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Vanderschelden RK, Benjamin NL, Shurin MR, Shelton L, Wheeler SE. Clinical laboratory test utilization of CSF oligoclonal bands and IgG index in a tertiary pediatric hospital. Clin Biochem 2024; 131-132:110803. [PMID: 39053601 DOI: 10.1016/j.clinbiochem.2024.110803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 07/02/2024] [Accepted: 07/22/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Criteria developed for the diagnosis of multiple sclerosis (MS) in adults are also used in the pediatric setting. However, differential diagnosis in pediatric-onset MS (POMS) is distinct from that of adult-onset MS. There is little literature characterizing the utility of oligoclonal bands (OCB) and IgG index in differentiating POMS from other childhood diseases with overlapping clinical presentation which can require immediate treatment. METHODS A retrospective review of all MS panels resulted between March 2022 and May 2023 on patients age ≤ 18 years at one tertiary care pediatric hospital in the northeastern United States was performed with pediatric neurology collaboration to characterize clinical utility (n = 85 cases). RESULTS Demyelinating diseases accounted for 31 of 85 total cases (36.5%), 12 of these cases were POMS (14%). Other diagnoses consisted of psychiatric etiologies (17.6%), infectious meningitis/encephalitis (5.9%), and migraine (5.9%). Elevated IgG index was seen in 67% of those with demyelinating diseases, versus only 13% of those with other conditions. Unique OCBs were found in 41% of those with demyelinating diseases, versus only 9% of those with other conditions. Fourteen of 15 patients (93.3%) with psychiatric conditions had normal MS panels. CONCLUSIONS Patients with demyelinating diseases were more likely to have elevated IgG index and unique OCBs versus patients with other conditions. For pediatric hospitals without in-house OCB evaluation, implementation of an in-house IgG index may serve as a rapid screen for differentials that include demyelinating diseases while awaiting OCB results, in the appropriate clinical context. IMPACT STATEMENT IgG index and CSF oligoclonal bands are important tools in the diagnosis of patients with suspected Multiple Sclerosis (MS). In the pediatric population, these markers are used to differentiate pediatric-onset MS (POMS) from other neurologic, psychiatric, and inflammatory diseases that display clinical overlap. The use of these markers in differentiating these conditions has not been thoroughly investigated. We examined the associations between abnormal markers and final diagnoses in pediatric patients undergoing testing for POMS in order to identify trends that may enhance ordering and reporting practices.
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Affiliation(s)
| | | | - Michael R Shurin
- University of Pittsburgh Medical Center, Department of Pathology, Pittsburgh, PA, USA; University of Pittsburgh, School of Medicine, Department of Pathology, Pittsburgh, PA, USA
| | - Levi Shelton
- University of Pittsburgh, School of Medicine, Department of Pediatrics, Pittsburgh, PA, USA
| | - Sarah E Wheeler
- University of Pittsburgh Medical Center, Department of Pathology, Pittsburgh, PA, USA; University of Pittsburgh, School of Medicine, Department of Pathology, Pittsburgh, PA, USA.
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Wang Y, Zhang D, Tong L, Yang L, Yin P, Li J, Lei G, Yang X, Li B. Anti-LGI1 encephalitis with initiating symptom of seizures in children. Front Neurosci 2023; 17:1151430. [PMID: 37179544 PMCID: PMC10169679 DOI: 10.3389/fnins.2023.1151430] [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: 01/26/2023] [Accepted: 03/30/2023] [Indexed: 05/15/2023] Open
Abstract
Background Anti-leucine-rich glioma-inactivated 1 (LGI1) encephalitis is infrequently reported but more and more recognizable in children. Here we give detailed description of the clinical features and long-term outcome of three cases of childhood onset anti-LGI1 encephalitis. Methods Three anti-LGI1 encephalitis patients were hospitalized in the Department of Pediatrics at Qilu Hospital of Shandong University. Data about the clinical manifestations, treatments and long-term follow-up outcomes were described in detail. Results Case 1 showed an adolescent girl with initiating symptom of acute-onset frequent focal seizures. Her serum LGI1-antibody test was positive, and she had a good response to antiseizure medication (ASM) and IVIG. Case 2 showed a preschool-age boy with long-period refractory focal seizures and recent behavioral change. Both serum and cerebrospinal fluid (CSF) tests of LGI1-antibody were positive, and the MRI showed progressive atrophy in the left hemisphere. The symptoms got improved after receiving second-line immunotherapy initially but there are still the sequelae of drug-resistant epilepsy and mild to moderate intellectual disability. Case 3 showed an adolescent boy with initiating symptom of acute-onset frequent focal seizures. Both serum and CSF tests of LGI1-antibody were positive, and he had a good response to immunotherapy. By analyzing all literature-reported 19 pediatric cases, we found pediatric anti-LGI1 encephalitis is more common in female and adolescent. Seizures and behavioral changes were the most common symptoms. CSF pleocytosis and LGI1-antibodies results were mostly negative. Most patients showed good response to immunotherapy. Conclusion Childhood onset anti-LGI1 encephalitis is a heterogeneous clinical syndrome, ranging from typical limbic encephalitis to isolating focal seizures. It is important to test autoimmune antibodies when encountering similar cases and repeat antibody testing if necessary. Timely recognition leads to earlier diagnosis and more rapid initiation of effective immunotherapy and potentially better outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | - Xiaofan Yang
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, Shandong, China
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Aendole D. Seronegative Autoimmune Limbic Encephalitis: A Case Report. JOURNAL OF THE ASSOCIATION OF PHYSICIANS OF INDIA 2022; 70:11-12. [DOI: 10.5005/japi-11001-0083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Autoimmune Encephalitis: A Physician’s Guide to the Clinical Spectrum Diagnosis and Management. Brain Sci 2022; 12:brainsci12091130. [PMID: 36138865 PMCID: PMC9497072 DOI: 10.3390/brainsci12091130] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/11/2022] [Accepted: 08/15/2022] [Indexed: 11/25/2022] Open
Abstract
The rapidly expanding spectrum of autoimmune encephalitis in the last fifteen years is largely due to ongoing discovery of many neuronal autoantibodies. The diagnosis of autoimmune encephalitis can be challenging due to the wide spectrum of clinical presentations, prevalence of psychiatric features that mimic primary psychiatric illnesses, frequent absence of diagnostic abnormalities on conventional brain MR-imaging, non-specific findings on EEG testing, and the lack of identified IgG class neuronal autoantibodies in blood or CSF in a subgroup of patients. Early recognition and treatment are paramount to improve outcomes and achieve complete recovery from these debilitating, occasionally life threatening, disorders. This review is aimed to provide primary care physicians and hospitalists who, together with neurologist and psychiatrists, are often the first port of call for individuals presenting with new-onset neuropsychiatric symptoms, with up-to-date data and evidence-based approach to the diagnosis and management of individuals with neuropsychiatric disorders of suspected autoimmune origin.
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Jia Y, Wang H, Zhang M, Wei M, Huang Z, Ye J, Liu A, Wang Y. LGI1 antibody-associated encephalitis without evidence of inflammation in CSF and brain MRI. Acta Neurol Belg 2022:10.1007/s13760-022-01955-8. [PMID: 35527332 DOI: 10.1007/s13760-022-01955-8] [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: 10/24/2021] [Accepted: 04/12/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study aimed to explore the frequency and distinct characteristics of adult patients with LGI1 antibody-associated encephalitis in the absence of inflammatory abnormalities in both routine CSF analysis and brain MRI. METHODS We conducted a retrospective study of adult patients with antibodies targeting LGI1 and then screened patients with no evidence of inflammation in brain MRI and normal results in routine CSF analysis, including white blood cell count, protein concentration, IgG, and oligoclonal bands. RESULTS Among 80 patients with LGI1 antibody-associated encephalitis in our center, 31 (38.8%) fulfilled the screening criteria. For these patients, the onset age was 57.0 ± 14.7 years, and 19 (61.3%) were female. Viral prodrome occurred in 5 patients (16.1%). Faciobrachial dystonic seizures (FBDS) were the most predominant symptom (38.7%), followed by seizure onset (22.6%) and memory deficits (19.4%). The sensitivity of antibody detection in serum was higher than CSF (96.8% vs. 48.4%, p < 0.001). Most patients (30/31, 96.8%) benefited from the first-line immunotherapy, and 23 patients (74.2%) achieved complete recovery, yet 3 patients (9.7%) had clinical relapses in 2-year follow-up after discharge. The patients had a higher prevalence of females (61.9% vs. 26.7%, p = 0.003) and were more frequently associated with FBDS during the disease course (38.7% vs. 10.2%, p = 0.004). However, there was no difference in treatment outcomes and recurrence ratio between the two groups (p = 0.144 and p = 0.515). Moreover, we divided all 80 patients into four groups according to antibody titer levels in serum and CSF at the time of diagnosis, respectively. WBC and protein concentrations in CSF showed no difference among the four groups. CONCLUSIONS The absence of evidence of inflammation in routine CSF analysis and brain MRI did not rule out anti-LGI1 associated encephalitis. FBDS and the subacute onset of cognitive dysfunction should push forward with autoantibody testing for patients even without inflammatory abnormalities. The routine inflammatory indicators in CSF seemed to be unrelated to antibody titer levels.
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Gruden G, Bernardi S, Scandella M, Arietti F, Gargiulo G, Papa C, Beccuti G, Rizzone MG, Villari V, Cavallo Perin P, Durazzo M. A man with hyponatremia, confusion, and involuntary limb movements. Intern Emerg Med 2022; 17:823-827. [PMID: 34021469 DOI: 10.1007/s11739-021-02716-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 03/16/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Gabriella Gruden
- Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy.
| | - Sara Bernardi
- Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Michela Scandella
- Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Francesca Arietti
- Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Giuseppe Gargiulo
- Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Claudia Papa
- Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Guglielmo Beccuti
- Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Mario Giorgio Rizzone
- Department of Neurosciences "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Vincenzo Villari
- Department of Neuroscience and Mental Health - A.O.U. Città della Salute e della Scienza, Turin, Italy
| | - Paolo Cavallo Perin
- Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Marilena Durazzo
- Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
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Rissanen E, Carter K, Cicero S, Ficke J, Kijewski M, Park MA, Kijewski J, Stern E, Chitnis T, Silbersweig D, Weiner HL, Kim CK, Lyons J, Klein JP, Bhattacharyya S, Singhal T. Cortical and Subcortical Dysmetabolism Are Dynamic Markers of Clinical Disability and Course in Anti-LGI1 Encephalitis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2022; 9:9/2/e1136. [PMID: 35091466 PMCID: PMC8802686 DOI: 10.1212/nxi.0000000000001136] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 12/14/2021] [Indexed: 12/19/2022]
Abstract
Background and Objectives This [18F]fluorodeoxyglucose (FDG) PET study evaluates the accuracy of semiquantitative measurement of putaminal hypermetabolism in identifying anti–leucine-rich, glioma–inactivated-1 (LGI1) protein autoimmune encephalitis (AE). In addition, the extent of brain dysmetabolism, their association with clinical outcomes, and longitudinal metabolic changes after immunotherapy in LGI1-AE are examined. Methods FDG-PET scans from 49 age-matched and sex-matched subjects (13 in LGI1-AE group, 15 in non–LGI1-AE group, 11 with Alzheimer disease [AD], and 10 negative controls [NCs]) and follow-up scans from 8 patients with LGI1 AE on a median 6 months after immunotherapy were analyzed. Putaminal standardized uptake value ratios (SUVRs) normalized to global brain (P-SUVRg), thalamus (P/Th), and midbrain (P/Mi) were evaluated for diagnostic accuracy. SUVRg was applied for all other analyses. Results P-SUVRg, P/Th, and P/Mi were higher in LGI1-AE group than in non–LGI1-AE group, AD group, and NCs (all p < 0.05). P/Mi and P-SUVRg differentiated LGI1-AE group robustly from other groups (areas under the curve 0.84–0.99). Mediotemporal lobe (MTL) SUVRg was increased in both LGI1-AE and non–LGI1-AE groups when compared with NCs (both p < 0.05). SUVRg was decreased in several frontoparietal regions and increased in pallidum, caudate, pons, olfactory, and inferior occipital gyrus in LGI1-AE group when compared with that in NCs (all p < 0.05). In LGI1-AE group, both MTL and putaminal hypermetabolism were reduced after immunotherapy. Normalization of regional cortical dysmetabolism associated with clinical improvement at the 6- and 20-month follow-up. Discussion Semiquantitative measurement of putaminal hypermetabolism with FDG-PET may be used to distinguish LGI1-AE from other pathologies. Metabolic abnormalities in LGI1-AE extend beyond putamen and MTL into other subcortical and cortical regions. FDG-PET may be used in evaluating disease evolution in LGI1-AE. Classification of Evidence This study provides Class II evidence that semiquantitative measures of putaminal metabolism on PET can differentiate patients with LGI1-AE from patients without LGI1-AE, patients with AD, or NCs.
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Affiliation(s)
- Eero Rissanen
- From the PET Imaging Program in Neurologic Diseases (E.R., K.C., S.C., J.F., T.S.) and Brigham Multiple Sclerosis Center (E.R., T.C., H.L.W., S.B., T.S.), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital and Harvard Medical School; Division of Nuclear Medicine and Molecular Imaging (M.K.), Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Medical Physics Section (M.-A.P.), Radiology Department, University of Texas Southwestern Medical Center, Dallas, TX; Department of Neurology (J.K.), Brigham and Women's Hospital, Boston, MA; Ceretype Neuromedicine (E.S.), Cambridge, MA; Functional Neuroimaging Laboratory (D.S.), Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Nuclear Medicine (C.K.K.), Department of Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Biogen Inc. (J.L.), Cambridge, MA; and Department of Neurology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Kelsey Carter
- From the PET Imaging Program in Neurologic Diseases (E.R., K.C., S.C., J.F., T.S.) and Brigham Multiple Sclerosis Center (E.R., T.C., H.L.W., S.B., T.S.), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital and Harvard Medical School; Division of Nuclear Medicine and Molecular Imaging (M.K.), Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Medical Physics Section (M.-A.P.), Radiology Department, University of Texas Southwestern Medical Center, Dallas, TX; Department of Neurology (J.K.), Brigham and Women's Hospital, Boston, MA; Ceretype Neuromedicine (E.S.), Cambridge, MA; Functional Neuroimaging Laboratory (D.S.), Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Nuclear Medicine (C.K.K.), Department of Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Biogen Inc. (J.L.), Cambridge, MA; and Department of Neurology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Steven Cicero
- From the PET Imaging Program in Neurologic Diseases (E.R., K.C., S.C., J.F., T.S.) and Brigham Multiple Sclerosis Center (E.R., T.C., H.L.W., S.B., T.S.), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital and Harvard Medical School; Division of Nuclear Medicine and Molecular Imaging (M.K.), Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Medical Physics Section (M.-A.P.), Radiology Department, University of Texas Southwestern Medical Center, Dallas, TX; Department of Neurology (J.K.), Brigham and Women's Hospital, Boston, MA; Ceretype Neuromedicine (E.S.), Cambridge, MA; Functional Neuroimaging Laboratory (D.S.), Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Nuclear Medicine (C.K.K.), Department of Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Biogen Inc. (J.L.), Cambridge, MA; and Department of Neurology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - John Ficke
- From the PET Imaging Program in Neurologic Diseases (E.R., K.C., S.C., J.F., T.S.) and Brigham Multiple Sclerosis Center (E.R., T.C., H.L.W., S.B., T.S.), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital and Harvard Medical School; Division of Nuclear Medicine and Molecular Imaging (M.K.), Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Medical Physics Section (M.-A.P.), Radiology Department, University of Texas Southwestern Medical Center, Dallas, TX; Department of Neurology (J.K.), Brigham and Women's Hospital, Boston, MA; Ceretype Neuromedicine (E.S.), Cambridge, MA; Functional Neuroimaging Laboratory (D.S.), Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Nuclear Medicine (C.K.K.), Department of Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Biogen Inc. (J.L.), Cambridge, MA; and Department of Neurology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Marie Kijewski
- From the PET Imaging Program in Neurologic Diseases (E.R., K.C., S.C., J.F., T.S.) and Brigham Multiple Sclerosis Center (E.R., T.C., H.L.W., S.B., T.S.), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital and Harvard Medical School; Division of Nuclear Medicine and Molecular Imaging (M.K.), Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Medical Physics Section (M.-A.P.), Radiology Department, University of Texas Southwestern Medical Center, Dallas, TX; Department of Neurology (J.K.), Brigham and Women's Hospital, Boston, MA; Ceretype Neuromedicine (E.S.), Cambridge, MA; Functional Neuroimaging Laboratory (D.S.), Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Nuclear Medicine (C.K.K.), Department of Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Biogen Inc. (J.L.), Cambridge, MA; and Department of Neurology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Mi-Ae Park
- From the PET Imaging Program in Neurologic Diseases (E.R., K.C., S.C., J.F., T.S.) and Brigham Multiple Sclerosis Center (E.R., T.C., H.L.W., S.B., T.S.), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital and Harvard Medical School; Division of Nuclear Medicine and Molecular Imaging (M.K.), Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Medical Physics Section (M.-A.P.), Radiology Department, University of Texas Southwestern Medical Center, Dallas, TX; Department of Neurology (J.K.), Brigham and Women's Hospital, Boston, MA; Ceretype Neuromedicine (E.S.), Cambridge, MA; Functional Neuroimaging Laboratory (D.S.), Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Nuclear Medicine (C.K.K.), Department of Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Biogen Inc. (J.L.), Cambridge, MA; and Department of Neurology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Joseph Kijewski
- From the PET Imaging Program in Neurologic Diseases (E.R., K.C., S.C., J.F., T.S.) and Brigham Multiple Sclerosis Center (E.R., T.C., H.L.W., S.B., T.S.), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital and Harvard Medical School; Division of Nuclear Medicine and Molecular Imaging (M.K.), Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Medical Physics Section (M.-A.P.), Radiology Department, University of Texas Southwestern Medical Center, Dallas, TX; Department of Neurology (J.K.), Brigham and Women's Hospital, Boston, MA; Ceretype Neuromedicine (E.S.), Cambridge, MA; Functional Neuroimaging Laboratory (D.S.), Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Nuclear Medicine (C.K.K.), Department of Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Biogen Inc. (J.L.), Cambridge, MA; and Department of Neurology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Emily Stern
- From the PET Imaging Program in Neurologic Diseases (E.R., K.C., S.C., J.F., T.S.) and Brigham Multiple Sclerosis Center (E.R., T.C., H.L.W., S.B., T.S.), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital and Harvard Medical School; Division of Nuclear Medicine and Molecular Imaging (M.K.), Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Medical Physics Section (M.-A.P.), Radiology Department, University of Texas Southwestern Medical Center, Dallas, TX; Department of Neurology (J.K.), Brigham and Women's Hospital, Boston, MA; Ceretype Neuromedicine (E.S.), Cambridge, MA; Functional Neuroimaging Laboratory (D.S.), Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Nuclear Medicine (C.K.K.), Department of Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Biogen Inc. (J.L.), Cambridge, MA; and Department of Neurology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Tanuja Chitnis
- From the PET Imaging Program in Neurologic Diseases (E.R., K.C., S.C., J.F., T.S.) and Brigham Multiple Sclerosis Center (E.R., T.C., H.L.W., S.B., T.S.), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital and Harvard Medical School; Division of Nuclear Medicine and Molecular Imaging (M.K.), Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Medical Physics Section (M.-A.P.), Radiology Department, University of Texas Southwestern Medical Center, Dallas, TX; Department of Neurology (J.K.), Brigham and Women's Hospital, Boston, MA; Ceretype Neuromedicine (E.S.), Cambridge, MA; Functional Neuroimaging Laboratory (D.S.), Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Nuclear Medicine (C.K.K.), Department of Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Biogen Inc. (J.L.), Cambridge, MA; and Department of Neurology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - David Silbersweig
- From the PET Imaging Program in Neurologic Diseases (E.R., K.C., S.C., J.F., T.S.) and Brigham Multiple Sclerosis Center (E.R., T.C., H.L.W., S.B., T.S.), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital and Harvard Medical School; Division of Nuclear Medicine and Molecular Imaging (M.K.), Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Medical Physics Section (M.-A.P.), Radiology Department, University of Texas Southwestern Medical Center, Dallas, TX; Department of Neurology (J.K.), Brigham and Women's Hospital, Boston, MA; Ceretype Neuromedicine (E.S.), Cambridge, MA; Functional Neuroimaging Laboratory (D.S.), Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Nuclear Medicine (C.K.K.), Department of Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Biogen Inc. (J.L.), Cambridge, MA; and Department of Neurology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Howard L Weiner
- From the PET Imaging Program in Neurologic Diseases (E.R., K.C., S.C., J.F., T.S.) and Brigham Multiple Sclerosis Center (E.R., T.C., H.L.W., S.B., T.S.), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital and Harvard Medical School; Division of Nuclear Medicine and Molecular Imaging (M.K.), Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Medical Physics Section (M.-A.P.), Radiology Department, University of Texas Southwestern Medical Center, Dallas, TX; Department of Neurology (J.K.), Brigham and Women's Hospital, Boston, MA; Ceretype Neuromedicine (E.S.), Cambridge, MA; Functional Neuroimaging Laboratory (D.S.), Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Nuclear Medicine (C.K.K.), Department of Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Biogen Inc. (J.L.), Cambridge, MA; and Department of Neurology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Chun K Kim
- From the PET Imaging Program in Neurologic Diseases (E.R., K.C., S.C., J.F., T.S.) and Brigham Multiple Sclerosis Center (E.R., T.C., H.L.W., S.B., T.S.), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital and Harvard Medical School; Division of Nuclear Medicine and Molecular Imaging (M.K.), Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Medical Physics Section (M.-A.P.), Radiology Department, University of Texas Southwestern Medical Center, Dallas, TX; Department of Neurology (J.K.), Brigham and Women's Hospital, Boston, MA; Ceretype Neuromedicine (E.S.), Cambridge, MA; Functional Neuroimaging Laboratory (D.S.), Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Nuclear Medicine (C.K.K.), Department of Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Biogen Inc. (J.L.), Cambridge, MA; and Department of Neurology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Jennifer Lyons
- From the PET Imaging Program in Neurologic Diseases (E.R., K.C., S.C., J.F., T.S.) and Brigham Multiple Sclerosis Center (E.R., T.C., H.L.W., S.B., T.S.), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital and Harvard Medical School; Division of Nuclear Medicine and Molecular Imaging (M.K.), Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Medical Physics Section (M.-A.P.), Radiology Department, University of Texas Southwestern Medical Center, Dallas, TX; Department of Neurology (J.K.), Brigham and Women's Hospital, Boston, MA; Ceretype Neuromedicine (E.S.), Cambridge, MA; Functional Neuroimaging Laboratory (D.S.), Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Nuclear Medicine (C.K.K.), Department of Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Biogen Inc. (J.L.), Cambridge, MA; and Department of Neurology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Joshua P Klein
- From the PET Imaging Program in Neurologic Diseases (E.R., K.C., S.C., J.F., T.S.) and Brigham Multiple Sclerosis Center (E.R., T.C., H.L.W., S.B., T.S.), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital and Harvard Medical School; Division of Nuclear Medicine and Molecular Imaging (M.K.), Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Medical Physics Section (M.-A.P.), Radiology Department, University of Texas Southwestern Medical Center, Dallas, TX; Department of Neurology (J.K.), Brigham and Women's Hospital, Boston, MA; Ceretype Neuromedicine (E.S.), Cambridge, MA; Functional Neuroimaging Laboratory (D.S.), Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Nuclear Medicine (C.K.K.), Department of Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Biogen Inc. (J.L.), Cambridge, MA; and Department of Neurology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Shamik Bhattacharyya
- From the PET Imaging Program in Neurologic Diseases (E.R., K.C., S.C., J.F., T.S.) and Brigham Multiple Sclerosis Center (E.R., T.C., H.L.W., S.B., T.S.), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital and Harvard Medical School; Division of Nuclear Medicine and Molecular Imaging (M.K.), Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Medical Physics Section (M.-A.P.), Radiology Department, University of Texas Southwestern Medical Center, Dallas, TX; Department of Neurology (J.K.), Brigham and Women's Hospital, Boston, MA; Ceretype Neuromedicine (E.S.), Cambridge, MA; Functional Neuroimaging Laboratory (D.S.), Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Nuclear Medicine (C.K.K.), Department of Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Biogen Inc. (J.L.), Cambridge, MA; and Department of Neurology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Tarun Singhal
- From the PET Imaging Program in Neurologic Diseases (E.R., K.C., S.C., J.F., T.S.) and Brigham Multiple Sclerosis Center (E.R., T.C., H.L.W., S.B., T.S.), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital and Harvard Medical School; Division of Nuclear Medicine and Molecular Imaging (M.K.), Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Medical Physics Section (M.-A.P.), Radiology Department, University of Texas Southwestern Medical Center, Dallas, TX; Department of Neurology (J.K.), Brigham and Women's Hospital, Boston, MA; Ceretype Neuromedicine (E.S.), Cambridge, MA; Functional Neuroimaging Laboratory (D.S.), Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Nuclear Medicine (C.K.K.), Department of Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Biogen Inc. (J.L.), Cambridge, MA; and Department of Neurology (J.P.K.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
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8
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Jarius S, Pache F, Körtvelyessy P, Jelčić I, Stettner M, Franciotta D, Keller E, Neumann B, Ringelstein M, Senel M, Regeniter A, Kalantzis R, Willms JF, Berthele A, Busch M, Capobianco M, Eisele A, Reichen I, Dersch R, Rauer S, Sandner K, Ayzenberg I, Gross CC, Hegen H, Khalil M, Kleiter I, Lenhard T, Haas J, Aktas O, Angstwurm K, Kleinschnitz C, Lewerenz J, Tumani H, Paul F, Stangel M, Ruprecht K, Wildemann B. Cerebrospinal fluid findings in COVID-19: a multicenter study of 150 lumbar punctures in 127 patients. J Neuroinflammation 2022; 19:19. [PMID: 35057809 PMCID: PMC8771621 DOI: 10.1186/s12974-021-02339-0] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/02/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Comprehensive data on the cerebrospinal fluid (CSF) profile in patients with COVID-19 and neurological involvement from large-scale multicenter studies are missing so far. OBJECTIVE To analyze systematically the CSF profile in COVID-19. METHODS Retrospective analysis of 150 lumbar punctures in 127 patients with PCR-proven COVID-19 and neurological symptoms seen at 17 European university centers RESULTS: The most frequent pathological finding was blood-CSF barrier (BCB) dysfunction (median QAlb 11.4 [6.72-50.8]), which was present in 58/116 (50%) samples from patients without pre-/coexisting CNS diseases (group I). QAlb remained elevated > 14d (47.6%) and even > 30d (55.6%) after neurological onset. CSF total protein was elevated in 54/118 (45.8%) samples (median 65.35 mg/dl [45.3-240.4]) and strongly correlated with QAlb. The CSF white cell count (WCC) was increased in 14/128 (11%) samples (mostly lympho-monocytic; median 10 cells/µl, > 100 in only 4). An albuminocytological dissociation (ACD) was found in 43/115 (37.4%) samples. CSF L-lactate was increased in 26/109 (24%; median 3.04 mmol/l [2.2-4]). CSF-IgG was elevated in 50/100 (50%), but was of peripheral origin, since QIgG was normal in almost all cases, as were QIgA and QIgM. In 58/103 samples (56%) pattern 4 oligoclonal bands (OCB) compatible with systemic inflammation were present, while CSF-restricted OCB were found in only 2/103 (1.9%). SARS-CoV-2-CSF-PCR was negative in 76/76 samples. Routine CSF findings were normal in 35%. Cytokine levels were frequently elevated in the CSF (often associated with BCB dysfunction) and serum, partly remaining positive at high levels for weeks/months (939 tests). Of note, a positive SARS-CoV-2-IgG-antibody index (AI) was found in 2/19 (10.5%) patients which was associated with unusually high WCC in both of them and a strongly increased interleukin-6 (IL-6) index in one (not tested in the other). Anti-neuronal/anti-glial autoantibodies were mostly absent in the CSF and serum (1509 tests). In samples from patients with pre-/coexisting CNS disorders (group II [N = 19]; including multiple sclerosis, JC-virus-associated immune reconstitution inflammatory syndrome, HSV/VZV encephalitis/meningitis, CNS lymphoma, anti-Yo syndrome, subarachnoid hemorrhage), CSF findings were mostly representative of the respective disease. CONCLUSIONS The CSF profile in COVID-19 with neurological symptoms is mainly characterized by BCB disruption in the absence of intrathecal inflammation, compatible with cerebrospinal endotheliopathy. Persistent BCB dysfunction and elevated cytokine levels may contribute to both acute symptoms and 'long COVID'. Direct infection of the CNS with SARS-CoV-2, if occurring at all, seems to be rare. Broad differential diagnostic considerations are recommended to avoid misinterpretation of treatable coexisting neurological disorders as complications of COVID-19.
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Affiliation(s)
- Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Florence Pache
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Peter Körtvelyessy
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE) in Magdeburg, Magdeburg, Germany
| | - Ilijas Jelčić
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Mark Stettner
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Medicine Essen, University of Duisburg-Essen, Essen, Germany
| | | | - Emanuela Keller
- Neurocritical Care Unit, Department of Neurosurgery and Institute of Intensive Care, University Hospital and University of Zurich, Zurich, Switzerland
| | - Bernhard Neumann
- Department of Neurology, University of Regensburg, Regensburg, Germany
- Department of Neurology, DONAUISAR Klinikum Deggendorf, Deggendorf, Germany
| | - Marius Ringelstein
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- Department of Neurology, Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Makbule Senel
- Department of Neurology, Ulm University, Ulm, Germany
| | - Axel Regeniter
- Medica Medical Laboratories Dr. F. Kaeppeli AG, Zurich, Switzerland
| | - Rea Kalantzis
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jan F. Willms
- Institute of Intensive Care Medicine, University Hospital and University of Zurich, Zurich, Switzerland
| | - Achim Berthele
- Department of Neurology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Markus Busch
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Marco Capobianco
- Regional Referral Multiple Sclerosis Centre, Department of Neurology, University Hospital S. Luigi - Orbassano (I), Orbassano, Italy
| | - Amanda Eisele
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Ina Reichen
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Rick Dersch
- Clinic of Neurology and Neurophysiology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sebastian Rauer
- Clinic of Neurology and Neurophysiology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina Sandner
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Ilya Ayzenberg
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
- Department of Neurology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Catharina C. Gross
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, Münster, Germany
| | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Khalil
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Ingo Kleiter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Thorsten Lenhard
- Neuroinfectiology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Jürgen Haas
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Klemens Angstwurm
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Medicine Essen, University of Duisburg-Essen, Essen, Germany
| | - Jan Lewerenz
- Department of Neurology, Ulm University, Ulm, Germany
| | - Hayrettin Tumani
- Department of Neurology, Ulm University, Ulm, Germany
- Specialty Hospital of Neurology Dietenbronn, Schwendi, Germany
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Stangel
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hannover Medical School, Hanover, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - ; in cooperation with the German Society for Cerebrospinal Fluid Diagnostics and Clinical Neurochemistry
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE) in Magdeburg, Magdeburg, Germany
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Medicine Essen, University of Duisburg-Essen, Essen, Germany
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Neurocritical Care Unit, Department of Neurosurgery and Institute of Intensive Care, University Hospital and University of Zurich, Zurich, Switzerland
- Department of Neurology, University of Regensburg, Regensburg, Germany
- Department of Neurology, DONAUISAR Klinikum Deggendorf, Deggendorf, Germany
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- Department of Neurology, Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- Department of Neurology, Ulm University, Ulm, Germany
- Medica Medical Laboratories Dr. F. Kaeppeli AG, Zurich, Switzerland
- Institute of Intensive Care Medicine, University Hospital and University of Zurich, Zurich, Switzerland
- Department of Neurology, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- Regional Referral Multiple Sclerosis Centre, Department of Neurology, University Hospital S. Luigi - Orbassano (I), Orbassano, Italy
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Clinic of Neurology and Neurophysiology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
- Department of Neurology, Sechenov First Moscow State Medical University, Moscow, Russia
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, Münster, Germany
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Neurology, Medical University of Graz, Graz, Austria
- Neuroinfectiology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
- Specialty Hospital of Neurology Dietenbronn, Schwendi, Germany
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité—Universitätsmedizin Berlin, Berlin, Germany
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hannover Medical School, Hanover, Germany
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9
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Abstract
Meningitis and encephalitis are inflammatory syndromes of the meninges and brain parenchyma, respectively, and may be identified either by finding definitive evidence of inflammation on tissue pathology or by cerebrocpinal fluid (CSF) analysis showing pleocytosis or intrathecal antibody synthesis. Clinicians evaluating undifferentiated meningitis or encephalitis should simultaneously consider autoimmune, infectious, and neoplastic causes, using patient risk factors, clinical syndrome, and diagnostic results including CSF and MRI findings to narrow the differential diagnosis. If an autoimmune cause is favored, an important early diagnostic question is whether a specific neural autoantibody is likely to be identified.
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Affiliation(s)
- Megan B Richie
- Department of Neurology, University of California San Francisco, 505 Parnassus Avenue, Box 0114, San Francisco, CA 94143, USA.
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10
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Bastiaansen AEM, van Steenhoven RW, de Bruijn MAAM, Crijnen YS, van Sonderen A, van Coevorden-Hameete MH, Nühn MM, Verbeek MM, Schreurs MWJ, Sillevis Smitt PAE, de Vries JM, Jan de Jong F, Titulaer MJ. Autoimmune Encephalitis Resembling Dementia Syndromes. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/5/e1039. [PMID: 34341093 PMCID: PMC8362342 DOI: 10.1212/nxi.0000000000001039] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/19/2021] [Indexed: 11/15/2022]
Abstract
Objective As autoimmune encephalitis (AIE) can resemble neurodegenerative dementia
syndromes, and patients do not always present as encephalitis, this study
evaluates how frequently AIE mimics dementia and provides red flags for AIE
in middle-aged and older patients. Methods In this nationwide observational cohort study, patients with
anti–leucine-rich glioma-inactivated 1 (LGI1), anti–NMDA
receptor (NMDAR), anti–gamma-aminobutyric acid B receptor
(GABABR), or anti–contactin-associated protein-like 2
(CASPR2) encephalitis were included. They had to meet 3 additional criteria:
age ≥45 years, fulfillment of dementia criteria, and no prominent
seizures early in the disease course (≤4 weeks). Results Two-hundred ninety patients had AIE, of whom 175 were 45 years or older.
Sixty-seven patients (38%) fulfilled criteria for dementia without prominent
seizures early in the disease course. Of them, 42 had anti-LGI1 (48%), 13
anti-NMDAR (52%), 8 anti-GABABR (22%), and 4 anti-CASPR2 (15%)
encephalitis. Rapidly progressive cognitive deterioration was seen in 48
patients (76%), whereas a neurodegenerative dementia syndrome was suspected
in half (n = 33). In 17 patients (27%; 16/17 anti-LGI1), subtle
seizures had been overlooked. Sixteen patients (25%) had neither
inflammatory changes on brain MRI nor CSF pleocytosis. At least 1 CSF
biomarker, often requested when dementia was suspected, was abnormal in 27
of 44 tested patients (61%), whereas 8 had positive 14-3-3 results (19%).
Most patients (84%) improved after immunotherapy. Conclusions Red flags for AIE in patients with suspected dementia are: (1) rapidly
progressive cognitive decline, (2) subtle seizures, and (3) abnormalities in
ancillary testing atypical for neurodegeneration. Physicians should be aware
that inflammatory changes are not always present in AIE, and that biomarkers
often requested when dementia was suspected (including 14-3-3) can show
abnormal results. Diagnosis is essential as most patients profit from
immunotherapy.
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Affiliation(s)
- Anna E M Bastiaansen
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Robin W van Steenhoven
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marienke A A M de Bruijn
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Yvette S Crijnen
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Agnes van Sonderen
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marleen H van Coevorden-Hameete
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marieke M Nühn
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marcel M Verbeek
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marco W J Schreurs
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Peter A E Sillevis Smitt
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Juna M de Vries
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Frank Jan de Jong
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Maarten J Titulaer
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
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11
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Ismail FS, Spatola M, Woermann FG, Popkirov S, Jungilligens J, Bien CG, Wellmer J, Schlegel U. Diagnostic challenges in patients with temporal lobe seizures and features of autoimmune limbic encephalitis. Eur J Neurol 2021; 29:1303-1310. [PMID: 34288284 DOI: 10.1111/ene.15026] [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: 03/19/2021] [Accepted: 07/08/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Consensus criteria for autoimmune limbic encephalitis (ALE) allow for a diagnosis even without neuronal antibodies (Abs), but it remains unclear which clinical features should prompt neuronal Ab screening in temporal lobe epilepsy patients. The aim of the study was to investigate whether patients with temporal lobe seizures associated with additional symptoms or signs of limbic involvement may harbor neuronal Abs, and which clinical features should prompt neuronal Ab screening in these patients. METHODS We identified 47 patients from a tertiary epilepsy center with mediotemporal lobe seizures and additional features suggestive of limbic involvement, including either memory deficits, psychiatric symptoms, mediotemporal magnetic resonance imaging (MRI) hyperintensities or inflammatory cerebrospinal fluid (CSF). Neuronal Ab testing was carried out at two independent reference laboratories (Bielefeld-Bethel, Germany, and Barcelona, Spain). All brain MRI scans were assessed by two reviewers independently. RESULTS Temporal lobe seizures were accompanied by memory deficits in 35/46 (76%), psychiatric symptoms in 27/42 (64%), and both in 19/42 patients (45%). Limbic T2/fluid-attenuated inversion recovery signal hyperintensities were found in 26/46 patients (57%; unilateral: n = 22, bilateral: n = 4). Standard CSF studies were abnormal in 2/37 patients (5%). Neuronal Abs were confirmed in serum and/or CSF in 8/47 patients (17%) and were directed against neuronal cell-surface targets (leucine-rich glioma inactivated protein 1: n = 1, contactin-associated protein-2: n = 1, undetermined target: n = 3) or glutamic acid decarboxylase in its 65-kD isoform (n = 3, all with high titers). Compared to Ab-negative patients, those who harbored neuronal Abs were more likely to have uni- or bilateral mediotemporal MRI changes (8/8, 100% vs. 18/38, 47%; p = 0.01, Fisher's exact test). CONCLUSIONS In patients with temporal lobe seizures and additional limbic signs, 17% had neuronal Abs affirming ALE diagnosis. Mediotemporal MRI changes were found in all Ab-positive cases and had a positive likelihood ratio of 2.11 (95% confidence interval 1.51-2.95).
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Affiliation(s)
- Fatme Seval Ismail
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Marianna Spatola
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic, University of Barcelona, Barcelona, Spain.,University of Lausanne (UNIL), Lausanne, Switzerland
| | - Friedrich G Woermann
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany
| | - Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Johannes Jungilligens
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany.,Department of Neuropsychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, Bochum, Germany
| | - Christian G Bien
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany.,Laboratory Krone, Bad Salzuflen, Germany
| | - Jörg Wellmer
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Uwe Schlegel
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
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12
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Zrzavy T, Höftberger R, Wimmer I, Berger T, Rommer P, Macher S. Longitudinal CSF Findings in Autoimmune Encephalitis-A Monocentric Cohort Study. Front Immunol 2021; 12:646940. [PMID: 33828556 PMCID: PMC8019787 DOI: 10.3389/fimmu.2021.646940] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 02/24/2021] [Indexed: 11/13/2022] Open
Abstract
Autoimmune encephalitis (AIE) poses a diagnostic challenge due to its heterogeneous clinical presentation, which overlaps with various neurological and psychiatric diseases. During the diagnostic work-up, cerebrospinal fluid (CSF) is routinely obtained, allowing for differential diagnostics as well as for the determination of antibody subclasses and specificities. In this monocentric cohort study, we describe initial and serial CSF findings of 33 patients diagnosed with antibody-associated AIE (LGI1 (n=8), NMDA (n=7), CASPR2 (n=3), IgLON5 (n=3), AMPAR (n=1), GAD65/67 (n=4), Yo (n=3), Ma-1/2 (n=2), CV2 (n=2)). Routine CSF parameters of 12.1% of AIE patients were in normal ranges, while 60.6% showed elevated protein levels and 45.4% had intrathecal oligoclonal bands (OCBs). Repeated CSF analyses showed a trend towards normalization of initial pathological CSF findings, while relapses were more likely to be associated with increased cell counts and total protein levels. OCB status conversion in anti-NMDARE patients coincided with clinical improvement. In summary, we show that in routine CSF analysis at diagnosis, a considerable number of patients with AIE did not exhibit alteration in the CSF and therefore, diagnosis may be delayed if antibody testing is not performed. Moreover, OCB status in anti-NMDAR AIE patients could represent a potential prognostic biomarker, however further studies are necessary to validate these exploratory findings.
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Affiliation(s)
- Tobias Zrzavy
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Isabella Wimmer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paulus Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Stefan Macher
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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13
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Broadley J, Wesselingh R, Seneviratne U, Kyndt C, Beech P, Buzzard K, Nesbitt C, D'souza W, Brodtmann A, Macdonell R, Kalincik T, Butzkueven H, O'Brien TJ, Monif M. Prognostic value of acute cerebrospinal fluid abnormalities in antibody-positive autoimmune encephalitis. J Neuroimmunol 2021; 353:577508. [PMID: 33588218 DOI: 10.1016/j.jneuroim.2021.577508] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 01/28/2021] [Accepted: 01/28/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To examine the prognostic value of CSF abnormalities in seropositive autoimmune encephalitis (AE). METHODS We retrospectively studied 57 cases of seropositive AE. Primary outcomes were mortality and modified Rankin Scale, while secondary outcomes were first line treatment failure, ICU admission and relapse. Regression analysis was performed. RESULTS CSF white cell count (WCC) was higher in the NMDAR group, while elevated protein was more common amongst other subtypes. We found an association between WCC >5 cells/mm3 and treatment failure (OR 16.0, p = 0.006)), and between WCC >20 cells/mm3 and ICU admission (OR 19.3, p = 0.026). CONCLUSIONS Different subsets of AE have characteristic CSF abnormalities, which may aid recognition during early evaluation. CSF WCC had prognostic significance in our study.
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Affiliation(s)
- James Broadley
- Department of Neuroscience, Monash University, Melbourne, Australia; Department of Neurology, Alfred Health, Melbourne, Australia
| | - Robb Wesselingh
- Department of Neuroscience, Monash University, Melbourne, Australia; Department of Neurology, Alfred Health, Melbourne, Australia
| | - Udaya Seneviratne
- Department of Neuroscience, Monash University, Melbourne, Australia; Department of Neuroscience, Monash Health, Melbourne, Australia; Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | - Chris Kyndt
- Department of Neurosciences, Eastern Health, Melbourne, Australia
| | - Paul Beech
- Department of Radiology, Alfred Health, Melbourne, Australia; Department of Radiology, Monash Health, Melbourne, Australia
| | - Katherine Buzzard
- Department of Neurosciences, Eastern Health, Melbourne, Australia; Department of Neurology, Melbourne Health, Melbourne, Australia
| | - Cassie Nesbitt
- Department of Neurology, Alfred Health, Melbourne, Australia; Department of Neuroscience, Barwon Health, Geelong, Australia
| | - Wendyl D'souza
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | - Amy Brodtmann
- Department of Neurosciences, Eastern Health, Melbourne, Australia; Department of Neurology, Melbourne Health, Melbourne, Australia; Department of Neurology, Austin Health, Melbourne, Australia
| | | | - Tomas Kalincik
- Department of Medicine, The University of Melbourne, Melbourne, Australia; CORe, The University of Melbourne, Melbourne, Australia
| | - Helmut Butzkueven
- Department of Neuroscience, Monash University, Melbourne, Australia; Department of Neurology, Alfred Health, Melbourne, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Monash University, Melbourne, Australia; Department of Neurology, Alfred Health, Melbourne, Australia
| | - Mastura Monif
- Department of Neuroscience, Monash University, Melbourne, Australia; Department of Neurology, Alfred Health, Melbourne, Australia; Department of Neurology, Melbourne Health, Melbourne, Australia; Department of Physiology, The University of Melbourne, Melbourne, Australia.
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14
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Culler G, Bachman E, VanHaerents S. Paraclinical serum markers as aids in the diagnosis of autoimmune encephalitis. J Neuroimmunol 2020; 347:577324. [PMID: 32763583 DOI: 10.1016/j.jneuroim.2020.577324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 11/17/2022]
Abstract
Expert opinion suggests the presence ANA and thyroid antibodies may be helpful to diagnosis autoimmune encephalitis (AE). This study investigates the sensitivity of these serum markers in a cohort of 26 patients with AE. TPO-Ab, TG-Ab and ANA (titer ≥1:320) were present in 45%, 35% and 32% of patients tested, respectively. The prevalence of TPO-Ab (11.3%), TG-Ab (10.4%) and ANA ≥1:320 (3.3%) has been previously reported in disease-free populations. Although these antibodies represent non-specific markers of autoimmunity, this study demonstrated that TPO-Ab, TG-Ab and ANA were significantly elevated in AE compared to disease-free populations (p < .001, p = .003, p < .001, respectively).
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Affiliation(s)
- George Culler
- Northwestern Memorial Hospital, Chicago, IL, USA; Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Elizabeth Bachman
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Stephen VanHaerents
- Northwestern Memorial Hospital, Chicago, IL, USA; Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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15
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Grimaldi S, Lagarde S, Harlé JR, Boucraut J, Guedj E. Autoimmune Encephalitis Concomitant with SARS-CoV-2 Infection: Insight from 18F-FDG PET Imaging and Neuronal Autoantibodies. J Nucl Med 2020; 61:1726-1729. [PMID: 32709734 PMCID: PMC8679632 DOI: 10.2967/jnumed.120.249292] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/23/2020] [Indexed: 12/20/2022] Open
Abstract
We report the case of a 72-y-old man with concomitant autoimmune encephalitis and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The patient presented with subacute cerebellar syndrome and myoclonus several days after general infectious symptoms began. Methods: Clinical examination, CT, PET, MRI, and autoantibody testing were performed. Results: The oropharyngeal swab test was positive for SARS-CoV-2. The brain MRI results were normal. Cerebrospinal fluid testing showed normal cell counts, a negative result on reverse-transcription polymerase chain reaction testing, and no oligoclonal banding. Brain 18F-FDG PET showed diffuse cortical hypometabolism associated with putaminal and cerebellum hypermetabolism, compatible with encephalitis and especially cerebellitis. The immunologic study revealed high titers of IgG autoantibodies in serum and cerebrospinal fluid directed against the nuclei of Purkinje cells, striatal neurons, and hippocampal neurons. Whole-body 18F-FDG PET and CT scans did not show neoplasia. Treatment with steroids allowed a rapid improvement in symptoms. Conclusion: This clinical case argues for a possible relationship between SARS-CoV-2 infection and autoimmune encephalitis and for the use of 18F-FDG PET in such a context.
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Affiliation(s)
- Stephan Grimaldi
- Aix Marseille Univ, APHM, Timone Hospital, Department of Neurology and Movement Disorders, Marseille, France
| | - Stanislas Lagarde
- Aix Marseille Univ, APHM, INSERM, INS, Inst Neurosci Syst, Timone Hospital, Epileptology Department, Marseille, France
| | - Jean-Robert Harlé
- Aix Marseille Univ, APHM, Timone Hospital, Department of Internal Medicine, Marseille, France
| | - José Boucraut
- Aix Marseille Univ, APHM, CNRS, INT, Conception Hospital, Immunology Laboratory, Marseille, France; and
| | - Eric Guedj
- Aix Marseille Univ, APHM, CNRS, Centrale Marseille, Institut Fresnel, Timone Hospital, CERIMED, Nuclear Medicine Department, Marseille, France
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16
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Autoimmune encephalitis as a differential diagnosis of schizophreniform psychosis: clinical symptomatology, pathophysiology, diagnostic approach, and therapeutic considerations. Eur Arch Psychiatry Clin Neurosci 2020; 270:803-818. [PMID: 32166503 PMCID: PMC7474714 DOI: 10.1007/s00406-020-01113-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 02/08/2020] [Indexed: 12/12/2022]
Abstract
Primary schizophreniform psychoses are thought to be caused by complex gene-environment interactions. Secondary forms are based on a clearly identifiable organic cause, in terms of either an etiological or a relevant pathogenetic factor. The secondary or "symptomatic" forms of psychosis have reentered the focus stimulated by the discovery of autoantibody (Ab)-associated autoimmune encephalitides (AEs), such as anti-NMDA-R encephalitis, which can at least initially mimic variants of primary psychosis. These newly described secondary, immune-mediated schizophreniform psychoses typically present with the acute onset of polymorphic psychotic symptoms. Over the course of the disease, other neurological phenomena, such as epileptic seizures, movement disorders, or reduced levels of consciousness, usually arise. Typical clinical signs for AEs are the acute onset of paranoid hallucinatory symptoms, atypical polymorphic presentation, psychotic episodes in the context of previous AE, and additional neurological and medical symptoms such as catatonia, seizure, dyskinesia, and autonomic instability. Predominant psychotic courses of AEs have also been described casuistically. The term autoimmune psychosis (AP) was recently suggested for these patients. Paraclinical alterations that can be observed in patients with AE/AP are inflammatory cerebrospinal fluid (CSF) pathologies, focal or generalized electroencephalographic slowing or epileptic activity, and/or suspicious "encephalitic" imaging findings. The antibody analyses in these patients include the testing of the most frequently found Abs against cell surface antigens (NMDA-R, CASPR2, LGI1, AMPA-R, GABAB-R), intracellular antigens (Hu, Ri, Yo, CV2/CRMP5, Ma2 [Ta], amphiphysin, GAD65), thyroid antigens (TG, TPO), and antinuclear Abs (ANA). Less frequent antineuronal Abs (e.g., against DPPX, GABAA-R, glycine-R, IgLON5) can be investigated in the second step when first step screening is negative and/or some specific clinical factors prevail. Beyond, tissue-based assays on brain slices of rodents may detect previously unknown antineuronal Abs in some cases. The detection of clinical and/or paraclinical pathologies (e.g., pleocytosis in CSF) in combination with antineuronal Abs and the exclusion of alternative causes may lead to the diagnosis of AE/AP and enable more causal therapeutic immunomodulatory opportunities.
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17
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Endres D, Bechter K, Prüss H, Hasan A, Steiner J, Leypoldt F, Tebartz van Elst L. [Autoantibody-associated schizophreniform psychoses: clinical symptomatology]. DER NERVENARZT 2019; 90:547-563. [PMID: 30968197 DOI: 10.1007/s00115-019-0700-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
According to present concepts, primary psychotic disorders in the schizophrenia spectrum are probably caused by a complex interaction between multigenetic vulnerability and causally relevant environmental factors. In contrast, secondary psychotic disorders are the result of likely identifiable organic factors either in terms of a first causation (etiology) or a secondary cause (pathogenesis). In this context, autoantibody(ab)-associated autoimmune encephalitis (AE) plays an increasingly important role. Within the group of ab-associated AE with neuropsychiatric symptoms, anti-N-methyl-D-aspartate receptor encephalitis is the most prevalent one. Psychopathologically, polymorphic psychotic symptoms are often observed at onset of AE; however, over the course of this condition or even initially other neuropsychiatric phenomena are also common. The ill-defined entity of a steroid-responsive encephalopathy with thyroid antibodies (Hashimoto's encephalitis) is a heterogeneous syndrome that may also comprise isolated psychotic disorders presenting as classical schizophrenia.
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Affiliation(s)
- Dominique Endres
- Sektion für experimentelle Neuropsychiatrie, Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hauptstr. 5, 79104, Freiburg, Deutschland
| | - Karl Bechter
- Klinik für Psychiatrie und Psychotherapie II, Bezirkskrankenhaus Günzburg, Universität Ulm, Günzburg, Deutschland
| | - Harald Prüss
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) Berlin, Berlin, Deutschland.,Experimentelle Neurologie und Klinik und Poliklinik für Neurologie, Charité Universitätsmedizin, Berlin, Deutschland
| | - Alkomiet Hasan
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Klinikum der Universität München, LMU, München, Deutschland
| | - Johann Steiner
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Deutschland
| | - Frank Leypoldt
- Institut für Klinische Chemie und Klinik, Universitätsklinik Schleswig-Holstein Campus Kiel, Kiel, Deutschland
| | - Ludger Tebartz van Elst
- Sektion für experimentelle Neuropsychiatrie, Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hauptstr. 5, 79104, Freiburg, Deutschland.
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18
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Zangrandi A, Gasparini F, Marti A, Bhalla R, Napoli M, Angelini D, Ghidoni E, Rizzi R. A 9-year neuropsychological report of a patient with LGI1-associated limbic encephalitis. J Clin Exp Neuropsychol 2019; 41:749-759. [PMID: 31142216 DOI: 10.1080/13803395.2019.1617836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Introduction: Anti-leucine-rich glioma-inactivated 1 limbic encephalitis (LGI1-LE) is an autoimmune disorder associated with antibodies to voltage-gated potassium channels (VGKC). It is a non-paraneoplastic and partially reversible encephalitis that can be diagnosed via serological testing. Untreated LGI1-LE can be associated with neurocognitive as well as neuropsychiatric sequelae. Here we report the neuropsychological and clinical profile of a patient with LGI1-LE following three different treatment approaches: plasmapheresis (PA), intravenous immunoglobulin (IVIG), and corticosteroids (CO). Method: We investigated our patient with 10 neuropsychological evaluations obtained over a 9-year follow-up period. Multiple MRI scans, EEG recordings, neurological examinations, and serum tests were also obtained. Results: The neurocognitive profile of our patient was characterized by long-term memory impairment (verbal and visual-spatial), and deficits in aspects of executive functioning and language. Neuropsychiatric symptoms of depression and anxiety were noted intermittently. Conclusions: Non-specific treatment prior to diagnosis had marginal effects on neurocognitive profile, neuropsychiatric symptoms, or control of epileptic seizure. In contrast, specific treatments for LGI1-LE following diagnosis resulted in neurocognitive improvement and epileptic control. Among the three treatments, IVIG and CO had the most beneficial impact on neurocognitive status, likely due to the continuity of administration.
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Affiliation(s)
- Andrea Zangrandi
- a Clinical Neuropsychology, Cognitive Disorders and Dyslexia Unit, Department of Neuro-Motor Diseases , Azienda Unità Sanitaria Locale - IRCCS Reggio Emilia , Reggio Emilia , Italy
| | - Federico Gasparini
- a Clinical Neuropsychology, Cognitive Disorders and Dyslexia Unit, Department of Neuro-Motor Diseases , Azienda Unità Sanitaria Locale - IRCCS Reggio Emilia , Reggio Emilia , Italy
| | - Alessandro Marti
- a Clinical Neuropsychology, Cognitive Disorders and Dyslexia Unit, Department of Neuro-Motor Diseases , Azienda Unità Sanitaria Locale - IRCCS Reggio Emilia , Reggio Emilia , Italy
| | - Rishi Bhalla
- b Department of Psychiatry , University of British Columbia , Vancouver , Canada
| | - Manuela Napoli
- c Neuroradiology Unit, Department of Diagnostic Imaging , Azienda Unità Sanitaria Locale - IRCCS Reggio Emilia , Reggio Emilia , Italy
| | - Damiano Angelini
- a Clinical Neuropsychology, Cognitive Disorders and Dyslexia Unit, Department of Neuro-Motor Diseases , Azienda Unità Sanitaria Locale - IRCCS Reggio Emilia , Reggio Emilia , Italy
| | - Enrico Ghidoni
- a Clinical Neuropsychology, Cognitive Disorders and Dyslexia Unit, Department of Neuro-Motor Diseases , Azienda Unità Sanitaria Locale - IRCCS Reggio Emilia , Reggio Emilia , Italy
| | - Romana Rizzi
- d Neurology Unit, Department of Neuro-Motor Diseases , Azienda Unità Sanitaria Locale - IRCCS Reggio Emilia , Reggio Emilia , Italy
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19
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Diagnostic tools for immune causes of encephalitis. Clin Microbiol Infect 2019; 25:431-436. [DOI: 10.1016/j.cmi.2018.12.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/01/2018] [Accepted: 12/08/2018] [Indexed: 12/26/2022]
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20
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Abstract
Autoimmune encephalitis is a severe inflammatory disorder of the brain with diverse causes and a complex differential diagnosis. Recent advances in the past decade have led to the identification of new syndromes and biological markers of limbic encephalitis, the commonest presentation of autoimmune encephalitis. The successful use of serum and intrathecal antibodies to diagnose affected patients has resulted in few biopsy and postmortem examinations. In those available, there can be variable infiltrating inflammatory T cells with cytotoxic granules in close apposition to neurons, consistent with an inflammatory autoimmune basis, but true vasculitis is rarely seen. The exception is Hashimoto encephalopathy.
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Affiliation(s)
- David S Younger
- Department of Neurology, Division of Neuro-Epidemiology, New York University School of Medicine, New York, NY 10016, USA; School of Public Health, City University of New York, New York, NY, USA.
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Freund B, Probasco JC, Cervenka MC, Sutter R, Kaplan PW. EEG Differences in Two Clinically Similar Rapid Dementias: Voltage-Gated Potassium Channel Complex-Associated Autoimmune Encephalitis and Creutzfeldt-Jakob Disease. Clin EEG Neurosci 2019; 50:121-128. [PMID: 29788790 DOI: 10.1177/1550059418774686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Distinguishing treatable causes for rapidly progressive dementia from those that are incurable is vital. Creutzfeldt-Jakob disease (CJD) and voltage-gated potassium channel complex-associated autoimmune encephalitis (VGKC AE) are 2 such conditions with disparate outcomes and response to treatment. To determine the differences in electroencephalography between CJD and VGKC AE, we performed a retrospective review of medical records and examined clinical data, neuroimaging, and electroencephalographs performed in patients admitted for evaluation for rapidly progressive dementia diagnosed with CJD and VGKC AE at the Johns Hopkins Hospital and Bayview Medical Center between January 1, 2007 and December 31, 2015. More patients in the VGKC AE group had seizures (12/17) than those with CJD (3/14; P = .008). Serum sodium levels were lower in those with VGKC AE (P = .001). Cerebrospinal fluid (CSF) white blood cell count was higher in VGKC AE (P = .008). CSF protein 14-3-3 (P = .018) was more commonly detected in CJD, and tau levels were higher in those with CJD (P < .006). On neuroimaging, diffusion restriction in the cortex (P = .001), caudate (P < .001), and putamen (P = .001) was more frequent in CJD. Periodic sharp wave complexes (P = .001) and generalized suppressed activity (P = .008) were more common on initial EEG in CJD. On serial EEGs, generalized periodic discharges (P = .004), generalized suppressed activity (P=0.008), and periodic sharp wave complexes (P < .001) were detected more in CJD. This study shows that there are a number of differentiating features between CJD and VGKC AE, and electroencephalography can aid in their diagnoses. Performing serial EEGs better delineates these conditions.
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Affiliation(s)
- Brin Freund
- Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - John C Probasco
- Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Raoul Sutter
- Department of Neurology and Intensive Care Units, University Hospital Basel, Basel, Switzerland
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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22
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Jarius S, Haas J, Paul F, Wildemann B. Myelinoclastic diffuse sclerosis (Schilder's disease) is immunologically distinct from multiple sclerosis: results from retrospective analysis of 92 lumbar punctures. J Neuroinflammation 2019; 16:51. [PMID: 30819213 PMCID: PMC6396538 DOI: 10.1186/s12974-019-1425-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 01/31/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Myelinoclastic diffuse sclerosis (MDS; also termed Schilder's disease) is a rare inflammatory demyelinating disorder of the central nervous system characterised by demyelination of vast areas of the white matter. It is unclear whether MDS is a variant of multiple sclerosis (MS) or a disease entity in its own right. OBJECTIVE To compare the cerebrospinal fluid (CSF) features of MDS with those of MS. METHODS Retrospective analysis of the CSF profile of all patients with MDS reported in the medical literature between 1960 and 2018. RESULTS The most striking finding was a substantial lack of oligoclonal bands (OCBs) in MDS, which were absent in at least 77% (30/39) of all lumbar punctures (LP) in the total cohort and in 86% in the subgroup of patients with normal very long-chain fatty acid serum ratios (VLCFA). Almost all cases published in the past 15 years were negative for OCBs. These findings are in contrast to MS, in which OCBs are present in up to 98% of cases (p < 0.00001 when compared with reference works in MS; both in adult and in pediatric patients). CSF pleocytosis was absent in at least 79% (46/58) of all LP (p < 0.0001 vs. MS) and in 92% (24/26) of LPs in the VLCFA-tested subgroup. CSF total protein levels were elevated in 56% of all LPs (p < 0.0001 vs. MS) and in 63% of LPs in the VLCFA-tested subgroup and were often higher than in typical MS (> 100 mg/dL in 13/22; up to 220 mg/dL). EBV serum antibodies, which are present in virtually all patients with MS, and the so-called MRZ (measles/rubella/zoster) reaction, a highly specific marker of MS, were absent in all of the few patients tested. In addition, we discuss further differences between MS and MDS, taking into account also Schilder's original comprehensive case description from 1912. CONCLUSION In the majority of patients diagnosed with MDS, CSF features differ significantly from those typically found in MS and are more similar to those previously reported in patients with myelin oligodendrocyte glycoprotein-immunoglobulin G (IgG)-positive encephalomyelitis, aquaporin-4-IgG-positive neuromyelitis optica spectrum disorders or Baló's concentric sclerosis. Our data suggest that MDS and MS are immunopathologically distinct entities in the majority of cases.
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Affiliation(s)
- S Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany.
| | - J Haas
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - F Paul
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Clinical and Experimental Multiple Sclerosis Research Center, Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - B Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
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Adult CSF total protein upper reference limits should be age-partitioned and significantly higher than 0.45 g/L: a systematic review. J Neurol 2019; 266:616-624. [PMID: 30617996 DOI: 10.1007/s00415-018-09174-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 12/24/2018] [Accepted: 12/26/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Cerebrospinal fluid total protein (CSF-TP) is measured in the diagnosis of a range of immune or infectious disorders of the nervous system. Most laboratories and the medical literature use an antiquated, age-independent upper limit of 0.45 g/L. Therefore, we performed a systematic review of reference studies in the medical literature, with the primary objective of determining the CSF total protein upper reference limit (URL). Secondary objectives were to assess the effects of age, gender, laboratory methods, and methodological quality. METHODS A pre-planned and peer-reviewed electronic search strategy was used to search Ovid Medline and EMBASE for 1960-2017. All records underwent title/abstract review, and potentially relevant records underwent independent full-text review by two researchers. The remaining studies underwent quality assessment using a modification of the QUADAS2 revised tool. CSF-TP upper reference limits extracted from these studies were used to compute weighted means. RESULTS Twenty-two articles were retained for qualitative analysis and 20 for quantitative analysis. The weighted average of CSF-TP URL was 0.55 g/L, in studies with high methodological quality. Studies that examined the effect of age reported consistent correlations with advancing age, and CSF-TP URL values incrementally exceeded 0.60 g/L after age 50. There were no meaningful differences according to gender, laboratory method, or quality assessment score. CONCLUSIONS There is concordance in available literature to recommend increasing CSF total protein upper reference limits, and to consider implementing age-adjusted values above 0.60 g/L starting at age 50. This information merits worldwide dissemination, to reduce the risk of over-diagnosis.
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24
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Autoimmune encephalitis and psychiatric disorders. Rev Neurol (Paris) 2018; 174:228-236. [DOI: 10.1016/j.neurol.2017.11.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/15/2017] [Accepted: 11/29/2017] [Indexed: 12/20/2022]
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Abstract
Paraneoplastic limbic encephalitis is an autoimmune syndrome characterized by the acute or subacute onset of encephalopathy, memory loss, confusion, temporal lobe seizures, and behavioral and mood changes. Although most patients with paraneoplastic limbic encephalitis have antineuronal antibodies, advances in the field now permit the diagnosis without autoantibody test results. In this case illustrating the new diagnostic criteria, we report a 70-year-old woman who was brought to the emergency room after the acute onset of cognitive impairment, altered mental status, and choreoathetoid movements. Brain magnetic resonance imaging showed hyperintense signals in both temporal lobes, and a chest computed tomogram revealed a thymoma. Because the patient met current diagnostic criteria for autoimmune limbic encephalitis, we were able to start treatment before her antibody tests were processed. The patient received immunotherapy and her tumor was resected. Her choreoathetoid movements disappeared and her other neurologic symptoms improved. Her cerebrospinal fluid proved to be negative for paraneoplastic limbic encephalitis antibodies. Most but not all patients with paraneoplastic limbic encephalitis associated with thymoma have evidence of paraneoplastic antibodies. Prompt management of the underlying malignancy determines whether patients survive and may minimize future cognitive and functional impairment. Practicing neurologists and psychiatrists should be aware of this diagnosis.
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Jarius S, Würthwein C, Behrens JR, Wanner J, Haas J, Paul F, Wildemann B. Baló's concentric sclerosis is immunologically distinct from multiple sclerosis: results from retrospective analysis of almost 150 lumbar punctures. J Neuroinflammation 2018; 15:22. [PMID: 29347989 PMCID: PMC5774135 DOI: 10.1186/s12974-017-1043-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 12/14/2017] [Indexed: 01/01/2023] Open
Abstract
Background Baló’s concentric sclerosis (BCS) is a rare inflammatory demyelinating disorder of the central nervous system characterised by concentric layers of demyelination. It is unclear whether BCS is a variant of multiple sclerosis (MS) or a disease entity in its own right. Objective To compare the cerebrospinal fluid (CSF) features of BCS to those of MS. Methods Retrospective analysis of the CSF profile of all patients with BCS reported in the medical literature between 1980 and 2017. Results In total, the results of 146 lumbar punctures (LP) in 132 patients were analysed. The most striking finding was a lack of CSF-restricted oligoclonal bands (OCB) in 66% (56/85) of all LP in the total BCS group, in 74% (14/19) in the subgroup of patients with both MRI and histological evidence for BCS, and in 82% (18/22) in the subgroup of patients with highest radiological confidence (high MRI quality, ≥ 3 layers of demyelination). OCB disappeared in 1/2 initially OCB-positive patients. These findings are in stark contrast to MS, in which OCB are present in ≥ 95% of patients and are thought to remain stably detectable over the entire course of disease (p < 0.000001). OCB frequency was low both in ‘historic’ patients (1980–2009; 37%) and in more recent patients (2010–2017; 31%). OCB-positive and OCB-negative patients did not differ significantly with regard to age, sex, disease duration, number of Baló-like lesions on MRI, number of relapses, treatment or final outcome. In accordance with the high rate of OCB negativity, Link’s IgG index was negative in 63% of all tested samples (p < 0.000001 vs. MS). CSF pleocytosis was present in 28% (27/96; p < 0.000001 vs. MS) and elevated CSF total protein levels in 41% (31/76) of samples. Conclusion OCB and IgG index frequencies in BCS are much more similar to those reported in neuromyelitis optica or myelin oligodendrocyte glycoprotein antibody-associated encephalomyelitis than to those in MS. Our findings suggest that in most cases, BCS-like lesions denote the presence of a disease entity immunologically distinct from MS. In addition, we provide data on the demographics, clinical course and radiological features of BCS based on the largest cohort analysed to date.
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Affiliation(s)
- S Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany.
| | - C Würthwein
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - J R Behrens
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - J Wanner
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - J Haas
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - F Paul
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Clinical and Experimental Multiple Sclerosis Research Center, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, Berlin, Germany
| | - B Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
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27
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Hao Q, Wang D, Guo L, Zhang B. Clinical characterization of autoimmune encephalitis and psychosis. Compr Psychiatry 2017; 74:9-14. [PMID: 28081431 DOI: 10.1016/j.comppsych.2016.12.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 11/12/2016] [Accepted: 12/23/2016] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND PURPOSE Autoimmune disorders are growing alarmingly high in prevalence across the globe. Autoimmune encephalitis has had a dramatic impact on the medical field, effectually altering diagnostic and treatment paradigms in regard to neuropsychiatric disorders. Our primary goal in conducting this study was to analyze the clinical characteristics of autoimmune encephalitis patients, with special focus on psychiatric presentations, in the West China Hospital and report patient prognoses after immunotherapy. METHODS Data for patients admitted to the West China Hospital with autoimmune encephalitis diagnoses from 2015 to 2016 were collected and the corresponding clinical features were analyzed. RESULTS We ultimately included 70 patients with autoimmune encephalitis: 56 (80%) anti-NMDAR encephalitis patients, 8 (11%) LGI1 antibody encephalitis patients, and 6 (9%) GABAbR antibody encephalitis patients. The median age of the 70 patients was 33years, 40% were female, and the initial symptoms in 31 patients (44%) were psychiatric in nature. Psychiatric disturbance appeared in 58 patients (83%) during inpatient treatment, after which 57 patients (81%) recovered. CONCLUSIONS Many patients with autoimmune encephalitis present psychotic symptoms; psychiatric symptoms typically appear before neurological features emerge. Timely diagnosis and treatment may yield favorable prognosis.
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Affiliation(s)
- Qinjian Hao
- Department of Psychiatry, West China Hospital, Sichuan University, Sichuan, China
| | - Dahai Wang
- Department of Psychiatry, West China Hospital, Sichuan University, Sichuan, China
| | - Lanting Guo
- Department of Psychiatry, West China Hospital, Sichuan University, Sichuan, China
| | - Bo Zhang
- Department of Psychiatry, West China Hospital, Sichuan University, Sichuan, China
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Abstract
Seizures are a common manifestation of autoimmune limbic encephalitis and multifocal paraneoplastic disorders. Accumulating evidence supports an autoimmune basis for seizures in the absence of syndromic manifestations of encephalitis. The autoimmune epilepsies are immunologically mediated disorders in which recurrent seizures are a primary and persistent clinical feature. When other etiologies have been excluded, an autoimmune etiology is suggested in a patient with epilepsy upon detection of neural autoantibodies and/or the presence of inflammatory changes on cerebrospinal fluid (CSF) or magnetic resonance imaging. In such patients, immunotherapy may be highly effective, depending on the particular autoimmune epilepsy syndrome present. In this chapter, several autoimmune epilepsy syndromes are discussed. First, epilepsies secondary to other primary autoimmune disorders will be discussed, and then those associated with antibodies that are likely to be pathogenic, such as voltage-gated potassium channel-complex and N-methyl-d-aspartate receptor, gamma-aminobutyric acid A and B receptor antibodies. For each syndrome, the typical clinical, imaging, electroencephaloram, CSF, and serologic features, and pathophysiology and treatment are described. Finally, suggested guidelines for the recognition, evaluation, and treatment of autoimmune epilepsy syndromes are provided.
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29
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Malter MP, Widman G, Galldiks N, Stoecker W, Helmstaedter C, Elger CE, Wagner J. Suspected new-onset autoimmune temporal lobe epilepsy with amygdala enlargement. Epilepsia 2016; 57:1485-94. [PMID: 27418040 DOI: 10.1111/epi.13471] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Recent reports define temporal lobe epilepsy with amygdala enlargement (TLE-AE) as a distinct electroclinical syndrome comparable to TLE with hippocampal sclerosis. In this retrospective observational study, we present the largest consecutive series of patients with new-onset TLE-AE to date and describe clinical characteristics and seizure outcome, and we aim to explore underlying autoimmune mechanisms within this syndrome. METHODS We reviewed all consecutive patients between 2004 and 2014 at our tertiary epilepsy center at the University of Bonn, Germany, with new-onset (<5 years) TLE-AE, negative serum antibody (ab) test results, and with available follow-up data for at least 12 months. RESULTS We identified 40 patients (23 male) with TLE-AE with a median age at epilepsy onset of 51 years (range 10-73) and a median disease duration of 11 months (range 0.5-55) at first presentation. At follow-up, 50% of the entire cohort achieved seizure freedom. Of interest, patients with remittent features of AE at follow-up (N = 24) had a superior outcome compared to those with stable magnetic resonance imaging (MRI) features of AE (N = 16): 17 (71%) of 24 were seizure-free for at least 6 months compared to 3 (19%) of 16, respectively (p = 0.003). MRI volumetry confirmed significantly enlarged amygdalae in TLE-AE in relation to healthy controls, and additionally showed significantly greater volume reductions in patients with remittent AE compared to those with stable AE. SIGNIFICANCE TLE-AE is a clinical syndrome beginning mostly in middle age, and in addition to its known association with ab-positive limbic encephalitis, it occurs in an ab-negative condition. Remission of AE in the course of the disease could be identified as a predictor for a favorable clinical outcome and is suspicious of an autoimmune etiology, although we could not confirm this hypothesis unequivocally with currently available noninvasive diagnostic tools.
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Affiliation(s)
- Michael P Malter
- Department of Epileptology, University of Bonn, Bonn, Germany.,Department of Neurology, University of Cologne, Cologne, Germany
| | - Guido Widman
- Department of Epileptology, University of Bonn, Bonn, Germany
| | - Norbert Galldiks
- Department of Neurology, University of Cologne, Cologne, Germany.,Institute of Neuroscience and Medicine, Research Center Juelich, Juelich, Germany
| | - Winfried Stoecker
- Institute of Experimental Immunology, Affiliated to Euroimmun AG, Luebeck, Germany
| | | | - Christian E Elger
- Department of Epileptology, University of Bonn, Bonn, Germany.,Department of NeuroCognition/Imaging, Life & Brain Centre, Bonn, Germany
| | - Jan Wagner
- Department of Epileptology, University of Bonn, Bonn, Germany.,Department of NeuroCognition/Imaging, Life & Brain Centre, Bonn, Germany.,Department of Neurology, Epilepsy Center Hessen-Marburg, University of Marburg Medical Centre, Marburg, Germany
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30
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Li Z, Cui T, Shi W, Wang Q. Clinical analysis of leucine-rich glioma inactivated-1 protein antibody associated with limbic encephalitis onset with seizures. Medicine (Baltimore) 2016; 95:e4244. [PMID: 27428233 PMCID: PMC4956827 DOI: 10.1097/md.0000000000004244] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
We summarized the clinical characteristics of patients presenting with seizures and limbic encephalitis (LE) associated with leucine-rich glioma inactivated-1 protein antibody (LGI1) in order help recognize and treat this condition at its onset.We analyzed clinical, video electroencephalogram (VEEG), magnetic resonance imaging (MRI), and laboratory data of 10 patients who presented with LGI1-LE and followed up their outcomes from 2 to 16 (9.4 ± 4.2) months.All patients presented with seizures onset, including faciobrachial dystonic seizure (FBDS), partial seizure (PS), and generalized tonic-clonic seizure (GTCS). Four patients (Cases 3, 5, 7, and 8) had mild cognitive deficits. Interictal VEEG showed normal patterns, focal slowing, or sharp waves in the temporal or frontotemporal lobes. Ictal VEEG of Cases 4, 5, and 7 showed diffuse voltage depression preceding FBDS, a left frontal/temporal origin, and a bilateral temporal origin, respectively. Ictal foci could not be localized in other cases. MRI scan revealed T2/fluid-attenuated inversion recovery (FLAIR) hyperintensity and evidence of edema in the right medial temporal lobe in Case 3, left hippocampal atrophy in Case 5, hyperintensities in the bilateral medial temporal lobes in Case 7, and hyperintensities in the basal ganglia and frontal cortex in Case 10. All 10 serum samples were positive for LGI1 antibody, but it was only detected in the cerebrospinal fluid (CSF) of 7 patients. Five patients (Cases 2, 4, 6, 7, and 8) presented with hyponatremia. One patient (Case 2) was diagnosed with small cell lung cancer. While responses to antiepileptic drugs (AEDs) were poor, most patients (except Case 2) responded favorably to immunotherapy.LGI1-LE may initially manifest with various types of seizures, particularly FBDS and complex partial seizures (CPS) of mesial temporal origin, and slowly progressive cognitive involvement. Clinical follow-up, VEEG monitoring, and MRI scan are helpful in early diagnosis. Immunotherapy is effective for the treatment of both seizure and LE associated with LGI1 antibody. Although mostly nonparaneoplastic, tumor screening is recommended in some cases.
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Affiliation(s)
| | | | | | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, China
- Correspondence: Qun Wang, No.6 Tiantanxili, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing,China (e-mail: )
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31
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Graus F, Titulaer MJ, Balu R, Benseler S, Bien CG, Cellucci T, Cortese I, Dale RC, Gelfand JM, Geschwind M, Glaser CA, Honnorat J, Höftberger R, Iizuka T, Irani SR, Lancaster E, Leypoldt F, Prüss H, Rae-Grant A, Reindl M, Rosenfeld MR, Rostásy K, Saiz A, Venkatesan A, Vincent A, Wandinger KP, Waters P, Dalmau J. A clinical approach to diagnosis of autoimmune encephalitis. Lancet Neurol 2016; 15:391-404. [PMID: 26906964 PMCID: PMC5066574 DOI: 10.1016/s1474-4422(15)00401-9] [Citation(s) in RCA: 2379] [Impact Index Per Article: 297.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 12/08/2015] [Accepted: 12/16/2015] [Indexed: 12/18/2022]
Abstract
Encephalitis is a severe inflammatory disorder of the brain with many possible causes and a complex differential diagnosis. Advances in autoimmune encephalitis research in the past 10 years have led to the identification of new syndromes and biomarkers that have transformed the diagnostic approach to these disorders. However, existing criteria for autoimmune encephalitis are too reliant on antibody testing and response to immunotherapy, which might delay the diagnosis. We reviewed the literature and gathered the experience of a team of experts with the aims of developing a practical, syndrome-based diagnostic approach to autoimmune encephalitis and providing guidelines to navigate through the differential diagnosis. Because autoantibody test results and response to therapy are not available at disease onset, we based the initial diagnostic approach on neurological assessment and conventional tests that are accessible to most clinicians. Through logical differential diagnosis, levels of evidence for autoimmune encephalitis (possible, probable, or definite) are achieved, which can lead to prompt immunotherapy.
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Affiliation(s)
- Francesc Graus
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Service of Neurology, Hospital Clinic, Barcelona, Spain.
| | | | - Ramani Balu
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Susanne Benseler
- Department of Pediatrics, Alberta Children Hospital, Calgary, AB, Canada
| | | | - Tania Cellucci
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - Irene Cortese
- Neuroimmunology Clinic, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Russell C Dale
- Neuroimmunology Group, Children's Hospital at Westmead, University of Sydney, Sydney, NSW, Australia
| | - Jeffrey M Gelfand
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Michael Geschwind
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Carol A Glaser
- Division of Pediatric Infectious Diseases, Kaiser Permanente, Oakland Medical Center and University of California, San Francisco, CA, USA
| | - Jerome Honnorat
- French Reference Center on Paraneoplastic Neurological Syndrome, Hospices Civils De Lyon, Hôpital Neurologique, Inserm U1028, CNRS UMR 5292, Lyon's Neurosciences Research Center, Université Claude-Bernard Lyon-1, Lyon, France
| | - Romana Höftberger
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Takahiro Iizuka
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Sarosh R Irani
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Eric Lancaster
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Frank Leypoldt
- Neuroimmunology, Institute of Clinical Chemistry, and Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Harald Prüss
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany; German Center for Neurodegenerative Disorders Berlin, Berlin, Germany
| | | | - Markus Reindl
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Myrna R Rosenfeld
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Kevin Rostásy
- Department of Pediatric Neurology, Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany
| | - Albert Saiz
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Service of Neurology, Hospital Clinic, Barcelona, Spain
| | - Arun Venkatesan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Klaus-Peter Wandinger
- Institute of Clinical Chemistry and Department of Neurology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Patrick Waters
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Josep Dalmau
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA; Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain.
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32
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Reintjes W, Romijn MD, Hollander D, ter Bruggen JP, van Marum RJ. Reversible Dementia: Two Nursing Home Patients With Voltage-Gated Potassium Channel Antibody-Associated Limbic Encephalitis. J Am Med Dir Assoc 2015; 16:790-4. [DOI: 10.1016/j.jamda.2015.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 06/04/2015] [Indexed: 11/24/2022]
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33
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Messelmani M, Fekih-Mrissa N, Zaouali J, Mrissa R. Limbic encephalitis associated with leucine-rich glioma-inactivated 1 antibodies. Ann Saudi Med 2015; 35:76-9. [PMID: 26142944 PMCID: PMC6152548 DOI: 10.5144/0256-4947.2015.76] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We describe the case of a patient with confirmed limbic encephalitis associated with leucine-rich glioma-inactivated 1 (LGI1) antibodies. A 59-year-old man presented to the Department of Neurology with bizarre behavior, memory loss, cognitive impairment, visual hallucinations, and myoclonus and facio-brachial dystonic seizures. A brain magnetic resonance imaging (MRI) revealed no hippocampal lesions. Blood tests showed hyponatremia. An electroencephalogram showed disorganization and slowing of background activity. Antiepileptic drugs were ineffective. The patient exhibited considerable improvement following immunotherapy. The diagnosis of limbic encephalitis associated with LGI1 antibodies should be considered in patients with clinical manifestations mimicking psychiatric disorders and in cases of refractory epilepsy especially with faciobrachial dystonic seizures. There is frequently hyponatremia, and cerebral MRI may be normal. Full recovery can be expected with early diagnosis and prompt treatment.
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Affiliation(s)
- Mariem Messelmani
- Mariem Messelmani, Department of Neurology,, Military Hospital 1008, Mont Fleury Tunis, Tunisia, T: +21699954557,
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Stich O, Rauer S. [Paraneoplastic neurological syndromes and autoimmune encephalitis]. DER NERVENARZT 2014; 85:485-98; quiz 499-501. [PMID: 24668402 DOI: 10.1007/s00115-014-4030-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Paraneoplastic neurological syndromes (PNS) are defined as remote effects on the central and peripheral nervous system that are not caused directly by the tumor, its metastases and treatment, or metabolic disorders. The most probable cause is a falsely initiated immune reaction. Well-defined classical PNSs are associated with distinct tumors and occur with onconeural antibodies directed against intracellular neuronal antigens. However, response to therapy is limited. Recently, new antibodies directed against neuronal surface antigens were described in encephalitic syndromes of autoimmune origin. These probably antibody-mediated disorders are more frequent than classical PNS, occur with or without tumor association and often show a good response to immunosuppressive treatment.
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Affiliation(s)
- O Stich
- Abteilung für Neurologie und Neurophysiologie, Neurozentrum, Universitätsklinik Freiburg, Breisacher Str. 64, 79106, Freiburg, Deutschland,
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Abstract
Over the past 10 years, the continual discovery of novel forms of encephalitis associated with antibodies to cell-surface or synaptic proteins has changed the paradigms for diagnosing and treating disorders that were previously unknown or mischaracterized. We review here the process of discovery, the symptoms, and the target antigens of 11 autoimmune encephalitic disorders, grouped by syndromes and approached from a clinical perspective. Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis, several subtypes of limbic encephalitis, stiff-person spectrum disorders, and other autoimmune encephalitides that result in psychosis, seizures, or abnormal movements are described in detail. We include a novel encephalopathy with prominent sleep dysfunction that provides an intriguing link between chronic neurodegeneration and cell-surface autoimmunity (IgLON5). Some of the caveats of limited serum testing are outlined. In addition, we review the underlying cellular and synaptic mechanisms that for some disorders confirm the antibody pathogenicity. The multidisciplinary impact of autoimmune encephalitis has been expanded recently by the discovery that herpes simplex encephalitis is a robust trigger of synaptic autoimmunity, and that some patients may develop overlapping syndromes, including anti-NMDAR encephalitis and neuromyelitis optica or other demyelinating diseases.
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Affiliation(s)
- Frank Leypoldt
- Service of Neurology, Hospital Clinic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona, Barcelona, Spain; Institute of Clinical Chemistry, Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
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Jones M, Odunsi S, du Plessis D, Vincent A, Bishop M, Head MW, Ironside JW, Gow D. Gerstmann-Straüssler-Scheinker disease: novel PRNP mutation and VGKC-complex antibodies. Neurology 2014; 82:2107-11. [PMID: 24814844 DOI: 10.1212/wnl.0000000000000500] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To describe a unique case of Gerstmann-Straüssler-Scheinker (GSS) disease caused by a novel prion protein (PRNP) gene mutation and associated with strongly positive voltage-gated potassium channel (VGKC)-complex antibodies (Abs). METHODS Clinical data were gathered from retrospective review of the case notes. Postmortem neuropathologic examination was performed, and DNA was extracted from frozen brain tissue for full sequence analysis of the PRNP gene. RESULTS The patient was diagnosed in life with VGKC-complex Ab-associated encephalitis based on strongly positive VGKC-complex Ab titers but no detectable LGI1 or CASPR2 Abs. He died despite 1 year of aggressive immunosuppressive treatment. The neuropathologic diagnosis was GSS disease, and a novel mutation, P84S, in the PRNP gene was found. CONCLUSION VGKC-complex Abs are described in an increasingly broad range of clinical syndromes, including progressive encephalopathies, and may be amenable to treatment with immunosuppression. However, the failure to respond to aggressive immunotherapy warns against VGKC-complex Abs being pathogenic, and their presence does not preclude the possibility of prion disease.
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Affiliation(s)
- Matthew Jones
- From the Greater Manchester Neurosciences Centre (M.J., D.d.P., D.G.), Salford Royal Foundation Trust, Salford; Manchester Medical School (S.O., D.d.P.), and Institute of Brain, Behaviour and Mental Health (M.J.), University of Manchester; Nuffield Department of Clinical Neurosciences (A.V.), John Radcliffe Hospital, University of Oxford; and National Creutzfeldt-Jakob Disease Research and Surveillance Unit (M.B., M.W.H., J.W.I.), University of Edinburgh, UK
| | - Sola Odunsi
- From the Greater Manchester Neurosciences Centre (M.J., D.d.P., D.G.), Salford Royal Foundation Trust, Salford; Manchester Medical School (S.O., D.d.P.), and Institute of Brain, Behaviour and Mental Health (M.J.), University of Manchester; Nuffield Department of Clinical Neurosciences (A.V.), John Radcliffe Hospital, University of Oxford; and National Creutzfeldt-Jakob Disease Research and Surveillance Unit (M.B., M.W.H., J.W.I.), University of Edinburgh, UK
| | - Daniel du Plessis
- From the Greater Manchester Neurosciences Centre (M.J., D.d.P., D.G.), Salford Royal Foundation Trust, Salford; Manchester Medical School (S.O., D.d.P.), and Institute of Brain, Behaviour and Mental Health (M.J.), University of Manchester; Nuffield Department of Clinical Neurosciences (A.V.), John Radcliffe Hospital, University of Oxford; and National Creutzfeldt-Jakob Disease Research and Surveillance Unit (M.B., M.W.H., J.W.I.), University of Edinburgh, UK
| | - Angela Vincent
- From the Greater Manchester Neurosciences Centre (M.J., D.d.P., D.G.), Salford Royal Foundation Trust, Salford; Manchester Medical School (S.O., D.d.P.), and Institute of Brain, Behaviour and Mental Health (M.J.), University of Manchester; Nuffield Department of Clinical Neurosciences (A.V.), John Radcliffe Hospital, University of Oxford; and National Creutzfeldt-Jakob Disease Research and Surveillance Unit (M.B., M.W.H., J.W.I.), University of Edinburgh, UK
| | - Matthew Bishop
- From the Greater Manchester Neurosciences Centre (M.J., D.d.P., D.G.), Salford Royal Foundation Trust, Salford; Manchester Medical School (S.O., D.d.P.), and Institute of Brain, Behaviour and Mental Health (M.J.), University of Manchester; Nuffield Department of Clinical Neurosciences (A.V.), John Radcliffe Hospital, University of Oxford; and National Creutzfeldt-Jakob Disease Research and Surveillance Unit (M.B., M.W.H., J.W.I.), University of Edinburgh, UK
| | - Mark W Head
- From the Greater Manchester Neurosciences Centre (M.J., D.d.P., D.G.), Salford Royal Foundation Trust, Salford; Manchester Medical School (S.O., D.d.P.), and Institute of Brain, Behaviour and Mental Health (M.J.), University of Manchester; Nuffield Department of Clinical Neurosciences (A.V.), John Radcliffe Hospital, University of Oxford; and National Creutzfeldt-Jakob Disease Research and Surveillance Unit (M.B., M.W.H., J.W.I.), University of Edinburgh, UK
| | - James W Ironside
- From the Greater Manchester Neurosciences Centre (M.J., D.d.P., D.G.), Salford Royal Foundation Trust, Salford; Manchester Medical School (S.O., D.d.P.), and Institute of Brain, Behaviour and Mental Health (M.J.), University of Manchester; Nuffield Department of Clinical Neurosciences (A.V.), John Radcliffe Hospital, University of Oxford; and National Creutzfeldt-Jakob Disease Research and Surveillance Unit (M.B., M.W.H., J.W.I.), University of Edinburgh, UK
| | - David Gow
- From the Greater Manchester Neurosciences Centre (M.J., D.d.P., D.G.), Salford Royal Foundation Trust, Salford; Manchester Medical School (S.O., D.d.P.), and Institute of Brain, Behaviour and Mental Health (M.J.), University of Manchester; Nuffield Department of Clinical Neurosciences (A.V.), John Radcliffe Hospital, University of Oxford; and National Creutzfeldt-Jakob Disease Research and Surveillance Unit (M.B., M.W.H., J.W.I.), University of Edinburgh, UK.
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Jarius S, Kleffner I, Dörr JM, Sastre-Garriga J, Illes Z, Eggenberger E, Chalk C, Ringelstein M, Aktas O, Montalban X, Fechner K, Stöcker W, Ringelstein EB, Paul F, Wildemann B. Clinical, paraclinical and serological findings in Susac syndrome: an international multicenter study. J Neuroinflammation 2014; 11:46. [PMID: 24606999 PMCID: PMC3995917 DOI: 10.1186/1742-2094-11-46] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 02/13/2014] [Indexed: 11/10/2022] Open
Abstract
Background Susac syndrome (SuS) is a rare disorder thought to be caused by autoimmune-mediated occlusions of microvessels in the brain, retina and inner ear leading to central nervous system (CNS) dysfunction, visual disturbances due to branch retinal artery occlusions (BRAO), and hearing deficits. Recently, a role for anti-endothelial cell antibodies (AECA) in SuS has been proposed. Objectives To report the clinical and paraclinical findings in the largest single series of patients so far and to investigate the frequency, titers, and clinical relevance of AECA in SuS. Patients and methods A total of 107 serum samples from 20 patients with definite SuS, 5 with abortive forms of SuS (all with BRAO), and 70 controls were tested for AECA by immunohistochemistry employing primate brain tissue sections. Results IgG-AECA >1:100 were detected in 25% (5/20) of patients with definite SuS and in 4.3% (3/70) of the controls. Median titers were significantly higher in SuS (1:3200, range 1:100 to 1:17500) than in controls (1:100, range 1:10 to 1:320); IgG-AECA titers >1:320 were exclusively present in patients with SuS; three controls had very low titers (1:10). Follow-up samples (n = 4) from a seropositive SuS patient obtained over a period of 29 months remained positive at high titers. In all seropositive cases, AECA belonged to the complement-activating IgG1 subclass. All but one of the IgG-AECA-positive samples were positive also for IgA-AECA and 45% for IgM-AECA. SuS took a severe and relapsing course in most patients and was associated with bilateral visual and hearing impairment, a broad panel of neurological and neuropsychological symptoms, and brain atrophy in the majority of cases. Seropositive and seronegative patients did not differ with regard to any of the clinical or paraclinical parameters analyzed. Conclusions SuS took a severe and protracted course in the present cohort, resulting in significant impairment. Our finding of high-titer IgG1 and IgM AECA in some patients suggest that humoral autoimmunity targeting the microvasculature may play a role in the pathogenesis of SuS, at least in a subset of patients. Further studies are warranted to define the exact target structures of AECA in SuS.
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Affiliation(s)
- Sven Jarius
- Molecular Neuroimmunology, Department of Neurology, University of Heidelberg, Heidelberg, Germany.
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Autoimmune encephalitis: recent updates and emerging challenges. J Clin Neurosci 2013; 21:722-30. [PMID: 24246947 DOI: 10.1016/j.jocn.2013.07.017] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 07/03/2013] [Accepted: 07/04/2013] [Indexed: 12/12/2022]
Abstract
The knowledge of immune dysregulation and autoimmunity in neurological disorders has expanded considerably in recent times. Recognition of clinical syndromes, reliable methods of diagnosis, and early targeted immunotherapy can lead to a favourable outcome in acute and subacute neurological disorders that may be associated with significant morbidity and mortality if left untreated. This review focuses on the rapidly expanding field of autoimmune encephalitis. We describe the differences between limbic encephalitis associated with antibodies targeting intracellular antigens, and neuronal surface antibody syndromes (NSAS) where the antigens are primarily receptors or synaptic proteins located on the neuronal cell surface. We chronologically highlight important developments in NSAS by focusing on voltage gated potassium channel complex-associated antibody mediated encephalitis, anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis, and anti-dopamine 2 receptor antibody-associated basal ganglia encephalitis. Contentious issues such as the complexities of using serum antibodies as biomarkers, the initiation of central nervous system autoimmunity, and possible pathogenic mechanisms of these antibodies will be reviewed. The therapeutic challenges that clinicians face such as the timing of therapy and the role of second-line therapy will be discussed, with crucial concepts highlighted in the form of clinical vignettes. Future directions will involve the identification of novel antigens and methods to establish their pathogenicity, as well as evaluation of the most efficacious therapeutic strategies in patients with established NSAS.
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Malter MP, Elger CE, Surges R. Diagnostic value of CSF findings in antibody-associated limbic and anti-NMDAR-encephalitis. Seizure 2013; 22:136-40. [DOI: 10.1016/j.seizure.2012.12.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 12/17/2012] [Accepted: 12/18/2012] [Indexed: 10/27/2022] Open
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Abstract
The term autoimmune encephalitis is used to describe a group of disorders characterised by symptoms of limbic and extra-limbic dysfunction occurring in association with antibodies against synaptic antigens and proteins localised on the neuronal cell surface. In recent years there has been a rapidly expanding knowledge of these syndromes resulting in a shift in clinical paradigms and new insights into pathogenic mechanisms. Since many patients respond well to immunosuppressive treatment, the recognition of these disorders is of utmost importance. In general, there are no brain-imaging modalities or biomarkers specific of these disorders other than the demonstration of the neuronal antibodies. A disease classification based on these antibodies provides information on prognosis and paraneoplastic aetiology. This article focuses on recent clinical advances, newly characterised antibodies and treatment approaches to these disorders.
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Affiliation(s)
- Frank Leypoldt
- Post doctoral Research Fellow, Catalan Institution for Research and Advanced Studies (ICREA), August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Junior Attending Physician, Department of Neurology, University Medical Centre Hamburg-Eppendorf, Germany
| | - Klaus-Peter Wandinger
- Attending Physician, Institute of Clinical Chemistry, University Medical-Centre Schleswig-Holstein Campus Lübeck, Germany
- Attending Physician, Department of Neurology, University Medical-Centre Schleswig-Holstein Campus Lübeck, Germany
| | - Christian G Bien
- Head of Department, Epilepsy Centre Bethel, Mara-Clinic Bethel, Bielefeld, Germany
| | - Josep Dalmau
- Post doctoral Research Fellow, Catalan Institution for Research and Advanced Studies (ICREA), August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
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Kleopa KA. Autoimmune channelopathies of the nervous system. Curr Neuropharmacol 2012; 9:458-67. [PMID: 22379460 PMCID: PMC3151600 DOI: 10.2174/157015911796557966] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Revised: 03/16/2010] [Accepted: 03/16/2010] [Indexed: 12/20/2022] Open
Abstract
Ion channels are complex transmembrane proteins that orchestrate the electrical signals necessary for normal function of excitable tissues, including the central nervous system, peripheral nerve, and both skeletal and cardiac muscle. Progress in molecular biology has allowed cloning and expression of genes that encode channel proteins, while comparable advances in biophysics, including patch-clamp electrophysiology and related techniques, have made the functional assessment of expressed proteins at the level of single channel molecules possible. The role of ion channel defects in the pathogenesis of numerous disorders has become increasingly apparent over the last two decades. Neurological channelopathies are frequently genetically determined but may also be acquired through autoimmune mechanisms. All of these autoimmune conditions can arise as paraneoplastic syndromes or independent from malignancies. The pathogenicity of autoantibodies to ion channels has been demonstrated in most of these conditions, and patients may respond well to immunotherapies that reduce the levels of the pathogenic autoantibodies. Autoimmune channelopathies may have a good prognosis, especially if diagnosed and treated early, and if they are non-paraneoplastic. This review focuses on clinical, pathophysiologic and therapeutic aspects of autoimmune ion channel disorders of the nervous system.
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Affiliation(s)
- Kleopas A Kleopa
- Neurology Clinics and Neuroscience Laboratory, The Cyprus Institute of Neurology and Genetics, Cyprus
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Illingworth MA, Hanrahan D, Anderson CE, O'Kane K, Anderson J, Casey M, de Sousa C, Cross JH, Wright S, Dale RC, Vincent A, Kurian MA. Elevated VGKC-complex antibodies in a boy with fever-induced refractory epileptic encephalopathy in school-age children (FIRES). Dev Med Child Neurol 2011; 53:1053-7. [PMID: 21592118 DOI: 10.1111/j.1469-8749.2011.04008.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Fever-induced refractory epileptic encephalopathy in school-age children (FIRES) is a clinically recognized epileptic encephalopathy of unknown aetiology. Presentation in previously healthy children is characterized by febrile status epilepticus. A pharmacoresistant epilepsy ensues, occurring in parallel with dramatic cognitive decline and behavioural difficulties. We describe a case of FIRES in a 4-year-old boy that was associated with elevated voltage-gated potassium channel (VGKC) complex antibodies and a significant clinical and immunological response to immunomodulation. This case, therefore, potentially expands the clinical phenotype of VGKC antibody-associated disease to include that of FIRES. Prior to immunomodulation, neuropsychology assessment highlighted significant attention, memory, and word-finding difficulties. The UK version of the Wechsler Preschool and Primary Scale of Intelligence assessment indicated particular difficulties with verbal skills (9th centile). Immunomodulation was initially administered as intravenous methylprednisolone (followed by maintenance oral prednisolone) and later in the disease course as regular monthly intravenous immunoglobulin infusions and low-dose azathioprine. Now aged 6 years, the seizure burden in this child is much reduced, although increased seizure frequency is observed in the few days before his monthly immunoglobulin infusions. Formal IQ assessment has not been repeated but there is no clinical suggestion of further cognitive regression. VGKC complex antibodies have been reported in a range of central and peripheral neurological disorders (predominantly presenting in adulthood), and the identification of elevated VGKC complex antibodies, combined with the response to immunotherapies in this child, supports an autoimmune pathogenesis in FIRES with potential diagnostic and therapeutic implications.
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Abstract
Limbic encephalitis (LE) was first described in 1960 by Brierley et al. and was defined by an acute or subacute temporal lobe epilepsy, memory loss and psychiatric disturbances. Corsellis et al. then demonstrated that LE was associated with small-cell lung cancer and a paraneoplastic origin of LE was suggested. In the 1980s, onconeuronal antibodies specific to paraneoplastic neurological syndromes were described and some of them, such as Hu-Ab, were clearly associated with LE. In the last 20 years, other onconeuronal antibodies targeting intracellular antigens were subsequently identified and LE was considered as a rare paraneoplastic neurological syndrome with a poor outcome and as mainly being associated with Hu-Ab, Ma2-Ab or CV2/CRMP5-Ab. The concept of LE has dramatically evolved since 2004, with the description of LE becoming associated with novel autoantibodies that target neuronal surface rather than intracellular antigens. In these cases, LE was not always paraneoplastic. Interestingly, these newly described LE cases offer a much better prognosis than the previous ones. At present, LE is considered to be an autoimmune disorder that can be paraneoplastic or not and could be more frequent than previously suspected. The associated antibodies lead to the classification of different subtypes of LE and are used as prognostic markers. Those that are directed against cell surface antigens could play a direct role in the neurological symptoms of LE.
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Affiliation(s)
- Adrien Didelot
- Centre de Référence de Diagnostic et de Traitement des Syndromes Neurologiques Paranéoplasiques, Hôpital Pierre Wertheimer, 59 Boulevard Pinel, Lyon F-69003, France
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Improvement of non-paraneoplastic voltage-gated potassium channel antibody-associated limbic encephalitis without immunosuppressive therapy. Epilepsy Behav 2010; 17:555-7. [PMID: 20163992 DOI: 10.1016/j.yebeh.2010.01.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2009] [Revised: 01/11/2010] [Accepted: 01/15/2010] [Indexed: 11/23/2022]
Abstract
We describe a 61-year-old patient with clinical evidence of limbic encephalitis who improved with anticonvulsant treatment only, that is, without the use of immunosuppressive agents. Three years following occurrence of anosmia, increasing memory deficits, and emotional disturbances, he presented with new-onset temporal lobe epilepsy, with antibodies binding to neuronal voltage-gated potassium channels and bitemporal hypometabolism on FDG-PET scan; the MRI scan was normal. This is most likely a case of spontaneous remission, illustrating that immunosuppressive therapy might be suspended in milder courses of limbic encephalitis. It remains open whether treatment with anticonvulsant drugs played an additional beneficiary role through the direct suppression of seizures or, additionally, through indirect immunomodulatory side effects.
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Graus F, Saiz A, Dalmau J. Antibodies and neuronal autoimmune disorders of the CNS. J Neurol 2009; 257:509-17. [DOI: 10.1007/s00415-009-5431-9] [Citation(s) in RCA: 280] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Accepted: 12/14/2009] [Indexed: 12/14/2022]
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Autoimmune autonomic ganglionopathy with late-onset encephalopathy. Auton Neurosci 2008; 146:29-32. [PMID: 19028442 DOI: 10.1016/j.autneu.2008.10.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2008] [Revised: 10/10/2008] [Accepted: 10/20/2008] [Indexed: 10/21/2022]
Abstract
A 47-year old female presented with a 4 month history of early satiety, constipation, light sensitivity, orthostatic intolerance, siccca, and anhydrosis. Her examination revealed dilated, unreactive pupils with dry eyes and mouth but normal strength, phasic reflexes, and sensation. After 3 min of quiet standing her systolic pressure dropped 70 mmHg with a fixed heart rate of 74 bpm. Her alpha3 ganglionic AChR level was 2060 pmol/L (normal < or = 50). Orthostatic symptoms significantly improved within 10 days of completing 2.0 g/kg IVIg. Her supine norepinephrine (NE) level improved over baseline but remained low (i.e., 0.36 à 0.61 nmol/L). Persisting gut inertia prompted a trial of plasma exchange (PLEx) which restored her supine NE level (2.18 nmol/L), bowel patterns, and pupillary reactivity. Five months later, while her AAG was well controlled, she developed gait unsteadiness, confusion, horizontal and vertical nystagmus, bladder retention, and long tract motor signs. A contrast MRI head was normal. Further serum testing demonstrated binding avidity for neuronal alpha4 and alpha7 nAChRs. She responded to high-dose steroid and immunomodulation. This is the first case report of AAG presenting with antibodies directed against both peripheral and central nAChRs. It is tempting to speculate that CNS alpha4 or alpha7 antibodies may have precipitated the treatment-responsive encephalopathy.
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Vincent A. Stiff, twitchy or wobbly: are GAD antibodies pathogenic? Brain 2008; 131:2536-7. [PMID: 18799517 DOI: 10.1093/brain/awn221] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Angela Vincent
- Department of Clinical Neurology, University of Oxford, Oxford, UK.
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Abstract
Major advances in the management of paraneoplastic neurologic disorders (PND) include the detection of new antineuronal antibodies, the improved characterisation of known syndromes, the discovery of new syndromes, and the use of CT and PET to reveal the associated tumours at an early stage. In addition, the definition of useful clinical criteria has facilitated the early recognition and treatment of these disorders. In this article, we review some classic concepts about PND and recent clinical and immunological developments, focusing on paraneoplastic cerebellar degeneration, opsoclonus-myoclonus, and encephalitides affecting the limbic system.
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