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Wang C, Zhang H, Lu W, Zhan Y. The EBV connection: a severe case of GFAP-A with central hypoventilation unresponsive to IVIG and literature review. Eur J Med Res 2024; 29:415. [PMID: 39135139 PMCID: PMC11320868 DOI: 10.1186/s40001-024-01926-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/06/2024] [Indexed: 08/15/2024] Open
Abstract
PURPOSE Glial fibrillary acidic protein astrocytopathy (GFAP-A) pathogenesis remains uncertain, with potential viral involvement. More clinical cases are needed to deepen our understanding of this disease, along with the exploration of more effective treatment options to provide clinicians with additional choices. METHODS We report a severe case of GFAP-A secondary to EBV infection, characterized predominantly by central respiratory failure. Additionally, we conducted a literature review summarizing the characteristics of GFAP-IgG-positive patients associated with EBV infection. RESULTS Among the 13 patients identified, fever (92.3%) and headache (84.6%) were the most common initial symptoms, while urinary dysfunction was universally present in all patients. Over half of the patients with altered consciousness required endotracheal intubation (7/11, 63.6%), with only one individual experiencing complete resolution without any residual sequela. Only two patients (16.7%) displayed the classic feature of periventricular enhancement on neuroimaging, whereas T2-FLAIR hyperintensities were more prevalent. All patients tested positive for GFAP-IgG in CSF, and 91.7% (11/12) had detectable serum GFAP-IgG antibodies. Three patients (23.1%) achieved full recovery solely through antiviral therapy. In patients receiving various immunotherapies, 60% (6/10) still had residual sequelae. CONCLUSION EBV infection may contribute to the pathogenesis of GFAP-A. GFAP antibody testing is recommended for diagnostic evaluation in cases of central nervous system viral infections presenting with respiratory insufficiency. For severe GFAP-A patients, Protein A immunoadsorption (Protein A IA).
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Affiliation(s)
- Changlun Wang
- Department of Neurology, Second Xiangya Hospital, Central South University, No. 139, Renmin Middle Road, Changsha, China
- Clinical Medical Research Center for Stroke Prevention and Treatment of Hunan Province, Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Hainan Zhang
- Department of Neurology, Second Xiangya Hospital, Central South University, No. 139, Renmin Middle Road, Changsha, China
- Clinical Medical Research Center for Stroke Prevention and Treatment of Hunan Province, Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Wei Lu
- Department of Neurology, Second Xiangya Hospital, Central South University, No. 139, Renmin Middle Road, Changsha, China
- Clinical Medical Research Center for Stroke Prevention and Treatment of Hunan Province, Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Yajing Zhan
- Department of Neurology, Second Xiangya Hospital, Central South University, No. 139, Renmin Middle Road, Changsha, China.
- Clinical Medical Research Center for Stroke Prevention and Treatment of Hunan Province, Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China.
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2
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Villain P, Kerbrat A, Cochard C. [Subacute blindness and aseptic meningitis as presenting signs of autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy]. J Fr Ophtalmol 2024; 47:104194. [PMID: 38761650 DOI: 10.1016/j.jfo.2024.104194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/20/2024] [Accepted: 03/21/2024] [Indexed: 05/20/2024]
Affiliation(s)
- P Villain
- Service d'ophtalmologie, hôpital Pontchaillou, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35000 Rennes, France.
| | - A Kerbrat
- Service de neurologie, hôpital Pontchaillou, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35000 Rennes, France
| | - C Cochard
- Service d'ophtalmologie, hôpital Pontchaillou, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35000 Rennes, France
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Shosha E, Connolly C, Budhram A. Case report: Headache as the sole neurological symptom in autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy. Front Neurol 2024; 15:1366263. [PMID: 38699059 PMCID: PMC11063300 DOI: 10.3389/fneur.2024.1366263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/14/2024] [Indexed: 05/05/2024] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a recently emerging autoimmune disease of the central nervous system (CNS); GFAP astrocytopathy is characterized by optic neuritis and meningoencephalomyelitis. We report the case of a 55-year-old man, otherwise healthy, who presented with isolated headaches for three months, without other features of meningoencephalitis or myelitis. His neurological examination and fundoscopy were unremarkable. Gadolinium-enhanced brain MRI demonstrated increased T2 hyperintensity within the right sub-lenticular basal ganglia, with additional leptomeningeal enhancement along the bilateral perisylvian regions and mesial temporal lobes. Cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis, elevated protein, matching oligoclonal bands, and a negative infectious and cytological workup. Cell-based assays for anti-aquaporin-4, anti-myelin oligodendrocyte glycoprotein, autoimmune encephalitis panel, and vasculitis workup were all negative, except for CSF positivity for GFAP α antibody. Oncological screening, including CT of the chest, abdomen, pelvis, and scrotal US, was unremarkable. Immunotherapy with high-dose intravenous steroids for five days and subsequent single four-weekly doses resulted in the resolution of both clinical and radiographic features, with a maintained status 24 months after onset. This case highlights isolated headache and basal ganglia, mesial temporal lobe involvement as a rare presentation of autoimmune GFAP astrocytopathy.
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Affiliation(s)
- Eslam Shosha
- Neurology Division, Department of Medicine, McMaster University, Hamilton Health Science Center, Hamilton, ON, Canada
| | - Colleen Connolly
- Neurology Division, Department of Medicine, McMaster University, Hamilton Health Science Center, Hamilton, ON, Canada
| | - Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Science Center, London, ON, Canada
- Department of Pathology and Laboratory Medicine, Western University, London Health Science Center, London, ON, Canada
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Cleaver J, Jeffery K, Klenerman P, Lim M, Handunnetthi L, Irani SR, Handel A. The immunobiology of herpes simplex virus encephalitis and post-viral autoimmunity. Brain 2024; 147:1130-1148. [PMID: 38092513 PMCID: PMC10994539 DOI: 10.1093/brain/awad419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/25/2023] [Accepted: 11/27/2023] [Indexed: 04/06/2024] Open
Abstract
Herpes simplex virus encephalitis (HSE) is the leading cause of non-epidemic encephalitis in the developed world and, despite antiviral therapy, mortality and morbidity is high. The emergence of post-HSE autoimmune encephalitis reveals a new immunological paradigm in autoantibody-mediated disease. A reductionist evaluation of the immunobiological mechanisms in HSE is crucial to dissect the origins of post-viral autoimmunity and supply rational approaches to the selection of immunotherapeutics. Herein, we review the latest evidence behind the phenotypic progression and underlying immunobiology of HSE including the cytokine/chemokine environment, the role of pathogen-recognition receptors, T- and B-cell immunity and relevant inborn errors of immunity. Second, we provide a contemporary review of published patients with post-HSE autoimmune encephalitis from a combined cohort of 110 patients. Third, we integrate novel mechanisms of autoimmunization in deep cervical lymph nodes to explore hypotheses around post-HSE autoimmune encephalitis and challenge these against mechanisms of molecular mimicry and others. Finally, we explore translational concepts where neuroglial surface autoantibodies have been observed with other neuroinfectious diseases and those that generate brain damage including traumatic brain injury, ischaemic stroke and neurodegenerative disease. Overall, the clinical and immunological landscape of HSE is an important and evolving field, from which precision immunotherapeutics could soon emerge.
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Affiliation(s)
- Jonathan Cleaver
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
| | - Katie Jeffery
- Department of Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, OX3 9DU, UK
| | - Paul Klenerman
- Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, OX1 3SY, UK
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 9DU, UK
| | - Ming Lim
- Children’s Neurosciences, Evelina London Children’s Hospital at Guy’s and St Thomas’ NHS Foundation Trust, London, SE1 7EH, UK
- Department Women and Children’s Health, School of Life Course Sciences, King’s College London, London, WC2R 2LS, UK
| | - Lahiru Handunnetthi
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, OX3 7BN, UK
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
| | - Adam Handel
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
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Kimura A. [Clinical features and pathogenesis of Glial fibrillary acidic protein (GFAP) antibody-associated disorders]. Rinsho Shinkeigaku 2024; 64:75-84. [PMID: 38281748 DOI: 10.5692/clinicalneurol.cn-001925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Glial fibrillary acidic protein (GFAP) antibody-associated disorders (AD) were recently proposed to be immune-mediated neurological disorders. The pathogenesis of GFAP antibody-AD is poorly understood. Pathologically, there is a marked infiltration of large numbers of lymphocytes, including CD8+ and CD4+ T cells, into the meningeal and brain parenchyma, especially around the perivascular areas. GFAP-specific cytotoxic T cells are considered to be the effector cells of GFAP antibody-AD. The common phenotype of GFAP antibody-AD includes meningoencephalitis with or without myelitis. During the clinical disease course, patients present with consciousness disturbances, urinary dysfunction, movement disorders, meningeal irritation, and cognitive dysfunction. The detection of GFAP antibodies in the cerebrospinal fluid (CSF) by cell-based assay is essential for a diagnosis of GFAP antibody-AD. The CSF can be examined for lymphocyte-predominant pleocytosis and elevated protein levels. Brain linear perivascular radial enhancement patterns are observed in about half of GFAP antibody-AD patients. Spinal cord magnetic resonance imaging is used to detect longitudinal extensive spinal cord lesions. Although corticosteroid therapy is generally effective, some patients have a poor prognosis and relapse.
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Affiliation(s)
- Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine
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Bien CG, Büttner T, Reichen IC, Thomas A, Vlad B, Woermann F, Bien CI, Jelcic I. Glial Fibrillary Acidic Protein Autoimmunity After Aseptic Meningitis: A Report of 2 Cases. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200180. [PMID: 37949666 PMCID: PMC10691222 DOI: 10.1212/nxi.0000000000200180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/21/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVES We describe 2 patients with glial fibrillary acidic protein (GFAP) autoimmunity secondary to aseptic viral meningitis or meningoencephalomyelitis. METHODS This study involved a retrospective chart review. RESULTS Two female patients, 45 and 55 years of age, developed aseptic meningoencephalomyelitis or meningitis; in one patient, it was likely caused by herpes simplex virus 2. The patients were recovering from the infectious condition when they, 51 and 5 days after onset, had new symptoms with detection of GFAP antibodies in the CSF; CSF and serum samples from the initial lumbar punctures had been negative for GFAP antibodies. Both patients recovered with steroid treatment (in one case, plus rituximab; in the other, plus azathioprine) including resolution of MRI and CSF abnormalities. DISCUSSION These 2 patients had GFAP autoimmunity secondary to viral meningoencephalomyelitis or meningitis. This suggests that GFAP astrocytopathy might not always be a primary disease entity; it may follow another brain injury that triggers this autoimmune response.
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Affiliation(s)
- Christian G Bien
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany.
| | - Thomas Büttner
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Ina C Reichen
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Annette Thomas
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Benjamin Vlad
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Friedrich Woermann
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Corinna I Bien
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany.
| | - Ilijas Jelcic
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
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Li X, Wang J, Li L, Yang C, Zhao X, Yang B, Zhang P, Liu B, Li Y, Zhang Z, Duan R. Epstein-Barr virus: To be a trigger of autoimmune glial fibrillary acidic protein astrocytopathy? CNS Neurosci Ther 2023; 29:4139-4146. [PMID: 37458208 PMCID: PMC10651959 DOI: 10.1111/cns.14336] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 05/30/2023] [Accepted: 06/18/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a novel autoimmune disease of central nervous system (CNS). It is unclear whether Epstein-Barr virus (EBV) is related to autoimmune GFAP astrocytopathy. OBJECTIVE To describe the clinical, laboratory, and imaging characteristics of patients with autoimmune GFAP astrocytopathy. METHODS The clinical, laboratory, and imaging findings of patients are presented. The levels of GFAP in CSF were detected by ELISA. T and B cell subsets in CSF were detected by flow cytometry. GFAP-IgG in serum and cerebrospinal fluid (CSF) were tested by cell-based assay (CBA) and tissue-based assay (TBA). RESULTS All three patients had fever, cognitive dysfunction, limb weakness, and positive GFAP-IgG with EBV infection in CSF. Enteric glia cells may involve in this disease. Typical imaging findings include the gadolinium enhancement of linear perivascular radial perpendicular to the ventricle, meningeal enhancement (especially in midbrain interpeduncal fossa), longitudinally extensive lesions involving spindle cords, and more T2/Flair-hyperintense lesions in the periventricular white matter at late stage. The patients had poor response to antiviral treatment and strong response to steroid pulse therapy. CONCLUSION EBV could induce CNS autoimmune response in autoimmune GFAP astrocytopathy. The detection of GFAP-IgG and EBV may facilitate the early diagnosis in these patients.
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Affiliation(s)
- Xiao‐Li Li
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Department of Neurology, Shandong Provincial Qianfoshan HospitalCheeloo College of Medicine, Shandong UniversityJinanChina
- Shandong Institute of NeuroimmunologyJinanChina
| | - Jun‐Yan Wang
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
| | - Liang‐Kang Li
- Department of Neurology, Shandong Provincial Qianfoshan HospitalCheeloo College of Medicine, Shandong UniversityJinanChina
| | - Chun‐Lin Yang
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Department of Neurology, Shandong Provincial Qianfoshan HospitalCheeloo College of Medicine, Shandong UniversityJinanChina
- Shandong Institute of NeuroimmunologyJinanChina
| | - Xue‐Lu Zhao
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
| | - Bing Yang
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Department of Neurology, Shandong Provincial Qianfoshan HospitalCheeloo College of Medicine, Shandong UniversityJinanChina
- Shandong Institute of NeuroimmunologyJinanChina
| | - Peng Zhang
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Department of Neurology, Shandong Provincial Qianfoshan HospitalCheeloo College of Medicine, Shandong UniversityJinanChina
- Shandong Institute of NeuroimmunologyJinanChina
| | - Bin Liu
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Department of Neurology, Shandong Provincial Qianfoshan HospitalCheeloo College of Medicine, Shandong UniversityJinanChina
- Shandong Institute of NeuroimmunologyJinanChina
| | - Yan‐Bin Li
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Department of Neurology, Shandong Provincial Qianfoshan HospitalCheeloo College of Medicine, Shandong UniversityJinanChina
- Shandong Institute of NeuroimmunologyJinanChina
| | - Zhao‐Xu Zhang
- Department of NeurologyPeking University People's HospitalBeijingChina
| | - Rui‐Sheng Duan
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Department of Neurology, Shandong Provincial Qianfoshan HospitalCheeloo College of Medicine, Shandong UniversityJinanChina
- Shandong Institute of NeuroimmunologyJinanChina
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Sun M, Liu H, Zhu B, Liu Y, Li A, Wang L. Comparison of glial fibrillary acidic protein-immunoglobulin G-associated myelitis with myelin oligodendrocyte glycoprotein-immunoglobulin G-associated myelitis. Front Neurol 2023; 14:1266067. [PMID: 38020648 PMCID: PMC10645061 DOI: 10.3389/fneur.2023.1266067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Objective Glial fibrillary acidic protein-immunoglobulin G (GFAP-IgG)-associated myelitis and myelin oligodendrocyte glycoprotein-IgG (MOG-IgG)-associated myelitis have rarely been compared. Therefore, this study aimed to explore the clinical, laboratory, and imaging features of them to identify the differences. Methods Overall, 14 and 24 patients with GFAP-IgG-and MOG-IgG-associated myelitis, respectively, were retrospectively screened and included in the study. Results Among the 14 patients with GFAP-IgG-associated myelitis, the condition was more common in males (71.4%), with a median age of onset of 36.5 years, and more common in adults than in children (35.7%). In contrast, among the 24 patients with MOG-IgG-associated myelitis, the condition was equally divided between males and females, with a median age of onset of 9.5 years and more in children (66.7%) than in adults. The median age of onset of GFAP-IgG-associated myelitis was later than that of the MOG-IgG group. Isolated myelitis was rare in both groups. Elevated cerebrospinal fluid (CSF) protein levels were more prevalent in patients with GFAP-IgG-associated myelitis (64.3%) than in those with MOG-IgG-associated myelitis (16.7%) (p < 0.05), whereas patchy gadolinium enhancement of the cerebral lesion site was less common in patients with GFAP-IgG-associated myelitis than in those with MOG-IgG associated myelitis (p < 0.05). Six patients had a combination of other neurological autoantibodies, the specific mechanism of the overlapping antibodies remains unclear. Conclusion Cerebrospinal fluid analysis and gadolinium enhanced MRI examination may help to distinguish the two kinds of myelitis.
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Affiliation(s)
- Mengyang Sun
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hao Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Bingqing Zhu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yang Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Aijia Li
- Zhengzhou University Medical College, Zhengzhou, China
| | - Limei Wang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Li T, Li X, Hong S, Jiang L, Ma J. Clinical characteristics of autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy in children: A case series of 16 patients. J Neuroimmunol 2023; 382:578176. [PMID: 37572437 DOI: 10.1016/j.jneuroim.2023.578176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/14/2023] [Accepted: 08/06/2023] [Indexed: 08/14/2023]
Abstract
PURPOSE To investigate the clinical characteristics of autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy in children. METHODS We reviewed the medical records of Children's Hospital of Chongqing Medical University from January 2020 to September 2021 and retrospectively analysed the clinical features, magnetic resonance imaging (MRI) findings, laboratory findings, treatment and outcome of children with autoimmune GFAP astrocytopathy. RESULTS Sixteen patients were included: 6 and 10 tested positive for GFAP-IgG in cerebrospinal fluid (CSF) and both CSF and serum, respectively. The median patient age was 115 months (range: 36-180 months), and 7 patients (43.8%) were male. All patients had the clinical syndrome of encephalitis/meningoencephalitis with or without myelitis: encephalitis (8), meningoencephalitis (3), encephalomyelitis (1) and meningoencephalomyelitis (4). The most common clinical symptoms were fever (11), altered consciousness (11), headache (10) and seizure (9). Four patients developed central respiratory failure for which mechanical ventilation was needed. All patients showed hyperintense T2-weighted lesions on brain MRI in the cerebral white matter (13), brainstem (11), basal ganglia (11), thalamus (9), and cerebellum (3). Nine patients (56%) had abnormal hyperintense lesions in the bilateral basal ganglia and thalamus. Six of 12 patients who underwent gadolinium-enhanced brain MRI showed abnormal enhancement images, and five of them showed linear perivascular radial enhancement. The modified Rankin scale (mRS) score decreased significantly in most patients after immunotherapy. Two patients with coexisting neural autoantibodies relapsed; however, 15 patients who were followed up successfully had favorable outcomes at the last follow-up. CONCLUSION Children with autoimmune GFAP astrocytopathy usually have a clinical syndrome of encephalitis/meningoencephalitis with or without myelitis. Except for the linear perivascular radial gadolinium enhancement pattern, hyperintense lesions in the bilateral basal ganglia and thalamus might be another characteristic brain MRI finding of autoimmune GFAP astrocytopathy in children. Although a few patients with coexisting neural autoantibodies might relapse, children with autoimmune GFAP astrocytopathy usually have favorable outcomes after immunotherapy.
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Affiliation(s)
- Tianyi Li
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xiujuan Li
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Siqi Hong
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Li Jiang
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jiannan Ma
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China.
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10
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Zhang JR, Zhuang S, Xu XD, Song WL, Li KR, Jiang Y, Cheng XY, Shi JJ, Hu WD, Liu CF, Zhang YL. Overlapping Epstein-Barr virus encephalitis and autoimmune glial fibrillary acidic protein astrocytopathy. J Neuroimmunol 2023; 382:578174. [PMID: 37573633 DOI: 10.1016/j.jneuroim.2023.578174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/30/2023] [Accepted: 08/06/2023] [Indexed: 08/15/2023]
Abstract
We describe three cases of overlapping Epstein-Barr virus (EBV) Encephalitis and Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy (GFAP-A). The three cases all presented with initial symptoms of fever, headache, coma, and posture tremor of the upper limbs, then followed by limb weakness and dysuria. All of the three cases were on ventilators. Case 1 and 2 improved dramatically after intravenous methylprednisoloneand immunoglobulin treatment. However, case 3 presented dyspneic, and died from gastrointestinal hemorrhage. The GFAP-A triggered by EBV intracranial infection could initially masquerade as EBV encephalitis only, and the detection of GFAP antibody is essential for differentiation.
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Affiliation(s)
- Jin-Ru Zhang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Sheng Zhuang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiao-Dong Xu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Wen-Li Song
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Ke-Ru Li
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yu Jiang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiao-Yu Cheng
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Ji-Jun Shi
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Wei-Dong Hu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China.
| | - Chun-Feng Liu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China; Jiangsu Key Laboratory of Neuropsychiatric Diseases and Institute of Neuroscience, Soochow University, Suzhou, China.
| | - Yan-Lin Zhang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China.
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McMahon CL, Castro J, Silvas J, Muniz Perez A, Estrada M, Carrion R, Hsieh J. Fetal brain vulnerability to SARS-CoV-2 infection. Brain Behav Immun 2023; 112:188-205. [PMID: 37329995 PMCID: PMC10270733 DOI: 10.1016/j.bbi.2023.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 06/08/2023] [Accepted: 06/10/2023] [Indexed: 06/19/2023] Open
Abstract
Whether or not SARS-CoV-2 can cross from mother to fetus during a prenatal infection has been controversial; however, recent evidence such as viral RNA detection in umbilical cord blood and amniotic fluid, as well as the discovery of additional entry receptors in fetal tissues suggests a potential for viral transmission to and infection of the fetus. Furthermore, neonates exposed to maternal COVID-19 during later development have displayed neurodevelopmental and motor skill deficiencies, suggesting the potential for consequential neurological infection or inflammation in utero. Thus, we investigated transmission potential of SARS-CoV-2 and the consequences of infection on the developing brain using human ACE2 knock-in mice. In this model, we found that viral transmission to the fetal tissues, including the brain, occurred at later developmental stages, and that infection primarily targeted male fetuses. In the brain, SARS-CoV-2 infection largely occurred within the vasculature, but also within other cells such as neurons, glia, and choroid plexus cells; however, viral replication and increased cell death were not observed in fetal tissues. Interestingly, early gross developmental differences were observed between infected and mock-infected offspring, and high levels of gliosis were seen in the infected brains 7 days post initial infection despite viral clearance at this time point. In the pregnant mice, we also observed more severe COVID-19 infections, with greater weight loss and viral dissemination to the brain, compared to non-pregnant mice. Surprisingly, we did not observe an increase in maternal inflammation or the antiviral IFN response in these infected mice, despite showing clinical signs of disease. Overall, these findings have concerning implications regarding neurodevelopment and pregnancy complications of the mother following prenatal COVID-19 exposure.
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Affiliation(s)
- Courtney L McMahon
- Department of Neuroscience, Developmental and Regenerative Biology, University of Texas at San Antonio, San Antonio, TX 78249, USA; Brain Health Consortium, University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Joshua Castro
- Texas Biomedical Research Institute, San Antonio, TX 78227, USA
| | - Jesus Silvas
- Texas Biomedical Research Institute, San Antonio, TX 78227, USA
| | - Aranis Muniz Perez
- Department of Neuroscience, Developmental and Regenerative Biology, University of Texas at San Antonio, San Antonio, TX 78249, USA; Brain Health Consortium, University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Manuel Estrada
- Department of Neuroscience, Developmental and Regenerative Biology, University of Texas at San Antonio, San Antonio, TX 78249, USA; Brain Health Consortium, University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Ricardo Carrion
- Texas Biomedical Research Institute, San Antonio, TX 78227, USA
| | - Jenny Hsieh
- Department of Neuroscience, Developmental and Regenerative Biology, University of Texas at San Antonio, San Antonio, TX 78249, USA; Brain Health Consortium, University of Texas at San Antonio, San Antonio, TX 78249, USA
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12
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Zhang W, Xie Y, Wang Y, Liu F, Wang L, Lian Y, Liu H, Wang C, Xie N. Clinical characteristics and prognostic factors for short-term outcomes of autoimmune glial fibrillary acidic protein astrocytopathy: a retrospective analysis of 33 patients. Front Immunol 2023; 14:1136955. [PMID: 37350972 PMCID: PMC10282742 DOI: 10.3389/fimmu.2023.1136955] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/23/2023] [Indexed: 06/24/2023] Open
Abstract
Background Autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A) is a recently discovered inflammatory central nervous system (CNS) disease, whose clinical characteristics and prognostic factors for short-term outcomes have not been defined yet. We aimed to assess the symptoms, laboratory tests, imaging findings, treatment, and short-term prognosis of GFAP-A. Methods A double-center retrospective cohort study was performed between May 2018 and July 2022. The clinical characteristics and prognostic factors for short-term outcomes were determined. Results We enrolled 33 patients with a median age of 28 years (range: 2-68 years), 15 of whom were children (<18 years). The clinical spectrum is dominated by meningoencephalomyelitis. Besides, we also found nausea, vomiting, poor appetite, and neuropathic pain in some GFAP-A patients, which were not mentioned in previous reports. And adults were more prone to limb numbness than children. Magnetic resonance imaging revealed lesions involving the brain parenchyma, meninges, and spinal cord, exhibiting patchy, linear, punctate, and strip T2 hyperintensities. First-line immunotherapy, including corticosteroid and gamma globulin, was effective in most patients in the acute phase (P = 0.02). However, patients with overlapping AQP4 antibodies did not respond well to first-line immunotherapy and coexisting neural autoantibodies were more common in women. Additionally, the short-term prognosis was significantly better in children than in adults (P = 0.04). Positive non-neural autoantibodies and proven viral infection were independent factors associated with poor outcomes (P = 0.03, 0.02, respectively). Conclusion We expanded the spectrum of clinical symptoms of autoimmune GFAP-A. The clinical symptoms and short-term prognosis differed between children and adults. Positive non-neural autoantibodies and proven viral infection at admission suggest a poor short-term prognosis.
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Affiliation(s)
- Wanwan Zhang
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yinyin Xie
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yali Wang
- Department of Neurology, Henan Children’s Hospital, Zhengzhou, China
| | - Fengxia Liu
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Li Wang
- Department of Neurology, Henan Children’s Hospital, Zhengzhou, China
| | - Yajun Lian
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongbo Liu
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Cui Wang
- Department of Clinical Laboratory, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Nanchang Xie
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Lubarski K, Mania A, Michalak S, Osztynowicz K, Mazur-Melewska K, Figlerowicz M. The Coexistence of Antibodies to Neuronal Cell and Synaptic Receptor Proteins, Gangliosides and Selected Neurotropic Pathogens in Neurologic Disorders in Children. Diagnostics (Basel) 2023; 13:diagnostics13071274. [PMID: 37046492 PMCID: PMC10093427 DOI: 10.3390/diagnostics13071274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/25/2023] [Accepted: 03/27/2023] [Indexed: 03/30/2023] Open
Abstract
Various primarily non-autoimmune neurological disorders occur synchronously with autoantibodies against tissues in the nervous system. We aimed to assess serum and cerebrospinal fluid (CSF) autoantibodies in children with neurologic disorders. To find new diagnostic tools, we compared the laboratory and clinical findings between the distinguished groups. Retrospectively, 508 patients were divided into six subgroups: neuroinfections, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, neurologic autoimmune and demyelinating diseases, epilepsy, pervasive developmental disorders and other patients. We analysed serum anti-aquaporin-4, antiganglioside, neuronal antinuclear and cytoplasmic antibodies, as well as antibodies against surface neuronal and synaptic antigens in the CSF and serum. We involved available demographic and clinical data. Autoantibodies appeared in 165 (32.3%) children, with 24 showing multiple types of them. The most common were anti-neuroendothelium (anti-NET), anti-N-Methyl-D-Aspartate receptor (anti-NMDAr), anti-glial fibrillary acidic protein and anti-myelin antibodies bothering 46/463 (9.9%), 32/343 (9.4%), 27/463 (5.8%) and 27/463 (5.8%), respectively. Anti-NET and anti-NMDAr antibodies appeared more frequently in children with autoimmunity (p = 0.017; p < 0.001, respectively), increasing the autoimmune disease risk (OR = 2.18, 95% CI 1.13–13.97; OR = 3.91, 95% CI 1.86–8.22, respectively). Similar pathomechanisms appeared in diseases of different aetiology with clinical spectrums mimicking each other, so we proposed the model helping to diagnose autoimmune disease. We proved the influence of age, living place and medical history on the final diagnosis.
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Affiliation(s)
- Karol Lubarski
- Department of Infectious Diseases and Child Neurology, Poznan University of Medical Sciences, 27/33 Szpitalna St., 60-572 Poznan, Poland
| | - Anna Mania
- Department of Infectious Diseases and Child Neurology, Poznan University of Medical Sciences, 27/33 Szpitalna St., 60-572 Poznan, Poland
| | - Sławomir Michalak
- Department of Neurology, Division of Neurochemistry and Neuropathology, Poznan University of Medical Sciences, 49 Przybyszewskiego St., 60-355 Poznan, Poland
| | - Krystyna Osztynowicz
- Department of Neurology, Division of Neurochemistry and Neuropathology, Poznan University of Medical Sciences, 49 Przybyszewskiego St., 60-355 Poznan, Poland
| | - Katarzyna Mazur-Melewska
- Department of Infectious Diseases and Child Neurology, Poznan University of Medical Sciences, 27/33 Szpitalna St., 60-572 Poznan, Poland
| | - Magdalena Figlerowicz
- Department of Infectious Diseases and Child Neurology, Poznan University of Medical Sciences, 27/33 Szpitalna St., 60-572 Poznan, Poland
- Correspondence:
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14
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Qin N, Wu X, Wang J, Wang W, Wang X, Ma Y, Wang L. Case report: Autoimmune glial fibrillary acidic protein astrocytopathy misdiagnosed as tuberculous meningitis. Front Neurol 2023; 14:1123603. [PMID: 36970528 PMCID: PMC10034075 DOI: 10.3389/fneur.2023.1123603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/13/2023] [Indexed: 03/11/2023] Open
Abstract
IntroductionAutoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a new form of autoimmunity-mediated central nervous system disease. It is especially easy to misdiagnose when clinical symptoms and cerebrospinal fluid (CSF) indicators are similar to those observed in patients with tuberculous meningitis (TBM).MethodsWe retrospectively analyzed five cases of autoimmune GFAP astrocytopathy that were initially misdiagnosed as TBM.ResultsIn the five reported cases, all but one patient had meningoencephalitis in the clinic, and all patients exhibited increased pressure, lymphocytosis, increased protein levels, and decreased glucose levels in their CSF results and did not have typical imaging findings of autoimmune GFAP astrocytopathy. TBM was the initial diagnosis in all five patients. However, we found no direct evidence of tuberculosis infection, and anti-tuberculosis treatment had inconclusive effects. Following a GFAP antibody test, the diagnosis of autoimmune GFAP astrocytopathy was made.ConclusionWhen there is a suspected diagnosis of TBM but TB-related tests are negative, the possibility of autoimmune GFAP astrocytopathy should be considered.
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Salari M, Etemadifar M, Soleymani R, Murgai AA, Rashedi R. A case of glial fibrillary acidotic protein (GFAP) meningoencephalitis with rheumatoid arthritis. Clin Case Rep 2023; 11:e7038. [PMID: 36879678 PMCID: PMC9984675 DOI: 10.1002/ccr3.7038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/12/2022] [Accepted: 02/12/2023] [Indexed: 03/06/2023] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is an inflammatory disease of the central nervous system (CNS), which affects various regions in the CNS, presenting by variable clinical manifestations. Meningoencephalitis is the most common clinical presentation and association with autoimmune disorders has been reported in about 20% of these patients. Diagnosis is confirmed by the presence of CSF or serum immunoglobulin-G (IgG) against GFAP. The reported case is a 53-year-old woman with the history of long-standing rheumatoid arthritis who first presented with acute-onset dizziness and gait disturbance, periventricular linear and radial enhancement pattern on MRI, and normal CSF analysis, successfully treated with an increase in the dose of oral steroids. After a year she had a subacute-onset, moderate to severe holocephalic headache, normal neurologic examination and CSF analysis, and bilateral diffuse, pachymeningeal, and leptomeningeal enhancement on MRI. According to her Brain MRI imaging with relapsing remitting course steroid responsive ataxia and aseptic meningitis, her serum was tested for GFAP IgG antibodies which was positive. The reported patient is the first in the literature reported pachymeningitis in GFAP astrocytopathy. This case highlights the co-occurrence of rheumatoid arthritis with GFAP-associated astrocytopathy, and expands on the previously reported cases with similar association. This might also suggest a common immune pathogenesis.
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Affiliation(s)
- Mehri Salari
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellence Shahid Beheshti University of medical Sciences Tehran Iran
| | - Masoud Etemadifar
- Department of Functional Neurosurgery, Medical School Isfahan University of Medical Sciences Isfahan Iran
| | - Reyhaneh Soleymani
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellence Shahid Beheshti University of medical Sciences Tehran Iran
| | | | - Ronak Rashedi
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellence Shahid Beheshti University of medical Sciences Tehran Iran
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Liang X, Shen Y. Area postrema syndrome with linear enhancement along the surface of the brainstem and fourth ventricle in autoimmune GFAP astrocytopathy. BMC Neurol 2023; 23:78. [PMID: 36805663 PMCID: PMC9940409 DOI: 10.1186/s12883-023-03126-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Glial fibrillary acidic protein (GFAP) astrocytopathy, a novel autoimmune disease of the nervous system, was first defined in 2016. To our knowledge, area postrema syndrome (APS) with linear enhancement along the surface of the brainstem and fourth ventricle is extremely rare in this disorder. CASE PRESENTATION A Chinese woman presented with intractable nausea and vomiting after onset of flu-like symptoms. Brain magnetic resonance imaging (MRI) disclosed abnormal signal intensities in the dorsal medulla oblongata including area postrema. Besides, linear enhancement surrounding the surface of the brainstem and fourth ventricle was visualized after gadolinium injection. Cerebrospinal fluid (CSF) analysis showed increased cell count and protein. A cell-based assay was positive for anti-GFAP IgG in CSF. She was diagnosed with autoimmune GFAP astrocytopathy and treated with high-dose glucocorticoid. The patient received a quick recovery with entire resolution of the initial abnormalities. CONCLUSIONS Isolated APS can be the initial manifestation of autoimmune GFAP astrocytopathy. Linear enhancement surrounding the surface of the brainstem and fourth ventricle is another neuroradiological hallmark.
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Affiliation(s)
- Xinming Liang
- Department of Neurology, Nanyang Central Hospital, Nanyang, Henan Province China
| | - Yaoyao Shen
- Department of Neurology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, No. 92 Aiguo Road, Donghu District, Nanchang, 330006, Jiangxi Province, China.
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Li K, Wu J, Chen J, You Y. Glial fibrillary acidic protein astrocytopathy and tuberculous meningoencephalitis occurring in a patient with Legionella pneumonia: a case report. BMC Neurol 2023; 23:69. [PMID: 36782173 PMCID: PMC9923896 DOI: 10.1186/s12883-023-03113-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a recently identified recurrent meningoencephalomyelitis with GFAP immunoglobulin G presence in the serum or cerebrospinal fluid (CSF) as a specific biomarker. GFAP astrocytopathy is closely associated with the occurrence of some tumors and often coexists with other antibodies, such as the N-methyl-D-aspartate receptor and aquaporin-4 antibodies. However, GFAP astrocytopathy complicated by central nervous system infection is rare. CASE PRESENTATION Here, we present the case of a patient admitted to a local hospital due to a prominent fever and cough. The patient had a 1-month history of headaches before admission that were not considered serious at the time. Metagenomic next-generation sequencing (mNGS) of bronchoalveolar lavage fluid revealed a high sequence number of Legionella pneumophila and a few mycobacteria. His cough and fever improved significantly after antibiotic treatment. Still, a slight headache remained. Subsequently, his condition worsened, and he visited our hospital with a disturbance of consciousness. Mycobacterium tuberculosis was detected with mNGS of the CSF, while the CSF and serum were also positive for GFAP antibodies. Following anti-tuberculosis and steroid therapy, the patient's symptoms improved, and he tested negative for the GFAP antibody. CONCLUSION This is the first reported case of GFAP astrocytopathy complicated by tuberculous meningoencephalitis. Due to overlaps in the clinical manifestations of the two diseases, GFAP astrocytopathy is sometimes misdiagnosed as tuberculous meningoencephalitis. Therefore, in addition to ensuring careful identification of the two diseases, clinicians need to be aware of their possible co-existence.
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Affiliation(s)
- Ke Li
- grid.443397.e0000 0004 0368 7493Department of Neurology, The Second Affiliated Hospital of Hainan Medical University, 570013 Haikou, China
| | - Jingwei Wu
- grid.443397.e0000 0004 0368 7493Department of Neurology, The Second Affiliated Hospital of Hainan Medical University, 570013 Haikou, China
| | - Junwu Chen
- Department of Internal Medicine, Changjiang County Medical Group, Changjiang, China
| | - Yong You
- Department of Neurology, The Second Affiliated Hospital of Hainan Medical University, 570013, Haikou, China.
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[Clinical features of autoimmune glial fibrillary acidic protein astrocytopathy in children: an analysis of 34 cases]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:67-72. [PMID: 36655666 PMCID: PMC9893831 DOI: 10.7499/j.issn.1008-8830.2208105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To study the clinical features of children with autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A). METHODS A retrospective analysis was performed on the medical data of 34 children with GFAP-A who attended the Department of Neurology, Children's Hospital of Chongqing Medical University, from January 2020 to February 2022. The medical data included clinical manifestations, cerebrospinal fluid features, imaging examination results, treatment, and prognosis. RESULTS The median age of onset was 8.4 (range 1.9-14.9) years for the 34 children with GFAP-A. The main clinical manifestations included headache (50%, 17/34), fever (47%, 16/34), visual impairment (47%, 16/34), and disturbance of consciousness (44%, 15/34). Abnormal cerebrospinal fluid results were observed in 19 children (56%, 19/34), among whom 8 children had positive autoantibody. The children with overlap syndrome had significantly higher recurrence rate and rate of use of immunosuppressant than those without overlap syndrome (P<0.05). About 77% (24/31) of the children had good response to immunotherapy, and only 1 child had poor prognosis. CONCLUSIONS Children with GFAP-A often have non-specific clinical symptoms and show good response to immunotherapy. Children with overlap syndrome have a high recurrence rate, and early application of immunosuppressants may help to prevent recurrence and alleviate symptoms.
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19
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Zhu B, Sun M, Yang T, Yu H, Wang L. Clinical, imaging features and outcomes of patients with anti-GFAP antibodies: a retrospective study. Front Immunol 2023; 14:1106490. [PMID: 37205100 PMCID: PMC10187143 DOI: 10.3389/fimmu.2023.1106490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 04/11/2023] [Indexed: 05/21/2023] Open
Abstract
Objective To evaluate and compare the clinical features, imaging, overlapping antibodies, and prognosis of pediatric and adult patients with anti-GFAP antibodies. Methods This study included 59 patients with anti-GFAP antibodies (28 females and 31 males) who were admitted between December 2019 and September 2022. Results Out of 59 patients, 18 were children (under 18 years old), and 31 were adults. The overall cohort's median age at onset was 32 years old, 7 for children, and 42 for adults. There were 23 (41.1%) patients with prodromic infection, 1 (1.7%) patient with a tumor, 29 (53.7%) patients with other non-neurological autoimmune diseases, and 17 (22.8%) patients with hyponatremia. Fourteen (23.7%) patients had multiple neural autoantibodies, with the AQP4 antibody being the most common. Encephalitis (30.5%) was the most common phenotypic syndrome. Common clinical symptoms included fever (59.3%), headache (47.5%), nausea and vomiting (35.6%), limb weakness (35.6%), and disturbance of consciousness (33.9%). Brain MRI lesions were primarily located in the cortex/subcortex (37.3%), brainstem (27.1%), thalamus (23.7%), and basal ganglia (22.0%). Spinal cord MRI lesions often involved the cervical and thoracic spinal cord. There was no statistically significant difference in the MRI lesion site between children and adults. Out of 58 patients, 47 (81.0%) had a monophasic course, and 4 died. The last follow-up showed that 41/58 (80.7%) patients had an improved functional outcome (mRS <3), and children were more likely than adults to have no residual disability symptoms (p = 0.001). Conclusion There was no statistically significant difference in clinical symptoms and imaging findings between children and adult patients with anti-GFAP antibodies; Patients with anti-GFAP antibodies may present with normal MRI findings or delayed MRI abnormalities, and patients with overlapping antibodies were common. Most patients had monophasic courses, and those with overlapping antibodies were more likely to relapse. Children were more likely than adults to have no disability. Finally, we hypothesize that the presence of anti-GFAP antibodies is a non-specific witness of inflammation.
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Natori T, Fukao T, Watanabe T, Kurita T, Hata T, Kimura A, Shindo K, Shimohata T, Takiyama Y. Repeated Brain Magnetic Resonance Imaging Provides Clues for the Diagnosis of Autoimmune Glial Fibrillary Acid Protein Astrocytopathy. Intern Med 2022; 61:2947-2950. [PMID: 35228425 PMCID: PMC9593140 DOI: 10.2169/internalmedicine.8964-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
We herein report a 47-year-old man with autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A) revealed by periventricular radial linear enhancement on repeated brain magnetic resonance imaging (MRI). He presented with a history of headache and a fever followed by somnolence and worsening of consciousness. On admission (16 days from the onset), although lymphocytic pleocytosis and hypoglycorrhachia in the cerebrospinal fluid (CSF) were noted, initial brain MRI demonstrated non-specific findings. At 30 days from the onset, repeated brain MRI revealed characteristic findings of GFAP-A, and we detected anti-GFAP antibodies in the CSF. Thus, repeated brain MRI provides clues for the diagnosis of GFAP-A.
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Affiliation(s)
- Takahiro Natori
- Department of Neurology, University of Yamanashi Hospital, Japan
| | - Toko Fukao
- Department of Neurology, University of Yamanashi Hospital, Japan
| | - Tsubasa Watanabe
- Department of Neurology, University of Yamanashi Hospital, Japan
| | - Takafumi Kurita
- Department of Neurology, University of Yamanashi Hospital, Japan
| | - Takanori Hata
- Department of Neurology, University of Yamanashi Hospital, Japan
| | - Akio Kimura
- Department of Neurology, Gifu University Hospital, Japan
| | - Kazumasa Shindo
- Department of Neurology, University of Yamanashi Hospital, Japan
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Matthews E, Beckham JD, Piquet AL, Tyler KL, Chauhan L, Pastula DM. Herpesvirus-Associated Encephalitis: an Update. CURRENT TROPICAL MEDICINE REPORTS 2022; 9:92-100. [PMID: 36186545 PMCID: PMC9510386 DOI: 10.1007/s40475-022-00255-8] [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] [Accepted: 02/08/2022] [Indexed: 11/03/2022]
Abstract
Purpose of Review Recent Findings Summary
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22
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He Q, Liu J, Zhu Z, Tang Y, Long L, Hu K. Case report: Revealing a special and rare autoimmune GFAP astrocytopathy in the spinal cord succeeding Neurobrucellosis infection. Front Immunol 2022; 13:950522. [PMID: 35990675 PMCID: PMC9389076 DOI: 10.3389/fimmu.2022.950522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/08/2022] [Indexed: 01/18/2023] Open
Abstract
Brucellosis, a zoonosis, can cause an inflammatory response in most organs and continues to be a public health problem in some endemic areas, whereas neurobrucellosis is a morbid form of brucellosis that affects the central nervous system (CNS) with poor prognosis. Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is an autoimmune disease, and there have been no reports of a Brucella infection, leading to GFAP astrocytopathy. We report the case of a patient with a positive and high level of GFAP antibodies in the cerebrospinal fluid (CSF), following a Brucella infection. Although this patient did not show any responsible lesions in the diffusion sequence of the magnetic resonant imaging (MRI) scan, we found an evidence of thoracolumbar (T12) involvement on fluorodeoxyglucose (FDG) positron emission tomography (PET). The symptoms of spinal cord involvement were only partly relieved after initial treatment [doxycycline (0.1 g Bid) and rifampicin (0.6 g Qd) for 6 weeks]; however, they markedly improved after the subsequent immunosuppressive therapy [intravenous methylprednisolone (1,000 mg for 3 days)], followed by a 50% reduction from the preceding dose after 3 days, and subsequently, oral prednisone tablets (60 mg/day) was started, which was then gradually tapered [reduced to 10 mg/day every 1–2 weeks)]. The positive response to immunosuppressive therapy and treatment outcome strongly indicated the presence of an autoimmune neurological disease probably triggered by some infectious factors. Therefore, our findings reveal that a Brucella infection is one of the causes of autoimmune GFAP astrocytopathy, and when this infection is difficult to be identified by regular MRI, FDG PET can be used as a supplementary method for diagnosis and treatment.
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Affiliation(s)
- Qiang He
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Epileptic Disease of Hunan Province, Central South University, Changsha, China
| | - Junxian Liu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Zehua Zhu
- Department of Nuclear Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Yongxiang Tang
- Department of Nuclear Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Lili Long
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Epileptic Disease of Hunan Province, Central South University, Changsha, China
| | - Kai Hu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Epileptic Disease of Hunan Province, Central South University, Changsha, China
- *Correspondence: Kai Hu,
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Ahn BJ, Kwon KY. Comment on "Parainfectious Anti-Glial Fibrillary Acidic Protein-Associated Meningoencephalitis". J Mov Disord 2022; 15:187-188. [PMID: 35531618 PMCID: PMC9171313 DOI: 10.14802/jmd.21184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/04/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Byoung June Ahn
- Department of Neurology, Soonchunhyang University Gumi Hospital, Soonchunhyang University College of Medicine, Gumi, Korea
| | - Kyum-Yil Kwon
- Department of Neurology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
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Lubarski K, Mania A, Michalak S, Osztynowicz K, Mazur-Melewska K, Figlerowicz M. The Clinical Spectrum of Autoimmune-Mediated Neurological Diseases in Paediatric Population. Brain Sci 2022; 12:brainsci12050584. [PMID: 35624969 PMCID: PMC9138824 DOI: 10.3390/brainsci12050584] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/21/2022] [Accepted: 04/26/2022] [Indexed: 11/26/2022] Open
Abstract
Neurological autoimmune diseases have various origins and pathogeneses. Specific antibodies are associated with paraneoplastic syndromes, other infectious agents, or inherited disorders. We aim to evaluate the relation between the autoantibodies, the chosen symptoms, demographic characteristics, and infection history. We retrospectively analysed 508 children during neurological diagnostics. We investigated serum antineuronal, IgG, IgM anti-ganglioside, and anti-aquaporin-4 in both the serum and cerebrospinal fluid (CSF) anti-cell surface and anti-synaptic protein antibodies in 463, 99, 44, 343, and 119 patients, respectively. The CSF polymerase chain reaction detection of Herpesviridae, enterovirus, B19 parvovirus, adenovirus, and parechovirus involved 261 patients. We included available clinical information and electroencephalographic, radiologic, and microbiological results. The IgM anti-ganglioside antibodies increased the risk of tics and positive symptoms (p = 0.0345, p = 0.0263, respectively), the anti-glutamic acid decarboxylase particle of paresis (p = 0.0074), and anti-neuroendothelium of mutism (p = 0.0361). Anti-neuroendothelium, IgM anti-ganglioside, and CSF anti-N-methyl-D-aspartate antibodies were more often associated with consciousness loss (p = 0.0496, p = 0.0044, p = 0.0463, respectively). Anti-myelin antibodies co-occured with Herpes simplex virus (HSV)-2 IgG (p = 0.0415), anti-CV2 with HSV-1 IgM (p = 0.0394), whereas anti-glial fibrillary acidic protein was linked with past Epstein-Barr virus infection. The anti-ganglioside IgM and anti-myelin particles were bilaterally correlated (p = 0.0472). The clinical pictures may overlap, requiring specialistic diagnostics. We noticed the links between the infection aetiology and the specific autoantibody’s positivity.
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Affiliation(s)
- Karol Lubarski
- Department of Infectious Diseases and Child Neurology, Poznan University of Medical Sciences, 27/33 Szpitalna St., 60-572 Poznan, Poland; (K.L.); (A.M.); (K.M.-M.)
| | - Anna Mania
- Department of Infectious Diseases and Child Neurology, Poznan University of Medical Sciences, 27/33 Szpitalna St., 60-572 Poznan, Poland; (K.L.); (A.M.); (K.M.-M.)
| | - Sławomir Michalak
- Department of Neurology, Division of Neurochemistry and Neuropathology, Poznan University of Medical Sciences, 49 Przybyszewskiego St., 60-355 Poznan, Poland; (S.M.); (K.O.)
| | - Krystyna Osztynowicz
- Department of Neurology, Division of Neurochemistry and Neuropathology, Poznan University of Medical Sciences, 49 Przybyszewskiego St., 60-355 Poznan, Poland; (S.M.); (K.O.)
| | - Katarzyna Mazur-Melewska
- Department of Infectious Diseases and Child Neurology, Poznan University of Medical Sciences, 27/33 Szpitalna St., 60-572 Poznan, Poland; (K.L.); (A.M.); (K.M.-M.)
| | - Magdalena Figlerowicz
- Department of Infectious Diseases and Child Neurology, Poznan University of Medical Sciences, 27/33 Szpitalna St., 60-572 Poznan, Poland; (K.L.); (A.M.); (K.M.-M.)
- Correspondence: ; Tel.: +48-61-8491362
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Zhuang X, Jin K, Li X, Li J. Autoimmune glial fibrillary acidic protein astrocytopathy in children: a retrospective study. Eur J Med Res 2022; 27:11. [PMID: 35065659 PMCID: PMC8783492 DOI: 10.1186/s40001-022-00641-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 01/12/2022] [Indexed: 11/10/2022] Open
Abstract
Objective To describe the clinical features of autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy in children. Method Data from 11 pediatric patients with autoimmune GFAP astrocytopathy were retrospectively analyzed. Results All of the patients showed encephalitis and meningoencephalitis or meningoencephalomyelitis with or without myelitis. 45.4% of the patients had fever, 27.3% headaches, 18.2% dizziness, 18.2% drowsiness, and 18.2% mental disorders. Cerebrospinal fluid (CSF) was detected in all patients. The white blood cell counts (WBC) (90.9%), lactic dehydrogenase levels (72.7%), protein level (36.4%), and adenosine deaminase activity (ADA) level (27.3%) were elevated, and the CSF glucose levels (72.7%) were slightly reduced. Nine patients (90%) were found to have brain abnormalities, of which five (50.0%) patients had abnormal symmetrical laminar patterns or line patterns hyperintensity lesions on T2-weighted and fluid-attenuated inversion recovery (FLAIR) images in the basal ganglia, hypothalamus, subcortical white matter and periventricular white matter. The linear radial enhancement pattern of the cerebral white matter was only seen in two patients, with the most common being abnormal enhancement of leptomeninges (50%). Five patients had longitudinally extensive spinal cord lesions. Conclusion The findings of pediatric patients with autoimmune GFAP astrocytopathy are different from previous reports.
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Xiao J, Chen X, Shang K, Tang Y, Chen M, Deng G, Qin C, Tian DS. Clinical, neuroradiological, diagnostic and prognostic profile of autoimmune glial fibrillary acidic protein astrocytopathy: A pooled analysis of 324 cases from published data and a single-center retrospective study. J Neuroimmunol 2021; 360:577718. [PMID: 34600199 DOI: 10.1016/j.jneuroim.2021.577718] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/10/2021] [Accepted: 09/08/2021] [Indexed: 12/15/2022]
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a recently defined autoimmune meningoencephalomyelitis, associated with GFAP-IgG antibody. A pooled analysis of 324 cases from published literature and a retrospective single-center study were performed, firstly reveals the possibility that patients with myelitic lesions respond better to initial immunotherapy, but are prone to relapse, suggesting a more aggressive and long-term immunosuppressive medication for them. Moreover, our results showed using tacrolimus at maintenance stage exhibited a less tendency to relapse, providing a possibly new choice to future clinical treatments.
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Affiliation(s)
- Jun Xiao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ke Shang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yue Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Man Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gang Deng
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chuan Qin
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Dai-Shi Tian
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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27
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Mabrouki FZ, Aziouaz F, Sekhsoukh R, Yassine M. Subacute Blindness Revealing an Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy. Cureus 2021; 13:e17588. [PMID: 34646641 PMCID: PMC8482051 DOI: 10.7759/cureus.17588] [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] [Accepted: 08/30/2021] [Indexed: 11/05/2022] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is an autoimmune disease of the central nervous system characterized by positive GFAP autoantibody. The most common are encephalitis, meningoencephalitis or meningoencephalomyelitis. Antibodies in cerebrospinal fluid (CSF) against GFAP are biomarkers and expressed in most cases with autoimmune GFAP astrocytopathy. Diagnosis by biopsy is not common practice and has been rarely performed in the literature. This is the particularity of our reported case of autoimmune GFAP astrocytopathy presented as opticopyramidal syndrome, all paraclinical investigations were normal, only the biopsy allowed the diagnosis.
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Affiliation(s)
- Fatima Zahra Mabrouki
- Ophthalmology, Mohammed VI University Hospital of Oujda/Faculty of Medicine and Pharmacy of Oujda, Oujda, MAR
| | - Faiza Aziouaz
- Neurology, Mohammed VI University Hospital of Oujda/Faculty of Medicine and Pharmacy of Oujda, Oujda, MAR
| | - Rachid Sekhsoukh
- Ophthalmology, Mohammed VI University Hospital of Oujda/Faculty of Medicine and Pharmacy of Oujda, Oujda, MAR
| | - Mebrouk Yassine
- Neurology, Mohammed VI University Hospital of Oujda/Faculty of Medicine and Pharmacy of Oujda, Oujda, MAR
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Ji S, Liu C, Bi Z, Gao H, Sun J, Bu B. Overlapping syndrome mimicking infectious meningoencephalitis in a patient with MOG and GFAP IgG. BMC Neurol 2021; 21:348. [PMID: 34507542 PMCID: PMC8431933 DOI: 10.1186/s12883-021-02381-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 09/02/2021] [Indexed: 12/28/2022] Open
Abstract
Background Central nervous system overlapping autoimmune syndromes are uncommon, especially with the coexistence of MOG-IgG and GFAP-IgG. Case presentation A 23-year-old woman presented with transient convulsions, a loss of consciousness, persistent fever, headache, and vomiting. Cerebrospinal fluid (CSF) analysis revealed elevated cellularity, and magnetic resonance imaging (MRI) showed diffuse leptomeningeal enhancement. She had fever and headache with antiviral and antibiotic treatment for 2 weeks, and she had empirical anti-tuberculosis treatment and oral prednisolone therapy. She was followed for 3 months after presentation with improved symptoms and normal CSF analysis. A 3-month follow-up MRI showed asymmetric lesions in the cerebellum, corona radiata, and white matter with enhancement. The anti-tuberculosis treatment was continued, and steroid therapy was discontinued. After she stopped taking prednisolone, an interrupted headache gradually appeared. MRI at 4 months after presentation revealed a partial reduction in lesions but enlarged areas in the left cerebellum and right parietal white matter and a new lesion in the region of the right ependyma with linear enhancement. Her CSF was positive for anti-myelin oligodendrocyte glycoprotein (MOG) and anti-glial fibrillary acidic protein (GFAP) antibodies using a transfected cell-based assay. She was diagnosed with overlapping syndrome of MOG‑IgG‑associated disease and GFAP astrocytopathy. She received steroid pulse therapy (methylprednisolone, 1 g for 5 days), followed by a gradual tapering of oral prednisolone and the addition of an immunosuppressant (tacrolimus, 3 mg per day). Six months after the initial presentation, she had no symptoms. An MRI showed that the lesions had diminished, and no enhancement was found. Conclusions We report a case that was positive for double antibodies, which was initially misdiagnosed as infectious meningoencephalitis. This case broadens the clinical and phenotypic presentation of the overlapping syndrome spectrum.
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Affiliation(s)
- Suqiong Ji
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Chenchen Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Zhuajin Bi
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Huajie Gao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Jian Sun
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China.
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Li J, Wang C, Cao Y, Shi J, Liu H, Zhou M, Liu C, Hu W. Autoimmune glial fibrillary acidic protein astrocytopathy mimicking acute disseminated encephalomyelitis: A case report. Medicine (Baltimore) 2021; 100:e26448. [PMID: 34160439 PMCID: PMC8238277 DOI: 10.1097/md.0000000000026448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/07/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is an increasingly recognized type of steroid-responsive autoimmune disease of the nervous system. Defined in 2016, it is associated with the presence of anti-GFAP immunoglobulinG in the serum or cerebrospinal fluid (CSF) of affected patients. PATIENT CHARACTERISTICS Herein, we report a case of acute neurological symptoms, including headache, fever, confusion, and paralysis of the lower extremities. CSF analysis revealed lymphocytic pleocytosis and elevated protein levels, indicating acute disseminated encephalomyelitis, and the patient was given immunotherapy. Cranial magnetic resonance imaging showed multifocal T2/fluid-attenuated inversion recovery hyperintense signal changes in the periventricular white matter, and electromyography testing showed changes consistent with severe sensorimotor neuropathy, indicating the involvement of the brain and peripheral nerves. DIAGNOSES Finally, a diagnosis of autoimmune GFAP astrocytopathy was confirmed due to the presence of GFAP-immunoglobulinG in the patient's CSF. INTERVENTIONS The patient was treated with one course of intravenous immunoglobulin therapy, then followed with intravenous methylprednisolone (1.0 g/d for 3 days) and oral prednisolone. OUTCOMES At 1 week after intravenous immunoglobulin therapy, his level of consciousness improved. However, flaccid paralysis persisted without substantial improvement. CONCLUSION In conclusion, the provision of an accurate early diagnosis and appropriate treatment are crucial for improving the prognosis of patients with autoimmune GFAP astrocytopathy. Further, this case highlights the importance of recognizing the role of peripheral nerve involvement in GFAP autoimmunity.
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Khushafa T, Jing L, Zhaojun Z, Jiameng S, Haixia Z. Insights into the biomarkers of viral encephalitis from clinical patients. Pathog Dis 2020; 79:6006267. [PMID: 33238302 DOI: 10.1093/femspd/ftaa073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 11/23/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND biomarkers can be helpful in identifying patients who may profit by explicit treatments or evaluating the reaction to the treatment of specific disease. Finding unique biomarkers in the process of disease could help clinicians in identifying serious disease in the early stage, so as to improve prognosis. OBJECTIVE these investigations, nonetheless, have made constrained progress. Numerous infections are known to cause intense viral encephalitis (VE) in people which can cause a variable level of meningeal just as parenchymal aggravation. Initial clinical manifestations in most encephalitis are nonspecific, resembling a viral-like illness. However, with disease progression, symptoms can become quite severe and fatal, including prominent cranial hypertension, cognitive problems, cerebral hernia and respiratory failure. Forwards: the clinical and research center discoveries in huge numbers of those viral issues are to a great extent comparable and in this way increasingly explicit biomarkers for indicative and prognostic intentions are justified. These biomarkers are progressively significant in the acknowledgment and treatment of the viral central nervous system (CNS) issue. CONCLUSION Clinical manifestations have been the indicative approaches for analysis of viral encephalitis. Lots of studies have been endeavored to distinguish progressively objective laboratory-based quantitative CSF biomarkers for VE.
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Affiliation(s)
- Thekra Khushafa
- Molecular Biology Research Center and Hunan Province Key Laboratory of Basic and Applied Hematology, School of Life Sciences, Central South University, Xiangya Road No. 110, Changsha 410078, Hunan, China
| | - Liu Jing
- Molecular Biology Research Center and Hunan Province Key Laboratory of Basic and Applied Hematology, School of Life Sciences, Central South University, Xiangya Road No. 110, Changsha 410078, Hunan, China
| | - Zeng Zhaojun
- Molecular Biology Research Center and Hunan Province Key Laboratory of Basic and Applied Hematology, School of Life Sciences, Central South University, Xiangya Road No. 110, Changsha 410078, Hunan, China
| | - Sun Jiameng
- Molecular Biology Research Center and Hunan Province Key Laboratory of Basic and Applied Hematology, School of Life Sciences, Central South University, Xiangya Road No. 110, Changsha 410078, Hunan, China
| | - Zhu Haixia
- The Third Xiangya Hospital, Central South University, Tongzipo Road No. 138, Changsha 410013, Hunan, China
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Yang X, Zhang C, Zhang J, Chen G, Zhao L, Yang P, Li H, Long Y. Autoimmune glial fibrillary acidic protein astrocytopathy mimics infectious meningitis: Two case reports. Mult Scler Relat Disord 2020; 45:102350. [PMID: 32645637 DOI: 10.1016/j.msard.2020.102350] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/07/2020] [Accepted: 06/30/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Autoimmune glial fibrillary acidic protein astrocytopathy (A-GFAP-A) has been recently characterized as a novel autoimmune central nervous system (CNS) disorder with GFAP antibody as the biomarker. However, nonspecific symptoms of A-GFAP-A contribute to misdiagnosis. CASE PRESENTATION The patients presented with initial symptoms of fever, headache, and nuchal rigidity. Case 1 exhibited mild signs of irritability, active tendon reflexes, and dysuria; case 2 had transient loss of consciousness. Cerebrospinal fluid (CSF) revealed lymphocytosis, elevated protein level, and decreased glucose level. Magnetic resonance imaging (MRI) revealed radial gadolinium enhancement perpendicular to the lateral ventricle. Viral meningitis or tubercular meningitis was suspected. However, their inflammatory and pathogenic indicators showed no abnormal changes, and empirical antibiotic and antiviral drugs did not result in remarkable recovery. Subsequently, cases were detected with a strongly positive expression of GFAP antibody in CSF and the symptoms improved dramatically after high-dose methylprednisolone pulse treatment. CONCLUSION A-GFAP-A with meningitis-like symptoms could initially masquerade as intracranial infection, and prompt detection of GFAP antibody is essential for differentiation.
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Affiliation(s)
- Xiao Yang
- Neuroscience Center, General Hospital of Ningxia Medical University, Key Laboratory of Craniocerebral Diseases of Ningxia Hui Autonomous Region, Yinchuan 75004, China
| | - Chenyang Zhang
- Neuroscience Center, General Hospital of Ningxia Medical University, Key Laboratory of Craniocerebral Diseases of Ningxia Hui Autonomous Region, Yinchuan 75004, China
| | - Jun Zhang
- Department of Intensive Care Unit, General Hospital of Ningxia Medical University, Yinchuan 75004, China
| | - Guisheng Chen
- Neuroscience Center, General Hospital of Ningxia Medical University, Key Laboratory of Craniocerebral Diseases of Ningxia Hui Autonomous Region, Yinchuan 75004, China
| | - Li Zhao
- Neuroscience Center, General Hospital of Ningxia Medical University, Key Laboratory of Craniocerebral Diseases of Ningxia Hui Autonomous Region, Yinchuan 75004, China
| | - Ping Yang
- Neuroscience Center, General Hospital of Ningxia Medical University, Key Laboratory of Craniocerebral Diseases of Ningxia Hui Autonomous Region, Yinchuan 75004, China
| | - Huilu Li
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Youming Long
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China.
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Kapadia RK, Ney DE, Hannan M, Farley M, Pastula DM, Piquet AL. Glial fibrillary acidic protein (GFAP) associated autoimmune meningoencephalitis in a patient receiving nivolumab. J Neuroimmunol 2020; 344:577259. [PMID: 32416558 DOI: 10.1016/j.jneuroim.2020.577259] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 10/24/2022]
Abstract
Immune checkpoint inhibitors (ICIs) represent a major development in cancer treatment, allowing for improved survival and disease control in an expanding number of cancer types. Due to their mechanism of disrupting immunologic homeostasis, ICIs are frequently associated with adverse effects, termed immune related adverse effects (irAE). These side effects can affect any organ system, including the central and peripheral nervous systems. We present a case of a 47 year old man with stage IIIc metastatic melanoma who received 3 cycles of nivolumab (a monoclonal antibody inhibitor of programmed cell death protein 1 (PD-1)). After completing the third cycle, he presented with a meningoencephalitis clinical picture with an inflammatory cerebrospinal fluid (CSF) and normal MRI. He was found to have a positive anti-glial fibrillary acidic protein (GFAP) autoantibody in his CSF by immunofluorescent assay (IFA) and cell based assay (CBA) which confirmed a diagnosis of anti-GFAP autoimmune encephalitis. He was treated with immunotherapy and made a full recovery. In this report, we present the first reported case of anti-GFAP autoimmune encephalitis associated with ICI therapy and provide a brief review of the literature.
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Affiliation(s)
- Ronak K Kapadia
- Neuro-Infectious Diseases Group, Department of Neurology and Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, United States of America; Department of Neurology, University of Colorado, Aurora, CO, United States of America; Division of Neurology, Department of Clinical Neurosciences, University of Calgary, Cummings School of Medicine, Calgary, Alberta, Canada.
| | - Douglas E Ney
- Department of Neurology, University of Colorado, Aurora, CO, United States of America; Department of Neurosurgery, University of Colorado, Aurora, CO, United States of America
| | - Markus Hannan
- Department of Neurology, University of Colorado, Aurora, CO, United States of America
| | - Morgan Farley
- Department of Neurology, University of Colorado, Aurora, CO, United States of America
| | - Daniel M Pastula
- Neuro-Infectious Diseases Group, Department of Neurology and Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, United States of America; Department of Neurology, University of Colorado, Aurora, CO, United States of America; Department of Epidemiology, Colorado School of Public Health, Aurora, CO, United States of America
| | - Amanda L Piquet
- Neuro-Infectious Diseases Group, Department of Neurology and Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, United States of America; Department of Neurology, University of Colorado, Aurora, CO, United States of America
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Abstract
Purpose of review To describe a recently characterized autoimmune, inflammatory central nervous system (CNS) disorder known as autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy. Recent findings Affected patients present with symptoms of one or more of meningitis (headache and neck ache), encephalitis (delirium, tremor, seizures, or psychiatric symptoms), and myelitis (sensory symptoms and weakness). Optic disc papillitis (blurred vision) is common. CNS inflammation is evident in characteristic T1 postgadolinium enhancement of GFAP-enriched CNS regions, and lymphocytic cerebrospinal fluid (CSF) white cell count elevation. CSF is more reliable than serum for GFAP-immunoglobulin G (IgG) testing. Ovarian teratoma commonly coexists, particularly among patients with accompanying N-methyl-D-aspartate receptor or aquaporin-4 autoimmunity. Parainfectious autoimmunity is suspected in some other patients, though the culprit organism is rarely verified. Pathophysiologic relevance of T cells is underscored by neuropathology and cases of dysregulated T-cell function (HIV or checkpoint inhibitor cancer therapy). Corticosteroid-responsiveness is a hallmark of the disease. Relapses occur in approximately 20% of patients, necessitating transition to a steroid-sparing drug. Reported outcomes vary, though in the authors’ experience, early and sustained intervention usually portends recovery. Summary Autoimmune GFAP astrocytopathy is a treatable autoimmune CNS disease diagnosable by GFAP-IgG testing in CSF. This disease presents opportunities to explore novel mechanisms of CNS autoimmunity and inflammation.
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Song M, Zhang J, Li X, Liu Y, Wang T, Yan Z, Chen J. Effects of Xiaoyaosan on Depressive-Like Behaviors in Rats With Chronic Unpredictable Mild Stress Through HPA Axis Induced Astrocytic Activities. Front Psychiatry 2020; 11:545823. [PMID: 33192662 PMCID: PMC7606759 DOI: 10.3389/fpsyt.2020.545823] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 08/25/2020] [Indexed: 12/11/2022] Open
Abstract
ABSTRACT Astrocytes in the hippocampus are immediately relevant to depressive-like behavior. By regulating their activities, Xiaoyaosan (XYS), a traditional Chinese medicine compound, works in the treatment of depression. OBJECTIVE Chronic unpredictable mild stress (CUMS) rat model was established to observe the regulation of XYS. We investigated the behavioral changes of CUMS, the expression of corticosterone (CORT) of the hypothalamo-pituitary-adrenal (HPA) axis, the expression of Glu-NMDA receptor and astrocytes glial fibrillary acidic protein (GFAP) in the hippocampus. We also investigated whether these changes were linked to XYS. METHODS 80 adult SD rats were randomly divided into four groups, control group, CUMS group, XYS group, and fluoxetine group. The rats in the control group and the CUMS group received 0.5 ml of deionized water once a day by intragastrically administration. Rats in the two treatment groups received XYS (2.224g/kg/d) and fluoxetine (2.0mg/kg/d) once a day, respectively. Rat hippocampus GFAP and Glu-NMDA receptor were respectively detected by real-time fluorescent quantitative PCR and western blot. The CORT of HPA axis was detected by Elisa. Body weight, food intake, and behavioral tests, such as open field tests, the sucrose preference test, and exhaustive swimming test, were used to assess depressive-like behavior in rats. RESULTS In this work, significant behavioral changes and differences in expression of the CORT of HPA axis and hippocampal GFAP and Glu-NMDA receptor were presented in CUMS-exposed rats. Like fluoxetine, XYS improved CUMS-induced rat's body weight, food intake, and depressive-like behavior. The study also proved that XYS could reverse the CUMS-induced changes of the CORT of HPA axis and affect the astrocytic activities and down-regulate the NR2B subunit of NMDA receptor (NR2B) level in the hippocampus. CONCLUSION Changes in the hippocampus GFAP and Glu-NMDA receptor may be an essential mechanism of depression. Besides, XYS may be critical to the treatment of depression by intervention the HPA axis, GFAP and Glu-NMDA receptor.
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Affiliation(s)
- Ming Song
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Jianjun Zhang
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaojuan Li
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.,Formula-pattern Research Center, School of Traditional Chinese Medicine, Jinan University, Guangzhou, China
| | - Yueyun Liu
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Tingye Wang
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Zhiyi Yan
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Jiaxu Chen
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.,Formula-pattern Research Center, School of Traditional Chinese Medicine, Jinan University, Guangzhou, China
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35
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Tomczak A, Su E, Tugizova M, Carlson AM, Kipp LB, Feng H, Han MH. A case of GFAP-astroglial autoimmunity presenting with reversible parkinsonism. Mult Scler Relat Disord 2019; 39:101900. [PMID: 31881522 DOI: 10.1016/j.msard.2019.101900] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/11/2019] [Accepted: 12/18/2019] [Indexed: 10/25/2022]
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a newly recognized autoimmune central nervous system (CNS) inflammatory disorder, presenting with an array of neurological symptoms in association with autoantibodies against GFAP, a hallmark protein expressed on astrocytes. Limited knowledge is available on the disease pathogenesis and clinical outcome. Here, we report a case of autoimmune GFAP astrocytopathy presenting with encephalomyelitis and parkinsonism. Our patient was a 66-year old male who experienced progressive somnolence, apathy, anxiety, right arm tremor, urinary retention, progressive weakness, and falls over the course of three months, followed by acute delusional psychosis. His neurologic exam on hospital admission was notable for cognitive impairment, myoclonus, rigidity, right hand action tremor, bradykinesia, shuffling gait, and dysmetria. Cerebrospinal fluid examination showed elevated protein, lymphocytic pleocytosis, and one unique oligoclonal band. Magnetic resonance imaging (MRI) revealed non-specific T2/FLAIR hyperintensities in the brain and longitudinally extensive transverse myelitis in the cervical spine. FDG-PET showed a pattern of brain uptake suspicious for limbic encephalitis. Serum and CSF paraneoplastic panel showed presence of GFAP immunoglobulin G (IgG). Treatment with corticosteroids resulted in clinical and radiographic improvement. However, the patient was treated with anti-CD20 immunotherapy due to steroid-dependence. This case exemplifies the recently described neurologic syndrome of autoimmune GFAP astrocytopathy presenting with encephalomyelitis and parkinsonism, reversed by B lymphocyte depletion.
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Affiliation(s)
- Anna Tomczak
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA 94305, United States.
| | - Elaine Su
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA 94305, United States.
| | - Madina Tugizova
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA 94305, United States.
| | - Aaron M Carlson
- Department of Neurology, University of Florida, Gainesville, FL 32610, United States.
| | - Lucas B Kipp
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA 94305, United States; Multiple Sclerosis Center, Neuroimmunology Division, Stanford University, Stanford, CA 94305, United States.
| | - Haojun Feng
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA 94305, United States
| | - May H Han
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA 94305, United States; Multiple Sclerosis Center, Neuroimmunology Division, Stanford University, Stanford, CA 94305, United States.
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36
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Handoko M, Hong W, Espineli E, Saxena K, Muscal E, Risen S. Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy Following Herpes Simplex Virus Encephalitis in a Pediatric Patient. Pediatr Neurol 2019; 98:85-86. [PMID: 31248671 DOI: 10.1016/j.pediatrneurol.2019.05.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 05/14/2019] [Accepted: 05/15/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Maureen Handoko
- Department of Pediatrics, Section of Neurology and Developmental Neuroscience, Baylor College of Medicine at Texas Children's Hospital, Houston, Texas.
| | - William Hong
- Department of Pediatrics, Section of Neurology and Developmental Neuroscience, Baylor College of Medicine at Texas Children's Hospital, Houston, Texas
| | - Edward Espineli
- Department of Pediatrics, Section of Neurology and Developmental Neuroscience, Baylor College of Medicine at Texas Children's Hospital, Houston, Texas
| | - Kirti Saxena
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine at Texas Children's Hospital, Houston, Texas
| | - Eyal Muscal
- Department of Pediatrics, Section of Neurology and Developmental Neuroscience, Baylor College of Medicine at Texas Children's Hospital, Houston, Texas; Department of Pediatrics, Section of Immunology, Allergy, and Rheumatology, Baylor College of Medicine at Texas Children's Hospital, Houston, Texas
| | - Sarah Risen
- Department of Pediatrics, Section of Neurology and Developmental Neuroscience, Baylor College of Medicine at Texas Children's Hospital, Houston, Texas
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Huang Q, Yang H, Liu T, Xu H, Chen B, Liu S, Li W, Long Y, Gao C. Patients with suspected benign tumors and glial fibrillary acidic protein autoantibody: an analysis of five cases. Int J Neurosci 2019; 129:1183-1188. [PMID: 31327295 DOI: 10.1080/00207454.2019.1645140] [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: 10/26/2022]
Abstract
Aim: To investigate the clinical features of five glial fibrillary acidic protein (GFAP) antibody positive patients with suspected benign tumors and explore its underlying pathogenesis. Materials and methods: Overall, 1018 serum and cerebrospinal fluid (CSF) samples were tested by indirect immunofluorescence assay and data from five patients with suspected tumors and positive for GFAP autoantibody in the CSF were analyzed retrospectively. Results: The positive rate of GFAP antibody in the serum and CSF was 3.93% by indirect immunofluorescence assay. Tumors were diagnosed before or after neurologic onset in 5 of 40 patients (12.5%) and no deterioration of the tumors was found during the long-term follow-up. Of the five patients, one patient suffered a thyroid nodule, one patient had a small nodule in the left lung, two patients suffered meningiomas, and one patient had a suspicious eosinophilic granuloma. Conclusion: GFAP autoimmunity may be a paraneoplastic immune response with a low frequency of tumor in Chinese patients with GFAP astrocytopathy.
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Affiliation(s)
- Qingmei Huang
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China.,Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China
| | - Huacai Yang
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China.,Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China
| | - Tianni Liu
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China.,Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China
| | - Huiming Xu
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China.,Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China
| | - Baikeng Chen
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China.,Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China
| | - Si Liu
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China.,Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China
| | - Wenfeng Li
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China.,Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China
| | - Youming Long
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China.,Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China
| | - Cong Gao
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China.,Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China
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Matricardi S, Farello G, Savasta S, Verrotti A. Understanding Childhood Neuroimmune Diseases of the Central Nervous System. Front Pediatr 2019; 7:511. [PMID: 31921724 PMCID: PMC6930888 DOI: 10.3389/fped.2019.00511] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/25/2019] [Indexed: 12/18/2022] Open
Abstract
Immune-mediated diseases of the central nervous system (CNS) in childhood are a heterogeneous group of rare conditions sharing the inflammatory involvement of the CNS. This review highlights the growing knowledge of childhood neuroimmune diseases that primarily affect the CNS, outlining the clinical and diagnostic features, the pathobiological mechanisms and genetics, current treatment options, and emerging challenges. The clinical spectrum of these conditions is increasingly expanded, and the underlying mechanisms of dysregulation of the immune system could vary widely. Cell-mediated and antibody-mediated disorders, infection-triggered and paraneoplastic conditions, and genetically defined mechanisms can occur in previously healthy children and can contribute to different stages of the disease. The careful evaluation of the clinical presentation and temporal course of symptoms, the specific neuroimaging and immunological findings, and the exclusion of alternative causes are mandatory in clinical practice for the syndromic diagnosis. A common feature of these conditions is that immunotherapeutic agents could modulate the clinical course and outcomes of the disease. Furthermore, specific symptomatic treatments and comprehensive multidisciplinary care are needed in the overall management. We focus on recent advances on immune-mediated demyelinating CNS disorders, autoimmune encephalitis, interferonopathies, and possible neuroimmune disorders as Rasmussen encephalitis. Better knowledge of these conditions could allow prompt diagnosis and targeted immunotherapy, to decrease morbidity and mortality as well as to improve clinical outcomes, reducing the burden of the disease due to possible long-term neuropsychiatric sequelae. Persisting controversies remain in the rigorous characterization of each specific clinical entity because of the relative rarity in children; moreover, in a large proportion of suspected neuroimmune diseases, the immune "signature" remains unidentified; treatment guidelines are mostly based on retrospective cohort studies and expert opinions; then advances in specific molecular therapies are required. In the future, a better characterization of specific immunological biomarkers may provide a useful understanding of the underlying pathobiological mechanisms of these conditions in order to individualize more tailored therapeutic options and paradigms. Multicenter collaborative research on homogeneous groups of patients who may undergo immunological studies and therapeutic trials could improve the characterization of the underlying mechanisms, the specific phenotypes, and tailored management.
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Affiliation(s)
- Sara Matricardi
- Department of Neuropsychiatry, Children's Hospital "G. Salesi", Ospedali Riuniti Ancona, Ancona, Italy
| | - Giovanni Farello
- Pediatric Clinic, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Salvatore Savasta
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Alberto Verrotti
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
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Xie L, Liu T, Yao H, Wu L, Qiu W, Chen B, Liu S, Huang Q, Yang H, Xu H, Long Y, Gao C. Autoimmune inflammatory meningoencephalitis in a patient negative for glial fibrillary acidic protein-specific immunoglobulin G. Mult Scler Relat Disord 2018; 28:167-171. [PMID: 30605794 DOI: 10.1016/j.msard.2018.12.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 11/08/2018] [Accepted: 12/28/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND In this study, we describe clinical findings in a patient with autoimmune inflammatory meningoencephalitis who was negative for antibodies against glial fibrillary acidic protein (GFAP-IgG). METHODS Serum and cerebral spinal fluid (CSF) samples were collected from the patient as part of a study of 520 patients with neurological syndromes. Antibodies against GFAP and other proteins associated with neurological disorders were measured by rat brain- and cell-based indirect immunofluorescence assays. RESULTS A 42-year-old female was diagnosed with autoimmune inflammatory meningoencephalitis. She experienced a subacute and relapsing course with decreased vision, fever, headache, ataxia, hemiplegia, and disturbance of consciousness. Brain magnetic resonance imaging showed extensive lesions in the white matter along the ventricle, brainstem, right internal capsule, and meninges. The patient responded well to steroid treatment. Examination of CSF revealed a normal white blood cell count and protein level. Serum and CSF were negative for GFAP-specific antibodies and all other autoantibodies tested. Immunohistochemical staining of a brain biopsy collected during relapse revealed chronic inflammation and severe edema. Extensive and strong staining of CD163+ macrophages were evident throughout the lesions; however, CD3+ cells were rare and CD138+ and CD20+ cells were absent. CONCLUSION We describe a case of subacute corticosteroid-responsive nonvasculitic autoimmune inflammatory meningoencephalitis in the absence of GFAP-IgG. The pathological features were distinct from those of patients with GFAP-IgG-positive meningoencephalitis, suggesting that nonvasculitic autoimmune inflammatory meningoencephalitis is a heterogeneous neurological syndrome.
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Affiliation(s)
- Longchang Xie
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
| | - Tianni Liu
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
| | - Haiyan Yao
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
| | - Linzhan Wu
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Guangzhou Medical University, 63# Duobao Road, Guangzhou 510150, China
| | - Baikeng Chen
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
| | - Si Liu
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
| | - Qingmei Huang
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
| | - Huacai Yang
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
| | - Huiming Xu
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
| | - Youming Long
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China.
| | - Cong Gao
- Department of Neurology, the Second Affiliated Hospital of GuangZhou Medical University, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China; Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, 250# Changgang east Road, Guangzhou 510260, Guangdong Province, China
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40
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Shan F, Long Y, Qiu W. Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy: A Review of the Literature. Front Immunol 2018; 9:2802. [PMID: 30568655 PMCID: PMC6290896 DOI: 10.3389/fimmu.2018.02802] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/13/2018] [Indexed: 11/13/2022] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is an autoimmune disease of the nervous system first defined in 2016. GFAP autoantibody, especially IgG that binds to GFAPα, has been reported in the cerebrospinal fluid (CSF) and serum of patients with GFAP astrocytopathy. The positive predictive value of GFAP antibody in the CSF is higher than in the serum. Tissue-based assay (TBA) and cell-based assay (CBA) are both recommended methods for the detection of GFAP antibody. GFAP astrocytopathy is accompanied by neoplasms, but the relationship between virus infection and GFAP astrocytopathy is unclear. GFAP antibody itself does not induce pathological changes; it is only a biomarker for the process of immune inflammation. The pathology of GFAP astrocytopathy in humans is heterogeneous. GFAP astrocytopathy is commonly diagnosed in individuals over 40 years old and most patients have an acute or subacute onset. Clinical manifestations include fever, headache, encephalopathy, involuntary movement, myelitis, and abnormal vision. Lesions involve the subcortical white matter, basal ganglia, hypothalamus, brainstem, cerebellum, and spinal cord. The characteristic MRI feature is brain linear perivascular radial gadolinium enhancement in the white matter perpendicular to the ventricle. Currently, there are no uniform diagnostic criteria or consensus for GFAP astrocytopathy and coexisting neural autoantibodies detected in the same patient make the diagnosis difficult. A standard treatment regimen is yet to be developed. Most GFAP astrocytopathy patients respond well to steroid therapy although some patients are prone to relapse or even die.
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Affiliation(s)
- Fulan Shan
- Department of Neurology, Zengcheng District People's Hospital of Guangzhou, Guangzhou, China
| | - Youming Long
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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41
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Autoimmune GFAP astrocytopathy: Prospective evaluation of 90 patients in 1 year. J Neuroimmunol 2018; 321:157-163. [DOI: 10.1016/j.jneuroim.2018.04.016] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 04/26/2018] [Accepted: 04/26/2018] [Indexed: 12/17/2022]
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