
Affiliation(s)
- Chai Ching Ng
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Mervyn Qi Wei Poh
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Su Ann Lim
- Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Tianrong Yeo
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Sellimi A, Barthez S, Ferrao Santos S, Wittebole X, El Sankari S. Severe acute meningo-encephalo-myelitis: think anti-GFAP! Acta Neurol Belg 2024:10.1007/s13760-024-02581-2. [PMID: 38771551 DOI: 10.1007/s13760-024-02581-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 05/10/2024] [Indexed: 05/22/2024]
Affiliation(s)
- A Sellimi
- Neurology Department, Cliniques Universitaires Saint-Luc, Woluwe-Saint-Lambert, Belgium.
| | - S Barthez
- Neurology Department, Cliniques Universitaires Saint-Luc, Woluwe-Saint-Lambert, Belgium
| | - S Ferrao Santos
- Neurology Department, Cliniques Universitaires Saint-Luc, Woluwe-Saint-Lambert, Belgium
| | - X Wittebole
- Intensive Care Department, Cliniques Universitaires Saint-Luc, Woluwe-Saint-Lambert, Belgium
| | - S El Sankari
- Neurology Department, Cliniques Universitaires Saint-Luc, Woluwe-Saint-Lambert, Belgium
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Zhao CW, Gheihman G, Nigam M, Manzano GS. Autoimmune encephalitis in glial fibrillary acidic protein astrocytopathy. BMJ Case Rep 2024; 17:e260628. [PMID: 38724215 PMCID: PMC11085714 DOI: 10.1136/bcr-2024-260628] [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] [Indexed: 05/13/2024] Open
Abstract
Autoimmune encephalitis due to glial fibrillar acidic protein (GFAP) astrocytopathy is a rare cause of subacute neuropsychiatric changes. In this case, a young patient presented with a viral prodrome and meningismus, followed by progressive encephalopathy and movement disorders over the span of 2 weeks. Due to his clinical trajectory, inflammatory cerebrospinal fluid (CSF) analysis, initial normal brain imaging and negative serum autoimmune encephalopathy panel, his initial diagnosis was presumed viral meningoencephalitis. The recurrence and progression of neuropsychiatric symptoms and myoclonus despite antiviral treatment prompted further investigation, inclusive of testing for CSF autoimmune encephalopathy autoantibodies, yielding a clinically meaningful, positive GFAP autoantibody. This case highlights the importance of appropriately testing both serum and CSF autoantibodies when an autoimmune encephalitic process is considered. Through this case, we review the clinical and radiographic manifestations of GFAP astrocytopathy, alongside notable pearls pertaining to this autoantibody syndrome and its management.
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Affiliation(s)
- Charlie Weige Zhao
- Harvard Medical School, Boston, Massachusetts, USA
- Neurology, Mass General Brigham Inc, Boston, Massachusetts, USA
| | - Galina Gheihman
- Harvard Medical School, Boston, Massachusetts, USA
- Neurology, Mass General Brigham Inc, Boston, Massachusetts, USA
| | - Minali Nigam
- Harvard Medical School, Boston, Massachusetts, USA
- Neurology, Mass General Brigham Inc, Boston, Massachusetts, USA
| | - Giovanna S Manzano
- Harvard Medical School, Boston, Massachusetts, USA
- Neurology, Mass General Brigham Inc, Boston, Massachusetts, USA
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Shosha E, Connolly C, Budhram A. Case report: Headache as the sole neurological symptom in autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy. Front Neurol 2024; 15:1366263. [PMID: 38699059 PMCID: PMC11063300 DOI: 10.3389/fneur.2024.1366263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/14/2024] [Indexed: 05/05/2024] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a recently emerging autoimmune disease of the central nervous system (CNS); GFAP astrocytopathy is characterized by optic neuritis and meningoencephalomyelitis. We report the case of a 55-year-old man, otherwise healthy, who presented with isolated headaches for three months, without other features of meningoencephalitis or myelitis. His neurological examination and fundoscopy were unremarkable. Gadolinium-enhanced brain MRI demonstrated increased T2 hyperintensity within the right sub-lenticular basal ganglia, with additional leptomeningeal enhancement along the bilateral perisylvian regions and mesial temporal lobes. Cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis, elevated protein, matching oligoclonal bands, and a negative infectious and cytological workup. Cell-based assays for anti-aquaporin-4, anti-myelin oligodendrocyte glycoprotein, autoimmune encephalitis panel, and vasculitis workup were all negative, except for CSF positivity for GFAP α antibody. Oncological screening, including CT of the chest, abdomen, pelvis, and scrotal US, was unremarkable. Immunotherapy with high-dose intravenous steroids for five days and subsequent single four-weekly doses resulted in the resolution of both clinical and radiographic features, with a maintained status 24 months after onset. This case highlights isolated headache and basal ganglia, mesial temporal lobe involvement as a rare presentation of autoimmune GFAP astrocytopathy.
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Affiliation(s)
- Eslam Shosha
- Neurology Division, Department of Medicine, McMaster University, Hamilton Health Science Center, Hamilton, ON, Canada
| | - Colleen Connolly
- Neurology Division, Department of Medicine, McMaster University, Hamilton Health Science Center, Hamilton, ON, Canada
| | - Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Science Center, London, ON, Canada
- Department of Pathology and Laboratory Medicine, Western University, London Health Science Center, London, ON, Canada
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Morishima Y, Hata T, Nakajima S, Shindo K, Tsuchiya M, Watanabe T, Tahara I, Kondo T, Kimura A, Shimohata T, Ueno Y. Case report: Atypical case of autoimmune glial fibrillary acidic protein astrocytopathy following COVID-19 vaccination refractory to immunosuppressive treatments. Front Immunol 2024; 15:1361685. [PMID: 38665914 PMCID: PMC11043467 DOI: 10.3389/fimmu.2024.1361685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
A 54-year-old Japanese man presented with headache and fever the day after SARS-CoV-2 vaccination. He became deeply unconscious within a week. Brain MRI showed periventricular linear enhancements and a few spotty lesions in the cerebral white matter. Cerebrospinal fluid (CSF) testing showed mild pleocytosis. He was treated with intravenous methylprednisolone and plasma exchange. However, the white matter lesions enlarged to involve the brainstem and cerebellum, and long cord spinal lesions appeared. Anti-glial fibrillary acidic protein (GFAP) antibody was positive in the CSF and serum, and he was therefore diagnosed as autoimmune GFAP-astrocytopathy (GFAP-A). In addition, high-dose immunoglobulin therapy was administered twice, but his symptoms did not improve; the white matter lesions enlarged further, and modified Rankin Scale score increased to 5. A brain biopsy specimen showed infiltration of macrophages and CD4 + lymphocytes together with neuron and oligodendrocytic injuries and glial scar. Although GFAP-A generally responds well to steroids, the present case developed GFAP-A following SARS-CoV-2 vaccination, with refractory to intensive immunosuppressive therapy and atypical pathologic findings of infiltration of CD4 + lymphocytes and demyelination.
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Affiliation(s)
- Yuto Morishima
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | - Takanori Hata
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | - Sho Nakajima
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | - Kazumasa Shindo
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | - Mai Tsuchiya
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | | | - Ippei Tahara
- Department of Pathology, University of Yamanashi, Chuo, Japan
| | - Tetsuo Kondo
- Department of Pathology, University of Yamanashi, Chuo, Japan
| | - Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yuji Ueno
- Department of Neurology, University of Yamanashi, Chuo, Japan
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Ke G, Jian S, Yang T, Zhao X. Clinical characteristics and MRI features of autoimmune glial fibrillary acidic protein astrocytopathy: a case series of 34 patients. Front Neurol 2024; 15:1375971. [PMID: 38585352 PMCID: PMC10995392 DOI: 10.3389/fneur.2024.1375971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 03/11/2024] [Indexed: 04/09/2024] Open
Abstract
Objectives To analyze the clinical and imaging characteristics of autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A). Methods Forty-three patients diagnosed with GFAP-A between March 2017 and July 2023 were retrospectively recruited. The clinical characteristics and magnetic resonance imaging (MRI) features were collected. Results Twenty-one patients (61.8%) had a fever and 16 (47.1%) had a headache. Five patients (14.7%) had coexisting neural autoantibodies and one patient (2.9%) had a coexisting neoplasm. The most common presentation was meningoencephalomyelitis (13/34, 38.3%), followed by meningoencephalitis (12/34, 35.3%). The other clinical manifestations included blurred visions (5/34, 14.7%) and peripheral nervous system involvement (4/34, 11.8%). Twenty-six patients (76.5%) had elevated nucleated cell count, predominantly lymphocytes (15/15, 100%), and 27 (79.4%) had elevated protein levels of cerebrospinal fluid. One-half (50%) of the patients presented with hyponatremia. A majority of the patients (30/33, 90.9%) exhibited abnormal hyperintense lesions on T2WI, which were often located in juxtacortical white matter (18/33, 54.5%), followed by periventricular white matter (16/33, 48.5%), basal ganglia (15/ 33, 45.5%), brainstem (11/33, 33.3%), and thalamic lesions (9/33, 27.3%). Twenty-four patients (72.7%) had abnormal brain enhancement, with supratentorial leptomeningeal enhancement being the most frequent enhancement pattern (15/33, 45.5%), followed by linear perivascular radial enhancement (14/33, 42.4%). Nineteen patients (70.4%) had hyperintense intramedullary spinal cord lesions, with long segments (15/27, 55.6%) and transverse lesions (14/27, 51.9%) being the most frequent lesions. Most cases were sensitive to immunotherapy, such as glucocorticoids, intravenous immunoglobulin, and tacrolimus, with three patients (8.8%) experiencing relapses. Patients with brainstem lesions had higher onset modified Rankin scale scores and were more prone to intensive care unit admissions. Linear perivascular radial enhancement was positively associated with poor prognosis (p < 0.05). Conclusion GFAP-A presented with meningoencephalomyelitis and meningoencephalitis. The brain lesions were often located in juxtacortical white matter, periventricular white matter, basal ganglia, brainstem, and thalamus. Long segments and transverse were the most frequent spine lesions. Leptomeningeal enhancement was the most frequent enhancement pattern, followed by linear perivascular radial enhancement, which may provide new insight into the differential diagnosis of GFAP-A.
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Affiliation(s)
| | | | | | - Xu Zhao
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Guo Y, Guo J, Wang X, Ma A, Gao Y, Chen J, Nie C, Chen N. Glial fibrillary acidic protein astrocytopathy presented as meningitis: A case report. Heliyon 2024; 10:e26827. [PMID: 38434407 PMCID: PMC10907785 DOI: 10.1016/j.heliyon.2024.e26827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 02/02/2024] [Accepted: 02/20/2024] [Indexed: 03/05/2024] Open
Abstract
Introduction Glial fibrillary acidic protein (GFAP) astrocytopathy is a novel autoimmune neurological disorder and is diagnosed by GFAP-IgG in cerebrospinal fluid (CSF) measurement. Case report Herein, we described a 10-year-old boy with abnormal neurological symptoms and signs. GFAP-IgG was detected in CSF using cell-based assay (CBA), and his CSF showed an increase in lymphocytes, a slight decrease in glucose and an increase in protein level in the early stage. The cranial MRI showed multiple strips of T2-FLAIR hyperintense signal changes on the surface of medulla oblongata, pons, and gyrus in bilateral cerebral hemispheres. He was treated with immunoglobulin (IVIG) and high-dose methylprednisolone pulse treatment, and his clinical presentations gradually improved. Conclusion We highlight that patients with normal inflammatory markers in peripheral blood have obvious meningitis-like symptoms, and clinicians need to consider GFAP astrocytopathy. The early diagnosis and treatment of GFAP astrocytopathy are important for improving the prognosis.
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Affiliation(s)
- Ya Guo
- Department of Pediatric, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Jiamin Guo
- Department of Pediatric, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Xueyu Wang
- Department of Pediatric, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Aihua Ma
- Department of Pediatric, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Yuxing Gao
- Department of Pediatric, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Jiacheng Chen
- Department of Pediatric, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Cuili Nie
- Department of Pediatric, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Na Chen
- Department of Pediatric, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
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Arlt FA, Miske R, Machule ML, Broegger Christensen P, Mindorf S, Teegen B, Borowski K, Buthut M, Rößling R, Sánchez-Sendín E, van Hoof S, Cordero-Gómez C, Bünger I, Radbruch H, Kraft A, Ayzenberg I, Klausewitz J, Hansen N, Timäus C, Körtvelyessy P, Postert T, Baur-Seack K, Rost C, Brunkhorst R, Doppler K, Haigis N, Hamann G, Kunze A, Stützer A, Maschke M, Melzer N, Rosenow F, Siebenbrodt K, Stenør C, Dichgans M, Georgakis MK, Fang R, Petzold GC, Görtler M, Zerr I, Wunderlich S, Mihaljevic I, Turko P, Schmidt Ettrup M, Buchholz E, Foverskov Rasmussen H, Nasouti M, Talucci I, Maric HM, Heinemann SH, Endres M, Komorowski L, Prüss H. KCNA2 IgG autoimmunity in neuropsychiatric diseases. Brain Behav Immun 2024; 117:399-411. [PMID: 38309639 DOI: 10.1016/j.bbi.2024.01.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 01/04/2024] [Accepted: 01/25/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Autoantibodies against the potassium voltage-gated channel subfamily A member 2 (KCNA2) have been described in a few cases of neuropsychiatric disorders, but their diagnostic and pathophysiological role is currently unknown, imposing challenges to medical practice. DESIGN / METHODS We retrospectively collected comprehensive clinical and paraclinical data of 35 patients with KCNA2 IgG autoantibodies detected in cell-based and tissue-based assays. Patients' sera and cerebrospinal fluid (CSF) were used for characterization of the antigen, clinical-serological correlations, and determination of IgG subclasses. RESULTS KCNA2 autoantibody-positive patients (n = 35, median age at disease onset of 65 years, range of 16-83 years, 74 % male) mostly presented with cognitive impairment and/or epileptic seizures but also ataxia, gait disorder and personality changes. Serum autoantibodies belonged to IgG3 and IgG1 subclasses and titers ranged from 1:32 to 1:10,000. KCNA2 IgG was found in the CSF of 8/21 (38 %) patients and in the serum of 4/96 (4.2 %) healthy blood donors. KCNA2 autoantibodies bound to characteristic anatomical areas in the cerebellum and hippocampus of mammalian brain and juxtaparanodal regions of peripheral nerves but reacted exclusively with intracellular epitopes. A subset of four KCNA2 autoantibody-positive patients responded markedly to immunotherapy alongside with conversion to seronegativity, in particular those presenting an autoimmune encephalitis phenotype and receiving early immunotherapy. An available brain biopsy showed strong immune cell invasion. KCNA2 autoantibodies occurred in less than 10 % in association with an underlying tumor. CONCLUSION Our data suggest that KCNA2 autoimmunity is clinically heterogeneous. Future studies should determine whether KCNA2 autoantibodies are directly pathogenic or develop secondarily. Early immunotherapy should be considered, in particular if autoantibodies occur in CSF or if clinical or diagnostic findings suggest ongoing inflammation. Suspicious clinical phenotypes include autoimmune encephalitis, atypical dementia, new-onset epilepsy and unexplained epileptic seizures.
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Affiliation(s)
- Friederike A Arlt
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Ramona Miske
- Institute for Experimental Immunology, affiliated to EUROIMMUN Medizinische Labordiagnostika AG, Lübeck, Germany
| | - Marie-Luise Machule
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | | | - Swantje Mindorf
- Institute for Experimental Immunology, affiliated to EUROIMMUN Medizinische Labordiagnostika AG, Lübeck, Germany
| | - Bianca Teegen
- Clinical immunological Laboratory Prof. Stöcker, Groß Grönau, Germany
| | - Kathrin Borowski
- Clinical immunological Laboratory Prof. Stöcker, Groß Grönau, Germany
| | - Maria Buthut
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Rosa Rößling
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Elisa Sánchez-Sendín
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Scott van Hoof
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - César Cordero-Gómez
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Isabel Bünger
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Helena Radbruch
- Department of Neuropathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Andrea Kraft
- Department of Neurology, Hospital Martha-Maria, Halle, Germany
| | - Ilya Ayzenberg
- Department of Neurology, St Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Jaqueline Klausewitz
- Department of Neurology, St Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Niels Hansen
- Department of Psychiatry and Psychotherapy, University Göttingen Medical Center, Göttingen, Germany
| | - Charles Timäus
- Department of Psychiatry and Psychotherapy, University Göttingen Medical Center, Göttingen, Germany
| | - Peter Körtvelyessy
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany; German Center for Neurodegenerative Diseases (DZNE) Magdeburg, Magdeburg, Germany
| | - Thomas Postert
- Department of Neurology, St. Vincenz-Krankenhaus Paderborn, Paderborn, Germany
| | - Kirsten Baur-Seack
- Department of Neurology, St. Vincenz-Krankenhaus Paderborn, Paderborn, Germany
| | - Constanze Rost
- Department of Neurology, St. Vincenz-Krankenhaus Paderborn, Paderborn, Germany
| | - Robert Brunkhorst
- Department of Neurology, University Hospital Aachen, Aachen, Germany
| | - Kathrin Doppler
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Niklas Haigis
- Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, University of Heidelberg, Heidelberg, Germany
| | - Gerhard Hamann
- Department of Neurology and Neurological Rehabilitation, BKH Günzburg, Günzburg, Germany
| | - Albrecht Kunze
- Department of Neurology, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Alexandra Stützer
- Department of Neurology, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Matthias Maschke
- Department of Neurology, Campus Trier, University of Mainz, Trier, Germany
| | - Nico Melzer
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe University Frankfurt, Frankfurt on the Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University, Frankfurt, Germany
| | - Kai Siebenbrodt
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe University Frankfurt, Frankfurt on the Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University, Frankfurt, Germany
| | - Christian Stenør
- Department of Neurology, Copenhagen University Hospital, Herlev-Gentofte, Denmark
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany; German Center for Neurodegenerative Diseases (DZNE) Munich, Munich, Germany
| | - Marios K Georgakis
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Rong Fang
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Gabor C Petzold
- German Center for Neurodegenerative Diseases (DZNE) Bonn, Bonn, Germany; Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Michael Görtler
- German Center for Neurodegenerative Diseases (DZNE) Magdeburg, Magdeburg, Germany; Department of Neurology, University Hospital, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Inga Zerr
- German Center for Neurodegenerative Diseases (DZNE) Göttingen, Göttingen, Germany; Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Silke Wunderlich
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | | | - Paul Turko
- Institute for Integrative Neuroanatomy, Charité-Universitätsmedizin, Berlin, Germany
| | | | - Emilie Buchholz
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Helle Foverskov Rasmussen
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Mahoor Nasouti
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Ivan Talucci
- Department of Neurology, University of Würzburg, Würzburg, Germany; Rudolf Virchow Center, Center for Integrative and Translational Bioimaging, University of Würzburg, Würzburg, Germany
| | - Hans M Maric
- Rudolf Virchow Center, Center for Integrative and Translational Bioimaging, University of Würzburg, Würzburg, Germany
| | - Stefan H Heinemann
- Friedrich Schiller University and Jena University Hospital, Center for Molecular Biomedicine, Department of Biophysics, Jena, Germany
| | - Matthias Endres
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Lars Komorowski
- Institute for Experimental Immunology, affiliated to EUROIMMUN Medizinische Labordiagnostika AG, Lübeck, Germany
| | - Harald Prüss
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany.
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11
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Kimura A. [Clinical features and pathogenesis of Glial fibrillary acidic protein (GFAP) antibody-associated disorders]. Rinsho Shinkeigaku 2024; 64:75-84. [PMID: 38281748 DOI: 10.5692/clinicalneurol.cn-001925] [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] [Indexed: 01/30/2024]
Abstract
Glial fibrillary acidic protein (GFAP) antibody-associated disorders (AD) were recently proposed to be immune-mediated neurological disorders. The pathogenesis of GFAP antibody-AD is poorly understood. Pathologically, there is a marked infiltration of large numbers of lymphocytes, including CD8+ and CD4+ T cells, into the meningeal and brain parenchyma, especially around the perivascular areas. GFAP-specific cytotoxic T cells are considered to be the effector cells of GFAP antibody-AD. The common phenotype of GFAP antibody-AD includes meningoencephalitis with or without myelitis. During the clinical disease course, patients present with consciousness disturbances, urinary dysfunction, movement disorders, meningeal irritation, and cognitive dysfunction. The detection of GFAP antibodies in the cerebrospinal fluid (CSF) by cell-based assay is essential for a diagnosis of GFAP antibody-AD. The CSF can be examined for lymphocyte-predominant pleocytosis and elevated protein levels. Brain linear perivascular radial enhancement patterns are observed in about half of GFAP antibody-AD patients. Spinal cord magnetic resonance imaging is used to detect longitudinal extensive spinal cord lesions. Although corticosteroid therapy is generally effective, some patients have a poor prognosis and relapse.
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Affiliation(s)
- Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine
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12
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Guo Y, Endmayr V, Zekeridou A, McKeon A, Leypoldt F, Hess K, Kalinowska-Lyszczarz A, Klang A, Pakozdy A, Höftberger E, Hametner S, Haider C, De Simoni D, Peters S, Gelpi E, Röcken C, Oberndorfer S, Lassmann H, Lucchinetti CF, Höftberger R. New insights into neuropathology and pathogenesis of autoimmune glial fibrillary acidic protein meningoencephalomyelitis. Acta Neuropathol 2024; 147:31. [PMID: 38310187 PMCID: PMC10838242 DOI: 10.1007/s00401-023-02678-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/06/2023] [Accepted: 12/24/2023] [Indexed: 02/05/2024]
Abstract
Anti-glial fibrillary acidic protein (GFAP) meningoencephalomyelitis (autoimmune GFAP astrocytopathy) is a new autoimmune central nervous system (CNS) disease diagnosable by the presence of anti-GFAP autoantibodies in the cerebrospinal fluid and presents as meningoencephalomyelitis in the majority of patients. Only few neuropathological reports are available and little is known about the pathogenic mechanisms. We performed a histopathological study of two autopsies and nine CNS biopsies of patients with anti-GFAP autoantibodies and found predominantly a lymphocytic and in one autopsy case a granulomatous inflammatory phenotype. Inflammatory infiltrates were composed of B and T cells, including tissue-resident memory T cells. Although obvious astrocytic damage was absent in the GFAP-staining, we found cytotoxic T cell-mediated reactions reflected by the presence of CD8+/perforin+/granzyme A/B+ cells, polarized towards astrocytes. MHC-class-I was upregulated in reactive astrocytes of all biopsies and two autopsies but not in healthy controls. Importantly, we observed a prominent immunoreactivity of astrocytes with the complement factor C4d. Finally, we provided insight into an early phase of GFAP autoimmunity in an autopsy of a pug dog encephalitis that was characterized by marked meningoencephalitis with selective astrocytic damage with loss of GFAP and AQP4 in the lesions.Our histopathological findings indicate that a cytotoxic T cell-mediated immune reaction is present in GFAP autoimmunity. Complement C4d deposition on astrocytes could either represent the cause or consequence of astrocytic reactivity. Selective astrocytic damage is prominent in the early phase of GFAP autoimmunity in a canine autopsy case, but mild or absent in subacute and chronic stages in human disease, probably due to the high regeneration potential of astrocytes. The lymphocytic and granulomatous phenotypes might reflect different stages of lesion development or patient-specific modifications of the immune response. Future studies will be necessary to investigate possible implications of pathological subtypes for clinical disease course and therapeutic strategies.
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Affiliation(s)
- Yong Guo
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Verena Endmayr
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
- Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
- Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Frank Leypoldt
- Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein Kiel, Lübeck, Germany
- Department of Neurology, University Medical Center Schleswig-Holstein and Kiel University, Kiel, Germany
| | - Katharina Hess
- Institute of Neuropathology, University Hospital Muenster, Muenster, North Rhine Westphalia, Germany
- Department of Pathology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Alicja Kalinowska-Lyszczarz
- Department of Neurology, Division of Neurochemistry and Neuropathology, Poznan University of Medical Sciences, Poznań, Poland
| | - Andrea Klang
- Institute of Pathology, University of Veterinary Medicine, Vienna, Austria
| | - Akos Pakozdy
- Internal Medicine, University Clinic for Small Animals, University of Veterinary Medicine, Vienna, Austria
| | - Elisabeth Höftberger
- Internal Medicine, University Clinic for Small Animals, University of Veterinary Medicine, Vienna, Austria
| | - Simon Hametner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Carmen Haider
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Désirée De Simoni
- Division of Neurology, Karl Landsteiner University of Health Sciences, University Hospital, St. Pölten, Austria
| | - Sönke Peters
- Clinic for Radiology and Neuroradiology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Ellen Gelpi
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christoph Röcken
- Department of Pathology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Stefan Oberndorfer
- Division of Neurology, Karl Landsteiner University of Health Sciences, University Hospital, St. Pölten, Austria
| | - Hans Lassmann
- Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | | | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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McKeon A, Tracy J. Paraneoplastic movement disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:211-227. [PMID: 38494279 DOI: 10.1016/b978-0-12-823912-4.00004-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic movement disorders are diverse autoimmune neurological illnesses occurring in the context of systemic cancer, either in isolation or as part of a multifocal neurological disease. Movement phenomena may be ataxic, hypokinetic (parkinsonian), or hyperkinetic (myoclonus, chorea, or other dyskinetic disorders). Some disorders mimic neurodegenerative or hereditary illnesses. The subacute onset and coexisting nonclassic features of paraneoplastic disorders aid distinction. Paraneoplastic autoantibodies provide further information regarding differentiating cancer association, disease course, and treatment responses. A woman with cerebellar ataxia could have metabotropic glutamate receptor 1 autoimmunity, in the setting of Hodgkin lymphoma, a mild neurological phenotype and response to immunotherapy. A different woman, also with cerebellar ataxia, could have Purkinje cytoplasmic antibody type 1 (anti-Yo), accompanying ovarian adenocarcinoma, a rapidly progressive phenotype and persistent disabling deficits despite immune therapy. The list of antibody biomarkers is growing year-on-year, each with its own ideal specimen type for detection (serum or CSF), accompanying neurological manifestations, cancer association, treatment response, and prognosis. Therefore, a profile-based approach to screening both serum and CSF is recommended. Immune therapy trials are generally undertaken, and include one or more of corticosteroids, IVIg, plasma exchange, rituximab, or cyclophosphamide. Symptomatic therapies can also be employed for hyperkinetic disorders.
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Affiliation(s)
- Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
| | - Jennifer Tracy
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
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14
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Wagner B, Irani S. Autoimmune and paraneoplastic seizures. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:151-172. [PMID: 38494275 DOI: 10.1016/b978-0-12-823912-4.00009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Seizures are a common feature of autoimmune encephalitis and are especially prevalent in patients with the commonest autoantibodies, against LGI1, CASPR2 and the NMDA, GABAB, and GABAA receptors. In this chapter, we discuss the classification, clinical, investigation, and treatment aspects of patients with these, and other autoantibody-mediated and -associated, illnesses. We highlight distinctive and common seizure semiologies which, often alongside other features we outline, can help the clinical diagnosis of an autoantibody-associated syndrome. Next, we classify these syndromes by either focusing on whether they represent underlying causative autoantibodies or T-cell-mediated syndromes and on the distinction between acute symptomatic seizures and a more enduring tendency to autoimmune-associated epilepsy, a practical and valuable distinction for both patients and clinicians which relates to the pathogenesis. We emphasize the more effective immunotherapy response in patients with causative autoantibodies, and discuss the emerging evidence for various first-, second-, and third-line immunotherapies. Finally, we highlight available clinical rating scales which can guide autoantibody testing and immunotherapy in patients with seizures of unknown etiology. Throughout, we relate the clinical and therapeutic observations to the immunobiology and neuroscience which drive these seizures.
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Affiliation(s)
- Barbara Wagner
- Neuroscience Department, NDCN, University of Oxford and Oxford University Hospitals, Oxford, United Kingdom; Kantonsspital Aarau Switzerland, Tellstrasse, Aarau, Switzerland
| | - Sarosh Irani
- Neuroscience Department, NDCN, University of Oxford and Oxford University Hospitals, Oxford, United Kingdom.
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15
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Villagrán-García M, Farina A, Campetella L, Arzalluz-Luque J, Honnorat J. Autonomic nervous system involvement in autoimmune encephalitis and paraneoplastic neurological syndromes. Rev Neurol (Paris) 2024; 180:107-116. [PMID: 38142198 DOI: 10.1016/j.neurol.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 12/25/2023]
Abstract
In autoimmune neurological diseases, the autonomic nervous system can be the primary target of autoimmunity (e.g. autoimmune autonomic ganglionopathy), or, more frequently, be damaged together with other areas of the nervous system (e.g. Guillain-Barré syndrome). Patients with autoimmune encephalitis and paraneoplastic neurological syndromes (PNS) often develop dysautonomia; however, the frequency and spectrum of autonomic signs and symptoms remain ill defined except for those scenarios in which dysautonomia is a core feature of the disease. Such is the case of Lambert-Eaton myasthenic syndrome, Morvan syndrome or anti-NMDAR encephalitis; in the latter, patients with dysautonomia have been reported to carry a more severe disease and to retain higher disability than those without autonomic dysfunction. Likewise, the presence of autonomic involvement indicates a higher risk of death due to neurological cause in patients with anti-Hu PNS. However, in anti-Hu and other PNS, as well as in the context of immune checkpoint inhibitors' toxicities, the characterization of autonomic involvement is frequently overshadowed by the severity of other neurological symptoms and signs. When evaluated with tests specific for autonomic function, patients with autoimmune encephalitis or PNS usually show a more widespread autonomic involvement than clinically suggested, which may reflect a potential gap of care when it comes to diagnosing dysautonomia. This review aims to revise the autonomic involvement in patients with autoimmune encephalitis and PNS, using for that purpose an antibody-based approach. We also discuss and provide general recommendations for the evaluation and management of dysautonomia in these patients.
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Affiliation(s)
- M Villagrán-García
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Inserm U1314, MeLiS-UCBL-CNRS UMR 5284, University Claude-Bernard Lyon 1, Lyon, France
| | - A Farina
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Inserm U1314, MeLiS-UCBL-CNRS UMR 5284, University Claude-Bernard Lyon 1, Lyon, France; Department of Neuroscience, Psychology, Pharmacology and Child Health, University of Florence, Florence, Italy
| | - L Campetella
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Inserm U1314, MeLiS-UCBL-CNRS UMR 5284, University Claude-Bernard Lyon 1, Lyon, France
| | - J Arzalluz-Luque
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - J Honnorat
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Inserm U1314, MeLiS-UCBL-CNRS UMR 5284, University Claude-Bernard Lyon 1, Lyon, France.
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16
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Budhram A, Flanagan EP. Optimizing the diagnostic performance of neural antibody testing for paraneoplastic and autoimmune encephalitis in clinical practice. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:365-382. [PMID: 38494290 DOI: 10.1016/b978-0-12-823912-4.00002-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
The detection of neural antibodies in patients with paraneoplastic and autoimmune encephalitis has majorly advanced the diagnosis and management of neural antibody-associated diseases. Although testing for these antibodies has historically been restricted to specialized centers, assay commercialization has made this testing available to clinical chemistry laboratories worldwide. This improved test accessibility has led to reduced turnaround time and expedited diagnosis, which are beneficial to patient care. However, as the utilization of these assays has increased, so too has the need to evaluate how they perform in the clinical setting. In this chapter, we discuss assays for neural antibody detection that are in routine use, draw attention to their limitations and provide strategies to help clinicians and laboratorians overcome them, all with the aim of optimizing neural antibody testing for paraneoplastic and autoimmune encephalitis in clinical practice.
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Affiliation(s)
- Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, ON, Canada; Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada.
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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Kadish R, Clardy SL. Epidemiology of paraneoplastic neurologic syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:57-77. [PMID: 38494297 DOI: 10.1016/b978-0-12-823912-4.00011-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes (PNS), initially depicted as seemingly cryptic remote manifestations of malignancy, were first described clinically in the early 20th century, with pathophysiologic correlates becoming better elucidated in the latter half of the century. There remain many questions not only about the pathophysiology but also regarding the epidemiology of these conditions. The continuous discovery of novel autoantigens and related neurologic disease has broadened the association in classical PNS to include conditions such as paraneoplastic cerebellar degeneration. It has also brought into focus several other neurologic syndromes with a putative neoplastic association. These conditions are overall rare, making it difficult to capture large numbers of patients to study, and raising the question of whether incidence is increasing over time or improved identification is driving the increased numbers of cases. With the rise and increasing use of immunotherapy for cancer treatment, the incidence of these conditions is additionally expected to rise and may present with various clinical symptoms. As we enter an era of clinical trial intervention in these conditions, much work is needed to capture more granular data on population groups defined by socioeconomic characteristics such as age, ethnicity, economic resources, and gender to optimize care and clinical trial planning.
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Affiliation(s)
- Robert Kadish
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Stacey L Clardy
- Department of Neurology, University of Utah, Salt Lake City, UT, United States; George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States.
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18
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Jean MJ, Samkoff L, Mohile N. Management of Paraneoplastic Syndromes in the Era of Immune Checkpoint Inhibitors. Curr Treat Options Oncol 2024; 25:42-65. [PMID: 38198120 DOI: 10.1007/s11864-023-01157-1] [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] [Accepted: 11/22/2023] [Indexed: 01/11/2024]
Abstract
OPINION STATEMENT Our understanding of paraneoplastic neurologic syndromes (PNS) has blossomed over the past few decades. Clinicians have access to more robust diagnostic criteria and have a heightened index of suspicion for these disorders. Nonetheless, treatment, which typically includes immunosuppression, and response to treatment, varies. Due to persistent difficulty in making a definitive diagnosis, we favor empiric treatment when a possible diagnosis of PNS is suspected, and other alternative causes have substantially been excluded (e.g., infections, toxic-metabolic derangements, metastasis, or leptomeningeal disease). Treatment of the underlying cancer, if identified, is the first therapeutic step and can prevent disease worsening and in rare cases, can reverse neurologic symptoms. In addition to anti-cancer treatment, first line immunotherapies, which include corticosteroids, intravenous immunoglobulins (IVIG), or plasma exchange (PLEX) are typically used. If partial or no benefit is seen, second line immunotherapeutic agents such as rituximab are considered. Additionally, the severity of the initial presentation and possible risk for relapse influences the use of the latter agents. Symptomatic management is also an important component in our practice and will depend on the syndrome being treated. One of the more novel entities we are facing currently is the management of immune checkpoint (ICI)-induced PNS. In those cases, current American Society of Clinical Oncology (ASCO) guidelines are followed.
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Affiliation(s)
- Maxime Junior Jean
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Lawrence Samkoff
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Nimish Mohile
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA.
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Bien CG, Büttner T, Reichen IC, Thomas A, Vlad B, Woermann F, Bien CI, Jelcic I. Glial Fibrillary Acidic Protein Autoimmunity After Aseptic Meningitis: A Report of 2 Cases. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200180. [PMID: 37949666 PMCID: PMC10691222 DOI: 10.1212/nxi.0000000000200180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/21/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVES We describe 2 patients with glial fibrillary acidic protein (GFAP) autoimmunity secondary to aseptic viral meningitis or meningoencephalomyelitis. METHODS This study involved a retrospective chart review. RESULTS Two female patients, 45 and 55 years of age, developed aseptic meningoencephalomyelitis or meningitis; in one patient, it was likely caused by herpes simplex virus 2. The patients were recovering from the infectious condition when they, 51 and 5 days after onset, had new symptoms with detection of GFAP antibodies in the CSF; CSF and serum samples from the initial lumbar punctures had been negative for GFAP antibodies. Both patients recovered with steroid treatment (in one case, plus rituximab; in the other, plus azathioprine) including resolution of MRI and CSF abnormalities. DISCUSSION These 2 patients had GFAP autoimmunity secondary to viral meningoencephalomyelitis or meningitis. This suggests that GFAP astrocytopathy might not always be a primary disease entity; it may follow another brain injury that triggers this autoimmune response.
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Affiliation(s)
- Christian G Bien
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany.
| | - Thomas Büttner
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Ina C Reichen
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Annette Thomas
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Benjamin Vlad
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Friedrich Woermann
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Corinna I Bien
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany.
| | - Ilijas Jelcic
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
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Montalvo M, Flanagan EP. Paraneoplastic/autoimmune myelopathies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:193-201. [PMID: 38494277 DOI: 10.1016/b978-0-12-823912-4.00017-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic myelopathies are a rare but important category of myelopathy. They usually present with an insidious or subacute progressive neurologic syndrome. Risk factors include tobacco use and family history of cancer. Cerebrospinal fluid analysis usually shows lymphocytic pleocytosis with elevated protein. MRI findings suggest that paraneoplastic myelopathies include longitudinally extensive T2 hyperintensities that are tract-specific and accompanied by enhancement, but spinal MRIs can also be normal. The most commonly associated neural antibodies include amphiphysin and collapsin-response-mediator-protein-5 (CRMP5/anti-CV2) antibodies with lung and breast cancers being the most frequent oncologic accompaniments. The differential diagnosis of paraneoplastic myelopathies includes nutritional deficiency myelopathy (B12, copper) as well as autoimmune/inflammatory conditions such as primary progressive multiple sclerosis or spinal cord sarcoidosis. Patients treated with immune checkpoint inhibitors for cancer may develop myelitis, that can be considered along the spectrum of paraneoplastic myelopathies. Management of paraneoplastic myelopathy includes oncologic treatment and immunotherapy. Despite these treatments, the prognosis is poor and the majority of patients eventually become wheelchair-dependent.
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Affiliation(s)
- Mayra Montalvo
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
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21
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Tang M, Huang S, Guo W, Zhou J, Huang Z, Li W, Sun Q, Wang Z. Case report: Excessive daytime sleepiness as a presenting manifestation of autoimmune glial fibrillary acidic protein astrocytopathy. Front Immunol 2023; 14:1302514. [PMID: 38173730 PMCID: PMC10761546 DOI: 10.3389/fimmu.2023.1302514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
Autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A) is a recently discovered autoimmune inflammatory disease of the central nervous system. It presents with a variety of clinical symptoms, including fever, seizures, psychiatric symptoms, limber weakness, and sensory symptoms. However, the symptoms of sleep disorders have not been sufficiently addressed. Here, we report a case of GFAP-A in which the patient complained of excessive daytime sleepiness and an excessive need for sleep. Our patient was a 58-year-old male who experienced excessive daytime sleepiness for 50 days following SARS-CoV-2 infection. He was diagnosed with coronavirus disease 2019 on June 1st. On the 7th of June, he experienced excessive daytime sleepiness, nausea, reduced food intake, lower limb weakness, and dysuria. Subsequently, his sleepiness significantly deteriorated on July 21st. Five months prior, the patient underwent laparoscopic partial right nephrectomy for clear-cell renal cell carcinoma. Brain MRI revealed abnormal hyperintense lesions in the pontine brain and around the mesencephalic aqueduct on T2 and T2-fluid attenuated inversion recovery (T2-FLAIR) sequences However, these lesions did not exhibit any pathological enhancement. Spinal cord MRI revealed lesions in the C6-C7 and T2-T3 segments on the T2 sequence. His Epworth Sleepiness Scale (ESS) score was 16 (reference range, <10), and 24-hour polysomnography supported the diagnosis of rapid-eye-movement sleep disorder and severe sleep apnea-hypopnea syndrome. Glial fibrillary acidic protein IgG antibodies were detected in the cerebrospinal fluid (1:32, cell-based assay) but not in the serum. The level of hypocretin in the cerebrospinal fluid was 29.92 pg/mL (reference range ≥110 pg/mL), suggesting narcolepsy type 1. After treatment with corticosteroids for approximately 1 month, the patient showed considerable clinical and radiological improvement, as well as an increase in hypocretin levels. Although repeated polysomnography and multiple sleep latency tests suggested narcolepsy, his ESS score decreased to 8. Our findings broaden the range of clinical manifestations associated with GFAP-A, thereby enhancing diagnostic and therapeutic strategies for this disease. Additionally, our results indicate a potential common autoimmune mechanism involving GFAP-A and orexin system dysregulation, warranting further investigation.
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Affiliation(s)
| | | | | | | | | | | | | | - Zan Wang
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin, China
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22
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Lowe MC, Money KM, Matthews E, Pastula DM, Piquet AL. case of autoimmune GFAP astrocytopathy with eosinophils in the cerebrospinal fluid. J Neuroimmunol 2023; 385:578249. [PMID: 37992587 DOI: 10.1016/j.jneuroim.2023.578249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 11/24/2023]
Abstract
Cerebrospinal fluid (CSF) eosinophilia is associated with a narrow differential, primarily including parasitic and fungal infections, neoplasm, and chemical meningitis. It has rarely been reported in neuroinflammatory conditions including as a finding of CSF cytology in two autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy cases. Here we describe a case of autoimmune GFAP astrocytopathy with classic clinical and radiographic features as well as presence of eosinophils in the CSF. This case highlights a potential association of eosinophils in the CSF with autoimmune GFAP astrocytopathy, which may suggest its inclusion in the differential diagnosis of eosinophilic meningitis, encephalitis, or myelitis.
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Affiliation(s)
- Mallory C Lowe
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Kelli M Money
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Elizabeth Matthews
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Daniel M Pastula
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States of America; Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, United States of America; Department of Epidemiology, Colorado School of Public Health, Aurora, CO, United States of America
| | - Amanda L Piquet
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States of America.
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Oprea E, Elosegi JA. Autoimmune GFAP-IgG astrocytopathy manifesting with acute cerebellitis and severe gastrointestinal symptoms. Rev Neurol (Paris) 2023; 179:1147-1151. [PMID: 37858434 DOI: 10.1016/j.neurol.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/31/2023] [Accepted: 08/04/2023] [Indexed: 10/21/2023]
Affiliation(s)
- E Oprea
- Neurology department, Cliniques Universitaires Saint Luc, Bruxelles, Belgique.
| | - J A Elosegi
- Neurology department, CHU Ambroise-Paré, Mons, Belgique
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24
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Weidauer S, Hattingen E, Arendt CT. Cervical myelitis: a practical approach to its differential diagnosis on MR imaging. ROFO-FORTSCHR RONTG 2023; 195:1081-1096. [PMID: 37479218 DOI: 10.1055/a-2114-1350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
BACKGROUND Differential diagnosis of non-compressive cervical myelopathy encompasses a broad spectrum of inflammatory, infectious, vascular, neoplastic, neurodegenerative, and metabolic etiologies. Although the speed of symptom onset and clinical course seem to be specific for certain neurological diseases, lesion pattern on MR imaging is a key player to confirm diagnostic considerations. METHODS The differentiation between acute complete transverse myelitis and acute partial transverse myelitis makes it possible to distinguish between certain entities, with the latter often being the onset of multiple sclerosis. Typical medullary MRI lesion patterns include a) longitudinal extensive transverse myelitis, b) short-range ovoid and peripheral lesions, c) polio-like appearance with involvement of the anterior horns, and d) granulomatous nodular enhancement prototypes. RESULTS AND CONCLUSION Cerebrospinal fluid analysis, blood culture tests, and autoimmune antibody testing are crucial for the correct interpretation of imaging findings. The combination of neuroradiological features and neurological and laboratory findings including cerebrospinal fluid analysis improves diagnostic accuracy. KEY POINTS · The differentiation of medullary lesion patterns, i. e., longitudinal extensive transverse, short ovoid and peripheral, polio-like, and granulomatous nodular, facilitates the diagnosis of myelitis.. · Discrimination of acute complete and acute partial transverse myelitis makes it possible to categorize different entities, with the latter frequently being the overture of multiple sclerosis (MS).. · Neuromyelitis optica spectrum disorders (NMOSD) may start as short transverse myelitis and should not be mistaken for MS.. · The combination of imaging features and neurological and laboratory findings including cerebrospinal fluid analysis improves diagnostic accuracy.. · Additional brain imaging is mandatory in suspected demyelinating, systemic autoimmune, infectious, paraneoplastic, and metabolic diseases..
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Affiliation(s)
- Stefan Weidauer
- Institute for Neuroradiology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Elke Hattingen
- Institute for Neuroradiology, Goethe University Frankfurt, Frankfurt am Main, Germany
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Uppal P, Smith J, Castillo-Pinto C, Wells EM, Jayakar A, Harrar D. Glial Fibrillary Acidic Protein (GFAP) Astrocytopathy: An Emerging Cause of Meningoencephalomyelitis in Children and Adolescents. J Child Neurol 2023; 38:659-664. [PMID: 37981797 DOI: 10.1177/08830738231214301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
Introduction: We describe 5 children with GFAP astrocytopathy with the goal of further characterizing this rare form of meningoencephalomyelitis. Methods: Retrospective chart review of patients diagnosed with GFAP astrocytopathy between 2019 and 2021. Results: Patients were 8-17 years old, and all were male. Fever, headache, and vomiting were common presenting symptoms, and weakness, tremor, and ataxia were common initial examination findings. Initial magnetic resonance imaging (MRI) showed spinal cord abnormalities in 2 patients and leptomeningeal enhancement in 1. Most patients had cerebral spinal fluid pleocytosis, and all screened negative for malignancy. Three patients progressed to coma, and all were treated with immunosuppressant therapy. By discharge, all patients had improved over their clinical nadir, although none had returned to baseline. Discussion: GFAP astrocytopathy is a recently recognized cause of meningoencephalomyelitis in children. Here, we expand our understanding of this entity with the goal of aiding those treating children with GFAP astrocytopathy.
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Affiliation(s)
- Prayerna Uppal
- The School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | - Jacklyn Smith
- Department of Neurology, Nicklaus Children's Hospital, Miami, FL, USA
| | | | - Elizabeth M Wells
- Division of Neurology, Children's National Hospital, Washington, DC, USA
| | - Anuj Jayakar
- Department of Neurology, Nicklaus Children's Hospital, Miami, FL, USA
| | - Dana Harrar
- Division of Neurology, Children's National Hospital, Washington, DC, USA
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Greco G, Colombo E, Gastaldi M, Ahmad L, Tavazzi E, Bergamaschi R, Rigoni E. Beyond Myelin Oligodendrocyte Glycoprotein and Aquaporin-4 Antibodies: Alternative Causes of Optic Neuritis. Int J Mol Sci 2023; 24:15986. [PMID: 37958968 PMCID: PMC10649355 DOI: 10.3390/ijms242115986] [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: 10/02/2023] [Revised: 10/27/2023] [Accepted: 11/02/2023] [Indexed: 11/15/2023] Open
Abstract
Optic neuritis (ON) is the most common cause of vision loss in young adults. It manifests as acute or subacute vision loss, often accompanied by retrobulbar discomfort or pain during eye movements. Typical ON is associated with Multiple Sclerosis (MS) and is generally mild and steroid-responsive. Atypical forms are characterized by unusual features, such as prominent optic disc edema, poor treatment response, and bilateral involvement, and they are often associated with autoantibodies against aquaporin-4 (AQP4) or Myelin Oligodendrocyte Glycoprotein (MOG). However, in some cases, AQP4 and MOG antibodies will return as negative, plunging the clinician into a diagnostic conundrum. AQP4- and MOG-seronegative ON warrants a broad differential diagnosis, including autoantibody-associated, granulomatous, and systemic disorders. These rare forms need to be identified promptly, as their management and prognosis are greatly different. The aim of this review is to describe the possible rarer etiologies of non-MS-related and AQP4- and MOG-IgG-seronegative inflammatory ON and discuss their diagnoses and treatments.
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Affiliation(s)
- Giacomo Greco
- Multiple Sclerosis Centre, IRCCS Mondino Foundation, 27100 Pavia, Italy; (G.G.); (E.C.); (L.A.); (E.T.); (R.B.)
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy
| | - Elena Colombo
- Multiple Sclerosis Centre, IRCCS Mondino Foundation, 27100 Pavia, Italy; (G.G.); (E.C.); (L.A.); (E.T.); (R.B.)
| | - Matteo Gastaldi
- Neuroimmunology Research Unit, IRCCS Mondino Foundation, 27100 Pavia, Italy;
| | - Lara Ahmad
- Multiple Sclerosis Centre, IRCCS Mondino Foundation, 27100 Pavia, Italy; (G.G.); (E.C.); (L.A.); (E.T.); (R.B.)
| | - Eleonora Tavazzi
- Multiple Sclerosis Centre, IRCCS Mondino Foundation, 27100 Pavia, Italy; (G.G.); (E.C.); (L.A.); (E.T.); (R.B.)
| | - Roberto Bergamaschi
- Multiple Sclerosis Centre, IRCCS Mondino Foundation, 27100 Pavia, Italy; (G.G.); (E.C.); (L.A.); (E.T.); (R.B.)
| | - Eleonora Rigoni
- Multiple Sclerosis Centre, IRCCS Mondino Foundation, 27100 Pavia, Italy; (G.G.); (E.C.); (L.A.); (E.T.); (R.B.)
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27
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Quack L, Glatter S, Wegener-Panzer A, Cleaveland R, Bertolini A, Endmayr V, Seidl R, Breu M, Wendel E, Schimmel M, Baumann M, Rauchenzauner M, Pritsch M, Boy N, Muralter T, Kluger G, Makoswski C, Kraus V, Leiz S, Loehr-Nilles C, Kreth JH, Braig S, Schilling S, Kern J, Blank C, Tro Baumann B, Vieth S, Wallot M, Reindl M, Ringl H, Wandinger KP, Leypoldt F, Höftberger R, Rostásy K. Autoantibody status, neuroradiological and clinical findings in children with acute cerebellitis. Eur J Paediatr Neurol 2023; 47:118-130. [PMID: 38284996 DOI: 10.1016/j.ejpn.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 10/10/2023] [Accepted: 10/13/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Acute cerebellitis (AC) in children and adolescents is an inflammatory disease of the cerebellum due to viral or bacterial infections but also autoimmune-mediated processes. OBJECTIVE To investigate the frequency of autoantibodies in serum and CSF as well as the neuroradiological features in children with AC. MATERIAL AND METHODS Children presenting with symptoms suggestive of AC defined as acute/subacute onset of cerebellar symptoms and MRI evidence of cerebellar inflammation or additional CSF pleocytosis, positive oligoclonal bands (OCBs), and/or presence of autoantibodies in case of negative cerebellar MRI. Children fulfilling the above-mentioned criteria and a complete data set including clinical presentation, CSF studies, testing for neuronal/cerebellar and MOG antibodies as well as MRI scans performed at disease onset were eligible for this retrospective multicenter study. RESULTS 36 patients fulfilled the inclusion criteria for AC (f:m = 14:22, median age 5.5 years). Ataxia was the most common cerebellar symptom present in 30/36 (83 %) in addition to dysmetria (15/36) or dysarthria (13/36). A substantial number of children (21/36) also had signs of encephalitis such as somnolence or seizures. In 10/36 (28 %) children the following autoantibodies (abs) were found: MOG-abs (n = 5) in serum, GFAPα-abs (n = 1) in CSF, GlyR-abs (n = 1) in CSF, mGluR1-abs (n = 1) in CSF and serum. In two further children, antibodies were detected only in serum (GlyR-abs, n = 1; GFAPα-abs, n = 1). MRI signal alterations in cerebellum were found in 30/36 children (83 %). Additional supra- and/or infratentorial lesions were present in 12/36 children, including all five children with MOG-abs. Outcome after a median follow-up of 3 months (range: 1 a 75) was favorable with an mRS ≤2 in 24/36 (67 %) after therapy. Antibody (ab)-positive children were significantly more likely to have a better outcome than ab-negative children (p = .022). CONCLUSION In nearly 30 % of children in our study with AC, a range of abs was found, underscoring that autoantibody testing in serum and CSF should be included in the work-up of a child with suspected AC. The detection of MOG-abs in AC does expand the MOGAD spectrum.
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Affiliation(s)
- L Quack
- Department of Pediatric Neurology, Childreńs Hospital Datteln, University Witten/Herdecke, Datteln, Germany
| | - S Glatter
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Austria; Comprehensive Center for Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - A Wegener-Panzer
- Department of Pediatric Radiology, Childreńs Hospital Datteln, University Witten/Herdecke, Datteln, Germany
| | - R Cleaveland
- Department of Pediatric Radiology, Childreńs Hospital Datteln, University Witten/Herdecke, Datteln, Germany
| | - A Bertolini
- Department of Pediatric Neurology, Childreńs Hospital Datteln, University Witten/Herdecke, Datteln, Germany
| | - V Endmayr
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Austria
| | - R Seidl
- Department of Pediatrics, Bethanien Hospital, Moers, Germany
| | - M Breu
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - E Wendel
- Division of Pediatric Neurology, Department of Pediatrics, Olgahospital, Stuttgart, Germany
| | - M Schimmel
- Division of Pediatric Neurology, Clinic of Pediatrics, Augsburg University Hospital, University of Augsburg, Augsburg, Germany
| | - M Baumann
- Department of Pediatric I, Pediatric Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - M Rauchenzauner
- Department of Pediatric I, Pediatric Neurology, Medical University of Innsbruck, Innsbruck, Austria; Centre of Epilepsy for Children and Adolescents, Schoen Klinik Vogtareuth, Hospital for Neuropediatrics and Neurological Rehabilitation, Vogtareuth, Germany
| | - M Pritsch
- Department of Neuropediatrics, Children's Hospital DRK Siegen, Siegen, Germany
| | - N Boy
- Centre for Child and Adolescent Medicine, Department of General Pediatrics, Division of Neuropediatrics and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - T Muralter
- Centre of Epilepsy for Children and Adolescents, Schoen Klinik Vogtareuth, Hospital for Neuropediatrics and Neurological Rehabilitation, Vogtareuth, Germany
| | - G Kluger
- Centre of Epilepsy for Children and Adolescents, Schoen Klinik Vogtareuth, Hospital for Neuropediatrics and Neurological Rehabilitation, Vogtareuth, Germany; Research Institute for Rehabilitation, Transition, and Palliation, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - C Makoswski
- Pediatric Neurology, Department of Pediatrics, Kinderklinik München Schwabing, School of Medicine, Technical University of Munich, Germany
| | - V Kraus
- Pediatric Neurology, Department of Pediatrics, Kinderklinik München Schwabing, School of Medicine, Technical University of Munich, Germany; Social Pediatrics, Department of Pediatrics, Technical University of Munich, Munich, Germany
| | - S Leiz
- Department of Pediatrics and Adolescent Medicine, Hospital Dritter Orden, Munich, Germany
| | - C Loehr-Nilles
- Department of Neuropediatrics, Klinikum Mutterhaus der Borromäerinnen, Trier, Germany
| | - J H Kreth
- Department of Neuropediatrics, Social Pediatric Center, Klinikum Leverkusen, Leverkusen, Germany
| | - S Braig
- Department of Pediatrics, Klinikum Bayreuth, Bayreuth, Germany
| | - S Schilling
- Department of Neuropediatrics, Clinic of Pediatrics, Barmherzige Brüder St. Hedwig Hospital, Regensburg, Germany
| | - J Kern
- Department of Pediatric Neurology and Developmental Medicine, University Children's Hospital Tübingen, Germany
| | - C Blank
- Department of Pediatric Neurology, Children's Hospital St. Marien, Landshut, Germany
| | - B Tro Baumann
- Department of Neuropediatrics, Children's Hospital DRK Siegen, Siegen, Germany
| | - S Vieth
- Department of Pediatrics, University Medical Center Schleswig Holstein, Kiel, Germany
| | - M Wallot
- Department of Pediatrics, Bethanien Hospital, Moers, Germany
| | - M Reindl
- Clinical Department of Neurology, Medical University of Innsbruck, Austria
| | - H Ringl
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria; Department of Radiology, Klinik Donaustadt, Vienna, Austria
| | - K P Wandinger
- Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Kiel/Lübeck, Germany
| | - F Leypoldt
- Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Kiel/Lübeck, Germany; Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - R Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria.
| | - K Rostásy
- Department of Pediatric Neurology, Childreńs Hospital Datteln, University Witten/Herdecke, Datteln, Germany.
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Theuriet J, Cluse F, Gravier-Dumonceau A, Picard G, Closs S, Rogemond V, Timestit N, Bouhour F, Petiot P, Davy V, Chanson E, Arzalluz-Luque J, Marignier R, Honnorat J, Pegat A. Peripheral nervous system involvement accompanies central nervous system involvement in anti-glial fibrillary acidic protein (GFAP) antibody-related disease. J Neurol 2023; 270:5545-5560. [PMID: 37540278 PMCID: PMC10576672 DOI: 10.1007/s00415-023-11908-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Glial fibrillary acidic protein (GFAP) is expressed by astrocytes in the central nervous system (CNS), but also by immature and regenerative Schwann cells in the peripheral nervous system (PNS). GFAP antibodies (GFAP-Abs) in cerebrospinal fluid (CSF) have been mainly described in patients with meningoencephalomyelitis. We aimed to study PNS symptoms in patients with CSF GFAP-Abs. METHODS We retrospectively included all patients tested positive for GFAP-Abs in the CSF by immunohistochemistry and confirmed by cell-based assay expressing human GFAPα since 2017, from two French reference centers. RESULTS In a cohort of 103 CSF GFAP-Abs patients, 25 (24%) presented with PNS involvement. Among them, the median age at onset was 48 years and 14/25 (56%) were female. Abnormal electroneuromyography was observed in 11/25 patients (44%), including eight isolated radiculopathies, one radiculopathy associated with polyneuropathy, one radiculopathy associated with sensory neuronopathy, and one demyelinating polyradiculoneuropathy. Cranial nerve involvement was observed in 18/25 patients (72%). All patients except one had an associated CNS involvement. The first manifestation of the disease concerned the PNS in three patients. First-line immunotherapy was administered to 18/24 patients (75%). The last follow-up modified Rankin Scale was ≤ 2 in 19/23 patients (83%). Patients with PNS involvement had significantly more bladder dysfunction than patients with isolated CNS involvement (68 vs 40.3%, p = 0.031). CONCLUSIONS PNS involvement in GFAP-Abs autoimmunity is heterogeneous but not rare and is mostly represented by acute or subacute cranial nerve injury and/or lower limb radiculopathy. Rarely, PNS involvement can be the first manifestation revealing the disease.
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Affiliation(s)
- Julian Theuriet
- Service d'electroneuromyographie et de pathologies neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, 59 boulevard Pinel, Bron, France
| | - Florent Cluse
- Service d'electroneuromyographie et de pathologies neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, 59 boulevard Pinel, Bron, France
- Service de Neurologie C, troubles du mouvement et pathologies neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, Bron, France
| | - Alice Gravier-Dumonceau
- Service de Neurologie C, troubles du mouvement et pathologies neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, Bron, France
| | - Géraldine Picard
- French Reference Centre on Paraneoplastic Neurological Syndrome, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
| | - Sterenn Closs
- French Reference Centre on Paraneoplastic Neurological Syndrome, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
| | - Véronique Rogemond
- French Reference Centre on Paraneoplastic Neurological Syndrome, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
| | - Noémie Timestit
- Service de biostatistique, Hospices Civils de Lyon, Lyon, France
| | - Françoise Bouhour
- Service d'electroneuromyographie et de pathologies neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, 59 boulevard Pinel, Bron, France
| | - Philippe Petiot
- Service d'electroneuromyographie et de pathologies neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, 59 boulevard Pinel, Bron, France
| | - Vincent Davy
- Service de neurologie, Hôpital Pitié Salpétrière, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Eve Chanson
- Service de neurologie, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Joaquín Arzalluz-Luque
- Service de Neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, Hôpital Neurologique Pierre-Wertheimer, Hospices Civils de Lyon, Bron, France
| | - Romain Marignier
- Service de Neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, Hôpital Neurologique Pierre-Wertheimer, Hospices Civils de Lyon, Bron, France
- Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre-Wertheimer, Hospices Civils de Lyon, Bron, France
| | - Jerome Honnorat
- French Reference Centre on Paraneoplastic Neurological Syndrome, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
- MeLiS-UCBL-CNRS UMR 5284-INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Antoine Pegat
- Service d'electroneuromyographie et de pathologies neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, 59 boulevard Pinel, Bron, France.
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Liu Q, Yang X, Zhang Bao J, Ma B, Niu X, Wang X, Zhang Q, Quan C. Clinical characteristics of patient with GFAP-IgG: a review of 31 patients from two tertiary referral centers in China. Int J Neurosci 2023:1-12. [PMID: 37897492 DOI: 10.1080/00207454.2023.2277664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/26/2023] [Indexed: 10/30/2023]
Abstract
OBJECTIVE This study presents a comprehensive analysis of the clinical characteristics of 31 patients exhibiting cerebrospinal fluid (CSF) and/or serum positivity for GFAP-IgG, with a specific emphasis on 24 cases demonstrating only GFAP-IgG positivity. The investigation thoroughly evaluates their clinical, radiological, and laboratory features, as well as treatment responses, with the objective of offering clinicians potential diagnostic and therapeutic approaches. METHODS A total of 31 patients with GFAP-IgG in the CSF and/or serum were registered between August 2016 and August 2021 at the General Hospital of Ningxia Medical University and Huashan Hospital of Fudan University. We retrospectively reviewed their clinical records. RESULTS Overall, the patients were positive with GFAP-IgG in their CSF (15/31), in serum (6/31), and both CSF and serum (10/31). Among them, two were eventually diagnosed with astroglioma and primary central nervous system lymphoma, respectively; one patient had typical multiple sclerosis; three exhibited overlapping GFAP-IgG and aquaporin-4-IgG (AQP4-IgG); and one patient was coexisting N-methyl-D-aspartate receptor IgG. The remaining 24 patients were only GFAP-IgG positive. In total, 22 out of the 24 patients had abnormal MRI outcomes, involving the brain, meninges, and spinal cord. Besides, seven of the 24 patients developed optic neuritis. The CSF protein levels positively correlated with the Expanded Disability Status Scale score (EDSSs). Significantly decreased EDSSs, modified Rankin Scale score, GFAP-IgG titer, CSF protein level, and CSF white blood cell counts were observed after immunomodulatory therapy. CONCLUSION The clinical manifestations of GFAP-IgG exhibit a wide range of phenotypes that lack specificity. These findings emphasize the significance of not exclusively relying on the presence of antibodies to diagnose GFAP-A, but rather integrating them with the clinical phenotypes. GFAP-IgG testing enables the diagnosis of autoimmune GFAP astrocytopathy, a treatable autoimmune disease affecting the central nervous system. This condition provides opportunities for investigating innovative mechanisms of CNS autoimmunity and inflammation.
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Affiliation(s)
- Qiang Liu
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, Ningxia Province, China
| | - Xiao Yang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, Ningxia Province, China
| | - Jingzi Zhang Bao
- Department of Neurology and Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
| | - Boya Ma
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, Ningxia Province, China
| | - Xiaoyan Niu
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, Ningxia Province, China
| | - Xu Wang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, Ningxia Province, China
| | - Qing Zhang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, Ningxia Province, China
| | - Chao Quan
- Department of Neurology and Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
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Sun M, Liu H, Zhu B, Liu Y, Li A, Wang L. Comparison of glial fibrillary acidic protein-immunoglobulin G-associated myelitis with myelin oligodendrocyte glycoprotein-immunoglobulin G-associated myelitis. Front Neurol 2023; 14:1266067. [PMID: 38020648 PMCID: PMC10645061 DOI: 10.3389/fneur.2023.1266067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Objective Glial fibrillary acidic protein-immunoglobulin G (GFAP-IgG)-associated myelitis and myelin oligodendrocyte glycoprotein-IgG (MOG-IgG)-associated myelitis have rarely been compared. Therefore, this study aimed to explore the clinical, laboratory, and imaging features of them to identify the differences. Methods Overall, 14 and 24 patients with GFAP-IgG-and MOG-IgG-associated myelitis, respectively, were retrospectively screened and included in the study. Results Among the 14 patients with GFAP-IgG-associated myelitis, the condition was more common in males (71.4%), with a median age of onset of 36.5 years, and more common in adults than in children (35.7%). In contrast, among the 24 patients with MOG-IgG-associated myelitis, the condition was equally divided between males and females, with a median age of onset of 9.5 years and more in children (66.7%) than in adults. The median age of onset of GFAP-IgG-associated myelitis was later than that of the MOG-IgG group. Isolated myelitis was rare in both groups. Elevated cerebrospinal fluid (CSF) protein levels were more prevalent in patients with GFAP-IgG-associated myelitis (64.3%) than in those with MOG-IgG-associated myelitis (16.7%) (p < 0.05), whereas patchy gadolinium enhancement of the cerebral lesion site was less common in patients with GFAP-IgG-associated myelitis than in those with MOG-IgG associated myelitis (p < 0.05). Six patients had a combination of other neurological autoantibodies, the specific mechanism of the overlapping antibodies remains unclear. Conclusion Cerebrospinal fluid analysis and gadolinium enhanced MRI examination may help to distinguish the two kinds of myelitis.
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Affiliation(s)
- Mengyang Sun
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hao Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Bingqing Zhu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yang Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Aijia Li
- Zhengzhou University Medical College, Zhengzhou, China
| | - Limei Wang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Du J, Cao S, Xia L, Li Q, Tian Y. Plasma exchange for two patients with autoimmune GFAP astrocytopathy with rapid progression to respiratory failure: a case report. Front Immunol 2023; 14:1265609. [PMID: 37869007 PMCID: PMC10585171 DOI: 10.3389/fimmu.2023.1265609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 09/13/2023] [Indexed: 10/24/2023] Open
Abstract
Background Patients with autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy can present with early neurological deterioration, but rapidly progressive respiratory failure is rarely reported. We present the cases of two patients with autoimmune GFAP astrocytopathy who experienced rapid progression to respiratory failure and were effectively treated using plasma exchange therapy. Case report Two patients were diagnosed with autoimmune GFAP astrocytopathy. Their initial symptoms were consistent with those of previously observed cases of autoimmune GFAP astrocytopathy. However, they experienced rapid progression to respiratory failure due to their lesion location. Specifically, case 1 had lesions in the medulla oblongata, and case 2 had lesions in the high cervical spinal cord, which are both common sites of lesions causing respiratory failure. The patients did not respond well to intravenous methylprednisolone and intravenous immunoglobulin initially and could not be withdrawn from ventilator support. Fortunately, subsequent plasma exchange therapy led to significant clinical improvements and successful withdrawal from ventilator support. Discussion Patients with autoimmune GFAP astrocytopathy can present with rapidly progressive respiratory failure. Early treatment with plasma exchange can be beneficial in withdrawing patients from ventilator support.
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Affiliation(s)
- Jing Du
- Department of Neurology, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Shugang Cao
- Department of Neurology, Second Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of Neurology, The Second People’s Hospital of Hefei, Affiliated Hefei Hospital of Anhui Medical University, Hefei, China
| | - Lan Xia
- Department of Neurology, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Qi Li
- Department of Neurology, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yanghua Tian
- Department of Neurology, Second Affiliated Hospital of Anhui Medical University, Hefei, China
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Kaga M, Ueda T, Yoshikawa S. A rare case of glial fibrillary acidic protein astrocytopathy that resolved spontaneously within a self-limited course. Heliyon 2023; 9:e20912. [PMID: 37867900 PMCID: PMC10589841 DOI: 10.1016/j.heliyon.2023.e20912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 10/06/2023] [Accepted: 10/11/2023] [Indexed: 10/24/2023] Open
Abstract
Glial fibrillary acidic protein astrocytopathy is a form of autoimmune meningoencephalomyelitis. The presence of antibodies in spinal fluid against glial fibrillary acidic protein is necessary to diagnose the disease. There is no standard treatment and few cases of glial fibrillary acidic protein astrocytopathy have been reported. A 31-year-old healthy Japanese man presented to our emergency department with a 7-day history of fever and headache. He was in good general condition, without abnormalities on physical examination, and a general hematological examination revealed hyponatremia (130 mEq/L). Five days later, he was followed up and new subjective symptoms were noted: tremor in the right hand, constipation, sweating, and lightheadedness. Cerebrospinal fluid examination revealed a cell count of 57/μL (96 % mononuclear cells, 4 % multinuclear cells), elevated protein level (103 mg/dL), elevated adenosine deaminase level (15.0 U/L), negative polymerase chain reaction test results for herpes simplex virus and Mycobacterium tuberculosis, negative cerebrospinal fluid culture, and negative cerebrospinal fluid anti-acid bacteria culture, indicating aseptic meningitis. T1-weighted contrast-enhanced magnetic resonance imaging of the head showed a linear contrast effect perpendicular to the lateral ventricular wall and along the perivascular vessels spreading radially. Based on the presence of hyponatremia, history of movement disorder and autonomic symptoms, high adenosine deaminase level in cerebrospinal fluid, and findings on contrast-enhanced magnetic resonance imaging of the head, we suspected glial fibrillary acidic protein astrocytopathy and assessed anti-glial fibrillary acidic proteinαantibody in cerebrospinal fluid, which was positive, and diagnosed glial fibrillary acidic protein astrocytopathy. After careful follow-up with symptomatic treatment without immunosuppressive therapy, the fever, headache, tremor, and autonomic symptoms were improved over time. Contrast-enhanced magnetic resonance imaging of the head and findings of cerebrospinal fluid also showed improvement. glial fibrillary acidic protein astrocytopathy should be a differential diagnosis in patients with aseptic meningitis with movement disorders or autonomic symptoms and elevated cerebrospinal fluid adenosine deaminase. Careful follow-up without immunosuppressive treatment should be considered for patients with minimal neurologic symptoms as glial fibrillary acidic protein astrocytopathy may have a self-limiting course and resolve.
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Affiliation(s)
- Mihiro Kaga
- Emergency and General Internal Medicine, Rakuwakai Marutamachi Hospital, Kyoto, Japan
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takeshi Ueda
- Emergency and General Internal Medicine, Rakuwakai Marutamachi Hospital, Kyoto, Japan
| | - Satoshi Yoshikawa
- Emergency and General Internal Medicine, Rakuwakai Marutamachi Hospital, Kyoto, Japan
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Kraker JA, Chen JJ. An update on optic neuritis. J Neurol 2023; 270:5113-5126. [PMID: 37542657 DOI: 10.1007/s00415-023-11920-x] [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: 07/09/2023] [Revised: 07/27/2023] [Accepted: 07/30/2023] [Indexed: 08/07/2023]
Abstract
Optic neuritis (ON) is the most common cause of subacute optic neuropathy in young adults. Although most cases of optic neuritis (ON) are classified as typical, meaning idiopathic or associated with multiple sclerosis, there is a growing understanding of atypical forms of optic neuritis such as antibody mediated aquaporin-4 (AQP4)-IgG neuromyelitis optica spectrum disorder (NMOSD) and the recently described entity, myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD). Differentiating typical ON from atypical ON is important because they have different prognoses and treatments. Findings of atypical ON, including severe vision loss with poor recovery with steroids or steroid dependence, prominent optic disc edema, bilateral vision loss, and childhood or late adult onset, should prompt serologic testing for AQP4-IgG and MOG-IgG. Although the traditional division of typical and atypical ON can be helpful, it should be noted that there can be severe presentations of otherwise typical ON and mild presentations of atypical ON that blur these traditional lines. Rare causes of autoimmune optic neuropathies, such as glial fibrillary acidic protein (GFAP) and collapsin response-mediator protein 5 (CRMP5) autoimmunity also should be considered in patients with bilateral painless optic neuropathy associated with optic disc edema, especially if there are other accompanying suggestive neurologic symptoms/signs. Typical ON usually recovers well without treatment, though recovery may be expedited by steroids. Atypical ON is usually treated with intravenous steroids, and some forms, such as NMOSD, often require plasma exchange for acute attacks and long-term immunosuppressive therapy to prevent relapses. Since treatment is tailored to the cause of the ON, elucidating the etiology of the ON is of the utmost importance.
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Affiliation(s)
- Jessica A Kraker
- Department of Ophthalmology, Mayo Clinic Hospital, Rochester, MN, USA
| | - John J Chen
- Department of Ophthalmology, Mayo Clinic Hospital, Rochester, MN, USA.
- Department of Neurology, Mayo Clinic Hospital, Rochester, MN, USA.
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Li T, Li X, Hong S, Jiang L, Ma J. Clinical characteristics of autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy in children: A case series of 16 patients. J Neuroimmunol 2023; 382:578176. [PMID: 37572437 DOI: 10.1016/j.jneuroim.2023.578176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/14/2023] [Accepted: 08/06/2023] [Indexed: 08/14/2023]
Abstract
PURPOSE To investigate the clinical characteristics of autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy in children. METHODS We reviewed the medical records of Children's Hospital of Chongqing Medical University from January 2020 to September 2021 and retrospectively analysed the clinical features, magnetic resonance imaging (MRI) findings, laboratory findings, treatment and outcome of children with autoimmune GFAP astrocytopathy. RESULTS Sixteen patients were included: 6 and 10 tested positive for GFAP-IgG in cerebrospinal fluid (CSF) and both CSF and serum, respectively. The median patient age was 115 months (range: 36-180 months), and 7 patients (43.8%) were male. All patients had the clinical syndrome of encephalitis/meningoencephalitis with or without myelitis: encephalitis (8), meningoencephalitis (3), encephalomyelitis (1) and meningoencephalomyelitis (4). The most common clinical symptoms were fever (11), altered consciousness (11), headache (10) and seizure (9). Four patients developed central respiratory failure for which mechanical ventilation was needed. All patients showed hyperintense T2-weighted lesions on brain MRI in the cerebral white matter (13), brainstem (11), basal ganglia (11), thalamus (9), and cerebellum (3). Nine patients (56%) had abnormal hyperintense lesions in the bilateral basal ganglia and thalamus. Six of 12 patients who underwent gadolinium-enhanced brain MRI showed abnormal enhancement images, and five of them showed linear perivascular radial enhancement. The modified Rankin scale (mRS) score decreased significantly in most patients after immunotherapy. Two patients with coexisting neural autoantibodies relapsed; however, 15 patients who were followed up successfully had favorable outcomes at the last follow-up. CONCLUSION Children with autoimmune GFAP astrocytopathy usually have a clinical syndrome of encephalitis/meningoencephalitis with or without myelitis. Except for the linear perivascular radial gadolinium enhancement pattern, hyperintense lesions in the bilateral basal ganglia and thalamus might be another characteristic brain MRI finding of autoimmune GFAP astrocytopathy in children. Although a few patients with coexisting neural autoantibodies might relapse, children with autoimmune GFAP astrocytopathy usually have favorable outcomes after immunotherapy.
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Affiliation(s)
- Tianyi Li
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xiujuan Li
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Siqi Hong
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Li Jiang
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jiannan Ma
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China.
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Zhang JR, Zhuang S, Xu XD, Song WL, Li KR, Jiang Y, Cheng XY, Shi JJ, Hu WD, Liu CF, Zhang YL. Overlapping Epstein-Barr virus encephalitis and autoimmune glial fibrillary acidic protein astrocytopathy. J Neuroimmunol 2023; 382:578174. [PMID: 37573633 DOI: 10.1016/j.jneuroim.2023.578174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/30/2023] [Accepted: 08/06/2023] [Indexed: 08/15/2023]
Abstract
We describe three cases of overlapping Epstein-Barr virus (EBV) Encephalitis and Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy (GFAP-A). The three cases all presented with initial symptoms of fever, headache, coma, and posture tremor of the upper limbs, then followed by limb weakness and dysuria. All of the three cases were on ventilators. Case 1 and 2 improved dramatically after intravenous methylprednisoloneand immunoglobulin treatment. However, case 3 presented dyspneic, and died from gastrointestinal hemorrhage. The GFAP-A triggered by EBV intracranial infection could initially masquerade as EBV encephalitis only, and the detection of GFAP antibody is essential for differentiation.
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Affiliation(s)
- Jin-Ru Zhang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Sheng Zhuang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiao-Dong Xu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Wen-Li Song
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Ke-Ru Li
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yu Jiang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiao-Yu Cheng
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Ji-Jun Shi
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Wei-Dong Hu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China.
| | - Chun-Feng Liu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China; Jiangsu Key Laboratory of Neuropsychiatric Diseases and Institute of Neuroscience, Soochow University, Suzhou, China.
| | - Yan-Lin Zhang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China.
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Greco G, Masciocchi S, Diamanti L, Bini P, Vegezzi E, Marchioni E, Colombo E, Rigoni E, Businaro P, Ferraro OE, Bianchi Marzoli S, Bergamaschi R, Franciotta D, Gastaldi M. Visual System Involvement in Glial Fibrillary Acidic Protein Astrocytopathy: Two Case Reports and a Systematic Literature Review. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200146. [PMID: 37582612 PMCID: PMC10427126 DOI: 10.1212/nxi.0000000000200146] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/27/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND AND OBJECTIVES Glial fibrillary acidic protein (GFAP) antibodies can associate with an astrocytopathy often presenting as a meningoencephalitis. Visual involvement has been reported but scarcely defined. We describe 2 cases of GFAP astrocytopathy with predominant visual symptoms and present a systematic review of the literature. METHODS We describe 2 patients with GFAP astrocytopathy from our neurology department. We performed a systematic review of the literature according to PRISMA guidelines, including all patients with this disease and available clinical data, focusing on visual involvement. RESULTS Patient 1 presented with bilateral optic disc edema and severe sudden bilateral loss of vision poorly responsive to therapy. Patient 2 showed bilateral optic disc edema, headache, and mild visual loss with complete recovery after steroids. We screened 275 records and included 84 articles (62 case reports and 22 case series) for a total of 592 patients. Visual involvement was reported in 149/592 (25%), with either clinical symptoms or paraclinical test-restricted abnormalities. Bilateral optic disc edema was found in 80/159 (50%) of patients investigated with fundoscopy, among which 49/80 (61%) were asymptomatic. One hundred (100/592, 17%) reported visual symptoms, often described as blurred vision or transient visual obscurations. Optic neuritis was rare and diagnosed in only 6% of all patients with GFAP astrocytopathy, often without consistent clinical and paraclinical evidence to support the diagnosis. Four patients (including patient 1) manifested a severe, bilateral optic neuritis with poor treatment response. In patients with follow-up information, a relapsing disease course was more frequently observed in those with vs without visual involvement (35% vs 11%, p = 0.0035, OR 3.6 [CI 1.44-8.88]). DISCUSSION Visual system involvement in GFAP astrocytopathy is common and heterogeneous, ranging from asymptomatic bilateral optic disc edema to severe bilateral loss of vision, but optic neuritis is rare. GFAP CSF antibody testing should be considered in patients with encephalitis/meningoencephalitis or myelitis and bilateral optic disc edema, even without visual symptoms, and in patients with severe bilateral optic neuritis, especially when AQP4 antibodies are negative. Visual symptoms might associate with a higher relapse risk and help to identify patients who may require chronic immunosuppression.
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Affiliation(s)
- Giacomo Greco
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Stefano Masciocchi
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Luca Diamanti
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Paola Bini
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Elisa Vegezzi
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Enrico Marchioni
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Elena Colombo
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Eleonora Rigoni
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Pietro Businaro
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Ottavia E Ferraro
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Stefania Bianchi Marzoli
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Roberto Bergamaschi
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Diego Franciotta
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Matteo Gastaldi
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy.
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Varley JA, Strippel C, Handel A, Irani SR. Autoimmune encephalitis: recent clinical and biological advances. J Neurol 2023; 270:4118-4131. [PMID: 37115360 PMCID: PMC10345035 DOI: 10.1007/s00415-023-11685-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 04/29/2023]
Abstract
In 2015, we wrote a review in The Journal of Neurology summarizing the field of autoantibody-associated neurological diseases. Now, in 2023, we present an update of the subject which reflects the rapid expansion and refinement of associated clinical phenotypes, further autoantibody discoveries, and a more detailed understanding of immunological and neurobiological pathophysiological pathways which mediate these diseases. Increasing awareness around distinctive aspects of their clinical phenotypes has been a key driver in providing clinicians with a better understanding as to how these diseases are best recognized. In clinical practice, this recognition supports the administration of often effective immunotherapies, making these diseases 'not to miss' conditions. In parallel, there is a need to accurately assess patient responses to these drugs, another area of growing interest. Feeding into clinical care are the basic biological underpinnings of the diseases, which offer clear pathways to improved therapies toward enhanced patient outcomes. In this update, we aim to integrate the clinical diagnostic pathway with advances in patient management and biology to provide a cohesive view on how to care for these patients in 2023, and the future.
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Affiliation(s)
- James A Varley
- Department of Brain Sciences, Charing Cross Hospital, Imperial College London, Fulham Palace Road, London, W6 8RF, UK
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Oxford, OX3 9DS, UK
| | - Christine Strippel
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Oxford, OX3 9DS, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
| | - Adam Handel
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Oxford, OX3 9DS, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Oxford, OX3 9DS, UK.
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK.
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Cheng W, He L, Luo H, Jiang Y, Tan C, Fan X. Magnetic Resonance Imaging Characteristics of Autoimmune Glial Fibrillary Acidic Protein (GFAP) Astrocytopathy: A Pediatric Series in Southwest China. Neuropsychiatr Dis Treat 2023; 19:1685-1693. [PMID: 37538100 PMCID: PMC10395509 DOI: 10.2147/ndt.s417492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 07/24/2023] [Indexed: 08/05/2023] Open
Abstract
Objective To investigate and summarize the magnetic resonance imaging (MRI) manifestations of autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy in children. Methods We retrospectively analyzed data from 17 pediatric patients with autoimmune GFAP astrocytopathy confirmed by the detection of GFAP autoantibodies in cerebrospinal fluid in our single-center. Furthermore, we reviewed current literature and summarized previous findings on the MRI characteristics of this disease in children. Results In these 17 patients, the clinical manifestations and results of CSF analysis were suggestive of autoimmune disorder, with a good improvement. The lesions on MRI were most commonly located in the bilateral basal ganglia (70.6%), thalamus (64.7%), cerebral white matter (29.4%). 93.3% of the cerebral lesions were relatively scattered and small, 80% of the spinal lesions presented as longitudinally extensive ones. Both periventricular radial linear (PVRL) (53.8%) and punctate or linear enhancement in basal ganglia and thalamus (53.8%) were commonly observed, followed by the leptomeningeal enhancement (46.2% in the brain and 62.5% in the spinal cord). We then included 55 pediatric patients with MRI data from current literature in our analysis (n = 72, 44 males). Our results revealed similar MRI findings but the enhancement pattern between our series and previously published cases, that is, leptomeningeal enhancement in the brain 46.2% vs 31.4%, in spinal cord 62.5% vs 18.4%, and PVRL enhancement 53.8% vs 11.2%. There were no detailed reports on punctate or linear enhancement. Conclusion The MRI characteristics of autoimmune GFAP astrocytopathy in children could be suggestive. Scattered and small lesions (especially punctate or linear) in the bilateral thalamus, basal ganglia, and white matter, as well as longitudinally extensive spinal cord lesions (if present), with punctate, PVRL and leptomeningeal enhancement might be a distinct indication for the early diagnosis of this disorder.
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Affiliation(s)
- Weiqin Cheng
- Department of Radiology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People’s Republic of China
| | - Ling He
- Department of Radiology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People’s Republic of China
| | - Hechuan Luo
- Department of Radiology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People’s Republic of China
| | - Yan Jiang
- Department of Neurology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People’s Republic of China
| | - Chengbing Tan
- Department of Neurology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People’s Republic of China
| | - Xiao Fan
- Department of Radiology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People’s Republic of China
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Schulz P, Lütt A, Stöcker W, Teegen B, Holtkamp M, Prüss H. High frequency of cerebrospinal fluid autoantibodies in patients with seizures or epilepsies of unknown etiology. Front Neurol 2023; 14:1211812. [PMID: 37475738 PMCID: PMC10356105 DOI: 10.3389/fneur.2023.1211812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/09/2023] [Indexed: 07/22/2023] Open
Abstract
Introduction The increasing identification of specific autoantibodies against brain structures allows further refinement of the group of autoimmune-associated epilepsies and affects diagnostic and therapeutic algorithms. The early etiological allocation of a first seizure is particularly challenging, and the contribution of cerebrospinal fluid (CSF) analysis is not fully understood. Methods In this retrospective study with a mean of 7.8 years follow-up involving 39 well-characterized patients with the initial diagnosis of new-onset seizure or epilepsy of unknown etiology and 24 controls, we determined the frequency of autoantibodies to brain proteins in CSF/serum pairs using cell-based assays and unbiased immunofluorescence staining of unfixed murine brain sections. Results Autoantibodies were detected in the CSF of 30.8% of patients. Underlying antigens involved glial fibrillary acidic protein (GFAP) and N-methyl-D-aspartate (NMDA) receptors, but also a range of yet undetermined epitopes on neurons, glial and vascular cells. While antibody-positive patients had higher frequencies of cancer, they did not differ from antibody-negative patients with respect to seizure type, electroencephalography (EEG) and cranial magnetic resonance imaging (cMRI) findings, neuropsychiatric comorbidities or pre-existing autoimmune diseases. In 5.1% of patients with seizures or epilepsy of initially presumed unknown etiology, mostly CSF findings resulted in etiological reallocation as autoimmune-associated epilepy. Discussion These findings strengthen the potential role for routine CSF analysis. Further studies are needed to understand the autoantibody contribution to etiologically unclear epilepsies, including determining the antigenic targets of underlying autoantibodies.
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Affiliation(s)
- Paulina Schulz
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Alva Lütt
- Psychiatric University Hospital Charité at St. Hedwig Hospital, Berlin, Germany
- Department of Psychiatry and Neurosciences, CCM, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Berlin, Germany
| | | | - Bianca Teegen
- Institute for Experimental Immunology, Lübeck, Germany
| | - Martin Holtkamp
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
- Epilepsy-Center Berlin-Brandenburg, Institute for Diagnostics of Epilepsy, Berlin, Germany
| | - Harald Prüss
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
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Zhang W, Xie Y, Wang Y, Liu F, Wang L, Lian Y, Liu H, Wang C, Xie N. Clinical characteristics and prognostic factors for short-term outcomes of autoimmune glial fibrillary acidic protein astrocytopathy: a retrospective analysis of 33 patients. Front Immunol 2023; 14:1136955. [PMID: 37350972 PMCID: PMC10282742 DOI: 10.3389/fimmu.2023.1136955] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/23/2023] [Indexed: 06/24/2023] Open
Abstract
Background Autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A) is a recently discovered inflammatory central nervous system (CNS) disease, whose clinical characteristics and prognostic factors for short-term outcomes have not been defined yet. We aimed to assess the symptoms, laboratory tests, imaging findings, treatment, and short-term prognosis of GFAP-A. Methods A double-center retrospective cohort study was performed between May 2018 and July 2022. The clinical characteristics and prognostic factors for short-term outcomes were determined. Results We enrolled 33 patients with a median age of 28 years (range: 2-68 years), 15 of whom were children (<18 years). The clinical spectrum is dominated by meningoencephalomyelitis. Besides, we also found nausea, vomiting, poor appetite, and neuropathic pain in some GFAP-A patients, which were not mentioned in previous reports. And adults were more prone to limb numbness than children. Magnetic resonance imaging revealed lesions involving the brain parenchyma, meninges, and spinal cord, exhibiting patchy, linear, punctate, and strip T2 hyperintensities. First-line immunotherapy, including corticosteroid and gamma globulin, was effective in most patients in the acute phase (P = 0.02). However, patients with overlapping AQP4 antibodies did not respond well to first-line immunotherapy and coexisting neural autoantibodies were more common in women. Additionally, the short-term prognosis was significantly better in children than in adults (P = 0.04). Positive non-neural autoantibodies and proven viral infection were independent factors associated with poor outcomes (P = 0.03, 0.02, respectively). Conclusion We expanded the spectrum of clinical symptoms of autoimmune GFAP-A. The clinical symptoms and short-term prognosis differed between children and adults. Positive non-neural autoantibodies and proven viral infection at admission suggest a poor short-term prognosis.
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Affiliation(s)
- Wanwan Zhang
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yinyin Xie
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yali Wang
- Department of Neurology, Henan Children’s Hospital, Zhengzhou, China
| | - Fengxia Liu
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Li Wang
- Department of Neurology, Henan Children’s Hospital, Zhengzhou, China
| | - Yajun Lian
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongbo Liu
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Cui Wang
- Department of Clinical Laboratory, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Nanchang Xie
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Lin J, Dong L, Yu L, Huang J. Autoimmune glial fibrillary acidic protein astrocytopathy coexistent with reversible splenial lesion syndrome: A case report and literature review. Front Neurol 2023; 14:1192118. [PMID: 37305765 PMCID: PMC10249068 DOI: 10.3389/fneur.2023.1192118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/03/2023] [Indexed: 06/13/2023] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a rare autoimmune disorder. Reversible splenial lesion syndrome (RESLES) is a transient clinical-imaging syndrome characterized by specific magnetic resonance imaging (MRI) pattern. A 58-year-old man was admitted with a fever, headache, and confusion for 1 week. Brain MRI showed abnormal leptomeningeal enhancement in the brainstem and high signal intensity on diffusion-weighted MRI of the corpus callosum. Anti-GFAP antibody was positive in the serum and cerebrospinal fluid analysis. This patient significantly improved and had no relapse after glucocorticoid and immune suppressant therapy. A repeated brain MRI revealed the lesion in the corpus callosum and abnormal leptomeningeal enhancement in the brainstem disappeared. Linear perivascular radial enhancement is the characteristic pattern of autoimmune GFAP astrocytopathy which is rarely coexistent with RESLES.
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Alkabie S, Casserly CS, Morrow SA, Racosta JM. Identifying specific myelopathy etiologies in the evaluation of suspected myelitis: A retrospective analysis. J Neurol Sci 2023; 450:120677. [PMID: 37207546 DOI: 10.1016/j.jns.2023.120677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/13/2023] [Accepted: 05/09/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Myelopathies require prompt etiologic diagnosis. We aimed to identify a specific myelopathy diagnosis in cases of suspected myelitis to highlight clinicoradiologic differences. METHODS In this retrospective, single-centre cohort of subjects with suspected myelitis referred to London Multiple Sclerosis (MS) Clinic between 2006 and 2021, we identified those with MS and reviewed the remaining charts for etiologic diagnosis based on clinical, serologic, and imaging details. RESULTS Of 333 included subjects, 318/333 (95.5%) received an etiologic diagnosis. Most (274/333, 82%) had MS or clinically isolated syndrome. Spinal cord infarction (n = 10) was the commonest non-inflammatory myelitis mimic characterized by hyperacute decline (n = 10/10, 100%), antecedent claudication (n = 2/10, 20%), axial owl/snake eye (n = 7/9, 77%) and sagittal pencillike (n = 8/9, 89%) MRI patterns, vertebral artery occlusion/stenosis (n = 4/10, 40%), and concurrent acute cerebral infarct (n = 3/9, 33%). Longitudinal lesions were frequent in aquaporin-4-IgG-positive neuromyelitis optica spectrum disorder (AQP4+NMOSD) (n = 7/7, 100%) and myelin oligodendrocyte glycoprotein-IgG-associated disorder (MOGAD) (n = 6/7, 86%), accompanied by bright spotty (n = 5/7, 71%) and central-grey-restricted (n = 4/7, 57%) T2-lesions on axial sequences, respectively. Leptomeningeal (n = 4/4, 100%), dorsal subpial (n = 4/4, 100%) enhancement, and positive body PET/CT (n = 4/4, 100%) aided the diagnosis of sarcoidosis. Spondylotic myelopathies had chronic sensorimotor presentations (n = 4/6, 67%) with relative bladder sparing (n = 5/6, 83%), localizable to sites of disc herniation (n = 6/6, 100%). Metabolic myelopathies showed dorsal column or inverted 'V' sign (n = 2/3, 67%) MRI T2-abnormality with B12 deficiency. CONCLUSIONS Although no single feature reliably confirms or refutes a specific myelopathy diagnosis, this study highlights patterns that narrow the differential diagnosis of myelitis and facilitate early recognition of mimics.
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Affiliation(s)
- Samir Alkabie
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Schulich Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Courtney S Casserly
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Schulich Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Sarah A Morrow
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Schulich Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Juan M Racosta
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Schulich Medicine and Dentistry, Western University, London, Ontario, Canada; MS Epidemiology Lab, London, Ontario, Canada.
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Cao S, Du J, Pan S, Zhang J, Xu S, Wei L, Tian Y. Case Report: Ofatumumab treatment in a patient with rituximab-intolerant refractory autoimmune GFAP astrocytopathy. Front Immunol 2023; 14:1164181. [PMID: 37223100 PMCID: PMC10200986 DOI: 10.3389/fimmu.2023.1164181] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 04/24/2023] [Indexed: 05/25/2023] Open
Abstract
Background Ofatumumab, a fully humanized anti-CD20 monoclonal antibody, has shown promising efficacy in limited cases of neuromyelitis optica spectrum disorder, but there is a lack of studies on its use in autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy. We present a case of refractory GFAP astrocytopathy with poor response to conventional immunosuppressants and rituximab who responded well to subcutaneous ofatumumab. Case report The patient is a 36-year-old woman with a diagnosis of GFAP astrocytopathy and high disease activity. She experienced five relapses over three years despite immunosuppressive treatment with oral prednisone, azathioprine, mycophenolate mofetil, and intravenous rituximab. Additionally, her circulating B cells were not completely depleted during the second administration of rituximab and an allergic reaction occurred. Based on insufficient B cell depletion and allergic reaction to rituximab, subcutaneous ofatumumab was introduced. After twelve injections of ofatumumab without injection-related reactions, she had no further relapses and was sufficiently depleted of the circulating B cells. Discussion This case illustrates the effective use and good tolerance of ofatumumab in GFAP astrocytopathy. Further studies are needed to investigate the efficacy and safety of ofatumumab in refractory GFAP astrocytopathy or those intolerant to rituximab.
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Affiliation(s)
- Shugang Cao
- Department of Neurology, Second Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of Neurology, The Second People’s Hospital of Hefei, Hefei, China
| | - Jing Du
- Department of Neurology, Second Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of Psychology, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Sidi Pan
- Department of Neurology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Juanjuan Zhang
- Department of Neurology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Si Xu
- Department of Neurology, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ling Wei
- Department of Neurology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yanghua Tian
- Department of Neurology, Second Affiliated Hospital of Anhui Medical University, Hefei, China
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Barthel PC, Staabs F, Li LY, Buthut M, Otto C, Ruprecht K, Prüss H, Höltje M. Immunoreactivity to astrocytes in different forms of dementia: High prevalence of autoantibodies to GFAP. Brain Behav Immun Health 2023; 29:100609. [PMID: 36923695 PMCID: PMC10008834 DOI: 10.1016/j.bbih.2023.100609] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/21/2023] [Accepted: 02/25/2023] [Indexed: 03/06/2023] Open
Abstract
Objective To study the prevalence of autoantibodies to glial and neuronal antigens with a focus on glial acidic fibrillary protein (GFAP) in patients with dementia. Methods Sera of 127 patients with different forms of dementia and sera of 82 age-matched patients with various neurological diseases except for dementia, as well as sera from 15 age-matched healthy controls were analyzed for anti-glial or anti-neuronal IgG using 1) primary murine embryonic hippocampus cell cultures, 2) murine brain sections, 3) immunoblotting on mouse brain homogenates and 4) astrocyte cultures. Sera reacting with astrocytes in hippocampus cell cultures were further analyzed using HEK293 cells transfected with human GFAP. Results IgG in serum from 45 of 127 (35.5%) patients with dementia but only 8 of 97 (8.2%, p ≤ 0.001) controls bound to either glial or neuronal structures in cultured murine hippocampus cells. In these cultures antibodies to astrocytes were detected in 35 of 127 (27.5%) of the dementia patients, whereas in controls antibodies to astrocytes were detected in 4 sera only (4.1%, p ≤ 0.001). Among the sera exhibiting reactivity to astrocytes, 14 of 35 (40%) showed immunoreaction to HEK293 cells transfected with GFAP in dementia patients, representing 11% of all sera. Within the 4 immunoreactive control sera reacting with astrocytes one reacted with GFAP (1.0% of total immunoreactivity, p = 0.003). Conclusions Autoantibodies to glial epitopes in general and to GFAP in particular are more frequent in patients with dementia than in age-matched controls without dementia, thus indicating the need for further investigations regarding the potential pathophysiological relevance of these antibodies.
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Affiliation(s)
- Paula Charlotte Barthel
- Institute of Integrative Neuroanatomy Berlin, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Finja Staabs
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lucie Y Li
- Institute of Integrative Neuroanatomy Berlin, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Maria Buthut
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
| | - Carolin Otto
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Harald Prüss
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
| | - Markus Höltje
- Institute of Integrative Neuroanatomy Berlin, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Yaguchi T, Kimura A, Takekoshi A, Matsuo M, Tomita H, Shimohata T. Autoimmune glial fibrillary acidic protein astrocytopathy associated with breast cancer: a case report. BMC Neurol 2023; 23:145. [PMID: 37016352 PMCID: PMC10071775 DOI: 10.1186/s12883-023-03194-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 03/30/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy (GFAP-A) is an autoimmune inflammatory central nervous system disorder characterized by the detection of autoantibodies that recognize GFAP in CSF. The pathogenesis of GFAP-A is poorly understood. Some patients had a neoplasm detected and GFAP expressed by neoplasms is plausible as immunogen triggering paraneoplastic neurological autoimmunity. CASE PRESENTATION We report a case of 76-year-old female patient with GFAP-A complicated with breast cancer. She presented with altered consciousness, nuchal rigidity, speech disturbances, and weakness. Her clinical symptoms were improved by immunotherapy and cancer treatments. Immunohistochemical analysis showed that the restricted tumor expressed GFAP. The infiltration of CD3 + T cells were observed in the peritumoral and intratumoral areas. The most common infiltrating lymphocytes were CD8 + T cells. CD4 + T cells and CD20 + B cells were also observed in the predominant peritumoral area. CONCLUSIONS These results suggest that GFAP-A may occur in a paraneoplastic neurological syndrome associated with breast cancer.
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Affiliation(s)
- Tomonori Yaguchi
- Department of Neurology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Akira Takekoshi
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Mikiko Matsuo
- Department of Tumor Pathology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hiroyuki Tomita
- Department of Tumor Pathology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan.
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Ide T, Kawanami T, Tada Y, Eriguchi M. Overlapping rheumatoid meningitis with anti-N-methyl-D-aspartate receptor encephalitis: A case report. Clin Case Rep 2023; 11:e7199. [PMID: 37155424 PMCID: PMC10122683 DOI: 10.1002/ccr3.7199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 05/10/2023] Open
Abstract
A 66-year-old woman in treatment for rheumatoid meningitis was found to be positive for anti-N-methyl-D-aspartate receptor (NMDAR) antibodies in the cerebrospinal fluid, and intravenous immunoglobulin improved her psychiatric symptoms. The co-existence of NMDAR antibodies should be considered in cases of poor response to treatments or atypical symptoms in rheumatoid meningitis.
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Affiliation(s)
- Toshihiro Ide
- Department of Internal Medicine, Division of NeurologySaga University, Faculty of MedicineSagaJapan
| | - Takeru Kawanami
- Department of Internal Medicine, Division of NeurologySaga University, Faculty of MedicineSagaJapan
| | - Yoshifumi Tada
- Department of Internal Medicine, Division of RheumatologySaga University, Faculty of MedicineSagaJapan
| | - Makoto Eriguchi
- Department of Internal Medicine, Division of NeurologySaga University, Faculty of MedicineSagaJapan
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Ali SB, Cecchin A, Burfoot R, Field D, Ravindran J, Pucar PA, Banovic T. Glial fibrillary acidic protein antibodies: a spectacular neuronal immunofluorescence pattern with important clinical implications. Pathology 2023; 55:405-407. [PMID: 36041890 DOI: 10.1016/j.pathol.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/25/2022] [Accepted: 06/01/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Syed Basharat Ali
- Department of Immunopathology, SA Pathology, Adelaide, SA, Australia; Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Amelia Cecchin
- Department of Immunopathology, SA Pathology, Adelaide, SA, Australia
| | - Rebecca Burfoot
- Department of Immunopathology, SA Pathology, Adelaide, SA, Australia
| | - Deborah Field
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Janakan Ravindran
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Phillippa A Pucar
- Department of Immunopathology, SA Pathology, Adelaide, SA, Australia; Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Tatjana Banovic
- Department of Immunopathology, SA Pathology, Adelaide, SA, Australia; Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, SA, Australia; Department of Immunology, Flinders University, Bedford Park, SA, Australia.
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Qin N, Wu X, Wang J, Wang W, Wang X, Ma Y, Wang L. Case report: Autoimmune glial fibrillary acidic protein astrocytopathy misdiagnosed as tuberculous meningitis. Front Neurol 2023; 14:1123603. [PMID: 36970528 PMCID: PMC10034075 DOI: 10.3389/fneur.2023.1123603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/13/2023] [Indexed: 03/11/2023] Open
Abstract
IntroductionAutoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a new form of autoimmunity-mediated central nervous system disease. It is especially easy to misdiagnose when clinical symptoms and cerebrospinal fluid (CSF) indicators are similar to those observed in patients with tuberculous meningitis (TBM).MethodsWe retrospectively analyzed five cases of autoimmune GFAP astrocytopathy that were initially misdiagnosed as TBM.ResultsIn the five reported cases, all but one patient had meningoencephalitis in the clinic, and all patients exhibited increased pressure, lymphocytosis, increased protein levels, and decreased glucose levels in their CSF results and did not have typical imaging findings of autoimmune GFAP astrocytopathy. TBM was the initial diagnosis in all five patients. However, we found no direct evidence of tuberculosis infection, and anti-tuberculosis treatment had inconclusive effects. Following a GFAP antibody test, the diagnosis of autoimmune GFAP astrocytopathy was made.ConclusionWhen there is a suspected diagnosis of TBM but TB-related tests are negative, the possibility of autoimmune GFAP astrocytopathy should be considered.
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Ramanathan S, Brilot F, Irani SR, Dale RC. Origins and immunopathogenesis of autoimmune central nervous system disorders. Nat Rev Neurol 2023; 19:172-190. [PMID: 36788293 DOI: 10.1038/s41582-023-00776-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 02/16/2023]
Abstract
The field of autoimmune neurology is rapidly evolving, and recent discoveries have advanced our understanding of disease aetiologies. In this article, we review the key pathogenic mechanisms underlying the development of CNS autoimmunity. First, we review non-modifiable risk factors, such as age, sex and ethnicity, as well as genetic factors such as monogenic variants, common variants in vulnerability genes and emerging HLA associations. Second, we highlight how interactions between environmental factors and epigenetics can modify disease onset and severity. Third, we review possible disease mechanisms underlying triggers that are associated with the loss of immune tolerance with consequent recognition of self-antigens; these triggers include infections, tumours and immune-checkpoint inhibitor therapies. Fourth, we outline how advances in our understanding of the anatomy of lymphatic drainage and neuroimmune interfaces are challenging long-held notions of CNS immune privilege, with direct relevance to CNS autoimmunity, and how disruption of B cell and T cell tolerance and the passage of immune cells between the peripheral and intrathecal compartments have key roles in initiating disease activity. Last, we consider novel therapeutic approaches based on our knowledge of the immunopathogenesis of autoimmune CNS disorders.
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Affiliation(s)
- Sudarshini Ramanathan
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead, Sydney, New South Wales, Australia
- Sydney Medical School, Faculty of Medicine and Health and Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Concord Hospital, Sydney, New South Wales, Australia
| | - Fabienne Brilot
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead, Sydney, New South Wales, Australia
- School of Medical Science, Faculty of Medicine and Health and Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Russell C Dale
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead, Sydney, New South Wales, Australia.
- Sydney Medical School, Faculty of Medicine and Health and Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia.
- TY Nelson Department of Paediatric Neurology, Children's Hospital Westmead, Sydney, New South Wales, Australia.
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Salari M, Etemadifar M, Soleymani R, Murgai AA, Rashedi R. A case of glial fibrillary acidotic protein (GFAP) meningoencephalitis with rheumatoid arthritis. Clin Case Rep 2023; 11:e7038. [PMID: 36879678 PMCID: PMC9984675 DOI: 10.1002/ccr3.7038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/12/2022] [Accepted: 02/12/2023] [Indexed: 03/06/2023] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is an inflammatory disease of the central nervous system (CNS), which affects various regions in the CNS, presenting by variable clinical manifestations. Meningoencephalitis is the most common clinical presentation and association with autoimmune disorders has been reported in about 20% of these patients. Diagnosis is confirmed by the presence of CSF or serum immunoglobulin-G (IgG) against GFAP. The reported case is a 53-year-old woman with the history of long-standing rheumatoid arthritis who first presented with acute-onset dizziness and gait disturbance, periventricular linear and radial enhancement pattern on MRI, and normal CSF analysis, successfully treated with an increase in the dose of oral steroids. After a year she had a subacute-onset, moderate to severe holocephalic headache, normal neurologic examination and CSF analysis, and bilateral diffuse, pachymeningeal, and leptomeningeal enhancement on MRI. According to her Brain MRI imaging with relapsing remitting course steroid responsive ataxia and aseptic meningitis, her serum was tested for GFAP IgG antibodies which was positive. The reported patient is the first in the literature reported pachymeningitis in GFAP astrocytopathy. This case highlights the co-occurrence of rheumatoid arthritis with GFAP-associated astrocytopathy, and expands on the previously reported cases with similar association. This might also suggest a common immune pathogenesis.
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Affiliation(s)
- Mehri Salari
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellence Shahid Beheshti University of medical Sciences Tehran Iran
| | - Masoud Etemadifar
- Department of Functional Neurosurgery, Medical School Isfahan University of Medical Sciences Isfahan Iran
| | - Reyhaneh Soleymani
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellence Shahid Beheshti University of medical Sciences Tehran Iran
| | | | - Ronak Rashedi
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellence Shahid Beheshti University of medical Sciences Tehran Iran
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