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Bai L, Ren H, Liang M, Lu Q, Lin N, Liu M, Fan S, Cui R, Guan H. Neurological disorders associated with glutamic acid decarboxylase 65 antibodies: Clinical spectrum and prognosis of a cohort from China. Front Neurol 2022; 13:990553. [PMID: 36277926 PMCID: PMC9581312 DOI: 10.3389/fneur.2022.990553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
Objective To describe clinical phenotypes and prognosis of neurological autoimmunity related to glutamic acid decarboxylase 65 (GAD65) antibodies in China. Method In this retrospective observational study from Peking Union Medical College Hospital, we identified patients with neurological disorders related to GAD65 antibodies (cell-based assay) from May 2015 to September 2021. Clinical manifestations, immunotherapy responsiveness, and outcomes were collected after obtaining informed consent from all patients. Results Fifty-five patients were included: 40 (72.73%) were women and initial neurological symptoms developed at 42(34-55) years of age. The median time to the nadir of the disease was 5 months (range from 1 day to 48 months). The clinical syndromes included limbic encephalitis (LE) or epilepsy (Ep) (n = 34, 61.82%), stiff-person syndromes (SPS) (n = 18, 32.73%), autoimmune cerebellar ataxia (ACA) (n = 11, 20%), and overlap syndrome in eight (14.55%) patients. Thirty-two (58.2%) patients had comorbidities of other autoimmune diseases, including Hashimoto thyroiditis (n = 17, 53.13%), T1DM (n = 11, 34.78%), vitiligo (n = 6, 18.75%), and others (n=5, 15.63%). Two (3.64%) patients had tumors, including thymoma and small cell lung cancer. Fifty-one (92.7%) patients received first-line immunotherapy (glucocorticoids and/or IV immunoglobulin), and 4 (7.3%) received second-line immunotherapy (rituximab). Long-term immunotherapy (mycophenolate mofetil) was administered to 23 (41.8%) patients. At the median time of 15 months (IQR 6–33.75 month, range 3–96 month) of follow-up, the patients' median modified Rankin Score (mRS) had declined from 2 to 1. Thirty-eight (70.4%) patients experienced clinical improvement (mRS declined ≥1), 47 (87%) had favorable clinical outcomes (mRS ≤2), and nine were symptom-free (16.7%). The sustained response to immunotherapy ranged from 7/15 (63.63%) in ACA patients and 22/34 (64.7%) in LE/Ep patients to 14/17 (82.35%) in SPS patients. Conclusions LE/Ep was the most common neurological phenotype of GAD65 antibody neurological autoimmunity in our cohort. Most patients had comorbidities of other autoimmune diseases, but underlying tumors were rare. Most patients responded to immunotherapy. However, the long-term prognosis varied among different clinical phenotypes.
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Affiliation(s)
- Lin Bai
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Menglin Liang
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Qiang Lu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Nan Lin
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Mange Liu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ruixue Cui
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Hongzhi Guan
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Spilioti M, Kiryttopoulos A, Panou T, Simos P, Alexopoulos H, Karafyles G, Geroukis T, Kalevrosoglou I, Kimiskidis V. Nonparaneoplastic Anti-GAD Limbic Encephalitis: Seizure Outcome and Long-term Neuropsychological Follow-up After Immunotherapy. Cogn Behav Neurol 2022; 35:212-220. [PMID: 35856876 DOI: 10.1097/wnn.0000000000000313] [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: 12/11/2020] [Accepted: 12/30/2021] [Indexed: 11/26/2022]
Abstract
Antibodies against glutamate decarboxylase (GAD-Abs), especially GAD65 antibodies, are associated with limbic encephalitis (LE) manifested by temporal lobe epilepsy and neuropsychological deficits. We present the case of a 42-year-old Greek woman with nonparaneoplastic anti-GAD LE, discussing the therapeutic management and highlighting the role of neuropsychological assessment. The patient underwent functional and structural brain studies and was investigated longitudinally over a 6-year period with a battery of neuropsychological tests that were designed to document her intellectual function and verbal and visual memory. The patient suffered from refractory temporal-impaired awareness seizures and memory impairment that was mediated by autoimmune nonparaneoplastic LE and comorbid autoimmune disorders (ie, Hashimoto thyroiditis and vitiligo). Neuroimaging studies demonstrated hyperintensities in the medial temporal lobes bilaterally on T2WI MRI sequences. Serial EEGs showed bitemporal intermittent delta activity as well as epileptiform discharges. Tumor blood markers and onconeural antibodies were negative. Immunological screening revealed extremely high GAD-Abs titers in both serum and CSF, as well as the presence of CSF oligoclonal bands. Neuropsychological testing revealed anterograde amnesia with relative preservation of more remote, premorbid memories. The patient underwent first-line immunotherapy followed by immunosuppressive maintenance treatment that led to a reduction of seizures, EEG improvement, and a significant decline in GAD-Abs titers. Neuropsychological evaluations at 5 months, 1 year, and 6 years posttreatment demonstrated improvement, particularly in recent memory and everyday functionality. In this case of anti-GAD LE, the long-term seizure reduction and the improvement of neuropsychological deficits were most likely related to the immunotherapy.
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Affiliation(s)
| | | | - Theodora Panou
- Department of Psychiatry & Laboratory of Neuropsychology, University of Crete, Medical School, Heraklion, Greece
| | - Panagiotis Simos
- Department of Psychiatry & Laboratory of Neuropsychology, University of Crete, Medical School, Heraklion, Greece
| | - Haris Alexopoulos
- Department of Pathophysiology, Neuroimmunology Unit, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Ioannis Kalevrosoglou
- First Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
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Gastaldi M, Scaranzin S, Pietro B, Lechiara A, Pesce G, Franciotta D, Lorusso L. Paraneoplastic Neurological Syndromes: Transitioning Between the Old and the New. Curr Oncol Rep 2022; 24:1237-1249. [PMID: 35476177 DOI: 10.1007/s11912-022-01279-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Paraneoplastic neurological syndromes (PNS) are caused by nervous system-targeting aberrant anti-tumoral immune responses. We review the updated criteria for PNS diagnosis, incorporating novel information on clinical phenotypes, neuronal autoantibodies (Nabs), and tumors. The impact of the oncologic use of immune checkpoint inhibitors (ICI) on PNS occurrence is also addressed. RECENT FINDINGS Clinical phenotypes and Nabs are redefined as "high/intermediate/low" risk, following the frequency of cancer association. Nabs, the diagnostic hallmark of PNS, can target intracellular or surface neuronal proteins, with important prognostic and pathogenic implications. Many novel assays have been incorporated into laboratory diagnostics, that is becoming increasingly complex. ICI fight tumors, but favor autoimmunity, thus increasing the incidence of PNS-like disorders. Overcoming the old PNS criteria, the new ones are centered around the presence of tumor. Clinical presentation, Nabs, and tumor findings are translated in diagnostic scores, providing a useful tool for PNS diagnosis and management.
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Affiliation(s)
- Matteo Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy.
| | - Silvia Scaranzin
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | | | - Anastasia Lechiara
- Autoimmunology Laboratory, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Giampaola Pesce
- Autoimmunology Laboratory, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine (Dimi), University of Genova, Genova, Italy
| | - Diego Franciotta
- Autoimmunology Laboratory, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Lorenzo Lorusso
- Neurology and Stroke Unit, Neuroscience Department, A.S.S.T.-Lecco, Merate (LC), Italy
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Wang Y, Sadaghiani MS, Tian F, Fitzgerald KC, Solnes L, Newsome SD. Brain and Muscle Metabolic Changes by FDG-PET in Stiff Person Syndrome Spectrum Disorders. Front Neurol 2021; 12:692240. [PMID: 34603180 PMCID: PMC8484315 DOI: 10.3389/fneur.2021.692240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/30/2021] [Indexed: 11/30/2022] Open
Abstract
Objective: To report clinical characteristics and fluorodeoxyglucose positron emission tomography (FDG-PET) findings in the brain and muscles of individuals with stiff person syndrome (SPS) spectrum disorders (SPSSDs). Methods: Retrospective cohort study from 1997 to 2018 at Johns Hopkins Hospital identified 170 individuals with SPS or cerebellar ataxia (CA) associated with anti-glutamic acid decarboxylase (anti-GAD)-65 antibodies. Fifty-one underwent FDG-PET, with 50 involving the body and 30 with dedicated brain acquisition. The clinical and immunological profiles were extracted via medical record review. The brain scans were analyzed quantitatively using the NeuroQ software, with comparison with an averaged normal database. The body scans were reviewed qualitatively by a blinded nuclear medicine radiologist. Results: Mean age of symptom onset was 41.5 years (range 12–75 years). Majority were female (68%) and White (64%). Of the patients, 82% had SPS (majority being classic phenotype), and 18% had CA. Three had a paraneoplastic process. Forty-seven had serum anti-GAD, two with anti-amphiphysin, and one with anti-glycine receptor antibodies. Brain metabolic abnormalities were seen in both SPS and CA, with significant differences between the groups noted in the right superior frontal cortex, right sensorimotor cortex, left inferior parietal cortex, bilateral thalami, vermis, and left cerebellum. Of the patients, 62% demonstrated muscle hypermetabolism, most commonly bilateral, involving the upper extremities or axial muscles. Neither brain nor muscle metabolism was correlated with functional outcomes nor treatments. Conclusions: Metabolic changes as seen by FDG-PET are present in the brain and muscle in many individuals with SPSSD. Future studies are needed to assess whether FDG-PET can help aid in the diagnosis and/or monitoring of individuals with SPSSD.
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Affiliation(s)
- Yujie Wang
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Mohammad S Sadaghiani
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Fan Tian
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kathryn C Fitzgerald
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Lilja Solnes
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Scott D Newsome
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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AlMuslamani A, Taha M. Thalamic Lesions in a Toddler with Glutamic Acid Decarboxylase Autoimmune Encephalitis. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0040-1716912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractWe present a child with glutamic acid decarboxylase (GAD) autoimmune encephalitis (AE) with bilateral thalamic lesions on magnetic resonance imaging (MRI) of the brain. A healthy 21-month-old girl, after superrefractory status epilepticus (SE) and fever developed dyskinesia and ataxia, which we subsequently diagnosed as GAD AE. She showed remarkable response to treatment with methylprednisolone and intravenous immunoglobulin (IVIg). Following an initial normal MRI of her brain, a further brain imaging showed bilateral thalamic lesions. This is an unusual finding since brain imaging abnormalities, when found in GAD AE, mostly involve the mesial temporal lobe structures. Thalamic lesions in GAD AE have not been reported previously.
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Affiliation(s)
- Ahood AlMuslamani
- Department of Pediatrics, King Hamad University Hospital, Muharraq, Kingdom of Bahrain
| | - Mohamed Taha
- Department of Pediatrics, King Hamad University Hospital, Muharraq, Kingdom of Bahrain
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Psychiatric symptoms in anti glutamic acid decarboxylase associated limbic encephalitis in adults: a systematic review. Neurosci Biobehav Rev 2020; 119:128-137. [PMID: 33022299 DOI: 10.1016/j.neubiorev.2020.08.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 07/13/2020] [Accepted: 08/22/2020] [Indexed: 01/17/2023]
Abstract
Autoimmune Limbic Encephalitis (LE) is a relatively new category of immune-mediated diseases with a wide range of neuropsychiatric symptoms. LE associated with Glutamic Acid Decarboxylase (GAD) antibodies is difficult to diagnose due to its possible atypical presentation with neuropsychiatric and behavioral features. We performed a systematic review of literature and retrieved 21 cases of anti GAD-associated LE with neuropsychiatric signs. Median age at onset was 27 years with a female predominance (81.0 %) and median diagnostic delay of 6 months. Clinical presentation included typical LE symptoms such as anterograde amnesia (95.2 %) and temporal lobe or tonico-clonic seizures (95.2 %). Psychiatric symptoms were described in 61.9 % of patients, presenting as anxiety, depressive symptoms, apathy and behavioral changes. Extra-limbic symptoms were present in 14.3 % of patients. No neoplasia associated was found. Some patients had poor epileptic, cognitive and psychiatric outcomes requiring prolonged immunosuppressive treatment. The description of the neuropsychiatric spectrum of anti-GAD LE and its specificities aims to improve our understanding of this entity, and may lead to earlier diagnosis as well as better outcome.
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Chengyu L, Weixiong S, Chao C, Songyan L, Lin S, Zhong Z, Hua P, Fan J, Na C, Tao C, Jianwei W, Haitao R, Hongzhi G, Xiaoqiu S. Clinical features and immunotherapy outcomes of anti-glutamic acid decarboxylase 65 antibody-associated neurological disorders. J Neuroimmunol 2020; 345:577289. [PMID: 32563127 DOI: 10.1016/j.jneuroim.2020.577289] [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: 12/17/2019] [Revised: 06/07/2020] [Accepted: 06/07/2020] [Indexed: 02/07/2023]
Abstract
We described the clinical and neuroimaging characteristics of seven Chinese patients with anti-GAD65 antibody-associated neurological disorders of whom epileptic seizures were the initial and main symptoms. All patients were given immunotherapy and followed up monthly. The outcome demonstrates that immunotherapy is helpful for non-seizure manifestations of anti-GAD65-associated neurological autoimmunity and is less effective in the treatment of seizures, yet partial responses can still occur in the early stage. Taken together we suggest a trial with immunotherapy in all patients in the early stage of the disease, and in patients with non-epilepsy symptoms in the later stage.
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Affiliation(s)
- Li Chengyu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China.
| | - Shi Weixiong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Chen Chao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Liu Songyan
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Sang Lin
- Epilepsy Center, Medical Alliance of Beijing Tian Tan Hospital, Peking University First Hospital Fengtai Hospital, Beijing 100071, China
| | - Zheng Zhong
- Epilepsy Center, Medical Alliance of Beijing Tian Tan Hospital, Peking University First Hospital Fengtai Hospital, Beijing 100071, China
| | - Pan Hua
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Jian Fan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Chen Na
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Cui Tao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Wu Jianwei
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Ren Haitao
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Guan Hongzhi
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Shao Xiaoqiu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China.
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Glutamic acid decarboxylase antibodies in neurocritical patients: a culprit or a bystander? Neurol Sci 2020; 41:3691-3696. [PMID: 32514855 PMCID: PMC7278224 DOI: 10.1007/s10072-020-04466-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/09/2020] [Indexed: 11/21/2022]
Abstract
Background Glutamic acid decarboxylase (GAD) is an intracellular enzyme, which is widely expressed in central nervous system (CNS), pancreas, and other organs. GAD antibodies (GAD-Abs) are linked to various neurological disorders. However, the significance of GAD-Abs in neurocritical patients is undetermined. Materials and methods Patients with serologically positive GAD-Abs and requiring neurocritical care were included. The clinical, laboratory, and outcome data were retrospectively collected. Results We included 9 patients with serologically positive GAD-Abs. Clinical manifestations involved both CNS and peripheral nervous system (PNS). Six (66.7%) patients had other specific autoimmune antibodies. Non-specific autoimmune responses were observed in 8 (88.9%) patients. All patients clinically responded well to immunotherapy. The titers of GAD-Abs decreased in 7 (77.8%) patients but remained unchanged in the other 2 patients. One (11.1%) patient awoke before the negative conversion of GAD-Abs, and 3 (33.3%) patients remained unconscious and/or under mechanical ventilation for several weeks after the vanishing of GAD-Abs. Conclusions Most neurocritical patients with serologically positive GAD-Abs had other specific autoimmune antibodies. All patients responded well to immunotherapy, but not parallel to the titers of GAD-Abs. These results indicated that GAD-Abs might be more a bystander than a culprit in neurocritical patients, suggesting that an underlying autoimmune disease should be explored.
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Graus F, Saiz A, Dalmau J. GAD antibodies in neurological disorders — insights and challenges. Nat Rev Neurol 2020; 16:353-365. [DOI: 10.1038/s41582-020-0359-x] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2020] [Indexed: 01/07/2023]
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10
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Di Giacomo R, Deleo F, Pastori C, Didato G, Andreetta F, Del Sole A, de Curtis M, Villani F. Predictive value of high titer of GAD65 antibodies in a case of limbic encephalitis. J Neuroimmunol 2019; 337:577063. [PMID: 31525619 DOI: 10.1016/j.jneuroim.2019.577063] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/27/2019] [Accepted: 09/09/2019] [Indexed: 12/18/2022]
Abstract
We report the case of a 42-year-old woman who presented with vertigo and migraine and rapidly developed cognitive decline and seizures. Both serum and cerebro-spinal fluid samples showed high titer of anti-glutamic acid decarboxylase (anti-GAD65) antibodies (998,881 IU/ml and 54,687 IU/ml respectively). Limbic encephalitis was diagnosed and high dose steroids treatment started. During one-year follow-up, without further immunomodulatory therapy, the patient became seizure free, and cognitive functions returned to normal. Serum anti-GAD65 antibodies titer decreased significantly but remained elevated (192,680 IU/ml). We discuss the prognostic and pathogenic value of high titer anti-GAD65 antibodies and its variations in a case of autoimmune limbic encephalitis.
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Affiliation(s)
- Roberta Di Giacomo
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Francesco Deleo
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Chiara Pastori
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Giuseppe Didato
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Francesca Andreetta
- UO Neurologia IV, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Angelo Del Sole
- Nuclear Medicine Unit, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Italy.
| | - Marco de Curtis
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Flavio Villani
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Division of Clinical Neurophysiology, Policlinico IRCCS San Martino, Genova, Italy.
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11
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Baizabal-Carvallo JF. The neurological syndromes associated with glutamic acid decarboxylase antibodies. J Autoimmun 2019; 101:35-47. [DOI: 10.1016/j.jaut.2019.04.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/07/2019] [Accepted: 04/08/2019] [Indexed: 12/12/2022]
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12
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Hamed NO, Al-Ayadhi L, Osman MA, Elkhawad AO, Qasem H, Al-Marshoud M, Merghani NM, El-Ansary A. Understanding the roles of glutamine synthetase, glutaminase, and glutamate decarboxylase autoantibodies in imbalanced excitatory/inhibitory neurotransmission as etiological mechanisms of autism. Psychiatry Clin Neurosci 2018; 72:362-373. [PMID: 29356297 DOI: 10.1111/pcn.12639] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 12/06/2017] [Accepted: 01/10/2018] [Indexed: 12/26/2022]
Abstract
AIM Autism is a heterogeneous neurological disorder that is characterized by impairments in communication and social interactions, repetitive behaviors, and sensory abnormalities. The etiology of autism remains unclear. Animal, genetic, and post-mortem studies suggest that an imbalance exists in the neuronal excitation and inhibition system in autism. The aim of this study was to determine whether alterations of the measured parameters in children with autism are significantly associated with the risk of a sensory dysfunction. METHODS The glutamine synthetase (GS), kidney-type glutaminase (GLS1), and glutamic acid decarboxylase autoantibody levels were analyzed in 38 autistic children and 33 age- and sex-matched controls using enzyme-linked immunosorbent assays. RESULTS The obtained data demonstrated significant alterations in glutamate and glutamine cycle enzymes, as represented by GS and GLS1, respectively. While the glutamic acid decarboxylase autoantibodies levels were remarkably increased, no significant difference was observed compared to the healthy control participants. CONCLUSION The obtained data indicate that GS and GLS1 are promising indicators of a neuronal excitation and inhibition system imbalance and that combined measured parameters are good predictive biomarkers of autism.
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Affiliation(s)
- Najat O Hamed
- Department of Medical Biochemistry, University of Medical Sciences and Technology, Khartoum, Sudan.,Department of Pharmacology, Almaarefa Colleges for Science & Technology (MCST), Riyadh, Saudi Arabia
| | - Laila Al-Ayadhi
- Department of Physiology, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia.,Autism Research and Treatment Center, King Khalid University Hospital, Riyadh, Saudi Arabia.,Shaik AL-Amodi Autism Research Chair, King Saud University, Riyadh, Saudi Arabia
| | - Mohamed A Osman
- Department of Medical Biochemistry, University of Medical Sciences and Technology, Khartoum, Sudan.,Department of Pharmacology, Faculty of Pharmacy, University of Medical Sciences and Technology, Sudan Medical and Scientific Research Institute, Khartoum, Sudan
| | | | - Hanan Qasem
- Autism Research and Treatment Center, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Majida Al-Marshoud
- Central Laboratory, Female Centre for Scientific and Medical Studies, King Saud University, Riyadh, Saudi Arabia
| | - Nada M Merghani
- Central Laboratory, Female Centre for Scientific and Medical Studies, King Saud University, Riyadh, Saudi Arabia
| | - Afaf El-Ansary
- Autism Research and Treatment Center, King Khalid University Hospital, Riyadh, Saudi Arabia.,Shaik AL-Amodi Autism Research Chair, King Saud University, Riyadh, Saudi Arabia.,Central Laboratory, Female Centre for Scientific and Medical Studies, King Saud University, Riyadh, Saudi Arabia
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13
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Antiglutamic acid decarboxylase 65 (GAD65) antibody-associated epilepsy. Epilepsy Behav 2018; 80:331-336. [PMID: 29433947 DOI: 10.1016/j.yebeh.2018.01.021] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/16/2018] [Accepted: 01/17/2018] [Indexed: 01/21/2023]
Abstract
Glutamic acid decarboxylase (GAD) antibody-associated encephalitis causes both acute seizures and chronic epilepsy with predominantly temporal lobe onset. This condition is challenging in diagnosis and management, and the incidence of GAD antibody (Ab)-related epilepsy could be much higher than commonly believed. Imaging and CSF evidence of inflammation along with typical clinical presentations, such as adult onset temporal lobe epilepsy (TLE) with unexplained etiology, should prompt testing for the diagnostic antibodies. High serum GAD Ab titer (≥2000U/mL or ≥20nmol/L) and evidence of intrathecal anti-GAD Ab synthesis support the diagnosis. Unlike other immune-mediated epilepsies, antiglutamic acid decarboxylase 65 (GAD65) antibody-mediated epilepsy is often poorly responsive to antiepileptic drugs (AEDs) and only moderately responsive to immune therapy with steroids, intravenous immunoglobulin (IVIG), or plasma exchange (PLEX). Long-term treatment with more aggressive immunosuppressants such as rituximab (RTX) and/or cyclophosphamide is often necessary and may be more effective than current immunosuppressive approaches. The aim of this review is to review the physiology, pathology, clinical presentation, related ancillary tests, and management of GAD Ab-associated autoimmune epilepsy by searching the keywords and to promote the recognition and the initiation of proper therapy for this condition.
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Metabolic topography of autoimmune non-paraneoplastic encephalitis. Neuroradiology 2017; 60:189-198. [DOI: 10.1007/s00234-017-1956-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 11/28/2017] [Indexed: 12/15/2022]
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Ju W, Qi B, Wang X, Yang Y. Anti-Ma2-associated limbic encephalitis with coexisting chronic inflammatory demyelinating polyneuropathy in a patient with non-Hodgkin lymphoma: A case report. Medicine (Baltimore) 2017; 96:e8228. [PMID: 28984777 PMCID: PMC5738013 DOI: 10.1097/md.0000000000008228] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
RATIONALE We report the rare case of a 74-year-old man with anti-Ma2-associated paraneoplastic neurologic syndrome (PNS), and review and analyze the clinical manifestations, diagnosis, and treatment of the disease. PATIENT CONCERNS The patient presented with a 5-month history of muscle weakness, progressive body aches, and weakness and numbness in both lower extremities. Before his hospitalization, he had experienced cognitive function decline; ptosis, inward gaze, and vertical gaze palsy in the right eye; and occasional visual hallucinations. Brain and spinal cord magnetic resonance imaging (MRI) yielded normal results. Anti-Ma2 antibodies were detected in both serum and cerebrospinal fluid. A 4-hour electroencephalogram showed irregular sharp slow waves and δ waves in the temporal region. Electromyography showed peripheral nerve demyelination. Positron-emission tomography/computed tomography (PET-CT) examination revealed hypermetabolism in the lymph nodes of the whole body. Biopsy of the lymph nodes showed non-Hodgkin lymphoma. DIAGNOSIS A clinical diagnosis of lymphoma and PNS was made. INTERVENTIONS The patient was treated with intravenous dexamethasone (15 mg/day) for 3 days. LESSONS We have presented a rare case of a PNS involving both the central and peripheral nervous systems. The clinical features of this case indicated anti-Ma2-associated encephalitis and chronic inflammatory demyelinating polyneuropathy. PET-CT played a critical role in enabling early diagnosis and prompt treatment in this case.
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Affiliation(s)
| | - Baochang Qi
- Department of Orthopedic Trauma, the First Hospital of Jilin University, Changchun, Jilin, China
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Grilo E, Pinto J, Caetano JS, Pereira H, Cardoso P, Cardoso R, Dinis I, Pereira C, Fineza I, Mirante A. Type 1 diabetes and GAD65 limbic encephalitis: a case report of a 10-year-old girl. J Pediatr Endocrinol Metab 2016; 29:985-90. [PMID: 27115322 DOI: 10.1515/jpem-2016-0016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 03/07/2016] [Indexed: 12/14/2022]
Abstract
Limbic encephalitis is a rare neurological disorder that may be difficult to recognize. Clinical features include memory impairment, temporal lobe seizures and affective disturbance. We report the case of a 10-year-old girl with type 1 diabetes mellitus that presented with seizures, depressed mood and memory changes. The diagnosis of glutamic acid decarboxylase 65 (GAD65) mediated limbic encephalitis relied on cerebral magnetic resonance imaging lesions and high serological and cerebrospinal fluid GAD65-antibodies titers. High-dose steroidal therapy was started with clinical improvement. Relapse led to a second high-dose steroid treatment followed by rituximab with remission. A correlation between serum GAD65-antibodies levels and symptoms was found, demonstrating GAD65-antibodies titers may be useful for clinical follow-up and immunotherapy guidance. This report raises awareness of this serious neurological condition that may be associated with type 1 diabetes, underlining the importance of an early diagnosis and prompt treatment for a better prognosis.
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Cholangiocarcinoma associated with limbic encephalitis and early cerebral abnormalities detected by 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography-positron emission tomography: a case report. J Med Case Rep 2016; 10:200. [PMID: 27439460 PMCID: PMC4955157 DOI: 10.1186/s13256-016-0989-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 06/23/2016] [Indexed: 12/11/2022] Open
Abstract
Background Limbic encephalitis was originally described as a rare clinical neuropathological entity involving seizures and neuropsychological disturbances. In this report, we describe cerebral patterns visualized by positron emission tomography in a patient with limbic encephalitis and cholangiocarcinoma. To our knowledge, there is no other description in the literature of cerebral positron emission tomography findings in the setting of limbic encephalitis and subsequent diagnosis of cholangiocarcinoma. Case presentation We describe a case of a 77-year-old Caucasian man who exhibited persistent cognitive changes 2 years before his death. A cerebral scan obtained at that time by 2-deoxy-2-[fluorine-18]fluoro-d-glucose integrated with computed tomography-positron emission tomography showed low radiotracer uptake in the frontal and temporal lobes. Cerebrospinal fluid analysis indicated the presence of voltage-gated potassium channel antibodies. Three months before the patient’s death, a lymph node biopsy indicated a cholangiocarcinoma, and a new cerebral scan obtained by 2-deoxy-2-[fluorine-18]fluoro-d-glucose integrated with computed tomography-positron emission tomography showed an increment in the severity of metabolic deficit in the frontal and parietal lobes, as well as hypometabolism involving the temporal lobes. Two months before the patient’s death, cerebral metastases were detected on a contrast-enhanced computed tomographic scan. Postmortem examination revealed a cholangiocarcinoma with multiple metastases including the lungs and lymph nodes. The patient’s brain weighed 1300 g, and mild cortical atrophy, ex vacuo dilation of the ventricles, and mild focal thickening of the cerebellar leptomeninges, which were infiltrated by neoplastic epithelial cells, were observed. Conclusions These findings support the need for continued vigilance in malignancy surveillance in patients with limbic encephalitis and early cerebral positron emission tomographic scan abnormalities. The difficulty in early diagnosis of small tumors, such as a cholangiocarcinoma, is discussed in the context of the clinical utility of early cerebral hypometabolism detected by 2-deoxy-2-[fluorine-18]fluoro-d-glucose integrated with computed tomography-positron emission tomography in patients with rapidly progressive dementia.
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Frye RE, Casanova MF, Fatemi SH, Folsom TD, Reutiman TJ, Brown GL, Edelson SM, Slattery JC, Adams JB. Neuropathological Mechanisms of Seizures in Autism Spectrum Disorder. Front Neurosci 2016; 10:192. [PMID: 27242398 PMCID: PMC4861974 DOI: 10.3389/fnins.2016.00192] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 04/18/2016] [Indexed: 01/09/2023] Open
Abstract
This manuscript reviews biological abnormalities shared by autism spectrum disorder (ASD) and epilepsy. Two neuropathological findings are shared by ASD and epilepsy: abnormalities in minicolumn architecture and γ-aminobutyric acid (GABA) neurotransmission. The peripheral neuropil, which is the region that contains the inhibition circuits of the minicolumns, has been found to be decreased in the post-mortem ASD brain. ASD and epilepsy are associated with inhibitory GABA neurotransmission abnormalities including reduced GABAA and GABAB subunit expression. These abnormalities can elevate the excitation-to-inhibition balance, resulting in hyperexcitablity of the cortex and, in turn, increase the risk of seizures. Medical abnormalities associated with both epilepsy and ASD are discussed. These include specific genetic syndromes, specific metabolic disorders including disorders of energy metabolism and GABA and glutamate neurotransmission, mineral and vitamin deficiencies, heavy metal exposures and immune dysfunction. Many of these medical abnormalities can result in an elevation of the excitatory-to-inhibitory balance. Fragile X is linked to dysfunction of the mGluR5 receptor and Fragile X, Angelman and Rett syndromes are linked to a reduction in GABAA receptor expression. Defects in energy metabolism can reduce GABA interneuron function. Both pyridoxine dependent seizures and succinic semialdehyde dehydrogenase deficiency cause GABA deficiencies while urea cycle defects and phenylketonuria cause abnormalities in glutamate neurotransmission. Mineral deficiencies can cause glutamate and GABA neurotransmission abnormalities and heavy metals can cause mitochondrial dysfunction which disrupts GABA metabolism. Thus, both ASD and epilepsy are associated with similar abnormalities that may alter the excitatory-to-inhibitory balance of the cortex. These parallels may explain the high prevalence of epilepsy in ASD and the elevated prevalence of ASD features in individuals with epilepsy.
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Affiliation(s)
- Richard E Frye
- Autism Research Program, Arkansas Children's Research InstituteLittle Rock, AR, USA; Department of Pediatrics, University of Arkansas for Medical SciencesLittle Rock, AR, USA
| | - Manuel F Casanova
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville Greenville, SC, USA
| | - S Hossein Fatemi
- Department of Psychiatry, University of Minnesota Medical School Minneapolis, MN, USA
| | - Timothy D Folsom
- Department of Psychiatry, University of Minnesota Medical School Minneapolis, MN, USA
| | - Teri J Reutiman
- Department of Psychiatry, University of Minnesota Medical School Minneapolis, MN, USA
| | | | | | - John C Slattery
- Autism Research Program, Arkansas Children's Research InstituteLittle Rock, AR, USA; Department of Pediatrics, University of Arkansas for Medical SciencesLittle Rock, AR, USA
| | - James B Adams
- School for Engineering of Matter, Transport, and Energy, Arizona State University Tempe, AZ, USA
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19
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Limbic encephalitis associated with glutamic acid decarboxylase antibodies in a young adolescent. Rev Neurol (Paris) 2016; 172:327-8. [DOI: 10.1016/j.neurol.2016.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 02/08/2016] [Accepted: 02/15/2016] [Indexed: 11/23/2022]
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20
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Limbic Encephalitis Associated With GAD65 Antibodies: Brief Review of the Relevant literature. Can J Neurol Sci 2016; 43:486-93. [DOI: 10.1017/cjn.2016.13] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
AbstractRecently, many cases of autoimmune limbic encephalitis with positive GAD65 (glutamic acid decarboxylase) antibodies have been described in the scientific literature. However, it remains an understudied topic of great relevance to practicing neurologists. Thus, we report here a review of published cases, in English, of autoimmune limbic encephalitis with this type of antibodies, focusing on presenting symptoms and signs, associated conditions, and findings upon investigation. We also report treatment responses. We aim to offer a better description of the clinical spectrum of autoimmune limbic encephalitis associated with GAD65 antibodies as well as to expose its paraclinical features and outcome.
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21
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Abstract
Over the last 15 years it has become clear that rare but highly recognizable diseases of the central nervous system (CNS), including newly identified forms of limbic encephalitis and other encephalopathies, are likely to be mediated by antibodies (Abs) to CNS proteins. The Abs are directed against membrane receptors and ion channel-associated proteins that are expressed on the surface of neurons in the CNS, such as N-methyl D-aspartate receptors and leucine-rich, glioma inactivated 1 protein and contactin-associated protein like 2, that are associated with voltage-gated potassium channels. The diseases are not invariably cancer-related and are therefore different from the classical paraneoplastic neurological diseases that are associated with, but not caused by, Abs to intracellular proteins. Most importantly, the new antibody-associated diseases almost invariably respond to immunotherapies with considerable and sometimes complete recovery, and there is convincing evidence of their pathogenicity in the relatively limited studies performed so far. Treatments include first-line steroids, intravenous immunoglobulins, and plasma exchange, and second-line rituximab and cyclophosphamide, followed in many cases by steroid-sparing agents in the long-term. This review focuses mainly on N-methyl D-aspartate receptor- and voltage-gated potassium channel complex-related Abs in adults, the clinical phenotypes, and treatment responses. Pediatric cases are referred to but not reviewed in detail. As there have been very few prospective studies, the conclusions regarding immunotherapies are based on retrospective studies.
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Affiliation(s)
- Matteo Gastaldi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
- University of Pavia, Pavia, Italy.
| | - Anaïs Thouin
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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22
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Sunwoo JS, Chu K, Byun JI, Moon J, Lim JA, Kim TJ, Lee ST, Jung KH, Park KI, Jeon D, Jung KY, Kim M, Lee SK. Intrathecal-specific glutamic acid decarboxylase antibodies at low titers in autoimmune neurological disorders. J Neuroimmunol 2015; 290:15-21. [PMID: 26711563 DOI: 10.1016/j.jneuroim.2015.11.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Revised: 11/13/2015] [Accepted: 11/15/2015] [Indexed: 01/07/2023]
Abstract
Autoantibodies to glutamic acid decarboxylase (Gad-Abs) are implicated in various neurological syndromes. The present study aims to identify intrathecal-specific GAD-Abs and to determine clinical manifestations and treatment outcomes. Nineteen patients had GAD-Abs in cerebrospinal fluid but not in paired serum samples. Neurological syndromes included limbic encephalitis, temporal lobe epilepsy, cerebellar ataxia, autonomic dysfunction, and stiff-person syndrome. Immunotherapy had beneficial effects in 57.1% of patients, and the patients with limbic encephalitis responded especially well to immunotherapy. Intrathecal-specific antibodies to GAD at low titers may appear as nonspecific markers of immune activation within the central nervous system rather than pathogenic antibodies causing neuronal dysfunction.
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Affiliation(s)
- Jun-Sang Sunwoo
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Kon Chu
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea.
| | - Jung-Ick Byun
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Jangsup Moon
- Department of Neurology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, South Korea
| | - Jung-Ah Lim
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Tae-Joon Kim
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Soon-Tae Lee
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Keun-Hwa Jung
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung-Il Park
- Department of Neurology, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, South Korea
| | - Daejong Jeon
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Ki-Young Jung
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Manho Kim
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea; Protein Metabolism Medical Research Center, Seoul National University College of Medicine, Seoul, South Korea
| | - Sang Kun Lee
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea.
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23
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Quartuccio N, Caobelli F, Evangelista L, Alongi P, Kirienko M, De Biasi V, Cocciolillo F. The role of PET/CT in the evaluation of patients affected by limbic encephalitis: A systematic review of the literature. J Neuroimmunol 2015; 284:44-8. [PMID: 26025057 DOI: 10.1016/j.jneuroim.2015.05.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 05/01/2015] [Indexed: 02/07/2023]
Abstract
Autoimmune limbic encephalitis (LE) is a rare disorder affecting the medial temporal lobe of the brain. Although brain Magnetic Resonance (MR) has been widely evaluated and is currently considered essential in the suspicion of LE, Positron Emission Tomography/Computed Tomography (PET/CT) has been demonstrated to be useful also in the evaluation of brain inflammatory diseases such as encephalitis. We therefore aim to review the current literature about the role of PET/CT in the evaluation of patients affected by LE.
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Affiliation(s)
- Natale Quartuccio
- Nuclear Medicine Unit, Department of Biomedical Sciences and of Morphological and Functional Images, University of Messina, Italy
| | - Federico Caobelli
- Klinik für Nuklearmedizin, Medizinische Hochschule Hannover, Germany.
| | - Laura Evangelista
- Radiotherapy and Nuclear Medicine Unit, Istituto Oncologico Veneto IOV - IRCCS, Padova, Italy
| | - Pierpaolo Alongi
- Nuclear Medicine Department, University of Milano-Bicocca, Milan, Italy
| | | | - Vincenzo De Biasi
- Nuclear Medicine Department, Arcispedale S. Maria Nuova, Reggio Emilia, Italy
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24
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Lin Q, Wang X. Differences in epileptic symptoms depending on the type of autoimmune-mediated limbic encephalitis. Expert Rev Clin Immunol 2015; 11:897-910. [PMID: 26163176 DOI: 10.1586/1744666x.2015.1055253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Limbic encephalitis (LE) is an inflammatory disease of the central nervous system that is characterized by the selective involvement of limbic structures. The clinical manifestations of LE include the acute or sub-acute onset of recent memory disorders, mental disorders and seizures. Autoimmune-mediated LE is a major type of non-infectious LE; seizure is a hallmark of this type of LE. The treatment of epilepsy, which is a key factor that affects the prognosis of LE patients, warrants special attention. Understanding the characteristics of epilepsy caused by autoimmune-mediated LE and providing the appropriate treatment will help to improve patients' outcomes. In this article, we extensively review the literature related to autoimmune-mediated LE epidemiology, mechanisms, characteristics and seizure frequency and onset, and we discuss the possible diagnosis and treatment of this disease.
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Affiliation(s)
- Qingxia Lin
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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25
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Abstract
PURPOSE Temporal lobe epilepsy with antibodies (abs) against the glutamic acid decarboxylase 65 isoform (GAD-TLE) is known as an immune-mediated neurological syndrome. Here we evaluate the therapy response to various immunotherapies and epilepsy surgery in this syndrome. METHOD All patients with GAD-TLE and follow-up data and stored serum and CSF samples, identified and treated at the Bonn centre from 2002 to 2010, were studied retrospectively. Seizure freedom for ≥1 year and reduction of ≥50%, i.e. therapy response, were assessed. GAD-ab titres and neuropsychological performances were documented prior and after individual interventions. RESULTS Thirteen patients with GAD-TLE were identified with the following seizure responses: corticosteroids (5 responders out of 11 treated patients); i.v. immunoglobulins (1/5), apheresis therapy (1/8); and natalizumab (1/1), selective amygdala-hippocampectomy (2/3). None of the patients achieved sustained seizure freedom apart from one patient. This patient was on antiepileptic drug treatment after discontinuation of immunotherapy. CONCLUSION The seizure response to immunotherapies in patients with GAD-TLE was poor. Corticosteroids were the most effective regarding seizure response. Especially the poor effects of apheresis therapies support the idea that GAD-abs are not directly pathogenic. None of three patients was seizure-free after temporal lobe surgery suggesting that GAD-TLE patients respond worse than others to this type of intervention. Our results reflect the chronic course of the disease with low likelihood for patients with GAD-TLE to attain long-term seizure freedom.
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26
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Incecik F, Hergüner OM, Yıldızdaş D, Horoz O, Besen S. Limbic encephalitis with antibodies to glutamic acid decarboxylase presenting with brainstem symptoms. Ann Indian Acad Neurol 2015; 18:243-5. [PMID: 26019430 PMCID: PMC4445208 DOI: 10.4103/0972-2327.150628] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 12/16/2014] [Accepted: 12/27/2014] [Indexed: 11/12/2022] Open
Abstract
Limbic encephalitis (LE) is a neurological syndrome that may present in association with cancer, infection, or as an isolate clinical condition often accompanying autoimmune disorders. LE associated with glutamic acid decarboxylase antibodies (anti-GAD) is rare in children. Here, we characterized the clinical and laboratory features of a patient presenting with brainstem involvement with non-paraneoplastic LE associated with anti-GAD antibodies. In our patient, after plasma exchange, we determined a dramatic improvement of the neurological deficits.
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Affiliation(s)
- Faruk Incecik
- Department of Pediatric Neurology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Ozlem M Hergüner
- Department of Pediatric Neurology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Dincer Yıldızdaş
- Department of Pediatric Intensive Care Unit, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Ozden Horoz
- Department of Pediatric Intensive Care Unit, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Seyda Besen
- Department of Pediatric Neurology, Cukurova University Faculty of Medicine, Adana, Turkey
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27
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Lin KL, Wang HS. Role of antineuronal antibodies in children with encephalopathy and febrile status epilepticus. Pediatr Neonatol 2014; 55:161-7. [PMID: 24050844 DOI: 10.1016/j.pedneo.2013.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 07/03/2013] [Accepted: 07/16/2013] [Indexed: 01/24/2023] Open
Abstract
Status epilepticus in childhood is more common, with a different range of causes and a lower risk of death, than convulsive status epilepticus in adults. Acute central nervous system infections appear to be markers for morbidity and mortality. Nevertheless, central nervous infection is usually presumed in these conditions. Many aspects of the pathogenesis of acute encephalitis and acute febrile encephalopathy with status epilepticus have been clarified in the past decade. The pathogenesis is divided into direct pathogens invasion or immune-mediated mechanisms. Over the past few decades, the number of antineuronal antibodies to ion channels, receptors, and other synaptic proteins described in association with central nervous system disorders has increased dramatically, especially their role in pediatric encephalitis and status epilepticus. These antineuronal antibodies are divided according to the location of their respective antigens: (1) intracellular antigens, including glutamic acid decarboxylase and classical onconeural antigens such as Hu (antineuronal nuclear antibody 1, ANNA1), Ma2, Yo (Purkinje cell autoantibody, PCA1), Ri (antineuronal nuclear antibody 2, ANNA2), CV2/CRMP5, and amphiphysin; and (2) cell membrane ion channels or surface antigens including voltage-gated potassium channel receptor, N-methyl-d-aspartate receptor, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor, γ-aminobutyric acid(B) receptor, leucine-rich glioma-inactivated protein 1, and contactin-associated protein-like 2. Identifying the mechanism of the disease may have important therapeutic implications.
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Affiliation(s)
- Kuang-Lin Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Huei-Shyong Wang
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
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28
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Mishra N, Rodan LH, Nita DA, Gresa-Arribas N, Kobayashi J, Benseler SM. Anti-glutamic Acid decarboxylase antibody associated limbic encephalitis in a child: expanding the spectrum of pediatric inflammatory brain diseases. J Child Neurol 2014; 29:677-83. [PMID: 24092895 DOI: 10.1177/0883073813500527] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Anti-glutamic acid decarboxylase directed antibodies are a rare cause of autoimmune limbic encephalitis that is relatively resistant to immunotherapy. Here we report a 15-year-old boy with nonparaneoplastic, anti-glutamic acid decarboxylase limbic encephalitis presenting with subacute headache, memory disturbance, psychiatric symptoms, and seizures. At onset, his memory disturbance manifested as transient global amnesia-like episodes. Clinical remission was achieved with rituximab, intravenous immunoglobulin, and corticosteroids.
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Affiliation(s)
- Navin Mishra
- 1Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
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29
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Petit-Pedrol M, Armangue T, Peng X, Bataller L, Cellucci T, Davis R, McCracken L, Martinez-Hernandez E, Mason WP, Kruer MC, Ritacco DG, Grisold W, Meaney BF, Alcalá C, Sillevis-Smitt P, Titulaer MJ, Balice-Gordon R, Graus F, Dalmau J. Encephalitis with refractory seizures, status epilepticus, and antibodies to the GABAA receptor: a case series, characterisation of the antigen, and analysis of the effects of antibodies. Lancet Neurol 2014; 13:276-86. [PMID: 24462240 DOI: 10.1016/s1474-4422(13)70299-0] [Citation(s) in RCA: 375] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Increasing evidence suggests that seizures and status epilepticus can be immune-mediated. We aimed to describe the clinical features of a new epileptic disorder, and to establish the target antigen and the effects of patients' antibodies on neuronal cultures. METHODS In this observational study, we selected serum and CSF samples for antigen characterisation from 140 patients with encephalitis, seizures or status epilepticus, and antibodies to unknown neuropil antigens. The samples were obtained from worldwide referrals of patients with disorders suspected to be autoimmune between April 28, 2006, and April 25, 2013. We used samples from 75 healthy individuals and 416 patients with a range of neurological diseases as controls. We assessed the samples using immunoprecipitation, mass spectrometry, cell-based assay, and analysis of antibody effects in cultured rat hippocampal neurons with confocal microscopy. FINDINGS Neuronal cell-membrane immunoprecipitation with serum of two index patients revealed GABAA receptor sequences. Cell-based assay with HEK293 expressing α1/β3 subunits of the GABAA receptor showed high titre serum antibodies (>1:160) and CSF antibodies in six patients. All six patients (age 3-63 years, median 22 years; five male patients) developed refractory status epilepticus or epilepsia partialis continua along with extensive cortical-subcortical MRI abnormalities; four patients needed pharmacologically induced coma. 12 of 416 control patients with other diseases, but none of the healthy controls, had low-titre GABAA receptor antibodies detectable in only serum samples, five of them also had GAD-65 antibodies. These 12 patients (age 2-74 years, median 26.5 years; seven male patients) developed a broader spectrum of symptoms probably indicative of coexisting autoimmune disorders: six had encephalitis with seizures (one with status epilepticus needing pharmacologically induced coma; one with epilepsia partialis continua), four had stiff-person syndrome (one with seizures and limbic involvement), and two had opsoclonus-myoclonus. Overall, 12 of 15 patients for whom treatment and outcome were assessable had full (three patients) or partial (nine patients) response to immunotherapy or symptomatic treatment, and three died. Patients' antibodies caused a selective reduction of GABAA receptor clusters at synapses, but not along dendrites, without altering NMDA receptors and gephyrin (a protein that anchors the GABAA receptor). INTERPRETATION High titres of serum and CSF GABAA receptor antibodies are associated with a severe form of encephalitis with seizures, refractory status epilepticus, or both. The antibodies cause a selective reduction of synaptic GABAA receptors. The disorder often occurs with GABAergic and other coexisting autoimmune disorders and is potentially treatable. FUNDING The National Institutes of Health, the McKnight Neuroscience of Brain Disorders, the Fondo de Investigaciones Sanitarias, Fundació la Marató de TV3, the Netherlands Organisation for Scientific Research (Veni-incentive), the Dutch Epilepsy Foundation.
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Affiliation(s)
- Mar Petit-Pedrol
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain; Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Thaís Armangue
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain; Department of Pediatric Neurology, Hospital Materno-Infantil Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Xiaoyu Peng
- Department of Neuroscience, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Luis Bataller
- Service of Neurology, University Hospital Politècnic La Fe, Valencia, Spain
| | - Tania Cellucci
- Division of Rheumatology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca Davis
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Lindsey McCracken
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Warren P Mason
- Department of Medicine, Princess Margaret Cancer Center and University of Toronto, Toronto, Canada
| | - Michael C Kruer
- Sanford Children's Health Research Center, Sanford Children's Specialty Clinic, Sioux Falls, SD, USA
| | - David G Ritacco
- Division of Pediatric Neurology, Lurie Children's Hospital, Chicago, USA
| | - Wolfgang Grisold
- Service of Neurology, Ludwig Boltzmann Institute of Neurooncology, Vienna, Austria
| | - Brandon F Meaney
- Division of Neurology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Carmen Alcalá
- Service of Neurology, University Hospital Politècnic La Fe, Valencia, Spain
| | | | | | - Rita Balice-Gordon
- Department of Neuroscience, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Francesc Graus
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain; Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Josep Dalmau
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA; Hospital Clinic, University of Barcelona, Barcelona, Spain; Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain.
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Lin JJ, Lin KL, Chiu CH, Hsia SH, Wang HS, Chou IJ, Lin YT. Antineuronal antibodies and infectious pathogens in severe acute pediatric encephalitis. J Child Neurol 2014; 29:11-6. [PMID: 23143714 DOI: 10.1177/0883073812461944] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The pathogenesis of acute encephalitis is divided into either direct infection or by immune-mediated inflammation, but the cause is still unknown. This retrospective study aimed to screen antineuronal antibodies in children with severe acute encephalitis. Thirty-four children (22 boys and 12 girls) underwent assessments such as antineuronal antibodies survey for autoimmune encephalitis and polymerase chain reaction/viral culture and antibody assays for all commonly recognized causes of infectious encephalitis. Sixteen (47.1%) were positive for autoantibodies, including antiglutamic acid decarboxylase antibodies in 16 and voltage-gated potassium channel complex antibodies in 1. Sixteen patients (47.1%) had presumed infectious etiologies, including 6 with influenza, 6 with Mycoplasma pneumoniae, 3 with enterovirus, and 1 with herpes simplex virus. In this study, influenza and Mycoplasma pneumoniae infection are the main presumed causes of severe acute encephalitis in children, although an immune-mediated mechanism may also play a role.
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Affiliation(s)
- Jainn-Jim Lin
- 1Division of Pediatric Neurology, Graduate Institute of Clinical Medical Sciences, Chang Gung University, College of Medicine, Taoyuan, Taiwan
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Abstract
The neurologic presentation of limbic encephalitis is variable and when it occurs due to a rare cause the diagnosis may be problematic. We present a case of autoimmune limbic encephalitis due to glutamic acid decarboxylase antibody and consider the magnetic resonance imaging and antineural antibody screening aspects in the diagnosis of this entity.
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Affiliation(s)
- Pasquale F Finelli
- Department of Neurology, Hartford Hospital and University of Connecticut School of Medicine, Hartford, CT, USA
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Limbic encephalitis in Taiwanese children and adolescence: a single center study. Pediatr Neonatol 2013; 54:246-53. [PMID: 23597520 DOI: 10.1016/j.pedneo.2013.01.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 11/26/2012] [Accepted: 01/23/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Non-viral limbic encephalitis, which may be paraneoplastic or idiopathic, is increasingly recognized in adults and children. Early identification of potential patients, who have neuronal autoantibodies to intracellular or neuronal surface antigens in order to give appropriate immunotherapy, is key to improving the prognosis. This cross-sectional study describes the clinical manifestation and the serological evidence of the presence of neuronal antibodies in Taiwanese children with limbic encephalitis. METHOD We enrolled children and adolescents who had been hospitalized due to nonviral limbic encephalitis. Serum samples from these patients were collected to screen antibodies against intracellular antigens [amphiphysin, Ma2, Ri, Yo, Hu and antiglutamic acid decarboxylase (GAD)] and neuronal surface antigens [N-methyl-d-aspartate (NMDA) receptor, γ-amino butyric acid (GABAB) receptor and voltage-gated potassium channel complexes (VGKCs)]. RESULTS All of the 10 enrolled patients had acute onset of fever and rapid clinical deterioration. They had persistent neuropsychiatric symptoms and 90% developed refractory epilepsy, despite six patients having been treated with methylprednisolone pulse therapy or intravenous immunoglobulin (IVIG) at the acute stage. In the laboratory findings, half of the cases were positive for antibodies with regards to intracellular antigens (amphiphysin or GAD). The general outcomes, assessed by Glasgow Outcome Scale, were similar between patients with and those without the antibodies (Mann-Whitney U test, p = 0.43). One patient, who was positive for antibodies to amphiphysin 10 years after disease onset, still had a significant response to oral prednisolone therapy. At the end of the follow-up period, no cancer or insulin-dependent diabetes mellitus was detected in any of the patients. CONCLUSION This study provides evidence for a potential association between antibodies and limbic encephalitis. The presence of antibodies, especially antibodies to GAD, may serve as an indicator for immunotherapy.
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Cerebral FDG-PET and MRI findings in autoimmune limbic encephalitis: correlation with autoantibody types. J Neurol 2013; 260:2744-53. [DOI: 10.1007/s00415-013-7048-2] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Revised: 07/06/2013] [Accepted: 07/12/2013] [Indexed: 01/18/2023]
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Ozkan M, Aksoy A, Çenesiz F, Atay NE, Yüksel D. The association of anti-glutamic acid decarboxylase antibodies with different neurological findings in childhood. Epilepsy Behav 2012; 25:464-7. [PMID: 22995927 DOI: 10.1016/j.yebeh.2012.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Revised: 08/04/2012] [Accepted: 08/06/2012] [Indexed: 10/27/2022]
Abstract
Glutamic acid decarboxylase antibodies can rarely be associated with various neurological syndromes, which are usually present in adults. Here, we present 2 affected children. Our first patient had a diagnosis of epilepsy and presented with continuous involuntary movements and multifocal myoclonic seizures following an infection at the age of 9 months. Anti-glutamic acid decarboxylase antibodies were found in the serum and cerebrospinal fluid. A partial response was obtained from intravenous immunoglobulin, steroid, and plasmapheresis treatment. The other patient presented with a clinical picture of acute cerebellar ataxia and mutism at the age of 6 years and recovered fully following intravenous immunoglobulin treatment. Neurological findings due to anti-glutamic acid decarboxylase antibodies may be more common in children than previously thought, and achieving an early diagnosis can be important for prompt treatment.
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Affiliation(s)
- Mehpare Ozkan
- Department of Pediatric Neurology, Dr. Sami Ulus Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
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Lin JJ, Lin KL, Hsia SH, Wang HS, Chou IJ, Lin YT. Antiglutamic acid decarboxylase antibodies in children with encephalitis and status epilepticus. Pediatr Neurol 2012; 47:252-8. [PMID: 22964438 DOI: 10.1016/j.pediatrneurol.2012.06.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 06/20/2012] [Indexed: 02/03/2023]
Abstract
Encephalitis may present with seizures or status epilepticus, and the etiology is usually presumed. Specific antibodies to ion channels, receptors, and other synaptic proteins were identified during the past decade. However, only a few studies investigated antiglutamic acid decarboxylase antibodies and antibodies to cell membrane ion channels or surface antigens in pediatric encephalitis and status epilepticus. We examined antibodies to glutamic acid decarboxylase and cell membrane ion channels or surface antigens in acute-phase serum from 17 children with encephalitis and status epilepticus. Antiglutamic acid decarboxylase antibody titers were compared with those of control children manifesting therapy-resistant epilepsy. Antiglutamic acid decarboxylase antibody titers were significantly higher in those with encephalitis and status epilepticus than in those with therapy-resistant epilepsy. No patient demonstrated antibodies to cell membrane ion channels or surface antigens. Six children exhibited positive antiglutamic acid decarboxylase antibodies. One child died, three manifested postencephalitic epilepsy with neurologic deficits, and two recovered well. Higher antiglutamic acid decarboxylase antibody titers were evident in the children with encephalitis and status epilepticus. Clinicians should be aware of the potential role of antiglutamic acid decarboxylase antibodies in children with encephalitis and status epilepticus.
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Affiliation(s)
- Jainn-Jim Lin
- Division of Pediatric Neurology, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Lopez-Sublet M, Bihan H, Reach G, Dupont S, Didelot A, Mourad JJ, Krivitzky A, Dhote R. Limbic encephalitis and type 1 diabetes with glutamic acid decarboxylase 65 (GAD65) autoimmunity: Improvement with high-dose intravenous immunoglobulin therapy. DIABETES & METABOLISM 2012; 38:273-5. [DOI: 10.1016/j.diabet.2012.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 02/28/2012] [Accepted: 02/28/2012] [Indexed: 10/28/2022]
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Kaplan PW, Rossetti AO, Kaplan EH, Wieser HG. Proposition: limbic encephalitis may represent limbic status epilepticus. A review of clinical and EEG characteristics. Epilepsy Behav 2012; 24:1-6. [PMID: 22459869 DOI: 10.1016/j.yebeh.2011.11.029] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 11/25/2011] [Indexed: 10/28/2022]
Abstract
Limbic encephalitis (LE) with waxing and waning neuropsychiatric manifestations including behavioral, personality, psychiatric, and memory changes can evolve over days to months. Many features of LE show remarkable overlap with the characteristics of mesial-temporal (limbic) status epilepticus (MTLSE or LSE). With LE, these prolonged impaired states are assumed not to be due to ongoing epileptic activity or MTLSE, because scalp EEGs usually show no epileptiform spike-wave activity; cycling behavioral and motor changes are attributed to LE; there may be little immediate improvement with antiepileptic drugs (AEDs); and of course, implanted electrodes are rarely used. Conversely, it is known that in pre-surgical patients with refractory limbic epilepsy, implanted electrodes have revealed limbic seizures that cannot be seen at the scalp. This paper assembles a chain of inferences to advance the proposition that refractory LE might represent LSE more often than is thought, and that implanted electrodes should be considered in some cases. We present two cases that suggest that LE was also LSE, one of which warranted implanted electrodes (case 1).
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Affiliation(s)
- Peter W Kaplan
- The Johns Hopkins Bayview Medical Center, Department of Neurology, 4940 Eastern Avenue, Baltimore, MD 21224, USA.
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Rout UK, Mungan NK, Dhossche DM. Presence of GAD65 autoantibodies in the serum of children with autism or ADHD. Eur Child Adolesc Psychiatry 2012; 21:141-7. [PMID: 22323074 DOI: 10.1007/s00787-012-0245-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Accepted: 01/13/2012] [Indexed: 11/30/2022]
Abstract
Antibodies against glutamic acid decarboxylase 65 (GAD65) have been detected in the serum of patients with several neurological disorders. The presence of antibodies against GAD65 has not yet been examined in the serum of patients with neurodevelopmental disorders such as autism or attention-deficit/hyperactivity disorder (ADHD). In this study, GAD65 antibodies and total IgG were assayed in the serum of normal subjects and patients diagnosed with autism or ADHD. GAD65 antibodies were detected in the serum of 15% of children with autism (N = 20), 27% of children with ADHD (N = 15) and of none of the controls (N = 14). The serum of 60% of autistic and 53% of ADHD patients reacted with Purkinje neurons in mouse cerebellum. Serum from 20% of ADHD patients reacted also with the cells in the molecular and granule cell layers and cells in the vicinity of the Purkinje neurons. No association was found between the titer of GAD65 antibodies and total IgG levels, and presence of seizures or mental retardation. None of the ADHD patients were diagnosed with mental retardation. Serum anti-GAD65 antibodies may be a common marker of subgroups of patients with autism and ADHD. Reactions of serum antibodies with the cells in the cerebellum in these patients suggest direct effects on brain function. The subgroup of children with autism and ADHD that tests positive for GAD65 antibodies needs further characterization in a larger study.
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Affiliation(s)
- Ujjwal K Rout
- Department of Surgery, University of Mississippi Medical Center, Clinical Sciences Building, Room L020, Jackson, MS, 39216, USA.
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Falip M, Carreño M, Miró J, Saiz A, Villanueva V, Quílez A, Molins A, Barceló I, Sierra A, Graus F. Prevalence and immunological spectrum of temporal lobe epilepsy with glutamic acid decarboxylase antibodies. Eur J Neurol 2012; 19:827-33. [DOI: 10.1111/j.1468-1331.2011.03609.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Extralimbic autoimmune encephalitis associated with glutamic acid decarboxylase antibodies: an underdiagnosed entity? Epilepsy Behav 2011; 21:306-13. [PMID: 21620774 DOI: 10.1016/j.yebeh.2011.03.038] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Revised: 03/27/2011] [Accepted: 03/28/2011] [Indexed: 12/16/2022]
Abstract
Nonparaneoplastic glutamic acid decarboxylase antibody (GADAb)-related autoimmune encephalitis is a syndrome characterized by refractory seizures, progressive cognitive deficits, and psychiatric manifestations. The limbic subtype is well described, has characteristic affective and memory disturbances, and typical mesial temporal MRI abnormalities. We found only one single case report of the extralimbic subtype. We report clinical, radiological, and pathological findings of two additional cases with contrast-enhancing lesions. One of our cases presented as vasculitis, and the other imitated a tumor. Pathological evidence of both vasculitis and encephalitis has never been previously reported in any inflammatory condition affecting the brain. Our cases confirm prior reports that immune therapy can better control seizures associated with GADAb autoimmune encephalitis, and support the rationale for assaying for GADAb titers in patients with etiologically unclear extralimbic lesions and refractory epilepsy, independent of seizure types.
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de Broucker T. Encéphalites paranéoplasiques et auto-immunes : quand y penser, comment en faire le diagnostic. ACTA ACUST UNITED AC 2011. [DOI: 10.1007/s13546-011-0252-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Scriven J, Davies S, Banerjee AK, Jenkins N, Watson J. Limbic encephalitis secondary to HIV seroconversion. Int J STD AIDS 2011; 22:236-7. [DOI: 10.1258/ijsa.2011.010331] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We present a case of acute limbic encephalitis secondary to HIV seroconversion. The patient made a gradual neurological recovery following treatment with antiretroviral therapy, steroids and intravenous immunoglobulin.
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Affiliation(s)
- J Scriven
- Department of Infection and Tropical Medicine
| | - S Davies
- Department of Sexual Health and HIV Medicine
| | - A K Banerjee
- Department of Radiology, Birmingham Heartlands Hospital, Birmingham, UK
| | - N Jenkins
- Department of Infection and Tropical Medicine
| | - J Watson
- Department of Sexual Health and HIV Medicine
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Méningoencéphalites — Encéphalites paranéoplasiques: les encéphalites limbiques. MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-010-0130-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Treatment of anti-glutamic acid decarboxylase antibody-associated limbic encephalitis with mycophenolate mofetil. J Neurol 2010; 257:1035-8. [DOI: 10.1007/s00415-010-5476-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Revised: 01/12/2010] [Accepted: 01/15/2010] [Indexed: 01/17/2023]
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