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Melzer N, Weber K, Räuber S, Rosenow F. [(Auto)immunity in focal epilepsy: mechanisms of (auto‑)immune-inflammatory epileptogenic neurodegeneration]. DER NERVENARZT 2024:10.1007/s00115-024-01695-5. [PMID: 38953922 DOI: 10.1007/s00115-024-01695-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/07/2024] [Indexed: 07/04/2024]
Abstract
OBJECTIVE While the neuronal mechanisms of epileptic hyperexcitability (HE) have been studied in detail, recent findings suggest that extraneuronal, mainly immune-mediated inflammatory and vascular mechanisms play an important role in the development and progression of HE in epilepsy and the cognitive and behavioral comorbidities. MATERIAL AND METHODS Narrative review. RESULTS As in autoimmune (limbic) encephalitis (ALE/AIE) or Rasmussen's encephalitis (RE), the primary adaptive and innate immune responses and associated changes in the blood-brain barrier (BBB) and neurovascular unit (NVU) can cause acute cortical hyperexcitability (HE) and the development of hippocampal sclerosis (HS) and other structural cortical lesions with chronic HE. Cortical HE, which is associated with malformation of cortical development (MCD) and low-grade epilepsy-associated tumors (LEAT), for example, can be accompanied by secondary adaptive and innate immune responses and alterations in the BBB and NVU, potentially modulating the ictogenicity and epileptogenicity. These associations illustrate the influence of adaptive and innate immune mechanisms and associated changes in the BBB and NVU on cortical excitability and vice versa, suggesting a dynamic and complex interplay of these factors in the development and progression of epilepsy in general. DISCUSSION The described concept of a neuro-immune-vascular interaction in focal epilepsy opens up new possibilities for the pathogenetic understanding and thus also for the selective therapeutic intervention.
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Affiliation(s)
- Nico Melzer
- Klinik für Neurologie, Medizinische Fakultät und Universitätsklinikum, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
| | - Katharina Weber
- Neurologisches Institut (Edinger Institut), Universitätsklinikum Frankfurt, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
- Frankfurt Cancer Institute (FCI), Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
- Partnerstätte Frankfurt, Frankfurt am Main und Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Deutsches Konsortium für Translationale Krebsforschung (DKTK), Heidelberg, Deutschland
- Universitäres Centrum für Tumorerkrankungen Frankfurt (UCT), Universitätsklinikum Frankfurt, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
| | - Saskia Räuber
- Klinik für Neurologie, Medizinische Fakultät und Universitätsklinikum, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - Felix Rosenow
- Epilepsiezentrum Frankfurt Rhein-Main, Klinik für Neurologie, Zentrum für Neurologie und Neurochirurgie, Universitätsklinikum Frankfurt, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland.
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland.
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Wagner B, Irani S. Autoimmune and paraneoplastic seizures. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:151-172. [PMID: 38494275 DOI: 10.1016/b978-0-12-823912-4.00009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Seizures are a common feature of autoimmune encephalitis and are especially prevalent in patients with the commonest autoantibodies, against LGI1, CASPR2 and the NMDA, GABAB, and GABAA receptors. In this chapter, we discuss the classification, clinical, investigation, and treatment aspects of patients with these, and other autoantibody-mediated and -associated, illnesses. We highlight distinctive and common seizure semiologies which, often alongside other features we outline, can help the clinical diagnosis of an autoantibody-associated syndrome. Next, we classify these syndromes by either focusing on whether they represent underlying causative autoantibodies or T-cell-mediated syndromes and on the distinction between acute symptomatic seizures and a more enduring tendency to autoimmune-associated epilepsy, a practical and valuable distinction for both patients and clinicians which relates to the pathogenesis. We emphasize the more effective immunotherapy response in patients with causative autoantibodies, and discuss the emerging evidence for various first-, second-, and third-line immunotherapies. Finally, we highlight available clinical rating scales which can guide autoantibody testing and immunotherapy in patients with seizures of unknown etiology. Throughout, we relate the clinical and therapeutic observations to the immunobiology and neuroscience which drive these seizures.
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Affiliation(s)
- Barbara Wagner
- Neuroscience Department, NDCN, University of Oxford and Oxford University Hospitals, Oxford, United Kingdom; Kantonsspital Aarau Switzerland, Tellstrasse, Aarau, Switzerland
| | - Sarosh Irani
- Neuroscience Department, NDCN, University of Oxford and Oxford University Hospitals, Oxford, United Kingdom.
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Dalmau J. Changing landscape in the field of paraneoplastic neurology: Personal perspectives over a 35-year career. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:11-32. [PMID: 38494272 DOI: 10.1016/b978-0-12-823912-4.00013-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes are a group of rare disorders that have fascinated neurologists for more than a century. The discovery in the 1980s that many of these disorders occurred in association with antibodies against neuronal proteins revived the interest for these diseases. This chapter first traces the history of the paraneoplastic neurologic syndromes during the era that preceded the discovery of immune mechanisms and then reviews the immunologic period during which many of these syndromes were found to be associated with antibodies against intracellular onconeuronal proteins and pathogenic cytotoxic T-cell mechanisms. Alongside these developments, investigations on the antibody-mediated disorders of the peripheral nervous system, such as the myasthenic syndromes or neuromyotonia, provided suggestions for the study of the central nervous system (CNS) syndromes. These converging areas of research culminated with the groundbreaking discovery of a new category of CNS disorders mediated by antibodies against neuronal surface proteins or receptors. These disorders are not always paraneoplastic, and the understanding of these syndromes and mechanisms has changed the landscape of neurology and neurosciences.
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Affiliation(s)
- Josep Dalmau
- IDIBAPS-Hospital Clinic, University of Barcelona, Barcelona, Spain; Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain.
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Papadopoulos VE, Papadimas GK, Androudi S, Anagnostouli M, Evangelopoulos ME. Stiff-Leg Syndrome Associated with Autoimmune Retinopathy and Its Treatment with IVIg-A Case Report and Review of the Literature. Brain Sci 2023; 13:1361. [PMID: 37891730 PMCID: PMC10605544 DOI: 10.3390/brainsci13101361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/17/2023] [Accepted: 09/20/2023] [Indexed: 10/29/2023] Open
Abstract
Antibodies to glutamic acid decarboxylase (GAD) have been predominantly associated with stiff-person syndrome (SPS), which is often accompanied by organ-specific autoimmune diseases, such as late-onset type 1 diabetes. Autoimmune retinal pathology in SPS has recently been suggested to coexist in patients suffering from this disease; however, evidence reporting potential treatment options for the neurological and visual symptoms these patients experience remains scarce. We provide a review of the relevant literature, presenting a rare case of a middle-aged woman with autoimmune retinopathy (AIR) followed by stiff-leg syndrome who responded to intravenous immune globulin treatment (IVIg). Our report adds to previously reported data supporting the efficacy of IVIg in SPS spectrum disorders while also proposing the potential effect of IVIg in treating SPS spectrum patients with coexisting AIR.
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Affiliation(s)
- Vassilis E Papadopoulos
- First Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - George K Papadimas
- First Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Sofia Androudi
- Department of Ophthalmology, University of Thessaly, 41110 Larissa, Greece
| | - Maria Anagnostouli
- First Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Maria-Eleftheria Evangelopoulos
- First Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
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Malekpour M, Salarikia SR, Kashkooli M, Asadi-Pooya AA. The genetic link between systemic autoimmune disorders and temporal lobe epilepsy: A bioinformatics study. Epilepsia Open 2023. [PMID: 36929812 DOI: 10.1002/epi4.12727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/11/2023] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVE We aimed to explore the underlying pathomechanisms of the comorbidity between three common systemic autoimmune disorders (SADs) [i.e., insulin-dependent diabetes mellitus (IDDM), systemic lupus erythematosus (SLE), and rheumatoid arthritis (RA)] and temporal lobe epilepsy (TLE), using bioinformatics tools. We hypothesized that there are shared genetic variations among these four conditions. METHODS Different databases (DisGeNET, Harmonizome, and Enrichr) were searched to find TLE-associated genes with variants; their single nucleotide polymorphisms (SNPs) were gathered from the literature. We also did a separate literature search using PubMed with the following keywords for original articles: "TLE" or "Temporal lobe epilepsy" AND "genetic variation," "single nucleotide polymorphism," "SNP," or "genetic polymorphism." In the next step, the SNPs associated with TLE were searched in the LitVar database to find the shared gene variations with RA, SLE, and IDDM. RESULTS Ninety unique SNPs were identified to be associated with TLE. LitVar search identified two SNPs that were shared between TLE and all three SADs (i.e., IDDM, SLE, and RA). The first SNP was rs16944 on the Interleukin-1β (IL-1β) gene. The second genetic variation was ε4 variation of apolipoprotein E (APOE) gene. SIGNIFICANCE The shared genetic variations (i.e., rs16944 on the IL-1β gene and ε4 variation of the APOE gene) may explain the underlying pathomechanisms of the comorbidity between three common SADs (i.e., IDDM, SLE, and RA) and TLE. Exploring such shared genetic variations may help find targeted therapies for patients with TLE, especially those with drug-resistant seizures who also have comorbid SADs.
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Affiliation(s)
- Mahdi Malekpour
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Mohammad Kashkooli
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Neurology, Jefferson Comprehensive Epilepsy Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Gillinder L, Britton J. Autoimmune-Associated Seizures. Continuum (Minneap Minn) 2022; 28:363-398. [PMID: 35393963 DOI: 10.1212/con.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article focuses on the seizure manifestations and presentations of autoimmune-associated epilepsy and acute symptomatic seizures in autoimmune encephalitis. It discusses the specificity of the various central nervous system autoantibodies and clarifies when their presence can be considered indicative of an immune etiology. Finally, current recommendations regarding patient selection for autoimmune antibody evaluation are reviewed, and an approach to immunotherapy is provided. RECENT FINDINGS Although autoimmune seizures are caused by a heterogeneous group of autoantibodies, key features reported in the literature should alert clinicians to the possible diagnosis. In particular, seizure characteristics including frequency, timing, duration, and symptomatology can provide vital clues to help differentiate autoimmune-associated seizures from other causes of epilepsy. Diagnostic certainty also requires an understanding and integration of the spectrum of clinical and paraclinical presentations, and several scoring systems have been developed that may be useful to aid the identification of autoimmune seizures. SUMMARY Seizures due to autoimmune etiology are increasingly encountered in clinical practice. It is critical that clinicians recognize immune seizure etiologies early in their course given they are often responsive to immunotherapy but are usually resistant to antiseizure medications. Currently, however, it is unfortunately not uncommon for autoimmune-associated seizure disorders to remain undiagnosed, resulting in missed opportunities to administer effective therapies. Efforts to better understand autoimmune seizure manifestations and treatment strategies are ongoing.
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Dik A, Widman G, Schulte-Mecklenbeck A, Witt JA, Pitsch J, Golombeck KS, Wagner J, Gallus M, Strippel C, Hansen N, Mönig C, Räuber S, Wiendl H, Elger CE, Surges R, Meuth SG, Helmstaedter C, Gross CC, Becker AJ, Melzer N. Impact of T cells on neurodegeneration in anti-GAD65 limbic encephalitis. Ann Clin Transl Neurol 2021; 8:2289-2301. [PMID: 34841709 PMCID: PMC8670322 DOI: 10.1002/acn3.51486] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/01/2021] [Accepted: 11/15/2021] [Indexed: 12/13/2022] Open
Abstract
Objective Direct pathogenic effects of autoantibodies to the 65 kDa isoform of glutamic acid decarboxylase (GAD65) in autoimmune limbic encephalitis (LE) have been questioned due to its intracellular localization. We therefore hypothesized a pathogenic role for T cells. Methods We assessed magnet resonance imaging, neuropsychological and peripheral blood, and CSF flow cytometry data of 10 patients with long‐standing GAD65‐LE compared to controls in a cross‐sectional manner. These data were related to each other within the GAD65‐LE group and linked to neuropathological findings in selective hippocampectomy specimen from another two patients. In addition, full‐resolution human leukocyte antigen (HLA) genotyping of all patients was performed. Results Compared to controls, no alteration in hippocampal volume but impaired memory function and elevated fractions of activated HLADR+ CD4+ and CD8+ T cells in peripheral blood and cerebrospinal fluid were found. Intrathecal fractions of CD8+ T cells negatively correlated with hippocampal volume and memory function, whereas the opposite was true for CD4+ T cells. Consistently, antigen‐experienced CD8+ T cells expressed increased levels of the cytotoxic effector molecule perforin in peripheral blood, and perforin‐expressing CD8+ T cells were found attached mainly to small interneurons but also to large principal neurons together with wide‐spread hippocampal neurodegeneration. 6/10 LE patients harbored the HLA‐A*02:01 allele known to present the immunodominant GAD65114–123 peptide in humans. Interpretation Our data suggest a pathogenic effect of CD8+ T cells and a regulatory effect of CD4+ T cells in patients with long‐standing GAD65‐LE.
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Affiliation(s)
- Andre Dik
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Guido Widman
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | | | - Juri-Alexander Witt
- Department of Epileptology, University Hospital Bonn, Bonn, Germany.,Institute of Neuropathology, Medical Faculty, University of Bonn, Section for Translational Epilepsy Research, Bonn, Germany
| | - Julika Pitsch
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Kristin S Golombeck
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Jan Wagner
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Marco Gallus
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Christine Strippel
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Niels Hansen
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Constanze Mönig
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Saskia Räuber
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | | | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | | | - Catharina C Gross
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Albert J Becker
- Department of Epileptology, University Hospital Bonn, Bonn, Germany.,Institute of Neuropathology, Medical Faculty, University of Bonn, Section for Translational Epilepsy Research, Bonn, Germany
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
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AlMuslamani A, Taha M. Thalamic Lesions in a Toddler with Glutamic Acid Decarboxylase Autoimmune Encephalitis. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0040-1716912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractWe present a child with glutamic acid decarboxylase (GAD) autoimmune encephalitis (AE) with bilateral thalamic lesions on magnetic resonance imaging (MRI) of the brain. A healthy 21-month-old girl, after superrefractory status epilepticus (SE) and fever developed dyskinesia and ataxia, which we subsequently diagnosed as GAD AE. She showed remarkable response to treatment with methylprednisolone and intravenous immunoglobulin (IVIg). Following an initial normal MRI of her brain, a further brain imaging showed bilateral thalamic lesions. This is an unusual finding since brain imaging abnormalities, when found in GAD AE, mostly involve the mesial temporal lobe structures. Thalamic lesions in GAD AE have not been reported previously.
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Affiliation(s)
- Ahood AlMuslamani
- Department of Pediatrics, King Hamad University Hospital, Muharraq, Kingdom of Bahrain
| | - Mohamed Taha
- Department of Pediatrics, King Hamad University Hospital, Muharraq, Kingdom of Bahrain
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Lacruz Ballester L, Fernandez-Fournier M, Puertas Muñoz I, Rodriguez Fraga O, Lastras Fernandez-Escandon C, Rodriguez de Rivera Garrido FJ, Alba Suarez EM, Tallon Barranco A. Serum glutamate decarboxylase antibodies and neurological disorders: when to suspect their association? Neurol Sci 2021; 43:633-641. [PMID: 33914193 DOI: 10.1007/s10072-021-05281-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 04/21/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To explore different neurological manifestations with suspicion of being associated to serum glutamate decarboxylase antibodies (GAD-Abs) in order to better characterize anti-GAD neurological syndromes. METHODS Observational retrospective study including all patients for whom GAD65-Abs titers in serum were requested by the Neurology Department at La Paz University Hospital between 2015 and 2019. GAD-Abs were measured by ELISA. Demographic data, neurological symptoms, comorbidity with diabetes mellitus (DM) or with another autoimmune disease, and GAD-Abs titers were studied. Stiff-person syndrome, ataxia, encephalitis, and epilepsy were considered typical anti-GAD neurological syndromes and were compared to other atypical manifestations. RESULTS A total of 173 patients (51.7% men, mean age 51.62) were included. A progressive increase in requests of serum GAD-Abs has occurred over the last 5 years, especially in patients with atypical neurological manifestations. GAD-Abs were found in the serum of 22 patients (12.7%); of those, 15 (68.18%) suffered a typical anti-GAD syndrome. Presence of DM or another organ-specific autoimmune disease was predictive of GAD-AB seropositivity (p < 0.001). 6.6% of requested patients with an atypical syndrome had GAD-Abs, but serum levels were significantly lower than those found in patients with a typical syndrome (706.67 vs 1430.23 UI/mL; Mann-Whitney U, p = 0.034), and were finally diagnosed with another neurological disease. CONCLUSION Serum GAD-Abs were infrequently found in patients with clinical phenotypes other than those classically described as anti-GAD disorders, and with very low titers. In typical anti-GAD syndromes, there is a high comorbidity with DM and with other autoimmune diseases, and high serum GAD-Abs levels are usually present.
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Affiliation(s)
- Laura Lacruz Ballester
- Department of Neurology, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046, Madrid, Spain.
| | - Mireya Fernandez-Fournier
- Department of Neurology, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046, Madrid, Spain
| | - Inmaculada Puertas Muñoz
- Department of Neurology, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046, Madrid, Spain
| | - Olaia Rodriguez Fraga
- Department of Clinical Analysis, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046, Madrid, Spain
| | | | | | - Elda Maria Alba Suarez
- Department of Neurology, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046, Madrid, Spain
| | - Antonio Tallon Barranco
- Department of Neurology, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046, Madrid, Spain
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Tsiortou P, Alexopoulos H, Dalakas MC. GAD antibody-spectrum disorders: progress in clinical phenotypes, immunopathogenesis and therapeutic interventions. Ther Adv Neurol Disord 2021; 14:17562864211003486. [PMID: 33854562 PMCID: PMC8013924 DOI: 10.1177/17562864211003486] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 02/27/2021] [Indexed: 12/14/2022] Open
Abstract
Antibodies against glutamic acid decarboxylase (GAD), originally linked to stiff person syndrome (SPS), now denote the "GAD antibody-spectrum disorders" (GAD-SD) that also include autoimmune epilepsy, limbic encephalitis, cerebellar ataxia and nystagmus with overlapping symptomatology highlighting autoimmune neuronal excitability disorders. The reasons for the clinical heterogeneity among GAD-antibody associated syndromes remain still unsettled, implicating variable susceptibility of GABAergic neurons to anti-GAD or other still unidentified autoantibodies. Although anti-GAD antibody titers do not correlate with clinical severity, very high serum titers, often associated with intrathecal synthesis of anti-GAD-specific IgG, point to in-situ effects of GAD or related autoantibodies within the central nervous system. It remains, however, uncertain what drives these antibodies, why they persist and whether they are disease markers or have pathogenic potential. The review, focused on these concerns, describes the widened clinical manifestations and overlapping features of all GAD-SD; addresses the importance of GAD antibody titers and potential significance of GAD epitopes; summarizes the biologic basis of autoimmune hyperexcitability; highlights the electrophysiological basis of reciprocal inhibition in muscle stiffness; and provides practical guidelines on symptomatic therapies with gamma-aminobutyric acid-enhancing drugs or various immunotherapies.
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Affiliation(s)
- Popianna Tsiortou
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Philadelphia, PA 19107, USA; Neuroimmunology Unit, National and Kapodistrian University of Athens, Athens, Greece
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Psychiatric symptoms in anti glutamic acid decarboxylase associated limbic encephalitis in adults: a systematic review. Neurosci Biobehav Rev 2020; 119:128-137. [PMID: 33022299 DOI: 10.1016/j.neubiorev.2020.08.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 07/13/2020] [Accepted: 08/22/2020] [Indexed: 01/17/2023]
Abstract
Autoimmune Limbic Encephalitis (LE) is a relatively new category of immune-mediated diseases with a wide range of neuropsychiatric symptoms. LE associated with Glutamic Acid Decarboxylase (GAD) antibodies is difficult to diagnose due to its possible atypical presentation with neuropsychiatric and behavioral features. We performed a systematic review of literature and retrieved 21 cases of anti GAD-associated LE with neuropsychiatric signs. Median age at onset was 27 years with a female predominance (81.0 %) and median diagnostic delay of 6 months. Clinical presentation included typical LE symptoms such as anterograde amnesia (95.2 %) and temporal lobe or tonico-clonic seizures (95.2 %). Psychiatric symptoms were described in 61.9 % of patients, presenting as anxiety, depressive symptoms, apathy and behavioral changes. Extra-limbic symptoms were present in 14.3 % of patients. No neoplasia associated was found. Some patients had poor epileptic, cognitive and psychiatric outcomes requiring prolonged immunosuppressive treatment. The description of the neuropsychiatric spectrum of anti-GAD LE and its specificities aims to improve our understanding of this entity, and may lead to earlier diagnosis as well as better outcome.
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Graus F, Saiz A, Dalmau J. GAD antibodies in neurological disorders — insights and challenges. Nat Rev Neurol 2020; 16:353-365. [DOI: 10.1038/s41582-020-0359-x] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2020] [Indexed: 01/07/2023]
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13
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Immune-mediated epilepsy with GAD65 antibodies. J Neuroimmunol 2020; 341:577189. [PMID: 32087461 DOI: 10.1016/j.jneuroim.2020.577189] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 02/11/2020] [Accepted: 02/11/2020] [Indexed: 12/18/2022]
Abstract
Anti-GAD65 antibodies have been identified in both acute/subacute seizures (limbic encephalitis and extralimbic encephalitis) and chronic isolated epilepsy. The evidence of high serum titers and intrathecal synthesis play a fundamental role in diagnosis but poorly correlate with disease severity or response to therapies. It remains controversial whether anti-GAD65 Abs are the pathogenic entity or only serve as a surrogate marker for autoimmune disorders mediated by cytotoxic T cells. Unlike other immune-mediated epilepsy, although multiple combinations of therapeutics are used, the efficacy and prognosis of patients with GAD65-epilepsy patients are poor. Besides, GAD65-epilepsy is more prone to relapse and potentially evolve into a more widespread CNS inflammatory disorder. This article reviews the recent advances of GAD65-epilepsy, focusing on the diagnosis, epidemiology, pathophysiology, clinical features, and treatment, to better promote the recognition and provide proper therapy for this condition.
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Frerker B, Rohde M, Müller S, Bien CG, Köhling R, Kirschstein T. Distinct Effects of Stereotactically Injected Human Cerebrospinal Fluid Containing Glutamic Acid Decarboxylase Antibodies into the Hippocampus of Rats on the Development of Spontaneous Epileptic Activity. Brain Sci 2020; 10:brainsci10020123. [PMID: 32098388 PMCID: PMC7071523 DOI: 10.3390/brainsci10020123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 02/17/2020] [Accepted: 02/20/2020] [Indexed: 12/16/2022] Open
Abstract
Background: The conversion of glutamic acid into γ-aminobutyric acid (GABA) is catalyzed by the glutamic acid decarboxylase (GAD). Antibodies against this enzyme have been described in neurological disorders, but the pathophysiological role of these antibodies is still poorly understood. We hypothesized that anti-GAD autoantibodies could diminish the GABA content in the slice and facilitate epileptic activity. Methods: Cerebrospinal fluids (CSF) from two patients containing anti-GAD (A and B) were injected into the rat hippocampus in vivo. Hippocampal slices were prepared for electrophysiological field potential recordings in order to record recurrent epileptic discharges (REDs) in the CA1 region induced by the removal of Mg2+ and/or by adding gabazine. As control groups, we injected an anti-GAD-negative human CSF or saline solution, and we used non-operated naive animals. Results: RED frequencies were significantly higher in the Mg2+-free solution than in the gabazine-containing solution. The average frequency of REDs in the last 10 min and the average duration of REDs in the last 5 min did not show significant differences between the anti-GAD-B-treated and the control slices, but in the Mg2+-free solution, anti-GAD-A had significantly higher epileptic activity than anti-GAD-B. Conclusions: These results indicate that anti-GAD has distinct effects on the development of spontaneous epileptic activity.
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Affiliation(s)
- Bernd Frerker
- Oscar Langendorff Institute of Physiology, University of Rostock, 18057 Rostock, Germany
- Department of Irradiation Therapy, University Hospital of Rostock, 18059 Rostock, Germany
- Correspondence: ; Tel.: +49(0)-381-494-9001; Fax: +49(0)-381-494-9002
| | - Marco Rohde
- Oscar Langendorff Institute of Physiology, University of Rostock, 18057 Rostock, Germany
| | - Steffen Müller
- Oscar Langendorff Institute of Physiology, University of Rostock, 18057 Rostock, Germany
| | | | - Rüdiger Köhling
- Oscar Langendorff Institute of Physiology, University of Rostock, 18057 Rostock, Germany
- Center of Transdisciplinary Neurosciences Rostock, University of Rostock, 18147 Rostock, Germany
| | - Timo Kirschstein
- Oscar Langendorff Institute of Physiology, University of Rostock, 18057 Rostock, Germany
- Center of Transdisciplinary Neurosciences Rostock, University of Rostock, 18147 Rostock, Germany
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15
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Baizabal-Carvallo JF. The neurological syndromes associated with glutamic acid decarboxylase antibodies. J Autoimmun 2019; 101:35-47. [DOI: 10.1016/j.jaut.2019.04.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/07/2019] [Accepted: 04/08/2019] [Indexed: 12/12/2022]
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16
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Abstract
Autoimmune encephalitis is a severe inflammatory disorder of the brain with diverse causes and a complex differential diagnosis. Recent advances in the past decade have led to the identification of new syndromes and biological markers of limbic encephalitis, the commonest presentation of autoimmune encephalitis. The successful use of serum and intrathecal antibodies to diagnose affected patients has resulted in few biopsy and postmortem examinations. In those available, there can be variable infiltrating inflammatory T cells with cytotoxic granules in close apposition to neurons, consistent with an inflammatory autoimmune basis, but true vasculitis is rarely seen. The exception is Hashimoto encephalopathy.
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Affiliation(s)
- David S Younger
- Department of Neurology, Division of Neuro-Epidemiology, New York University School of Medicine, New York, NY 10016, USA; School of Public Health, City University of New York, New York, NY, USA.
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17
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Geis C, Planagumà J, Carreño M, Graus F, Dalmau J. Autoimmune seizures and epilepsy. J Clin Invest 2019; 129:926-940. [PMID: 30714986 DOI: 10.1172/jci125178] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The rapid expansion in the number of encephalitis disorders associated with autoantibodies against neuronal proteins has led to an incremental increase in use of the term "autoimmune epilepsy," yet has occurred with limited attention to the physiopathology of each disease and genuine propensity to develop epilepsy. Indeed, most autoimmune encephalitides present with seizures, but the probability of evolving to epilepsy is relatively small. The risk of epilepsy is higher for disorders in which the antigens are intracellular (often T cell-mediated) compared with disorders in which the antigens are on the cell surface (antibody-mediated). Most autoantibodies against neuronal surface antigens show robust effects on the target proteins, resulting in hyperexcitability and impairment of synaptic function and plasticity. Here, we trace the evolution of the concept of autoimmune epilepsy and examine common inflammatory pathways that might lead to epilepsy. Then, we focus on several antibody-mediated encephalitis disorders that associate with seizures and review the synaptic alterations caused by patients' antibodies, with emphasis on those that have been modeled in animals (e.g., antibodies against NMDA, AMPA receptors, LGI1 protein) or in cultured neurons (e.g., antibodies against the GABAb receptor).
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Affiliation(s)
- Christian Geis
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Jesus Planagumà
- Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and
| | - Mar Carreño
- Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Francesc Graus
- Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and.,Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Josep Dalmau
- Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and.,Hospital Clinic, University of Barcelona, Barcelona, Spain.,Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain.,Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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18
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Falip M, Rodriguez-Bel L, Castañer S, Sala-Padró J, Miro J, Jaraba S, Casasnovas C, Morandeira F, Berdejo J, Carreño M. Hippocampus and Insula Are Targets in Epileptic Patients With Glutamic Acid Decarboxylase Antibodies. Front Neurol 2019; 9:1143. [PMID: 30687213 PMCID: PMC6334555 DOI: 10.3389/fneur.2018.01143] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/11/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Antibodies to glutamic acid decarboxylase (GAD ab) have been found in patients with limbic encephalitis (LE) and chronic pharmacoresistant focal epilepsy (FE). The objectives of the study were to: (1) analyze the clinical and neuroimaging course of patients with FE+GAD ab, (2) compare these characteristics with a control group, and (3) describe the most affected cerebral areas with structural and functional imaging. Methods: Patients with FE + high titers of GAD ab and a follow-up of at least 5 years were selected. Titers of serum GAD ab exceeding 2,000 UI/ml were considered high. Evolutive clinical and radiological characteristics were studied in comparison to two different control groups: patients with bilateral or with unilateral mesial temporal sclerosis (BMTS or UMTS) of a non-autoimmune origin. Results: A group of 13 patients and 17 controls were included (8 BMTS, 9 UMTS). The most frequent focal aware seizures (FAS) reported by patients were psychic (5/13: 33%). Somatosensorial, motor, and visual FAS (4/13:32%) (p: 0.045), musicogenic reflex seizures (MRS), and a previous history of cardiac syncope were reported only patients (2/13:16% each) (p: NS). Comparing EEG characteristics between patients and controls, a more widespread distribution of interictal epileptiform discharges (IED) was observed in FE+ GAD ab patients than in controls (p:0.01). Rhythmic delta activity was observed in all controls in anterior temporal lobes while in patients this was less frequent (p: 0.001). No IED, even in 24 h cVEEG, was seen in 6 patients (46%).First MRI was normal in 4/5 (75%) patients. During the follow-up mesial temporal lobe (MTsL) sclerosis was observed in 5/8 (62%) of patients. All patients had abnormal FDG-PET study. MTL hypometabolism was observed in 10/11 (91%) patients, being bilateral in 7/11 (63%). In controls, this was observed in 16/17 (94%), and it was bilateral in 8/17 (47%) (p: NS). Insular hypometabolism was observed in 5/11 (45%) patients (P:0.002). Conclusions: Clinical, EEG, and FDG-PET findings in FE+GAD ab suggest a widespread disease not restricted to the temporal lobe. Progressive MTL sclerosis may be observed during follow-up. In comparison to what is found in patients with non-autoimmune MTL epilepsy, insular hypometabolism is observed only in patients with GAD ab, so it may be an important diagnostic clue.
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Affiliation(s)
- Mercè Falip
- Epilepsy Unit, Department of Neurology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Laura Rodriguez-Bel
- PET Division, Institute of Diagnostic Imaging (IDI), Hospital de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Sara Castañer
- MRI Division, Institute of Diagnostic Imaging (IDI), Hospital de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Jacint Sala-Padró
- Epilepsy Unit, Department of Neurology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Júlia Miro
- Epilepsy Unit, Department of Neurology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Sónia Jaraba
- Epilepsy Unit, Department of Neurology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Carlos Casasnovas
- Neuromuscular Unit, Department of Neurology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Francisco Morandeira
- Immunology Unit, Biochemistry Department, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Javier Berdejo
- Department of Cardiology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Mar Carreño
- Epilepsy Unit, Department of Neurology, Hospital Clinic i Provincial, Barcelona, Spain
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19
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Rakocevic G, Alexopoulos H, Dalakas MC. Quantitative clinical and autoimmune assessments in stiff person syndrome: evidence for a progressive disorder. BMC Neurol 2019; 19:1. [PMID: 30606131 PMCID: PMC6317182 DOI: 10.1186/s12883-018-1232-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 12/19/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Stiff Person Syndrome (SPS) is an under-diagnosed disorder that affects mobility and the quality of life of affected patients. The aim of the study is to describe the natural history of SPS, the extent of accumulated disability and the associated clinical and immunological features in patients followed for up to 8 years in a single center. METHODS Our collective cohort included 57 SPS patients. Additionally, 32 of these patients were examined every 6 months for a two-year period in a longitudinal study protocol, to assess disease progression using quantitative measures of stiffness and heightened sensitivity. RESULTS The most frequent initial symptom was leg stiffness, followed by paraspinal muscle rigidity and painful spasms in 95% of the patients. Although none of the patients required assistance for ambulation during the first 2 years of disease onset, 46 patients (80%) lost the ability to walk independently during our follow-up, despite symptomatic medications. In the longitudinal cohort, the number of stiff areas increased (p < 0.0001), consistent with worsening functional status and quality of life. High-titer anti-GAD antibodies were present in serum and CSF with elevated intrathecal GAD-specific IgG synthesis, but they did not correlate with clinical severity or progression. CONCLUSIONS This large study on SPS patients, combining an eight-year follow-up at a single center by the same leading neurologist and his team, is the first to provide longitudinal data in a large patient subgroup using objective clinical measures. One of the main findings is that SPS is a progressive disease leading to physical disability over time.
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Affiliation(s)
- Goran Rakocevic
- Department of Neurology, Thomas Jefferson University, Philadelphia, USA
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C. Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, USA
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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20
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Inhibition of glutamate decarboxylase (GAD) by ethyl ketopentenoate (EKP) induces treatment-resistant epileptic seizures in zebrafish. Sci Rep 2017; 7:7195. [PMID: 28775328 PMCID: PMC5543107 DOI: 10.1038/s41598-017-06294-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 06/09/2017] [Indexed: 11/09/2022] Open
Abstract
Epilepsy is a chronic brain disorder characterized by recurrent seizures due to abnormal, excessive and synchronous neuronal activities in the brain. It affects approximately 65 million people worldwide, one third of which are still estimated to suffer from refractory seizures. Glutamic acid decarboxylase (GAD) that converts glutamate into GABA is a key enzyme in the dynamic regulation of neural network excitability. Importantly, clinical evidence shows that lowered GAD activity is associated with several forms of epilepsy which are often treatment resistant. In the present study, we synthetized and explored the possibility of using ethyl ketopentenoate (EKP), a lipid-permeable GAD-inhibitor, to induce refractory seizures in zebrafish larvae. Our results demonstrate that EKP evoked robust convulsive locomotor activities, excessive epileptiform discharges and upregulated c-fos expression in zebrafish. Moreover, transgenic animals in which neuronal cells express apoaequorin, a Ca2+-sensitive bioluminescent photoprotein, displayed large luminescence signals indicating strong EKP-induced neuronal activation. Molecular docking data indicated that this proconvulsant activity resulted from the direct inhibition of both gad67 and gad65. Limited protective efficacy of tested anti-seizure drugs (ASDs) demonstrated a high level of treatment resistance of EKP-induced seizures. We conclude that the EKP zebrafish model can serve as a high-throughput platform for novel ASDs discovery.
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21
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Irani SR, Vincent A. Voltage-gated potassium channel-complex autoimmunity and associated clinical syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2017; 133:185-97. [PMID: 27112678 DOI: 10.1016/b978-0-444-63432-0.00011-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Voltage-gated potassium channel (VGKC)-complex antibodies are defined by the radioimmunoprecipitation of Kv1 potassium channel subunits from brain tissue extracts and were initially discovered in patients with peripheral nerve hyperexcitability (PNH). Subsequently, they were found in patients with PNH plus psychosis, insomnia, and dysautonomia, collectively termed Morvan's syndrome (MoS), and in a limbic encephalopathy (LE) with prominent amnesia and frequent seizures. Most recently, they have been described in patients with pure epilepsies, especially in patients with the novel and distinctive semiology termed faciobrachial dystonic seizures (FBDS). In each of these conditions, there is a close correlation between clinical measures and antibody levels. The VGKC-complex is a group of proteins that are strongly associated in situ and after extraction in mild detergent. Two major targets of the autoantibodies are leucine-rich glioma-inactivated 1 (LGI1) and contactin-associated protein 2 (CASPR2). The patients with PNH or MoS are most likely to have CASPR2 antibodies, whereas LGI1 antibodies are found characteristically in patients with FBDS and LE. Crucially, each of these conditions has a good response to immunotherapies, often corticosteroids and plasma exchange, although optimal regimes require further study. VGKC-complex antibodies have also been described in neuropathic pain syndromes, chronic epilepsies, a polyradiculopathy in porcine abattoir workers, and some children with status epilepticus. Increasingly, however, the antigenic targets in these patients are not defined and in some cases the antibodies may be secondary rather than the primary cause. Future serologic studies should define all the antigenic components of the VGKC-complex, and further inform mechanisms of antibody pathogenicity and related inflammation.
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Affiliation(s)
- Sarosh R Irani
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK.
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
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22
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Flores-Cantu H, Camara-Lemarroy CR, Calderon-Hernandez HJ, Zapata-Rivera MA, Villareal-Perez JZ, Villareal-Velazquez HJ. Anti-GAD Antibody, Seizures, Cerebellar Ataxias and Vitiligo: A Diagnostic Challenge. THE CEREBELLUM 2016; 14:375-7. [PMID: 25575726 DOI: 10.1007/s12311-014-0625-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Hazael Flores-Cantu
- Servicio de Neurologia, Hospital Universitario "Dr. José E. González". Universidad Autónoma de Nuevo León, Madero y Gonzalitos S/N, 64460, Monterrey, NL, Mexico
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23
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Limbic Encephalitis Associated With GAD65 Antibodies: Brief Review of the Relevant literature. Can J Neurol Sci 2016; 43:486-93. [DOI: 10.1017/cjn.2016.13] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
AbstractRecently, many cases of autoimmune limbic encephalitis with positive GAD65 (glutamic acid decarboxylase) antibodies have been described in the scientific literature. However, it remains an understudied topic of great relevance to practicing neurologists. Thus, we report here a review of published cases, in English, of autoimmune limbic encephalitis with this type of antibodies, focusing on presenting symptoms and signs, associated conditions, and findings upon investigation. We also report treatment responses. We aim to offer a better description of the clinical spectrum of autoimmune limbic encephalitis associated with GAD65 antibodies as well as to expose its paraclinical features and outcome.
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Folli F, Daniele G, Werner S, Kamath S, Munera JV, Abboud H, Fanti P. Membranous nephropathy and cerebellar degeneration with anti-GAD antibodies in type 2 diabetes mellitus. Acta Diabetol 2015; 52:897-903. [PMID: 25753172 DOI: 10.1007/s00592-015-0728-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 02/13/2015] [Indexed: 10/23/2022]
Abstract
AIMS To study the potential pathogenic significance of the coexistence of membranous nephropathy, cerebellar degeneration and anti-glutamic acid decarboxylase (GAD) autoantibodies in patients with diabetes. METHODS We performed a direct immunocytochemistry on human kidney slides, electron microscopy on human kidney biopsy, direct immunofluorescence on human kidney biopsy. Baboon and rat kidney cell lines were fractionated and subjected to western blotting with antibodies to GAD. RESULTS In this patient we demonstrate the presence of autoantibodies to GAD, which is highly enriched in podocytes plasma membrane and tubular cells of the kidney as well as sub-endothelial IgG and complement C3 deposits in the glomerular basement membrane (GBM). CONCLUSIONS We hypothesize the existence in this patient of a common autoimmune pathogenic mechanism with GAD as the autoantigenic determinant, underlying cerebellar degeneration and membranous nephropathy.
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Affiliation(s)
- Franco Folli
- Division of Diabetes, Department of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.
- Departamento de Clinica Medica, Faculdade de Ciencias Medicas (FCM), Obesity and Comorbidities Research Center (O.C.R.C.), Universidade Estadual de Campinas (UNICAMP), Campinas, S.P., Brazil.
| | - Giuseppe Daniele
- Division of Diabetes, Department of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Sherry Werner
- Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Subash Kamath
- Division of Diabetes, Department of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Jose Velez Munera
- Division of Nephrology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Hanna Abboud
- Division of Nephrology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Paolo Fanti
- Division of Nephrology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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25
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Abstract
Over the last years, there has been an increasing interest in the potential association between type 1 diabetes (T1D) and epilepsy. Both T1D and epilepsy are common conditions in children and adolescents, and therefore, their association might represent simply a coincidence or be related to common underlying mechanisms with a potential causal relationship. Few epidemiological studies have been performed in the pediatric population, and they have reached discordant conclusions, with some studies reporting an increased prevalence of epilepsy in children and adolescents with T1D, whereas others have not confirmed this finding. Several mechanisms could explain the occurrence of epilepsy in young people with T1D, such as metabolic abnormalities (hypo/hyperglycemia) and autoantibodies, along with a genetic predisposition and the presence of brain lesions/damage. Further studies are required to better define whether there is a causal relationship between the two conditions and to understand the underlying mechanisms.
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26
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Farooqi MS, Lai Y, Lancaster E, Schmitt SE, Sachais BS. Therapeutic plasma exchange and immunosuppressive therapy in a patient with anti-GAD antibody-related epilepsy: quantification of the antibody response. J Clin Apher 2014; 30:8-14. [PMID: 24961613 DOI: 10.1002/jca.21342] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 05/26/2014] [Accepted: 06/05/2014] [Indexed: 11/09/2022]
Abstract
Antibodies to glutamic acid decarboxylase (GAD) have been associated with a host of neurological disorders including stiff person syndrome, cerebellar ataxia, limbic encephalitis, and epilepsy. Whether anti-GAD antibodies have an etiological role in these neurological disorders or simply serve as disease markers is unclear. Here, we report a case of a patient with recurrent seizures, poorly responsive to conventional treatment, associated with anti-GAD antibodies. The patient was experiencing near daily seizures at the time of presentation and had marked improvement while receiving immunosuppressive therapy and therapeutic plasma exchange (TPE). We go on to show that the patient had a substantial reduction of her GAD autoantibody burden following this therapy. Using immunostaining, we further demonstrate a progressive loss of GAD reactivity in the patient's sera to neurons and GAD-expressing HELA cells with successive TPEs. Hence, these data support the concept of an immune-mediated pathogenic component to these autoantibody-associated neurological syndromes.
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Affiliation(s)
- Midhat S Farooqi
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, 19104
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27
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Lilleker JB, Biswas V, Mohanraj R. Glutamic acid decarboxylase (GAD) antibodies in epilepsy: diagnostic yield and therapeutic implications. Seizure 2014; 23:598-602. [PMID: 24836709 DOI: 10.1016/j.seizure.2014.04.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 04/05/2014] [Accepted: 04/19/2014] [Indexed: 11/19/2022] Open
Abstract
PURPOSE The aetiology of adult onset epilepsy remains unascertained in a significant proportion of patients. Antibodies directed against neuronal antigens have been suggested to have a potential pathogenic role in some cases of epilepsy. We describe a series of patients with adult onset epilepsy in whom antibodies to glutamic acid decarboxylase (GAD Abs) have been identified. METHODS All patients attending a regional epilepsy service with unexplained adult onset epilepsy' were tested for the presence of GAD Abs. Those with high serum titres underwent CSF analysis, and were offered additional treatment with immunotherapy. Those who underwent immunotherapy were monitored by monthly review. Clinical details and response to treatment was collated by review of notes. RESULTS Of 112 patients tested, high serum titres were found in 6 (5.4%) patients. These patients had clinical and electroencephalographic evidence of focal epilepsy. CSF analysis revealed oligoclonal bands and intrathecal GAD Abs in all patients. Five patients received immunotherapy. No improvement in seizures was observed in any. One patient with equivocal MRI evidence of hippocampal sclerosis and concordant video EEG and PET scan, achieved 12 months seizure freedom following temporal lobectomy. CONCLUSIONS The relevance of GAD Abs to epilepsy remains uncertain. Our experience does not support the routine use of immunotherapy in patients with epilepsy and GAD Abs. Larger studies enrolling greater numbers of patients are required to identify sufficient numbers of patients for controlled treatment trials.
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Affiliation(s)
| | | | - Rajiv Mohanraj
- Greater Manchester Neurosciences Centre, United Kingdom; University of Manchester, United Kingdom.
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28
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Curia G, Lucchi C, Vinet J, Gualtieri F, Marinelli C, Torsello A, Costantino L, Biagini G. Pathophysiogenesis of mesial temporal lobe epilepsy: is prevention of damage antiepileptogenic? Curr Med Chem 2014; 21:663-88. [PMID: 24251566 PMCID: PMC4101766 DOI: 10.2174/0929867320666131119152201] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 07/04/2013] [Accepted: 08/29/2013] [Indexed: 12/26/2022]
Abstract
Temporal lobe epilepsy (TLE) is frequently associated with hippocampal sclerosis, possibly caused by a primary brain injury that occurred a long time before the appearance of neurological symptoms. This type of epilepsy is characterized by refractoriness to drug treatment, so to require surgical resection of mesial temporal regions involved in seizure onset. Even this last therapeutic approach may fail in giving relief to patients. Although prevention of hippocampal damage and epileptogenesis after a primary event could be a key innovative approach to TLE, the lack of clear data on the pathophysiological mechanisms leading to TLE does not allow any rational therapy. Here we address the current knowledge on mechanisms supposed to be involved in epileptogenesis, as well as on the possible innovative treatments that may lead to a preventive approach. Besides loss of principal neurons and of specific interneurons, network rearrangement caused by axonal sprouting and neurogenesis are well known phenomena that are integrated by changes in receptor and channel functioning and modifications in other cellular components. In particular, a growing body of evidence from the study of animal models suggests that disruption of vascular and astrocytic components of the blood-brain barrier takes place in injured brain regions such as the hippocampus and piriform cortex. These events may be counteracted by drugs able to prevent damage to the vascular component, as in the case of the growth hormone secretagogue ghrelin and its analogues. A thoroughly investigation on these new pharmacological tools may lead to design effective preventive therapies.
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Affiliation(s)
| | | | | | | | | | | | | | - G Biagini
- Dipartimento di Scienze Biomediche, Metaboliche e Neuroscienze, Laboratorio di Epilettologia Sperimentale, Universita di Modena e Reggio Emilia, Via Campi, 287, 41125 Modena, Italy.
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29
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Kowski AB, Volz MS, Holtkamp M, Prüss H. High frequency of intrathecal immunoglobulin synthesis in epilepsy so far classified cryptogenic. Eur J Neurol 2013; 21:395-401. [DOI: 10.1111/ene.12261] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Accepted: 08/15/2013] [Indexed: 11/28/2022]
Affiliation(s)
- A. B. Kowski
- Department of Neurology and Experimental Neurology; Charité University Medicine Berlin; Berlin Germany
| | - M. S. Volz
- Department of Neurology and Experimental Neurology; Charité University Medicine Berlin; Berlin Germany
| | - M. Holtkamp
- Department of Neurology and Experimental Neurology; Charité University Medicine Berlin; Berlin Germany
- Epilepsy-Center Berlin-Brandenburg; Berlin Germany
| | - H. Prüss
- Department of Neurology and Experimental Neurology; Charité University Medicine Berlin; Berlin Germany
- German Center for Neurodegenerative Diseases (DZNE); Berlin Germany
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30
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Newly-diagnosed pediatric epilepsy is associated with elevated autoantibodies to glutamic acid decarboxylase but not cardiolipin. Epilepsy Res 2013; 105:86-91. [DOI: 10.1016/j.eplepsyres.2013.02.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 02/04/2013] [Accepted: 02/12/2013] [Indexed: 11/19/2022]
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Xu X, Bergman P, Willows T, Tammik C, Sund M, Hökfelt T, Söderberg-Naucler C, Varani S. CMV-associated encephalitis and antineuronal autoantibodies--a case report. BMC Neurol 2012; 12:87. [PMID: 22947340 PMCID: PMC3502587 DOI: 10.1186/1471-2377-12-87] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Accepted: 08/28/2012] [Indexed: 01/06/2023] Open
Abstract
Background Human cytomegalovirus (CMV) is an ubiquitous pathogen capable of modulating the host immune system. Immune dysfunction is common during CMV infection and includes autoimmune phenomena. Here we focus on a case of primary CMV infection associated with encephalopathy in a patient with a rudimentary spleen. We discuss diagnostic challenges and immunological aspects as well as the hypothesis that CMV may break tolerance and induce potentially encephalitogenic autoantibodies. Case presentation A 33-year-old woman was admitted with features of encephalitis, rapidly progressing into a catatonic state. The patient tested negative for presence of herpes simplex virus DNA in cerebrospinal fluid (CSF), and had elevated liver enzymes and hepatomegaly at computed tomography scan (CT) examination. CT scan and magnetic resonance imaging (MRI) showed only a rudimentary spleen. Initially, serum was negative for anti-CMV IgM, but borderline for anti-CMV IgG by enzyme-linked immunosorbent assay. However, a more sensitive assay resulted in a positive specific IgM Western blot profile and low IgG avidity, suggesting primary CMV infection. Further, CMV DNA was retrospectively detected in a CSF sample collected at admission. We also detected antineuronal autoantibodies, which stained GAD-positive neurons in the hippocampus. The patient was treated by a combination of prednisone, intravenous immunoglobulins (IVIg) and antivirals, which resulted in a dramatic amelioration of the patient’s neurological status. One year after admission the patient exhibited a nearly complete recovery with mild deficits in attention and memory. Conclusions A possible reason for the critical course of CMV infection could be the lack of a functional spleen in this patient, a condition previously associated with severe CMV infection. Prompt treatment with antiviral drugs, steroids and IVIg was most likely important for the positive outcome in this case and should be considered for similar cases of severe primary CMV infection associated with immunopathological phenomena.
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Affiliation(s)
- Xinling Xu
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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Rakocevic G, Floeter MK. Autoimmune stiff person syndrome and related myelopathies: understanding of electrophysiological and immunological processes. Muscle Nerve 2012; 45:623-34. [PMID: 22499087 DOI: 10.1002/mus.23234] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Stiff person syndrome (SPS) is a disabling autoimmune central nervous system disorder characterized by progressive muscle rigidity and gait impairment with superimposed painful spasms that involve axial and limb musculature, triggered by heightened sensitivity to external stimuli. Impaired synaptic GABAergic inhibition resulting from intrathecal B-cell-mediated clonal synthesis of autoantibodies against various presynaptic and synaptic proteins in the inhibitory neurons of the brain and spinal cord is believed to be an underlying pathogenic mechanism. SPS is most often idiopathic, but it can occur as a paraneoplastic condition. Despite evidence that anti-GAD and related autoantibodies impair GABA synthesis, the exact pathogenic mechanism of SPS is not fully elucidated. The strong association with several MHC-II alleles and improvement of symptoms with immune-modulating therapies support an autoimmune etiology of SPS. In this review, we discuss the clinical spectrum, neurophysiological mechanisms, and therapeutic options, including a rationale for agents that modulate B-cell function in SPS.
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Affiliation(s)
- Goran Rakocevic
- Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, Pennsylvania 19107, USA.
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Zuliani L, Graus F, Giometto B, Bien C, Vincent A. Central nervous system neuronal surface antibody associated syndromes: review and guidelines for recognition. J Neurol Neurosurg Psychiatry 2012; 83:638-45. [PMID: 22448032 PMCID: PMC3348613 DOI: 10.1136/jnnp-2011-301237] [Citation(s) in RCA: 204] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The concept of antibody mediated CNS disorders is relatively recent. The classical CNS paraneoplastic neurological syndromes are thought to be T cell mediated, and the onconeural antibodies merely biomarkers for the presence of the tumour. Thus it was thought that antibodies rarely, if ever, cause CNS disease. Over the past 10 years, identification of autoimmune forms of encephalitis with antibodies against neuronal surface antigens, particularly the voltage gated potassium channel complex proteins or the glutamate N-methyl-D-aspartate receptor, have shown that CNS disorders, often without associated tumours, can be antibody mediated and benefit from immunomodulatory therapies. The clinical spectrum of these diseases is not yet fully explored, there may be others yet to be discovered and some types of more common disorders (eg, epilepsy or psychosis) may prove to have an autoimmune basis. Here, the known conditions associated with neuronal surface antibodies are briefly reviewed, some general aspects of these syndromes are considered and guidelines that could help in the recognition of further disorders are suggested.
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Affiliation(s)
- Luigi Zuliani
- Department of Neurology,Ospedale Ca'Foncello, Treviso,Italy
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Lopez-Sublet M, Bihan H, Reach G, Dupont S, Didelot A, Mourad JJ, Krivitzky A, Dhote R. Limbic encephalitis and type 1 diabetes with glutamic acid decarboxylase 65 (GAD65) autoimmunity: Improvement with high-dose intravenous immunoglobulin therapy. DIABETES & METABOLISM 2012; 38:273-5. [DOI: 10.1016/j.diabet.2012.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 02/28/2012] [Accepted: 02/28/2012] [Indexed: 10/28/2022]
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Falip M, Carreño M, Miró J, Saiz A, Villanueva V, Quílez A, Molins A, Barceló I, Sierra A, Graus F. Prevalence and immunological spectrum of temporal lobe epilepsy with glutamic acid decarboxylase antibodies. Eur J Neurol 2012; 19:827-33. [DOI: 10.1111/j.1468-1331.2011.03609.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Caietta E, Halbert C, Lépine A, Khammar A, Cano A, Gavaret M, Mancini J, Villeneuve N, Chabrol B, Simonin G, Reynaud R, Milh M. [Association of type 1 diabetes mellitus and epilepsy in children. A cohort of 10 cases]. Arch Pediatr 2011; 19:9-16. [PMID: 22112607 DOI: 10.1016/j.arcped.2011.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 08/21/2011] [Accepted: 10/10/2011] [Indexed: 10/15/2022]
Abstract
UNLABELLED The association of type 1 diabetes mellitus (DM) and epilepsy has been previously reported. However, the physiopathology of this association remains misunderstood. OBJECTIVE To describe epilepsy combined with type 1 DM in children. METHODS Retrospective monocentric study of all the epileptic and type 1 diabetic children consulting at the Timone University Hospital, Marseille, France. For each patient, the type of epilepsy and its electroclinical and radiographic characteristics were studied as well as the type of diabetes (biological characteristics, glycemic control), and the onset of these 2 diseases. RESULTS Ten patients are reported. Five suffered from generalized epilepsy (4 idiopathic, 1 nonidiopathic) and 5 from focal epilepsy (4 non-idiopathic, 1 idiopathic). For most of these cases, presence of GAD (glutamic acid decarboxylase) autoantibodies were confirmed and epilepsy followed diabetes. CONCLUSIONS The 2 most common types of epilepsy in this association are idiopathic generalized epilepsy and non-idiopathic temporal epilepsy. Several mechanisms could be involved (immune, glycemia, and genetic disorders).
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Affiliation(s)
- E Caietta
- Service de neurologie pédiatrique, Assistance publique-Hôpitaux de Marseille, CHU La Timone, 264, rue Saint-Pierre, 13005 Marseille, France.
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Vincent A, Irani SR, Lang B. Potentially pathogenic autoantibodies associated with epilepsy and encephalitis in children and adults. Epilepsia 2011; 52 Suppl 8:8-11. [DOI: 10.1111/j.1528-1167.2011.03224.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Errichiello L, Striano S, Zara F, Striano P. Temporal lobe epilepsy and anti glutamic acid decarboxylase autoimmunity. Neurol Sci 2011; 32:547-50. [PMID: 21468678 DOI: 10.1007/s10072-011-0566-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2010] [Accepted: 03/19/2011] [Indexed: 01/07/2023]
Abstract
Epilepsy is one of the most impactful diseases on social life. A significant number of epileptic syndromes have been linked to immunological alterations. Elevated levels of antibodies against glutamic acid decarboxylase have been recently found in a significant percentage of patients with temporal lobe epilepsy, the most common epilepsy type. The clinical and pathogenetic relationship of this association is discussed. This link may have important therapeutic implications and merits additional clinical and laboratory research.
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Affiliation(s)
- Luca Errichiello
- Department of Neurological Sciences, Epilepsy Center, Federico II University, Via Pansini 5, Naples, Italy.
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Abstract
Limbic encephalitis (LE) was first described in 1960 by Brierley et al. and was defined by an acute or subacute temporal lobe epilepsy, memory loss and psychiatric disturbances. Corsellis et al. then demonstrated that LE was associated with small-cell lung cancer and a paraneoplastic origin of LE was suggested. In the 1980s, onconeuronal antibodies specific to paraneoplastic neurological syndromes were described and some of them, such as Hu-Ab, were clearly associated with LE. In the last 20 years, other onconeuronal antibodies targeting intracellular antigens were subsequently identified and LE was considered as a rare paraneoplastic neurological syndrome with a poor outcome and as mainly being associated with Hu-Ab, Ma2-Ab or CV2/CRMP5-Ab. The concept of LE has dramatically evolved since 2004, with the description of LE becoming associated with novel autoantibodies that target neuronal surface rather than intracellular antigens. In these cases, LE was not always paraneoplastic. Interestingly, these newly described LE cases offer a much better prognosis than the previous ones. At present, LE is considered to be an autoimmune disorder that can be paraneoplastic or not and could be more frequent than previously suspected. The associated antibodies lead to the classification of different subtypes of LE and are used as prognostic markers. Those that are directed against cell surface antigens could play a direct role in the neurological symptoms of LE.
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Affiliation(s)
- Adrien Didelot
- Centre de Référence de Diagnostic et de Traitement des Syndromes Neurologiques Paranéoplasiques, Hôpital Pierre Wertheimer, 59 Boulevard Pinel, Lyon F-69003, France
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Abstract
The study of antibodies to the glutamate AMPA receptor subtype 3 in the pathogenesis of severe epilepsy associated with Rasmussen's encephalitis helped to crystallize the concept of autoimmune epilepsy. This work has been used as a paradigm to investigate autoimmunity, especially the humoral components, in several severe childhood epilepsies and more recently, in some of the more common acquired adult epilepsies. In addition, it helped prompt many open-label trials of immunotherapy for various epilepsies. We discuss the evidence that antiglutamate AMPA receptor subtype 3 antibodies are pathogenic and review the findings of the studies of immunotherapy for epilepsy. We conclude that immune treatments can have useful disease-modifying effects in some rare epilepsies, such as Rasmussen's encephalitis, at least in the short term and that their potential should be studied in the management of some forms of severe adult epilepsy.
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Affiliation(s)
- Mia Levite
- Dept of Neurobiology, The Weizmann Institute of Science, 76100 Rehovot, Israel.
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Kobayakawa Y, Tateishi T, Kawamura N, Doi H, Ohyagi Y, Kira JI. [A case of immune-mediated encephalopathy showing refractory epilepsy and extensive brain MRI lesions associated with anti-glutamic acid decarboxylase antibody]. Rinsho Shinkeigaku 2010; 50:92-7. [PMID: 20196490 DOI: 10.5692/clinicalneurol.50.92] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We reported a patient with immune-mediated encephalopathy showing refractory epilepsy and multiple brain lesions on MRI. The patient had high titers of anti-glutamic acid decarboxylase (GAD) antibody in sera and cerebrospinal fluid (CSF). A 36-year-old previously healthy woman was admitted to our hospital with onset of sudden generalized seizure that then persisted for one month. She had repeated epileptic attacks accompanied with loss of consciousness, and was refractory to valproic acid, zonisamide (200 mg/day) and phenobarbital (200 mg/day). Brain MRI showed multiple hyperintense lesions in predominantly bilateral frontal lobes, parietal lobes, occipital lobes and cingulate cortices. EEG showed epileptic activities (frequent sharp waves) in bilateral frontal regions. After admission, attacks disappeared through the administration of clonazepam (1.5 mg/day), though the patient remained slightly disoriented. As titers of anti-GAD antibody in sera and CSF were extremely high, we implemented plasma exchanges. After treatment, titers of anti-GAD antibody in sera and CSF decreased. The patient completely recovered to an alert state and the abnormal MRI lesions almost disappeared. Since GAD catalyzes production of gamma-aminobutyric acid (GABA), it is proposed that anti-GAD antibodies reduce synthesis of GABA or interferes with exocytosis of GABA in the nervous system. Anti-GAD antibodies are detected in some rare neurological disorders such as stiff-person syndrome. Recently, anti-GAD antibodies have been reported as implicated in cerebellar ataxia, palatal myoclonus, refractory epilepsy and limbic encephalitis. Epilepsy associated with the anti-GAD antibody is mostly pharmacoresistant temporal lobe epilepsy; with brain MRI showing no abnormality or only hippocampal sclerosis. It is very rare that brain MRI shows extensive abnormal lesions except in the hippocampus. This case suggests that anti-GAD antibodies could contribute to unexplained encephalopathy with extensive brain MRI lesions and drug-resistant symptomatic epilepsy.
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Affiliation(s)
- Yuko Kobayakawa
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University
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Hijazi J, Bedat-Millet AL, Hannequin D. Le syndrome de l’homme raide et autres maladies neurologiques associées aux anticorps anti-GAD. Rev Med Interne 2010; 31:23-8. [DOI: 10.1016/j.revmed.2009.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Revised: 12/11/2008] [Accepted: 01/22/2009] [Indexed: 11/16/2022]
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Blanc F, Ruppert E, Kleitz C, Valenti M, Cretin B, Humbel R, Honnorat J, Namer I, Hirsch E, Manning L, de Seze J. Acute limbic encephalitis and glutamic acid decarboxylase antibodies: A reality? J Neurol Sci 2009; 287:69-71. [DOI: 10.1016/j.jns.2009.09.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Revised: 09/01/2009] [Accepted: 09/04/2009] [Indexed: 11/25/2022]
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Nociti V, Frisullo G, Tartaglione T, Patanella AK, Iorio R, Tonali PA, Batocchi AP. Refractory generalized seizures and cerebellar ataxia associated with anti-GAD antibodies responsive to immunosuppressive treatment. Eur J Neurol 2009; 17:e5. [DOI: 10.1111/j.1468-1331.2009.02839.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Malter MP, Helmstaedter C, Urbach H, Vincent A, Bien CG. Antibodies to glutamic acid decarboxylase define a form of limbic encephalitis. Ann Neurol 2009; 67:470-8. [DOI: 10.1002/ana.21917] [Citation(s) in RCA: 363] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Liimatainen S, Peltola M, Sabater L, Fallah M, Kharazmi E, Haapala AM, Dastidar P, Knip M, Saiz A, Peltola J. Clinical significance of glutamic acid decarboxylase antibodies in patients with epilepsy. Epilepsia 2009; 51:760-7. [PMID: 19817821 DOI: 10.1111/j.1528-1167.2009.02325.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE Glutamic acid decarboxylase antibodies (GADAs) have been detected in patients with epilepsy, but the clinical determinants of epilepsy associated with GADA have not been defined. METHODS We analyzed GADA with a radioimmunoassay in sera of 253 well-characterized patients with epilepsy and 200 control subjects. The positive samples were confirmed by immunohistochemistry and western blotting (WB). Sera were screened for other autoantibodies. RESULTS GADA were detected in 15 patients (5.9%) and in three control subjects (1.5%) (p = 0.026). Seven patients (2.8%) had high GADA titers [>or=1,000 relative units (RUs)/ml], six of whom had temporal lobe epilepsy (TLE). All three GADA-positive control subjects had low titers. Two of the five patients with high GADA titers and available cerebrospinal fluid (CSF) samples had intrathecal synthesis (IS) of GADA; one patient had CSF oligoclonal bands. The prevalence of increased levels of GADA tended to be higher in patients with TLE than in patients with extra-TLE [odds ratio (OR) 1.32, 95% confidence interval (CI) 0.39-4.42; p = 0.657]. The patients with high GADA titers had significantly higher number of other autoantibodies compared to the patients with low GADA titers (p = 0.001) and the patients with normal GADA (p < 0.001). DISCUSSION High GADA titers were present in a subgroup of patients; close to 90% had TLE. The immunologic profile of these patients suggests that the most probable origin of their epilepsy is autoimmune. A positive IS of GADA may be a marker of an ongoing immune response that could identify those patients in whom a trial with immunosuppressive therapy might be warranted.
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Affiliation(s)
- Suvi Liimatainen
- Department of Neurology and Rehabilitation, Tampere University Hospital, Tampere, Finland.
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Vianello M, Vianello M, Bisson G, Vianello M, Bisson G, Dal Maschio M, Vassanelli S, Girardi S, Mucignat C, Fountzoulas K, Giometto B. Increased spontaneous activity of a network of hippocampal neurons in culture caused by suppression of inhibitory potentials mediated by anti-gad antibodies. Autoimmunity 2009; 41:66-73. [DOI: 10.1080/08916930701619565] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Vulliemoz S, Vanini G, Truffert A, Chizzolini C, Seeck M. Epilepsy and cerebellar ataxia associated with anti-glutamic acid decarboxylase antibodies. BMJ Case Rep 2009; 2009:bcr09.2008.0977. [PMID: 21686528 DOI: 10.1136/bcr.09.2008.0977] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Anti-glutamic acid decarboxylase (GAD) antibodies are described in stiff-person syndrome and also in other neurological syndromes, including cerebellar ataxia and epilepsy. This paper reports the case of a patient who had chronic focal epilepsy, upbeat nystagmus and cerebellar ataxia, associated with a polyautoimmune response including anti-GAD antibodies. Both gait and nystagmus improved markedly after immunosuppressive treatment with corticosteroids and azathioprine. After the introduction of benzodiazepines, previously refractory seizures were completely controlled. Anti-GAD antibodies should be actively sought out in pharmacoresistant epilepsy, particularly if other neurological abnormalities are present. Combined treatment with immunosuppressants and γhydroxybutyric acidergic agents may be highly effective.
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Affiliation(s)
- S Vulliemoz
- University Hospital, rue Micheli-du Crest 24, Geneva, 1211, Switzerland
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