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Meng H, He L, Chunyu H, Zhou Q, Wang J, Qu Q, Hai W, Zhang Y, Li B, Zhang M, Chen S. 18F-DPA714 PET/MRI as a potential imaging tool for detecting possible antibody-negative autoimmune encephalitis: a prospective study. J Neurol 2024:10.1007/s00415-024-12690-w. [PMID: 39294471 DOI: 10.1007/s00415-024-12690-w] [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: 07/10/2024] [Revised: 09/06/2024] [Accepted: 09/07/2024] [Indexed: 09/20/2024]
Abstract
BACKGROUND AND OBJECTIVES Conventional magnetic resonance imaging (MRI) used for detecting possible antibody-negative autoimmune encephalitis (AIE) often fails to meet the diagnostic requirements of this disease. Positron emission tomography (PET) with a translocator protein radioligand can help visualize microglia distribution density in inflammation-related diseases, thereby offering potentially incremental value to conventional MRI for the in vivo assessment of possible antibody-negative AIE. METHODS In this prospective study, 15 participants diagnosed with possible antibody-negative AIE and 10 healthy controls were enrolled (ClinicalTrials.gov: NCT05293405, dated March 15, 2022). All participants underwent hybrid 18F-DPA714 PET/MRI and evaluation for modified Rankin scale (mRS) score, clinical assessment scale for AIE (CASE), and appropriate antibodies. A positive finding was defined as the intensity of 18F-DPA714 uptake that was above a threshold of mean standardized uptake value ratio (SUVR) + two standard deviations of SUVR within the corresponding brain regions of healthy controls. RESULTS The positive detection rate of 18F-DPA714 PET for possible antibody-negative AIE was significantly higher than that of brain MRI (10/15 [67%] vs. 3/15 [20%]; P = 0.039). In addition, both the intensity and extent of 18F-DPA714 uptake were significantly associated with the CASE score (P = 0.002 and 0.001). Meanwhile, SUVR levels in the cerebellar region were significantly higher in patients with ataxia than in those without ataxia (P = 0.006). Furthermore, 18F-DPA714 uptake decreased in 5/10 [50%] patients who underwent follow-up PET/MRI, which mirrored their symptom relief. CONCLUSION 18F-DPA714 PET demonstrated its potentially incremental value to conventional MRI for detecting possible antibody-negative AIE.
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Affiliation(s)
- Huanyu Meng
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025, China
- Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, China
| | - Lu He
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025, China
| | - Hangxing Chunyu
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Qinming Zhou
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025, China
| | - Jin Wang
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Qian Qu
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Wangxi Hai
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Yu Zhang
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Biao Li
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanxi Medical University-Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Shanxi, China
| | - Min Zhang
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
- Shanxi Medical University-Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Shanxi, China.
| | - Sheng Chen
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025, China.
- Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, China.
- Department of Neurology, Xinrui Hospital, Wuxi, China.
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Guasp M, Dalmau J. Predicting the future of autoimmune encephalitides. Rev Neurol (Paris) 2024:S0035-3787(24)00583-6. [PMID: 39277478 DOI: 10.1016/j.neurol.2024.08.003] [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: 06/14/2024] [Revised: 07/25/2024] [Accepted: 08/02/2024] [Indexed: 09/17/2024]
Abstract
The concept that many neurologic and psychiatric disorders of unknown cause are immune-mediated has evolved fast during the past 20 years. The main contribution to the expansion of this field has been the discovery of antibodies that attack neuronal or glial cell-surface proteins or receptors, directly modifying their structure and function. These antibodies facilitate the diagnosis and prompt treatment of patients who often improve with immunotherapy. The identification of this group of diseases, collectively named "autoimmune encephalitides", was preceded by many years of investigations on other autoimmune CNS disorders in which the antibodies are against intracellular proteins, occur more frequently with cancer, and associate with cytotoxic T-cell responses that are less responsive to immunotherapy. Here, we first trace the recent history of the autoimmune encephalitides and address how to assess the clinical value and implement in our practice the rapid pace of autoantibody discovery. In addition, we review recent developments in the post-acute stage of the two main autoimmune encephalitides (NMDAR and LGI1) focusing on symptoms that are frequently overlooked or missed, and therefore undertreated. Because a better understanding of the pathophysiology of these diseases relies on animal models, we examine currently available studies, recognizing the existing needs for better and all-inclusive neuro-immunobiological models. Finally, we assess the status of biomarkers of disease outcome, clinical scales, current treatment strategies, and emerging therapies including CAR T-cell technology. Altogether, this overview is intended to identify gaps of knowledge and provide suggestions for improvement and insights for future research.
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Affiliation(s)
- M Guasp
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-CaixaResearch Institute, Barcelona, Spain; Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red, Enfermedades Raras (CIBERER), Madrid, Spain
| | - J Dalmau
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-CaixaResearch Institute, Barcelona, Spain; Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red, Enfermedades Raras (CIBERER), Madrid, Spain; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Ronchi NR, Castro MA, Coutinho AM, Lucato LT, Silva GD, Brucki SM, Kok F, Trés ES, Nóbrega PR, Freua F, Nitrini R, Simabukuro MM. Young-Onset Alzheimer Dementia Due to a Novel Pathogenic Presenilin 1 Variant Initially Misdiagnosed as Autoimmune Encephalitis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200280. [PMID: 39024526 PMCID: PMC11271388 DOI: 10.1212/nxi.0000000000200280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 05/30/2024] [Indexed: 07/20/2024]
Abstract
OBJECTIVES Pathogenic variants in presenilin 1 (PSEN1) are related to early-onset Alzheimer disease (AD) and may occur as de novo variants. In comparison with sporadic forms, it can present with psychiatric manifestations, seizures, myoclonus, and focal presentation. Because PSEN1 can occur in young patients who lack a family history of neurologic disorders and because these symptoms are also frequent in autoimmune encephalitis (AE), diagnosis may be overlooked. Our aim was to demonstrate the challenge in diagnosing young patients with neurodegenerative diseases that simulate AE. METHODS We describe a case of a young patient with insidious progressive dementia, myoclonus, seizures, and aphasia, with no family history of dementia, along with signs suggestive of neuroinflammation on brain MRI and CSF examination. RESULTS She was initially misdiagnosed as having AE. Further investigation was performed, leading to the discovery of a novel and de novo pathogenic variant in PSEN1. DISCUSSION This case demonstrates the importance of considering PSEN1 in young patients with insidious progressive dementia with atypical clinical and neuroimaging features, even in patients without a family history of neurologic disorders. Not adhering to published criteria of possible and probable AE and overinterpretation of subtle inflammatory findings in CSF and MRI contribute to misdiagnosis.
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Affiliation(s)
- Nathalia Rossoni Ronchi
- From the Department of Neurology (N.R.R.), Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto; Division of Neurology (M.A.C., G.D.S., S.M.B., F.K., E.S.T., F.F., R.N., M.M.S.); Laboratory of Nuclear Medicine (LIM43) (A.M.C.); Neuroradiology Section (L.T.L.), Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo; Grupo Fleury (L.T.L.); Instituto do Câncer do Estado de São Paulo (G.D.S.); Department of Neurology (P.R.N.), Universidade Federal do Ceará; Centro Universitário Christus (P.R.N.), Ceará; and Instituto do Câncer do Estado de São Paulo (M.M.S.), Brazil
| | - Matheus A Castro
- From the Department of Neurology (N.R.R.), Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto; Division of Neurology (M.A.C., G.D.S., S.M.B., F.K., E.S.T., F.F., R.N., M.M.S.); Laboratory of Nuclear Medicine (LIM43) (A.M.C.); Neuroradiology Section (L.T.L.), Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo; Grupo Fleury (L.T.L.); Instituto do Câncer do Estado de São Paulo (G.D.S.); Department of Neurology (P.R.N.), Universidade Federal do Ceará; Centro Universitário Christus (P.R.N.), Ceará; and Instituto do Câncer do Estado de São Paulo (M.M.S.), Brazil
| | - Artur M Coutinho
- From the Department of Neurology (N.R.R.), Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto; Division of Neurology (M.A.C., G.D.S., S.M.B., F.K., E.S.T., F.F., R.N., M.M.S.); Laboratory of Nuclear Medicine (LIM43) (A.M.C.); Neuroradiology Section (L.T.L.), Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo; Grupo Fleury (L.T.L.); Instituto do Câncer do Estado de São Paulo (G.D.S.); Department of Neurology (P.R.N.), Universidade Federal do Ceará; Centro Universitário Christus (P.R.N.), Ceará; and Instituto do Câncer do Estado de São Paulo (M.M.S.), Brazil
| | - Leandro T Lucato
- From the Department of Neurology (N.R.R.), Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto; Division of Neurology (M.A.C., G.D.S., S.M.B., F.K., E.S.T., F.F., R.N., M.M.S.); Laboratory of Nuclear Medicine (LIM43) (A.M.C.); Neuroradiology Section (L.T.L.), Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo; Grupo Fleury (L.T.L.); Instituto do Câncer do Estado de São Paulo (G.D.S.); Department of Neurology (P.R.N.), Universidade Federal do Ceará; Centro Universitário Christus (P.R.N.), Ceará; and Instituto do Câncer do Estado de São Paulo (M.M.S.), Brazil
| | - Guilherme Diogo Silva
- From the Department of Neurology (N.R.R.), Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto; Division of Neurology (M.A.C., G.D.S., S.M.B., F.K., E.S.T., F.F., R.N., M.M.S.); Laboratory of Nuclear Medicine (LIM43) (A.M.C.); Neuroradiology Section (L.T.L.), Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo; Grupo Fleury (L.T.L.); Instituto do Câncer do Estado de São Paulo (G.D.S.); Department of Neurology (P.R.N.), Universidade Federal do Ceará; Centro Universitário Christus (P.R.N.), Ceará; and Instituto do Câncer do Estado de São Paulo (M.M.S.), Brazil
| | - Sonia M Brucki
- From the Department of Neurology (N.R.R.), Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto; Division of Neurology (M.A.C., G.D.S., S.M.B., F.K., E.S.T., F.F., R.N., M.M.S.); Laboratory of Nuclear Medicine (LIM43) (A.M.C.); Neuroradiology Section (L.T.L.), Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo; Grupo Fleury (L.T.L.); Instituto do Câncer do Estado de São Paulo (G.D.S.); Department of Neurology (P.R.N.), Universidade Federal do Ceará; Centro Universitário Christus (P.R.N.), Ceará; and Instituto do Câncer do Estado de São Paulo (M.M.S.), Brazil
| | - Fernando Kok
- From the Department of Neurology (N.R.R.), Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto; Division of Neurology (M.A.C., G.D.S., S.M.B., F.K., E.S.T., F.F., R.N., M.M.S.); Laboratory of Nuclear Medicine (LIM43) (A.M.C.); Neuroradiology Section (L.T.L.), Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo; Grupo Fleury (L.T.L.); Instituto do Câncer do Estado de São Paulo (G.D.S.); Department of Neurology (P.R.N.), Universidade Federal do Ceará; Centro Universitário Christus (P.R.N.), Ceará; and Instituto do Câncer do Estado de São Paulo (M.M.S.), Brazil
| | - Eduardo Sturzeneker Trés
- From the Department of Neurology (N.R.R.), Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto; Division of Neurology (M.A.C., G.D.S., S.M.B., F.K., E.S.T., F.F., R.N., M.M.S.); Laboratory of Nuclear Medicine (LIM43) (A.M.C.); Neuroradiology Section (L.T.L.), Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo; Grupo Fleury (L.T.L.); Instituto do Câncer do Estado de São Paulo (G.D.S.); Department of Neurology (P.R.N.), Universidade Federal do Ceará; Centro Universitário Christus (P.R.N.), Ceará; and Instituto do Câncer do Estado de São Paulo (M.M.S.), Brazil
| | - Paulo Ribeiro Nóbrega
- From the Department of Neurology (N.R.R.), Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto; Division of Neurology (M.A.C., G.D.S., S.M.B., F.K., E.S.T., F.F., R.N., M.M.S.); Laboratory of Nuclear Medicine (LIM43) (A.M.C.); Neuroradiology Section (L.T.L.), Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo; Grupo Fleury (L.T.L.); Instituto do Câncer do Estado de São Paulo (G.D.S.); Department of Neurology (P.R.N.), Universidade Federal do Ceará; Centro Universitário Christus (P.R.N.), Ceará; and Instituto do Câncer do Estado de São Paulo (M.M.S.), Brazil
| | - Fernando Freua
- From the Department of Neurology (N.R.R.), Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto; Division of Neurology (M.A.C., G.D.S., S.M.B., F.K., E.S.T., F.F., R.N., M.M.S.); Laboratory of Nuclear Medicine (LIM43) (A.M.C.); Neuroradiology Section (L.T.L.), Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo; Grupo Fleury (L.T.L.); Instituto do Câncer do Estado de São Paulo (G.D.S.); Department of Neurology (P.R.N.), Universidade Federal do Ceará; Centro Universitário Christus (P.R.N.), Ceará; and Instituto do Câncer do Estado de São Paulo (M.M.S.), Brazil
| | - Ricardo Nitrini
- From the Department of Neurology (N.R.R.), Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto; Division of Neurology (M.A.C., G.D.S., S.M.B., F.K., E.S.T., F.F., R.N., M.M.S.); Laboratory of Nuclear Medicine (LIM43) (A.M.C.); Neuroradiology Section (L.T.L.), Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo; Grupo Fleury (L.T.L.); Instituto do Câncer do Estado de São Paulo (G.D.S.); Department of Neurology (P.R.N.), Universidade Federal do Ceará; Centro Universitário Christus (P.R.N.), Ceará; and Instituto do Câncer do Estado de São Paulo (M.M.S.), Brazil
| | - Mateus Mistieri Simabukuro
- From the Department of Neurology (N.R.R.), Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto; Division of Neurology (M.A.C., G.D.S., S.M.B., F.K., E.S.T., F.F., R.N., M.M.S.); Laboratory of Nuclear Medicine (LIM43) (A.M.C.); Neuroradiology Section (L.T.L.), Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo; Grupo Fleury (L.T.L.); Instituto do Câncer do Estado de São Paulo (G.D.S.); Department of Neurology (P.R.N.), Universidade Federal do Ceará; Centro Universitário Christus (P.R.N.), Ceará; and Instituto do Câncer do Estado de São Paulo (M.M.S.), Brazil
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De Napoli G, Gastaldi M, Natali P, Bedin R, Simone AM, Santangelo M, Mariotto S, Vitetta F, Smolik K, Cardi M, Meletti S, Ferraro D. Kappa index in the diagnostic work-up of autoimmune encephalitis. J Neurol Sci 2024; 463:123146. [PMID: 39033735 DOI: 10.1016/j.jns.2024.123146] [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: 05/06/2024] [Revised: 07/03/2024] [Accepted: 07/16/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND The presence of inflammatory changes in the cerebrospinal fluid (CSF), including immunoglobulin intrathecal synthesis (IS), can support the diagnosis of autoimmune encephalitis (AE) and allow prompt treatment. The main aim of our study was to calculate the Kappa index as a marker of IS, in patients with AE. METHODS Charts of patients undergoing a diagnostic work-up for suspected AE between 2009 and 2023 were reviewed and the Graus criteria applied. CSF and serum kappa free light chains were determined using the Freelite assay (The Binding Site Group) and the turbidimetric Optilite analyzer. RESULTS We identified 34 patients with "definite" AE (9 anti-NMDAR AE and 25 limbic AE) and nine patients with "possible" AE. Five patients (15%) with definite AE had pleocytosis and twelve (34%) showed CSF-restricted oligoclonal bands (OCB) at isoelectric focusing. The Kappa index was >6 in 29.4% and > 3 in 50% of the definite AE patients. It was elevated (>3) in 36.4% of patients with definite AE who resulted negative to OCB testing and was the only altered parameter suggestive of an ongoing inflammatory process in the CNS in three definite AE patients with otherwise normal CSF findings (i.e. normal cell count and protein levels, no OCBs). In the possible AE group, one patient had a Kappa index >3 in the absence of OCB. CONCLUSIONS The Kappa index could be useful, as a more sensitive marker of IS and as a supportive marker of neuroinflammation, in the diagnostic work-up of suspected AE.
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Affiliation(s)
- Giulia De Napoli
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy; Department of Neurosciences, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | - Patrizia Natali
- Department of Laboratory Medicine, Azienda Ospedaliero-Universitaria and Azienda Unità Sanitaria Locale, Ospedale Civile di Baggiovara, Modena, Italy
| | - Roberta Bedin
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy
| | | | | | - Sara Mariotto
- Neurology Unit, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Francesca Vitetta
- Department of Neurosciences, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Krzysztof Smolik
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy; Department of Neurosciences, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Martina Cardi
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Meletti
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy; Department of Neurosciences, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Diana Ferraro
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy; Department of Neurosciences, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy.
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Zeng R, He L, Kuang Z, Jian Y, Qiu M, Liu Y, Hu M, Ye Y, Wu L. Clinical characteristics, immunological alteration and distinction of MOG-IgG-associated disorders and GFAP-IgG-associated disorders. J Neuroimmunol 2024; 393:578398. [PMID: 39002186 DOI: 10.1016/j.jneuroim.2024.578398] [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: 05/09/2024] [Accepted: 06/19/2024] [Indexed: 07/15/2024]
Abstract
The classification of autoimmune encephalitis (AE) is based on the presence of different types of antibodies. Currently, the clinical manifestations and treatment regimens of patients with all types of AE exhibit similarities. However, the presence of immunological distinctions among different types of AE remains uncertain. In this study, we prospectively collected clinical data, as well as blood and cerebrospinal fluid (CSF) samples from patients diagnosed with MOG antibody-associated disease (MOGAD) or GFAP astrocytopathy (GFAP-A), in order to assess changes in inflammatory biomarkers such as immunoglobulin oligoclonal bands, cytokines in serum and CSF, as well as peripheral blood lymphocyte subtypes within different subsets. To further distinguish the immune response in patients with MOGAD and GFAP-A from that of healthy individuals, we prospectively recruited 20 hospitalized patients diagnosed with AE. Among them, 15 (75%) tested positive for MOG antibodies, 4 (20%) tested positive for GFAP antibodies, and 1 (5%) tested positive for both MOG and GFAP antibodies. These patients were then followed up for a period of 18 months. Compared to healthy controls (HC), AE patients exhibited elevated levels of MIP-1beta, SDF-1alpha, IL-12p70, IL-5, IL-1RA, IL-8 and decreased levels of IL-23, IL-31, IFN-alpha, IL-7, TNF-beta and TNF-alpha in serum. The CSF of AE patients showed increased levels of IL-1RA, IL-6 and IL-2 while decreased levels of RANTES, IL-18,IL-7,TNF-beta,TNF-alpha,RANTES,Eotaxin,and IL-9. The level of MCP-1 in the CSF of GFAP-A patients was found to be lower compared to that of MOGAD patients, while RANTES levels were higher. And the levels of IL-17A, Eotaxin, GRO-alpha, IL-8, IL-1beta, MIP-1beta were higher in the CSF of patients with epilepsy. The presence of intrathecal immune responses is also observed in patients with spinal muscular atrophy (SMA). However, no biomarker was found to be associated with disease severity in patients with AE. Among the 17 patients, recovery was observed, while 2 patients experienced persistent symptoms after an 18-month follow-up period. Additionally, within one year of onset, 8 patients had a single recurrence. Therefore, the immunological profiles of MOGAD and GFAP-A patients differ from those of normal individuals, and the alterations in cytokine levels may also exhibit a causal association with the clinical presentations, such as seizure.
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Affiliation(s)
- Rongrong Zeng
- The School of Pediatrics, Hengyang Medical School, University of South China (Hunan Children's Hospital), China
| | - Lu He
- The School of Pediatrics, Hengyang Medical School, University of South China (Hunan Children's Hospital), China
| | - Zhuo Kuang
- The School of Pediatrics, Hengyang Medical School, University of South China (Hunan Children's Hospital), China
| | - Yiemin Jian
- The School of Pediatrics, Hengyang Medical School, University of South China (Hunan Children's Hospital), China
| | | | - Yuting Liu
- The School of Pediatrics, Hengyang Medical School, University of South China (Hunan Children's Hospital), China
| | - Mengdie Hu
- The School of Pediatrics, Hengyang Medical School, University of South China (Hunan Children's Hospital), China
| | - Yizhi Ye
- The School of Pediatrics, Hengyang Medical School, University of South China (Hunan Children's Hospital), China
| | - Liwen Wu
- Hunan Children's Hospital, China.
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6
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Smith KM, Budhram A, Geis C, McKeon A, Steriade C, Stredny CM, Titulaer MJ, Britton JW. Autoimmune-associated seizure disorders. Epileptic Disord 2024; 26:415-434. [PMID: 38818801 DOI: 10.1002/epd2.20231] [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: 01/24/2024] [Revised: 03/28/2024] [Accepted: 04/13/2024] [Indexed: 06/01/2024]
Abstract
With the discovery of an expanding number of neural autoantibodies, autoimmune etiologies of seizures have been increasingly recognized. Clinical phenotypes have been identified in association with specific underlying antibodies, allowing an earlier diagnosis. These phenotypes include faciobrachial dystonic seizures with LGI1 encephalitis, neuropsychiatric presentations associated with movement disorders and seizures in NMDA-receptor encephalitis, and chronic temporal lobe epilepsy in GAD65 neurologic autoimmunity. Prompt recognition of these disorders is important, as some of them are highly responsive to immunotherapy. The response to immunotherapy is highest in patients with encephalitis secondary to antibodies targeting cell surface synaptic antigens. However, the response is less effective in conditions involving antibodies binding intracellular antigens or in Rasmussen syndrome, which are predominantly mediated by cytotoxic T-cell processes that are associated with irreversible cellular destruction. Autoimmune encephalitides also may have a paraneoplastic etiology, further emphasizing the importance of recognizing these disorders. Finally, autoimmune processes and responses to novel immunotherapies have been reported in new-onset refractory status epilepticus (NORSE) and febrile infection-related epilepsy syndrome (FIRES), warranting their inclusion in any current review of autoimmune-associated seizure disorders.
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Affiliation(s)
- Kelsey M Smith
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Adrian Budhram
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Christian Geis
- Department of Neurology and Section Translational Neuroimmunology, Jena University Hospital, Jena, Germany
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Claude Steriade
- Department of Neurology, New York University Langone Health, New York, New York, USA
| | - Coral M Stredny
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Maarten J Titulaer
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
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Briceno B, Ariza-Varon M, Pinzon N, Castro-Sepulveda JS, Oviedo L. Postencephalitic syndrome with immune-mediated psychosis in an adult with meningitis due to Streptococcus pneumoniae: A case report. IDCases 2024; 37:e02041. [PMID: 39220423 PMCID: PMC11364120 DOI: 10.1016/j.idcr.2024.e02041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 07/21/2024] [Accepted: 07/29/2024] [Indexed: 09/04/2024] Open
Abstract
Introduction A first psychotic episode may be related to neurological diseases, especially encephalitis of infectious or autoimmune origin. It is remarkable that an immune-mediated encephalitis triggered by a confirmed subacute bacterial meningitis is documented, and this is the case we will present. Clinical case A 22-year-old woman with no previous medical history, immunocompetent, with three months of behavioral, affective and cognitive symptoms with subsequent compromise of sensory perception and psychosis. Examination of cerebrospinal fluid showed inflammatory signs with positive FilmArray© for Streptococcus pneumoniae. She received anti-psychotic and antibiotic treatment for 2 weeks without clinical improvement. Postencephalitic syndrome with immune-mediated psychosis was considered as a diagnosis, and immunosuppressive management with corticosteroid and plasmapheresis was initiated with complete resolution of symptoms. After one year of follow-up no neurological relapse has been identified. Discussion Encephalitis is a neurological syndrome due to brain parenchymal damage that can result in psychiatric symptoms including psychosis and behavioral changes. Its causes are usually infectious (usually viral) or autoimmune (Anti NMDA, AMPA, LGI1 or others). A psychiatric condition in bacterial meningitis without improvement with antibiotic treatment is remarkable, its presence should suggest an immune-mediated post-infectious syndrome that may respond to the use of immunomodulators even in the absence of identification of autoimmune encephalitis-associated antibodies. No similar cases have been reported in the literature. Conclusion Immune-mediated psychosis may be a manifestation of post-encephalitic syndrome associated with bacterial meningitis and its treatment with immunosuppressants may offer benefit in cases where the use of antipsychotics and antibiotics shows no improvement.
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Affiliation(s)
- Bibiana Briceno
- Resident physician in the Psychiatry Department. Universidad del Rosario, Bogotá, Colombia
- MSc in Epidemiology. Universidad CES, Medellín, Colombia
| | - Michael Ariza-Varon
- Clinical Neurologist. Hospital Universitario Mayor - Méderi, Bogotá, Colombia
- Clinical Neurologist. Universidad Nacional de Colombia, Bogotá, Colombia
- MSc in Tropical Neurology and Infectious Diseases. Universitat Internacional de Catalunya, Catalunya, Spain
| | - Nicole Pinzon
- Resident physician in the Neurology Department. Universidad del Rosario, Bogotá, Colombia
- MSc in Epidemiology. Universidad CES, Medellín, Colombia
| | - Juan-Sebastian Castro-Sepulveda
- Inpatient physician. Hospital Universitario Mayor - Méderi, Bogotá, Colombia
- MSc in Clinical Epidemiology and Public Health. Universidad Internacional de Valencia, Valencia, Spain
| | - Laura Oviedo
- Research Coordinator. Neurology Unit. Hospital Universitario Mayor - Méderi, Bogotá, Colombia
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Cui RM, Fan FR, Ma SH, Li H, Li JC, Wen Y, Liu MW. Autoimmune glial fibrillary acidic protein astrocytopathy with anti-NMDAR and sulfatide-IgG-positive encephalitis overlap syndrome: A case report and literature review. Medicine (Baltimore) 2024; 103:e38983. [PMID: 38996095 PMCID: PMC11245231 DOI: 10.1097/md.0000000000038983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/28/2024] [Indexed: 07/14/2024] Open
Abstract
RATIONALE Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a rare autoimmune disease of the central nervous system that affects the meninges, brain, spinal cord, and optic nerves. GFAP astrocytopathy can coexist with a variety of antibodies, which is known as overlap syndrome. Anti-NMDAR-positive encephalitis overlap syndrome has been reported; however, encephalitis overlap syndrome with both anti-NMDAR and sulfatide-IgG positivity has not been reported. PATIENT CONCERNS The patient was a 50-year-old male who was drowsy and had chills and weak limbs for 6 months. His symptoms worsened after admission to our hospital with persistent high fever, dysphoria, gibberish, and disturbance of consciousness. Positive cerebrospinal fluid NMDA, GFAP antibodies, and serum sulfatide antibody IgG were positive. DIAGNOSES Autoimmune GFAP astrocytopathy with anti-NMDAR and sulfatide-IgG-positive encephalitis overlap syndrome. INTERVENTIONS In addition to ventilator support and symptomatic supportive treatment, step-down therapy with methylprednisolone (1000 mg/d, halved every 3 days) and pulse therapy with human immunoglobulin (0.4 g/(kg d) for 5 days) were used. OUTCOMES After 6 days of treatment, the patient condition did not improve, and the family signed up to give up the treatment and left the hospital. CONCLUSIONS Patients with autoimmune GFAP astrocytopathy may be positive for anti-NMDAR and sulfatide-IgG, and immunotherapy may be effective in patients with severe conditions. LESSONS Autoimmune GFAP astrocytopathy with nonspecific symptoms is rarely reported and is easy to be missed and misdiagnosed. GFAP astrocytopathy should be considered in patients with fever, headache, disturbance of consciousness, convulsions, and central infections that do not respond to antibacterial and viral agents. Autoimmune encephalopathy-related antibody testing should be performed as soon as possible, early diagnosis should be confirmed, and immunomodulatory therapy should be administered promptly.
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Affiliation(s)
- Ruo-mei Cui
- Department of Rheumatology, The First Hospital Affiliated to Kunming Medical University, Kunming, China
| | - Fu-rong Fan
- Department of Emergency, The First Hospital Affiliated to Kunming Medical University, Kunming, China
| | - Shou-hong Ma
- Department of Neurology, The six Hospital Affiliated to Kunming Medical University, Yuxi, China
| | - Hua Li
- Department of Emergency, The Third People’s Hospital of Yunnan Province, Kunming, China
| | - Jin-chun Li
- Department of Emergency, The First Hospital Affiliated to Kunming Medical University, Kunming, China
| | - Yu Wen
- Department of Emergency, The First Hospital Affiliated to Kunming Medical University, Kunming, China
| | - Ming-wei Liu
- Department of Emergency, Dali Bai Autonomous Prefecture People’s Hospital, Dali, China
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Dai Y, Zhu Z, Tang Y, Xiao L, Liu X, Zhang M, Xiao B, Hu K, Long L, Xie Y, Hu S. The clinical and predictive value of 18F-FDG PET/CT metabolic patterns in a clinical Chinese cohort with autoimmune encephalitis. CNS Neurosci Ther 2024; 30:e14821. [PMID: 38948940 PMCID: PMC11215490 DOI: 10.1111/cns.14821] [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: 02/26/2024] [Revised: 05/29/2024] [Accepted: 06/14/2024] [Indexed: 07/02/2024] Open
Abstract
AIMS To investigate the diagnostic and predictive role of 18F-FDG PET/CT in patients with autoimmune encephalitis (AE) as a whole group. METHODS Thrty-five patients (20 females and 15 males) with AE were recruited. A voxel-to-voxel semi-quantitative analysis based on SPM12 was used to analyze 18F-FDG PET/CT imaging data compared to healthy controls. Further comparison was made in different prognostic groups categorized by modified Rankin Scale (mRS). RESULTS In total, 24 patients (68.6%) were tested positive neuronal antibodies in serum and/or CSF. Psychiatric symptoms and seizure attacks were major clinical symptoms. In the acute stage, 13 patients (37.1%) demonstrated abnormal brain MRI results, while 33 (94.3%) presented abnormal metabolism patterns. 18F-FDG PET/CT was more sensitive than MRI (p < 0.05). Patients with AE mainly presented mixed metabolism patterns compared to the matched controls, demonstrating hypermetabolism mainly in the cerebellum, BG, MTL, brainstem, insula, middle frontal gyrus, and relatively hypometabolism in the frontal cortex, occipital cortex, temporal gyrus, right parietal gyrus, left cingulate gyrus (p < 0.05, FWE corrected). After a median follow-up of 26 months, the multivariable analysis identified a decreased level of consciousness as an independent risk factor associated with poor outcome of AE (HR = 3.591, p = 0.016). Meanwhile, decreased metabolism of right superior frontal gyrus along with increased metabolism of the middle and upper brainstem was more evident in patients with poor outcome (p < 0.001, uncorrected). CONCLUSION 18F-FDG PET/CT was more sensitive than MRI to detect neuroimaging abnormalities of AE. A mixed metabolic pattern, characterized by large areas of cortical hypometabolism with focal hypermetabolism was a general metabolic pattern. Decreased metabolism of right superior frontal gyrus with increased metabolism of the middle and upper brainstem may predict poor long-term prognosis of AE.
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Affiliation(s)
- Yuwei Dai
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Clinical Research Center for Epileptic disease of Hunan ProvinceCentral South UniversityChangshaHunanP.R. China
| | - Zehua Zhu
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Department of Nuclear Medicine, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Division of Life Sciences and Medicine, Department of Nuclear Medicine, The First Affiliated Hospital of USTCUniversity of Science and Technology of ChinaHefeiAnhuiP.R. China
| | - Yongxiang Tang
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Department of Nuclear Medicine, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
| | - Ling Xiao
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Department of Nuclear Medicine, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
| | - Xianghe Liu
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Clinical Research Center for Epileptic disease of Hunan ProvinceCentral South UniversityChangshaHunanP.R. China
| | - Min Zhang
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Clinical Research Center for Epileptic disease of Hunan ProvinceCentral South UniversityChangshaHunanP.R. China
| | - Bo Xiao
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Clinical Research Center for Epileptic disease of Hunan ProvinceCentral South UniversityChangshaHunanP.R. China
| | - Kai Hu
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Clinical Research Center for Epileptic disease of Hunan ProvinceCentral South UniversityChangshaHunanP.R. China
| | - Lili Long
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Clinical Research Center for Epileptic disease of Hunan ProvinceCentral South UniversityChangshaHunanP.R. China
| | - Yuanyuan Xie
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Clinical Research Center for Epileptic disease of Hunan ProvinceCentral South UniversityChangshaHunanP.R. China
| | - Shuo Hu
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Department of Nuclear Medicine, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
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Bai L, Di W, Xu Z, Liu B, Lin N, Fan S, Ren H, Lu Q, Wang J, Guan H. Febrile infection-related epilepsy syndrome with claustrum lesion: an underdiagnosed inflammatory encephalopathy. Neurol Sci 2024; 45:3411-3419. [PMID: 38342839 DOI: 10.1007/s10072-024-07363-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/29/2023] [Indexed: 02/13/2024]
Abstract
OBJECTIVE To summarize the clinical characteristics and prognosis of febrile infection-related epilepsy syndrome with claustrum lesions (FIRES-C). METHOD Clinical data of FIRES-C patients were collected retrospectively. The study reviewed and analyzed their clinical manifestations, treatment strategies, and prognosis. RESULT Twenty patients were enrolled, including 13 females and 7 males, with a median onset age of 20.5 years. All patients developed seizures after fever, with a median interval of 5 days. Brain MRI showed symmetric lesions in the claustrum in all patients. The median interval from seizure onset to abnormal MRI signals detection was 12.5 days. All patients had negative results for comprehensive tests of neurotropic viruses and antineuronal autoantibodies. Seventy percent of cases had been previously empirically diagnosed with autoimmune encephalitis or viral encephalitis before. All patients received anti-seizure medicine. Eleven patients (55%) received antiviral therapy. All patients received immunotherapy, including glucocorticoids (100%), intravenous immunoglobulin (IVIg) (65%), plasma exchange (PLEX) (10%), tocilizumab (10%), rituximab (5%), and cyclophosphamide (5%). Sixty percent of patients received long-term immunotherapy (≥ 3 months). The median follow-up was 11.5 months;60% of patients were diagnosed with refractory epilepsy. CONCLUSION Bilateral claustrum lesion on MRI is a distinctive neuroimage feature for FIRES, which may serve as an indication for the initial clinical assessments. FIRES-C should be classified as a type of inflammatory encephalopathy characterized by a monophasic nature. Some FIRES-C patients respond to immunotherapy and antiseizure treatments but most experience refractory epilepsy as a long-term outcome.
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Affiliation(s)
- Lin Bai
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Weiying Di
- Department of Neurology, Affiliated Hospital of Hebei University, Baoding, Hebei, China
| | - Zucai Xu
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Bin Liu
- Department of Neurology, Inner Mongolia Autonomous Region People's Hospital, Hohhot, Inner Mongolia, China
| | - Nan Lin
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Qiang Lu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jiawei Wang
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
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Dutra LA, Silva PVDC, Ferreira JHF, Marques AC, Toso FF, Vasconcelos CCF, Brum DG, Pereira SLDA, Adoni T, Rocha LJDA, Sampaio LPDB, Sousa NADC, Paolilo RB, Pizzol AD, Costa BKD, Disserol CCD, Pupe C, Valle DAD, Diniz DS, Abrantes FFD, Schmidt FDR, Cendes F, Oliveira FTMD, Martins GJ, Silva GD, Lin K, Pinto LF, Santos MLSF, Gonçalves MVM, Krueger MB, Haziot MEJ, Barsottini OGP, Nascimento OJMD, Nóbrega PR, Proveti PM, Castilhos RMD, Daccach V, Glehn FV. Brazilian consensus recommendations on the diagnosis and treatment of autoimmune encephalitis in the adult and pediatric populations. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-15. [PMID: 39089672 DOI: 10.1055/s-0044-1788586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
BACKGROUND Autoimmune encephalitis (AIE) is a group of inflammatory diseases characterized by the presence of antibodies against neuronal and glial antigens, leading to subacute psychiatric symptoms, memory complaints, and movement disorders. The patients are predominantly young, and delays in treatment are associated with worse prognosis. OBJECTIVE With the support of the Brazilian Academy of Neurology (Academia Brasileira de Neurologia, ABN) and the Brazilian Society of Child Neurology (Sociedade Brasileira de Neurologia Infantil, SBNI), a consensus on the diagnosis and treatment of AIE in Brazil was developed using the Delphi method. METHODS A total of 25 panelists, including adult and child neurologists, participated in the study. RESULTS The panelists agreed that patients fulfilling criteria for possible AIE should be screened for antineuronal antibodies in the serum and cerebrospinal fluid (CSF) using the tissue-based assay (TBA) and cell-based assay (CBA) techniques. Children should also be screened for anti-myelin oligodendrocyte glucoprotein antibodies (anti-MOG). Treatment should be started within the first 4 weeks of symptoms. The first-line option is methylprednisolone plus intravenous immunoglobulin (IVIG) or plasmapheresis, the second-line includes rituximab and/or cyclophosphamide, while third-line treatment options are bortezomib and tocilizumab. Most seizures in AIE are symptomatic, and antiseizure medications may be weaned after the acute stage. In anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis, the panelists have agreed that oral immunosuppressant agents should not be used. Patients should be evaluated at the acute and postacute stages using functional and cognitive scales, such as the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA), the Modified Rankin Scale (mRS), and the Clinical Assessment Scale in Autoimmune Encephalitis (CASE). CONCLUSION The present study provides tangible evidence for the effective management of AIE patients within the Brazilian healthcare system.
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Affiliation(s)
- Lívia Almeida Dutra
- Hospital Israelita Albert Einstein, Instituto do Cérebro, São Paulo, São Paulo SP, Brazil
| | | | | | | | - Fabio Fieni Toso
- Hospital Israelita Albert Einstein, Instituto do Cérebro, São Paulo, São Paulo SP, Brazil
| | | | - Doralina Guimarães Brum
- Universidade Estadual Paulista, Faculdade de Medicina de Botucatu, Departamento de Neurologia, Psicologia e Psiquiatria, Botucatu SP, Brazil
| | - Samira Luisa Dos Apóstolos Pereira
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil
| | - Tarso Adoni
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil
| | | | | | | | - Renata Barbosa Paolilo
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, São Paulo SP, Brazil
| | - Angélica Dal Pizzol
- Hospital Moinhos de Vento, Departamento de Neurologia, Porto Alegre RS, Brazil
| | - Bruna Klein da Costa
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre RS, Brazil
- Santa Casa de Misericórdia de Porto Alegre, Porto Alegre RS, Brazil
| | - Caio César Diniz Disserol
- Universidade Federal do Paraná, Hospital das Clínicas, Curitiba PR, Brazil
- Instituto de Neurologia de Curitiba, Curitiba PR, Brazil
| | - Camila Pupe
- Universidade Federal Fluminense, Niterói RJ, Brazil
| | | | | | | | | | | | | | | | - Guilherme Diogo Silva
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil
| | - Katia Lin
- Universidade Federal de Santa Catarina, Florianópolis SC, Brazil
| | - Lécio Figueira Pinto
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil
| | | | | | | | | | | | | | | | | | | | - Vanessa Daccach
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto SP, Brazil
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Wu X, Zhang H, Shi M, Fang S. Clinical features in antiglycine receptor antibody-related disease: a case report and update literature review. Front Immunol 2024; 15:1387591. [PMID: 38953026 PMCID: PMC11215014 DOI: 10.3389/fimmu.2024.1387591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 06/06/2024] [Indexed: 07/03/2024] Open
Abstract
Background and objectives Antiglycine receptor (anti-GlyR) antibody mediates multiple immune-related diseases. This study aimed to summarize the clinical features to enhance our understanding of anti-GlyR antibody-related disease. Methods By collecting clinical information from admitted patients positive for glycine receptor (GlyR) antibody, the clinical characteristics of a new patient positive for GlyR antibody were reported in this study. To obtain additional information regarding anti-GlyR antibody-linked illness, clinical data and findings on both newly reported instances in this study and previously published cases were merged and analyzed. Results A new case of anti-GlyR antibody-related progressive encephalomyelitis with rigidity and myoclonus (PERM) was identified in this study. A 20-year-old man with only positive cerebrospinal fluid anti-GlyR antibody had a good prognosis with first-line immunotherapy. The literature review indicated that the common clinical manifestations of anti-GlyR antibody-related disease included PERM or stiff-person syndrome (SPS) (n = 179, 50.1%), epileptic seizure (n = 94, 26.3%), and other neurological disorders (n = 84, 24.5%). Other neurological issues included demyelination, inflammation, cerebellar ataxia and movement disorders, encephalitis, acute psychosis, cognitive impairment or dementia, celiac disease, Parkinson's disease, neuropathic pain and allodynia, steroid-responsive deafness, hemiballism/tics, laryngeal dystonia, and generalized weakness included respiratory muscles. The group of PERM/SPS exhibited a better response to immunotherapy than others. Conclusions The findings suggest the presence of multiple clinical phenotypes in anti-GlyR antibody-related disease. Common clinical phenotypes include PERM, SPS, epileptic seizure, and paraneoplastic disease. Patients with RERM/SPS respond well to immunotherapy.
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Affiliation(s)
- Xiaoke Wu
- Department of Neurology, Neuroscience Centre, The First Hospital of Jilin University, Changchun, China
| | - Haifeng Zhang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mengmeng Shi
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shaokuan Fang
- Department of Neurology, Neuroscience Centre, The First Hospital of Jilin University, Changchun, China
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Papi C, Milano C, Spatola M. Mechanisms of autoimmune encephalitis. Curr Opin Neurol 2024; 37:305-315. [PMID: 38667756 DOI: 10.1097/wco.0000000000001270] [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: 04/30/2024]
Abstract
PURPOSE OF REVIEW To provide an overview of the pathogenic mechanisms involved in autoimmune encephalitides mediated by antibodies against neuronal surface antigens, with a focus on NMDAR and LGI1 encephalitis. RECENT FINDINGS In antibody-mediated encephalitides, binding of IgG antibodies to neuronal surface antigens results in different pathogenic effects depending on the type of antibody, IgG subclass and epitope specificity. NMDAR IgG1 antibodies cause crosslinking and internalization of the target, synaptic and brain circuitry alterations, as well as alterations of NMDAR expressing oligodendrocytes, suggesting a link with white matter lesions observed in MRI studies. LGI1 IgG4 antibodies, instead, induce neuronal dysfunction by disrupting the interaction with cognate proteins and altering AMPAR-mediated signaling. In-vitro findings have been corroborated by memory and behavioral changes in animal models obtained by passive transfer of patients' antibodies or active immunization. These models have been fundamental to identify targets for innovative therapeutic strategies, aimed at counteracting or preventing antibody effects, such as the use of soluble ephrin-B2, NMDAR modulators (e.g., pregnenolone, SGE-301) or chimeric autoantibody receptor T cells (CAART) in models of NMDAR encephalitis. SUMMARY A deep understanding of the pathogenic mechanisms underlying antibody-mediated encephalitides is crucial for the development of new therapeutic approaches targeting brain autoimmunity.
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Affiliation(s)
- Claudia Papi
- Department of Neuroscience, Catholic University of the Sacred Heart, Rome, Italy
- Fundació Recerca Biomedica Clinic - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRBC-IDIBAPS), Barcelona, Spain
| | - Chiara Milano
- Fundació Recerca Biomedica Clinic - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRBC-IDIBAPS), Barcelona, Spain
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Marianna Spatola
- Fundació Recerca Biomedica Clinic - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRBC-IDIBAPS), Barcelona, Spain
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Liu J, Huang Y, Qian T, Chen J, Ding Y, Lai Z, Zhong X, Lai M, Zhang H, Wang Y, Wang H, Peng Y. Exploring the neuroprotective role of artesunate in mouse models of anti-NMDAR encephalitis: insights from molecular mechanisms and transmission electron microscopy. Cell Commun Signal 2024; 22:269. [PMID: 38745240 PMCID: PMC11094908 DOI: 10.1186/s12964-024-01652-4] [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: 02/20/2024] [Accepted: 05/06/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND The pathway involving PTEN-induced putative kinase 1 (PINK1) and PARKIN plays a crucial role in mitophagy, a process activated by artesunate (ART). We propose that patients with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis exhibit insufficient mitophagy, and ART enhances mitophagy via the PINK1/PARKIN pathway, thereby providing neuroprotection. METHODS Adult female mice aged 8-10 weeks were selected to create a passive transfer model of anti-NMDAR encephalitis. We conducted behavioral tests on these mice within a set timeframe. Techniques such as immunohistochemistry, immunofluorescence, and western blotting were employed to assess markers including PINK1, PARKIN, LC3B, p62, caspase3, and cleaved caspase3. The TUNEL assay was utilized to detect neuronal apoptosis, while transmission electron microscopy (TEM) was used to examine mitochondrial autophagosomes. Primary hippocampal neurons were cultured, treated, and then analyzed through immunofluorescence for mtDNA, mtROS, TMRM. RESULTS In comparison to the control group, mitophagy levels in the experimental group were not significantly altered, yet there was a notable increase in apoptotic neurons. Furthermore, markers indicative of mitochondrial leakage and damage were found to be elevated in the experimental group compared to the control group, but these markers showed improvement following ART treatment. ART was effective in activating the PINK1/PARKIN pathway, enhancing mitophagy, and diminishing neuronal apoptosis. Behavioral assessments revealed that ART ameliorated symptoms in mice with anti-NMDAR encephalitis in the passive transfer model (PTM). The knockdown of PINK1 led to a reduction in mitophagy levels, and subsequent ART intervention did not alleviate symptoms in the anti-NMDAR encephalitis PTM mice, indicating that ART's therapeutic efficacy is mediated through the activation of the PINK1/PARKIN pathway. CONCLUSIONS At the onset of anti-NMDAR encephalitis, mitochondrial damage is observed; however, this damage is mitigated by the activation of mitophagy via the PINK1/PARKIN pathway. This regulatory feedback mechanism facilitates the removal of damaged mitochondria, prevents neuronal apoptosis, and consequently safeguards neural tissue. ART activates the PINK1/PARKIN pathway to enhance mitophagy, thereby exerting neuroprotective effects and may achieve therapeutic goals in treating anti-NMDAR encephalitis.
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Affiliation(s)
- Jingsi Liu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Yingyi Huang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Department of Neurology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510641, China
| | - Tinglin Qian
- School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, 510515, China
| | - Jinyu Chen
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Yuewen Ding
- School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, 510515, China
| | - Zhaohui Lai
- Department of Neurology, Ganzhou People's Hospital, Ganzhou, 341000, China
| | - Xinghua Zhong
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Mingjun Lai
- Department of Neurology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510641, China
| | - Huili Zhang
- Department of Neurology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510641, China
| | - Yuanyuan Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| | - Honghao Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| | - Yu Peng
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
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Chen X, Di L, Qian M, Shen D, Feng X, Zhang X. Neurological features of Hansen disease: a retrospective, multicenter cohort study. Sci Rep 2024; 14:10374. [PMID: 38710787 PMCID: PMC11074337 DOI: 10.1038/s41598-024-60457-0] [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: 11/28/2023] [Accepted: 04/23/2024] [Indexed: 05/08/2024] Open
Abstract
To elucidate the neurological features of Hansen disease. The medical records of patients with confirmed Hansen disease transferred from the neurology department were reviewed, and all medical and neurological manifestations of Hansen disease were assessed. Eleven patients with confirmed Hansen disease, 10 with newly detected Hansen disease and 1 with relapsed Hansen disease, who visited neurology departments were enrolled. The newly detected patients with Hansen disease were classified as having lepromatous leprosy (LL, n = 1), borderline lepromatous leprosy (BL, n = 2), borderline leprosy (BB, n = 2), borderline tuberculoid leprosy (BT, n = 1), tuberculoid leprosy (TT, n = 2), or pure neural leprosy (PNL, n = 2). All of the patients with confirmed Hansen were diagnosed with peripheral neuropathy (100.00%, 11/11). The symptoms and signs presented were mainly limb numbness (100.00%, 11/11), sensory and motor dysfunction (100.00%, 11/11), decreased muscle strength (90.90%, 10/11), and skin lesions (81.81%, 9/11). Nerve morphological features in nerve ultrasonography (US) included peripheral nerve asymmetry and segmental thickening (100.00%, 9/9). For neuro-electrophysiology feature, the frequency of no response of sensory nerves was significantly higher than those of motor nerves [(51.21% 42/82) vs (24.70%, 21/85)(P = 0.0183*)] by electrodiagnostic (EDX) studies. Nerve histological features in nerve biopsy analysis included demyelination (100.00%, 5/5) and axonal damage (60.00%, 3/5). In addition to confirmed diagnoses by acid-fast bacteria (AFB) staining (54.54%, 6/11) and skin pathology analysis (100.00%, 8/8), serology and molecular technology were positive in 36.36% (4/11) and 100.00% (11/11) of confirmed patients of Hansen disease, respectively. It is not uncommon for patients of Hansen disease to visit neurology departments due to peripheral neuropathy. The main pathological features of affected nerves are demyelination and axonal damage. The combination of nerve US, EDX studies, nerve biopsy, and serological and molecular tests can improve the diagnosis of Hansen disease.
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Affiliation(s)
- Xiaohua Chen
- Leprosy Department, Beijing Tropical Medicine Research Institute, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
- Beijing Key Laboratory for Research On Prevention and Treatment of Tropical Diseases, Capital Medical University, Beijing, China.
| | - Li Di
- Department of Neurology, Beijing Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Min Qian
- Department of Neurology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, China
| | - Dongchao Shen
- Department of Neurology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, China
| | - Xinhong Feng
- Department of Neurology, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Xiqing Zhang
- Department of Neurology, Beijing Junyi Traditional Chinese Medicine Hospital, Beijing, China
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16
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Alshutaihi MS, Mazketly M, Tabbakh M, Akkash N, Bahro T, Alsaman MZB. Mimickers of autoimmune encephalitis: a literature review. J Int Med Res 2024; 52:3000605241248050. [PMID: 38775376 PMCID: PMC11140194 DOI: 10.1177/03000605241248050] [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: 11/20/2023] [Accepted: 04/02/2024] [Indexed: 05/25/2024] Open
Abstract
Autoimmune encephalitis (AIE) is a rapid, progressive neurological disorder characterized by nervous system inflammation. While the Graus criteria are the best known criteria for AIE diagnosis, other differential diagnoses meeting the Graus criteria must be considered before management. This narrative review discusses the most common etiologies that resemble AIE. We suggest routine exclusion of mimickers meeting the Graus criteria before confirming an AIE diagnosis. We reviewed 28 studies including 356 patients. The main initial diagnosis was AIE, then paraneoplastic limbic encephalitis and anti-N-methyl-D-aspartate receptor encephalitis. Only 194 patients met the possible Graus criteria. The most frequent conditions among the total population were dementia, other neurodegenerative diseases, and psychiatric and functional neurological disorders. AIE is often misdiagnosed, leading to unnecessary treatment. Despite publication of the Graus criteria, medical cases mimicking this condition are being published. Many neurological diseases entering the differential diagnosis of AIE could be excluded through a detailed history, neurological examination, laboratory analysis, and other investigations, including cerebrospinal fluid and brain magnetic resonance imaging. However, some differential diagnoses complied with the possible Graus criteria, with some having concurrent antineuronal antibodies, which were considered true mimickers. AIE diagnosis suspicion is primarily clinical, but a definitive diagnosis requires various diagnostic tools.
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Affiliation(s)
- Mohamad Sami Alshutaihi
- Division of Neurology, Department of Internal Medicine, Aleppo University Hospital, Aleppo, Syria
| | - Muhammad Mazketly
- Department of Internal Medicine, Aleppo University Hospital, Aleppo, Syria
| | - Mohannad Tabbakh
- Department of Internal Medicine, Aleppo University Hospital, Aleppo, Syria
| | - Nour Akkash
- Division of Neurology, Department of Internal Medicine, Aleppo University Hospital, Aleppo, Syria
| | - Tuqa Bahro
- Division of Neurology, Department of Internal Medicine, Aleppo University Hospital, Aleppo, Syria
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17
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Sanvito F, Pichiecchio A, Paoletti M, Rebella G, Resaz M, Benedetti L, Massa F, Morbelli S, Caverzasi E, Asteggiano C, Businaro P, Masciocchi S, Castellan L, Franciotta D, Gastaldi M, Roccatagliata L. Autoimmune encephalitis: what the radiologist needs to know. Neuroradiology 2024; 66:653-675. [PMID: 38507081 PMCID: PMC11031487 DOI: 10.1007/s00234-024-03318-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/20/2024] [Indexed: 03/22/2024]
Abstract
Autoimmune encephalitis is a relatively novel nosological entity characterized by an immune-mediated damage of the central nervous system. While originally described as a paraneoplastic inflammatory phenomenon affecting limbic structures, numerous instances of non-paraneoplastic pathogenesis, as well as extra-limbic involvement, have been characterized. Given the wide spectrum of insidious clinical presentations ranging from cognitive impairment to psychiatric symptoms or seizures, it is crucial to raise awareness about this disease category. In fact, an early diagnosis can be dramatically beneficial for the prognosis both to achieve an early therapeutic intervention and to detect a potential underlying malignancy. In this scenario, the radiologist can be the first to pose the hypothesis of autoimmune encephalitis and refer the patient to a comprehensive diagnostic work-up - including clinical, serological, and neurophysiological assessments.In this article, we illustrate the main radiological characteristics of autoimmune encephalitis and its subtypes, including the typical limbic presentation, the features of extra-limbic involvement, and also peculiar imaging findings. In addition, we review the most relevant alternative diagnoses that should be considered, ranging from other encephalitides to neoplasms, vascular conditions, and post-seizure alterations. Finally, we discuss the most appropriate imaging diagnostic work-up, also proposing a suggested MRI protocol.
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Affiliation(s)
- Francesco Sanvito
- Unit of Radiology, Department of Clinical, Surgical, Diagnostic, and Paediatric Sciences, University of Pavia, Viale Camillo Golgi, 19, 27100, Pavia, Italy.
- UCLA Brain Tumor Imaging Laboratory (BTIL), Center for Computer Vision and Imaging Biomarkers, University of California Los Angeles, Los Angeles, CA, USA.
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | - Anna Pichiecchio
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Matteo Paoletti
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Giacomo Rebella
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Martina Resaz
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Luana Benedetti
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Federico Massa
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Largo Daneo 3, 16132, Genoa, Italy
| | - Silvia Morbelli
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Via Antonio Pastore 1, 16132, Genoa, Italy
| | - Eduardo Caverzasi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Carlo Asteggiano
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Pietro Businaro
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Stefano Masciocchi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Lucio Castellan
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Diego Franciotta
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Luca Roccatagliata
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Via Antonio Pastore 1, 16132, Genoa, Italy
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Dinoto A, Trentinaglia M, Carta S, Mantovani E, Ferrari S, Tamburin S, Tinazzi M, Mariotto S. Autoimmune Movement Disorders Complicating Treatment with Immune Checkpoint Inhibitors. Mov Disord Clin Pract 2024; 11:543-549. [PMID: 38400610 PMCID: PMC11078485 DOI: 10.1002/mdc3.14003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/05/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) may trigger autoimmune neurological conditions, including movement disorders (MD). OBJECTIVES The aim of this study was to characterize MDs occurring as immune-related adverse events (irAEs) of ICIs. METHODS A systematic literature review of case reports/series of MDs as irAEs of ICIs was performed. RESULTS Of 5682 eligible papers, 26 articles with 28 patients were included. MDs occur as a rare complication of cancer immunotherapy with heterogeneous clinical presentations and in most cases in association with other irAEs. Inflammatory basal ganglia T2/fluid attenuated inversion recovery abnormalities are rarely observed, but brain imaging is frequently unrevealing. Cerebrospinal fluid findings are frequently suggestive of inflammation. Half of cases are associated with a wide range of autoantibodies. Steroids and ICI withdrawal usually lead to improvement, even though some patients experienced relapses or a severe clinical course. CONCLUSION MDs are a rare complication of ICIs that should be promptly recognized to offer patients a correct diagnosis and treatment.
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Affiliation(s)
- Alessandro Dinoto
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement SciencesUniversity of VeronaVeronaItaly
| | - Milena Trentinaglia
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement SciencesUniversity of VeronaVeronaItaly
| | - Sara Carta
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement SciencesUniversity of VeronaVeronaItaly
| | - Elisa Mantovani
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement SciencesUniversity of VeronaVeronaItaly
| | - Sergio Ferrari
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement SciencesUniversity of VeronaVeronaItaly
| | - Stefano Tamburin
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement SciencesUniversity of VeronaVeronaItaly
| | - Michele Tinazzi
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement SciencesUniversity of VeronaVeronaItaly
| | - Sara Mariotto
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement SciencesUniversity of VeronaVeronaItaly
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Legouy C, Cervantes A, Sonneville R, Thakur KT. Autoimmune and inflammatory neurological disorders in the intensive care unit. Curr Opin Crit Care 2024; 30:142-150. [PMID: 38441114 DOI: 10.1097/mcc.0000000000001139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW The present review summarizes the diagnostic approach to autoimmune encephalitis (AE) in the intensive care unit (ICU) and provides practical guidance on therapeutic management. RECENT FINDINGS Autoimmune encephalitis represents a group of immune-mediated brain diseases associated with antibodies that are pathogenic against central nervous system proteins. Recent findings suggests that the diagnosis of AE requires a multidisciplinary approach including appropriate recognition of common clinical syndromes, brain imaging and electroencephalography to confirm focal pathology, and cerebrospinal fluid and serum tests to rule out common brain infections, and to detect autoantibodies. ICU admission may be necessary at AE onset because of altered mental status, refractory seizures, and/or dysautonomia. Early management in ICU includes prompt initiation of immunotherapy, detection and treatment of seizures, and supportive care with neuromonitoring. In parallel, screening for neoplasm should be systematically performed. Despite severe presentation, epidemiological studies suggest that functional recovery is likely under appropriate therapy, even after prolonged ICU stays. CONCLUSION AE and related disorders are increasingly recognized in the ICU population. Critical care physicians should be aware of these conditions and consider them early in the differential diagnosis of patients presenting with unexplained encephalopathy. A multidisciplinary approach is mandatory for diagnosis, ICU management, specific therapy, and prognostication.
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Affiliation(s)
- Camille Legouy
- GHU Paris Psychiatrie & Neurosciences, Department of Intensive Care Medicine, Paris, France
| | - Anna Cervantes
- Divisions of Neurocritical Care and Neuroinfectious Disease, Boston Medical Center, Boston, Massachusetts, USA
| | - Romain Sonneville
- Université Paris Cité, IAME, INSERM UMR1137
- AP-HP, Hôpital Bichat - Claude Bernard, Department of Intensive Care Medicine, Paris, France
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, New York, USA
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20
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Peng W, Wang M, Shi W, Wang J, Zhou D, Li J. Performance of assessment tools in predicting neural autoantibody positivity in patients with seizures. Int Immunopharmacol 2024; 130:111763. [PMID: 38412674 DOI: 10.1016/j.intimp.2024.111763] [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: 11/24/2023] [Revised: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND The identification of patients with seizures of unknown etiology who would benefit from neural antibody testing necessitates effective assessment tools. The study aimed to compare the performance of the Antibody Prevalence in Epilepsy and Encephalopathy (APE2) score and the "Obvious" Indications for Neural Antibody Testing in Epilepsy or Seizures (ONES) checklist. We also intended to evaluate whether the performance of the tools varied by types of antibody. METHODS Patients diagnosed with epilepsy, seizures, or status epilepticus of unknown etiology at West China Hospital from January 2019 to December 2021 were included. Paired serum/cerebrospinal fluid samples were analyzed for antineuronal and antiglial antibodies. The APE2 score and ONES checklist were applied, and their outcomes were compared to laboratory antibody test results. Possible false positive neuronal antibody results were excluded in sensitivity/specificity analysis reasonably. RESULTS A total of 113 antibody-positive and 159 antibody-negative patients were enrolled in sensitivity/specificity analysis. The ONES checklist showed superior sensitivity than APE2 score (95.6 % vs.79.6 %, P < 0.001). Specificity was not statistically different (60.4 % vs. 57.9 %, P = 0.557). The negative predictive value (NPV) of ONES checklist was higher than that of APE2 score (94.8 % vs 80.7 %, P < 0.001). The positive predictive value of them was not statistically different (61.7 % vs 58.8 %, P = 0.557). APE2 score exhibited lower sensitivity for predicting LGI-Abs (52.9 % vs. 80.3 %, P = 0.022) compared to NMDAR-Abs. Similarly, ONES checklist showed lower sensitivity for LGI1-Abs than NMDAR-Abs (82.4 % vs. 100.0 %, P = 0.009). CONCLUSIONS The ONES checklist demonstrates superior sensitivity for neural antibody positivity than APE2 score. Specificity of the two assessment tools was similar. ONES checklist performed better NPV than the APE2 score. Both assessment tools performed less well in predicting the presence of LGI1- Abs when compared to NMDAR-Abs.
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Affiliation(s)
- Wei Peng
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China.
| | - Minjin Wang
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China; Department of Laboratory Medicine, West China Hospital, Sichuan University, 610041, China.
| | - Wenyan Shi
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China.
| | - Jierui Wang
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China.
| | - Dong Zhou
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China.
| | - Jinmei Li
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China.
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21
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Zhang M, Meng H, Zhou Q, Chunyu H, He L, Meng H, Wang H, Wang Y, Sun C, Xi Y, Hai W, Huang Q, Li B, Chen S. Microglial Activation Imaging Using 18F-DPA-714 PET/MRI for Detecting Autoimmune Encephalitis. Radiology 2024; 310:e230397. [PMID: 38441089 DOI: 10.1148/radiol.230397] [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: 03/07/2024]
Abstract
Background Translocator protein (TSPO) PET has been used to visualize microglial activation in neuroinflammation and is a potential imaging tool for detecting autoimmune encephalitis (AIE). Purpose To compare the detection rate between TSPO radioligand fluorine 18 (18F) DPA-714 PET and conventional MRI and assess the relationship between 18F-DPA-714 uptake and clinical features in participants with AIE. Materials and Methods Healthy volunteers and patients with AIE were enrolled in this prospective study between December 2021 and April 2023. All participants underwent hybrid brain 18F-DPA-714 PET/MRI and antibody testing. Modified Rankin scale scoring and AIE-related symptoms were assessed in participants with AIE. Positive findings were defined as intensity of 18F-DPA-714 uptake above a threshold of the mean standardized uptake value ratio (SUVR) plus 2 SD inside the corresponding brain regions of healthy controls. The McNemar test was used to compare the positive detection rate between the two imaging modalities; the independent samples t test was used to compare continuous variables; and correlation with Bonferroni correction was used to assess the relationship between 18F-DPA-714 uptake and clinical features. Results A total of 25 participants with AIE (mean age, 39.24 years ± 19.03 [SD]) and 10 healthy controls (mean age, 28.70 years ± 5.14) were included. The positive detection rate of AIE was 72% (18 of 25) using 18F-DPA-714 PET compared to 44% (11 of 25) using conventional MRI, but the difference was not statistically significant (P = .065). Participants experiencing seizures exhibited significantly higher mean SUVR in the entire cortical region than those without seizures (1.23 ± 0.21 vs 1.15 ± 0.18; P = .003). Of the 13 participants with AIE who underwent follow-up PET/MRI, 11 (85%) demonstrated reduced uptake of 18F-DPA-714 accompanied by relief of symptoms after immunosuppressive treatment. Conclusion 18F-DPA-714 PET has potential value in supplementing MRI for AIE detection. Clinical trial registration no. NCT05293405 © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Zaharchuk in this issue.
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Affiliation(s)
- Min Zhang
- From the Departments of Nuclear Medicine (M.Z., H.C., Hongping Meng, Y.W., C.S., Y.X., W.H., B.L.) and Neurology (Huanyu Meng, Q.Z., L.H., S.C.), Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Rd, Shanghai, China; Shanxi Medical University-Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, China (M.Z., B.L.); School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China (H.W., Q.H.); and Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, China (S.C.)
| | - Huanyu Meng
- From the Departments of Nuclear Medicine (M.Z., H.C., Hongping Meng, Y.W., C.S., Y.X., W.H., B.L.) and Neurology (Huanyu Meng, Q.Z., L.H., S.C.), Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Rd, Shanghai, China; Shanxi Medical University-Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, China (M.Z., B.L.); School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China (H.W., Q.H.); and Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, China (S.C.)
| | - Qinming Zhou
- From the Departments of Nuclear Medicine (M.Z., H.C., Hongping Meng, Y.W., C.S., Y.X., W.H., B.L.) and Neurology (Huanyu Meng, Q.Z., L.H., S.C.), Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Rd, Shanghai, China; Shanxi Medical University-Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, China (M.Z., B.L.); School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China (H.W., Q.H.); and Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, China (S.C.)
| | - Hangxing Chunyu
- From the Departments of Nuclear Medicine (M.Z., H.C., Hongping Meng, Y.W., C.S., Y.X., W.H., B.L.) and Neurology (Huanyu Meng, Q.Z., L.H., S.C.), Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Rd, Shanghai, China; Shanxi Medical University-Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, China (M.Z., B.L.); School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China (H.W., Q.H.); and Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, China (S.C.)
| | - Lu He
- From the Departments of Nuclear Medicine (M.Z., H.C., Hongping Meng, Y.W., C.S., Y.X., W.H., B.L.) and Neurology (Huanyu Meng, Q.Z., L.H., S.C.), Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Rd, Shanghai, China; Shanxi Medical University-Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, China (M.Z., B.L.); School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China (H.W., Q.H.); and Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, China (S.C.)
| | - Hongping Meng
- From the Departments of Nuclear Medicine (M.Z., H.C., Hongping Meng, Y.W., C.S., Y.X., W.H., B.L.) and Neurology (Huanyu Meng, Q.Z., L.H., S.C.), Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Rd, Shanghai, China; Shanxi Medical University-Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, China (M.Z., B.L.); School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China (H.W., Q.H.); and Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, China (S.C.)
| | - Hanzhong Wang
- From the Departments of Nuclear Medicine (M.Z., H.C., Hongping Meng, Y.W., C.S., Y.X., W.H., B.L.) and Neurology (Huanyu Meng, Q.Z., L.H., S.C.), Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Rd, Shanghai, China; Shanxi Medical University-Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, China (M.Z., B.L.); School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China (H.W., Q.H.); and Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, China (S.C.)
| | - Yue Wang
- From the Departments of Nuclear Medicine (M.Z., H.C., Hongping Meng, Y.W., C.S., Y.X., W.H., B.L.) and Neurology (Huanyu Meng, Q.Z., L.H., S.C.), Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Rd, Shanghai, China; Shanxi Medical University-Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, China (M.Z., B.L.); School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China (H.W., Q.H.); and Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, China (S.C.)
| | - Chenwei Sun
- From the Departments of Nuclear Medicine (M.Z., H.C., Hongping Meng, Y.W., C.S., Y.X., W.H., B.L.) and Neurology (Huanyu Meng, Q.Z., L.H., S.C.), Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Rd, Shanghai, China; Shanxi Medical University-Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, China (M.Z., B.L.); School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China (H.W., Q.H.); and Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, China (S.C.)
| | - Yun Xi
- From the Departments of Nuclear Medicine (M.Z., H.C., Hongping Meng, Y.W., C.S., Y.X., W.H., B.L.) and Neurology (Huanyu Meng, Q.Z., L.H., S.C.), Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Rd, Shanghai, China; Shanxi Medical University-Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, China (M.Z., B.L.); School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China (H.W., Q.H.); and Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, China (S.C.)
| | - Wangxi Hai
- From the Departments of Nuclear Medicine (M.Z., H.C., Hongping Meng, Y.W., C.S., Y.X., W.H., B.L.) and Neurology (Huanyu Meng, Q.Z., L.H., S.C.), Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Rd, Shanghai, China; Shanxi Medical University-Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, China (M.Z., B.L.); School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China (H.W., Q.H.); and Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, China (S.C.)
| | - Qiu Huang
- From the Departments of Nuclear Medicine (M.Z., H.C., Hongping Meng, Y.W., C.S., Y.X., W.H., B.L.) and Neurology (Huanyu Meng, Q.Z., L.H., S.C.), Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Rd, Shanghai, China; Shanxi Medical University-Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, China (M.Z., B.L.); School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China (H.W., Q.H.); and Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, China (S.C.)
| | - Biao Li
- From the Departments of Nuclear Medicine (M.Z., H.C., Hongping Meng, Y.W., C.S., Y.X., W.H., B.L.) and Neurology (Huanyu Meng, Q.Z., L.H., S.C.), Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Rd, Shanghai, China; Shanxi Medical University-Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, China (M.Z., B.L.); School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China (H.W., Q.H.); and Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, China (S.C.)
| | - Sheng Chen
- From the Departments of Nuclear Medicine (M.Z., H.C., Hongping Meng, Y.W., C.S., Y.X., W.H., B.L.) and Neurology (Huanyu Meng, Q.Z., L.H., S.C.), Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Rd, Shanghai, China; Shanxi Medical University-Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, China (M.Z., B.L.); School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China (H.W., Q.H.); and Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, China (S.C.)
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22
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Budhram A, Irani SR, Flanagan EP. Looking Beyond Syndrome-Based Criteria for Autoimmune Encephalitis-The Need for Complementary Neural Antibody-Based Diagnostic Criteria. JAMA Neurol 2024; 81:227-228. [PMID: 38147324 DOI: 10.1001/jamaneurol.2023.4894] [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: 12/27/2023]
Abstract
This Viewpoint discusses how neural antibody–based diagnostic criteria for autoimmune encephalitis would complement the syndrome-based diagnostic algorithm to improve sensitivity while maintaining high specificity.
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Affiliation(s)
- Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, Ontario, Canada
- Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Sarosh R Irani
- Department of Neurology, Mayo Clinic, Jacksonville, Florida
- Department of Neuroscience, Mayo Clinic, Jacksonville, Florida
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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23
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Shim YM, Kim SI, Lim SD, Lee K, Kim EE, Won JK, Park SH. An Autopsy-proven Case-based Review of Autoimmune Encephalitis. Exp Neurobiol 2024; 33:1-17. [PMID: 38471800 PMCID: PMC10938074 DOI: 10.5607/en23036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
Autoimmune encephalitis (AIE) is a type of immunoreactive encephalitic disorder and is recognized as the most prevalent noninfectious encephalitis. Nevertheless, the rarity of definitive AIE diagnosis through biopsy or autopsy represents a significant hurdle to understanding and managing the disease. In this article, we present the pathological findings of AIE and review the literature based on a distinct case of AIE presenting as CD8+ T-lymphocyte predominant encephalitis. We describe the clinical progression, diagnostic imaging, laboratory data, and autopsy findings of an 80-year-old deceased male patient. The patient was diagnosed with pulmonary tuberculosis 6 months before death and received appropriate medications. A week before admission to the hospital, the patient manifested symptoms such as a tendency to sleep, decreased appetite, and confusion. Although the patient temporally improved with medication including correction of hyponatremia, the patient progressed rapidly and died in 6 weeks. The brain tissue revealed lymphocytic infiltration in the gray and white matter, leptomeninges, and perivascular infiltration with a predominance of CD8+ T lymphocytes, suggesting a case of AIE. There was no detectable evidence of viral infection or underlying neoplasm. The autopsy revealed that this patient also had Alzheimer's disease, atherosclerosis, arteriolosclerosis, and aging-related tau astrogliopathy. This report emphasizes the pivotal role of pathological examination in the diagnosis of AIE, especially when serological autoantibody testing is not available or when a patient is suspected of having multiple diseases.
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Affiliation(s)
- Yu-Mi Shim
- Department of Pathology, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Seong-Ik Kim
- Department of Pathology, Seoul National University College of Medicine, Seoul 03080, Korea
| | - So Dug Lim
- Department of Pathology, KonKuk University School of Medicine, Seoul 05029, Korea
| | - Kwanghoon Lee
- Department of Pathology, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Eric Eunshik Kim
- Department of Pathology, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Jae Kyung Won
- Department of Pathology, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Sung-Hye Park
- Department of Pathology, Seoul National University College of Medicine, Seoul 03080, Korea
- Institute of Neuroscience, Seoul National University College of Medicine, Seoul 03080, Korea
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24
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Hahn C, Budhram A, Alikhani K, AlOhaly N, Beecher G, Blevins G, Brooks J, Carruthers R, Comtois J, Cowan J, de Robles P, Hébert J, Kapadia RK, Lapointe S, Mackie A, Mason W, McLane B, Muccilli A, Poliakov I, Smyth P, Williams KG, Uy C, McCombe JA. Canadian Consensus Guidelines for the Diagnosis and Treatment of Autoimmune Encephalitis in Adults. Can J Neurol Sci 2024:1-21. [PMID: 38312020 DOI: 10.1017/cjn.2024.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Abstract
Autoimmune encephalitis is increasingly recognized as a neurologic cause of acute mental status changes with similar prevalence to infectious encephalitis. Despite rising awareness, approaches to diagnosis remain inconsistent and evidence for optimal treatment is limited. The following Canadian guidelines represent a consensus and evidence (where available) based approach to both the diagnosis and treatment of adult patients with autoimmune encephalitis. The guidelines were developed using a modified RAND process and included input from specialists in autoimmune neurology, neuropsychiatry and infectious diseases. These guidelines are targeted at front line clinicians and were created to provide a pragmatic and practical approach to managing such patients in the acute setting.
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Affiliation(s)
- Christopher Hahn
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Adrian Budhram
- Clinical Neurological Sciences, London Health Sciences Centre, London, ON, Canada
- Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada
| | - Katayoun Alikhani
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Nasser AlOhaly
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Grayson Beecher
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - Gregg Blevins
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - John Brooks
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Robert Carruthers
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Jacynthe Comtois
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Juthaporn Cowan
- Division of Infectious Diseases, Department of Medicine Ottawa Hospital, Ottawa, ON, Canada
| | - Paula de Robles
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Julien Hébert
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Ronak K Kapadia
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Sarah Lapointe
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Aaron Mackie
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Warren Mason
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Brienne McLane
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | | | - Ilia Poliakov
- Division of Neurology, University of Saskatchewan College of Medicine, Saskatoon, SK, Canada
| | - Penelope Smyth
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | | | - Christopher Uy
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
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25
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Sullivan MI, Gupta MJ, Taylor KA, Van Mater HA, Pizoli CE. Disease Course and Response to Immunotherapy in Children With Childhood Disintegrative Disorder: A Retrospective Case Series. J Child Neurol 2024; 39:11-21. [PMID: 38115714 DOI: 10.1177/08830738231220278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
Childhood disintegrative disorder is a poorly understood neurobehavioral disorder of early childhood characterized by acute to subacute profound regression in previously developed language, social behavior, and adaptive functions. The etiology of childhood disintegrative disorder remains unknown and treatment is focused on symptomatic management. Interest in neuroinflammatory mechanisms has grown with the increased recognition of autoimmune brain diseases and similarities between the presenting symptoms of childhood disintegrative disorder and pediatric autoimmune encephalitis. Importantly, a diagnosis of pediatric autoimmune encephalitis requires evidence of inflammation on paraclinical testing, which is absent in childhood disintegrative disorder. Here we report 5 children with childhood disintegrative disorder who were initially diagnosed with possible autoimmune encephalitis and treated with immunotherapy. Two children had provocative improvements, whereas 3 did not change significantly on immunotherapy. Additionally, a sixth patient with childhood disintegrative disorder evaluated in our Autoimmune Brain Disease Clinic showed spontaneous improvement and is included to highlight the variable natural history of childhood disintegrative disorder that may mimic treatment responsiveness.
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Affiliation(s)
| | - Megha J Gupta
- Department of Neurology, Washington University in St Louis, St Louis, MO, USA
| | - Kathryn A Taylor
- Division of Child Neurology, Medical University of South Carolina, Charleston, SC, USA
| | | | - Carolyn E Pizoli
- Division of Child Neurology, Duke University School of Medicine, Durham, NC, USA
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Saliba M, Wilton A, Hagen K, Romanowicz M. A complex case of young child with ADHD, developmental delay who developed seronegative autoimmune encephalitis exacerbated by stimulants. Brain Behav Immun Health 2023; 34:100692. [PMID: 37842135 PMCID: PMC10569956 DOI: 10.1016/j.bbih.2023.100692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 08/07/2023] [Accepted: 09/30/2023] [Indexed: 10/17/2023] Open
Abstract
Autoimmune encephalitis (AE) is a group of disorders characterized by a wide clinical spectrum ranging from the typical limbic encephalitis to more complex neuropsychiatric symptoms including abnormal movements, psychosis, deficits in memory and cognition, dysautonomia, seizures, or coma. Psychiatric symptoms can occur early in the disease progress or manifest during its course. These symptoms are challenging and often slow down the diagnosis of AE. This is a crucial aspect considering that early diagnosis and management of AE are critical for a good outcome. However, there is a lack in studies outlining the exact symptomatology and specific appropriate care that would allow clinicians to achieve an early diagnosis and management. Additionally, AE in children mostly presents with neuropsychiatric symptoms and diagnosis is especially challenging in kids because of their limited capacity in describing their symptoms, the normal childhood behavioral changes and the possibility of a comorbid psychiatric diagnosis. We present a complex case of seronegative AE with comorbid ADHD (Attention Deficit Hyperactivity Disorder) and anxiety in a young six-year-old girl.
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Affiliation(s)
- M. Saliba
- Dept. of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - A. Wilton
- Dept. of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - K. Hagen
- Dept. of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - M. Romanowicz
- Dept. of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
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27
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Meira AT, de Moraes MPM, Ferreira MG, Franklin GL, Rezende Filho FM, Teive HAG, Barsottini OGP, Pedroso JL. Immune-mediated ataxias: Guide to clinicians. Parkinsonism Relat Disord 2023; 117:105861. [PMID: 37748994 DOI: 10.1016/j.parkreldis.2023.105861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/13/2023] [Accepted: 09/17/2023] [Indexed: 09/27/2023]
Abstract
Immune-mediated cerebellar ataxias were initially described as a clinical entity in the 1980s, and since then, an expanding body of evidence has contributed to our understanding of this topic. These ataxias encompass various etiologies, including postinfectious cerebellar ataxia, gluten ataxia, paraneoplastic cerebellar degeneration, opsoclonus-myoclonus-ataxia syndrome and primary autoimmune cerebellar ataxia. The increased permeability of the brain-blood barrier could potentially explain the vulnerability of the cerebellum to autoimmune processes. In this manuscript, our objective is to provide a comprehensive review of the most prevalent diseases within this group, emphasizing clinical indicators, pathogenesis, and current treatment approaches.
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Affiliation(s)
- Alex T Meira
- Universidade Federal da Paraíba, Departamento de Medicina Interna, Serviço de Neurologia, João Pessoa, PB, Brazil.
| | | | - Matheus G Ferreira
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Serviço de Neurologia, Curitiba, PR, Brazil
| | - Gustavo L Franklin
- Pontifícia Universidade Católica, Departamento de Medicina Interna, Serviço de Neurologia, Curitiba, PR, Brazil
| | | | - Hélio A G Teive
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Serviço de Neurologia, Curitiba, PR, Brazil
| | | | - José Luiz Pedroso
- Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo, SP, Brazil
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28
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dos Passos GR, Adoni T, Mendes MF, Sato DK. Reshaping neuroimmunology: diagnosis and treatment in the era of precision medicine. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:1125-1133. [PMID: 38157878 PMCID: PMC10756840 DOI: 10.1055/s-0043-1777752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/17/2023] [Indexed: 01/03/2024]
Abstract
Precision medicine has revolutionized the field of neuroimmunology, with innovative approaches that characterize diseases based on their biology, deeper understanding of the factors leading to heterogeneity within the same disease, development of targeted therapies, and strategies to tailor therapies to each patient. This review explores the impact of precision medicine on various neuroimmunological conditions, including multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), optic neuritis, autoimmune encephalitis, and immune-mediated neuropathies. We discuss advances in disease subtyping, recognition of novel entities, promising biomarkers, and the development of more selective monoclonal antibodies and cutting-edge synthetic cell-based immunotherapies in neuroimmunological disorders. In addition, we analyze the challenges related to affordability and equity in the implementation of these emerging technologies, especially in situations with limited resources.
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Affiliation(s)
- Giordani Rodrigues dos Passos
- Pontifícia Universidade Católica do Rio Grande do Sul, Escola de Medicina e Instituto do Cérebro do Rio Grande do Sul, Porto Alegre RS, Brazil.
| | - Tarso Adoni
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brazil.
| | | | - Douglas Kazutoshi Sato
- Pontifícia Universidade Católica do Rio Grande do Sul, Escola de Medicina e Instituto do Cérebro do Rio Grande do Sul, Porto Alegre RS, Brazil.
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de Freitas Dias B, Fieni Toso F, Slhessarenko Fraife Barreto ME, de Araújo Gleizer R, Dellavance A, Kowacs PA, Teive H, Spitz M, Freire Borges Juliano A, Januzi de Almeida Rocha L, Braga-Neto P, Ribeiro Nóbrega P, Oliveira-Filho J, Maciel Dias R, de Oliveira Godeiro Júnior C, Martins Maia F, Barbosa Thomaz R, Santos ML, Sousa de Melo E, da Nóbrega Júnior AW, Lin K, Graziani Povoas Barsottini O, Endmayr V, Coelho Andrade LE, Höftberger R, Almeida Dutra L. Brazilian autoimmune encephalitis network (BrAIN): antibody profile and clinical characteristics from a multicenter study. Front Immunol 2023; 14:1256480. [PMID: 37954587 PMCID: PMC10634608 DOI: 10.3389/fimmu.2023.1256480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/04/2023] [Indexed: 11/14/2023] Open
Abstract
Background The frequency of antibodies in autoimmune encephalitis (AIE) may vary in different populations, however, data from developing countries are lacking. To describe the clinical profile of AIE in Brazil, and to evaluate seasonality and predictors of AIE in adult and pediatric patients. Methods We evaluated patients with possible AIE from 17 centers of the Brazilian Autoimmune Encephalitis Network (BrAIN) between 2018 and 2022. CSF and serum were tested with TBAs and CBAs. Data on clinical presentation, complementary investigation, and treatment were compiled. Seasonality and predictors of AIE in adult and pediatric populations were analyzed. Results Of the 564 patients, 145 (25.7%) were confirmed as seropositive, 69 (12.23%) were seronegative according to Graus, and 58% received immunotherapy. The median delay to diagnosis confirmation was 5.97 ± 10.3 months. No seasonality variation was observed after 55 months of enrolment. The following antibodies were found: anti-NMDAR (n=79, 54%), anti-MOG (n=14, 9%), anti-LGI1(n=12, 8%), anti-GAD (n=11, 7%), anti-GlyR (n=7, 4%), anti-Caspr2 (n=6, 4%), anti-AMPAR (n=4, 2%), anti-GABA-BR (n=4, 2%), anti-GABA-AR (n=2, 1%), anti-IgLON5 (n=1, 1%), and others (n=5, 3%). Predictors of seropositive AIE in the pediatric population (n=42) were decreased level of consciousness (p=0.04), and chorea (p=0.002). Among adults (n=103), predictors of seropositive AIE were movement disorders (p=0.0001), seizures (p=0.0001), autonomic instability (p=0.026), and memory impairment (p=0.001). Conclusion Most common antibodies in Brazilian patients are anti-NMDAR, followed by anti-MOG and anti-LGI1. Only 26% of the possible AIE patients harbor antibodies, and 12% were seronegative AIE. Patients had a 6-month delay in diagnosis and no seasonality was found. Findings highlight the barriers to treating AIE in developing countries and indicate an opportunity for cost-effect analysis. In this scenario, some clinical manifestations help predict seropositive AIE such as decreased level of consciousness, chorea, and dystonia among children, and movement disorders and memory impairment among adults.
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Affiliation(s)
| | | | | | | | | | | | - Helio Teive
- Hospital Universitário da Universidade Federal do Paraná, Curitiba, Brazil
| | - Mariana Spitz
- Hospital Universitário Pedro Ernesto da Universidade Estadual do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Pedro Braga-Neto
- Division of Neurology, Department of Clinical Medicine, Universidade Federal do Ceará, Fortaleza, Brazil
| | - Paulo Ribeiro Nóbrega
- Division of Neurology, Department of Clinical Medicine, Universidade Federal do Ceará, Fortaleza, Brazil
| | | | | | | | | | | | | | | | | | - Katia Lin
- Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | | | - Verena Endmayr
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | | | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
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30
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Bertram D, Tsaktanis T, Berthele A, Korn T. The role of intrathecal free light chains kappa for the detection of autoimmune encephalitis in subacute onset neuropsychiatric syndromes. Sci Rep 2023; 13:17224. [PMID: 37821561 PMCID: PMC10567819 DOI: 10.1038/s41598-023-44427-6] [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: 07/28/2023] [Accepted: 10/08/2023] [Indexed: 10/13/2023] Open
Abstract
Intrathecal synthesis of free light chains kappa (FLCK) is increasingly recognized as a marker of inflammatory CNS pathologies. Here, we tested the performance of FLCK in differentiating autoimmune encephalitis (AIE) from non-inflammatory etiologies in subacute onset neuropsychiatric syndromes. Patients undergoing diagnostic work-up for suspected autoimmune encephalitis at our department between 2015 and 2020 were retrospectively assessed for definitive diagnosis, available CSF and blood samples, as well as complete clinical records. Intrathecal FLCK was measured along with established CSF markers of CNS inflammation. The study cohort consisted of 19 patients with antibody-mediated AIE (AIE+), 18 patients with suspected AIE but without detectable autoantibodies (AIE-), 10 patients with infectious (viral) encephalitis (INE), and 15 patients with degenerative encephalopathies (DGE). 25 age- and sex-matched patients with non-inflammatory neurological diseases (NIND) were used as a control group. All AIE+ patients exhibited intrathecal synthesis of FLCK compared to only 39% of AIE- patients and 81% of patients in the INE group. No intrathecal synthesis of FLCK was found in DGE and NIND patients. While intrathecal FLCK was equally specific for an inflammatory etiology as oligoclonal bands (OCB) in the cerebrospinal fluid (CSF), the sensitivity of intrathecal FLCK for any inflammatory intrathecal process was higher than that of OCB (83% vs. 38%). Intrathecal FLCK synthesis was found to discriminate AIE+ from non-inflammatory encephalopathies and AIE- when the CSF cell count was normal [receiver operating characteristic (ROC) analysis area under the curve (AUC): 0.867, p = 0.002], while it failed to differentiate between AIE+ and INE in the presence of CSF pleocytosis (AUC: 0.561, p = 0.607). In conclusion, in the absence of CSF pleocytosis, intrathecal FLCK discriminated AIE+ from competing diagnoses in our cohort of subacute onset neuropsychiatric syndromes. In addition to established markers of CSF inflammation, intrathecal FLCK might support clinical decision-making and contribute to selecting patients for (repeated) antibody testing.
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Affiliation(s)
- Dominic Bertram
- Department of Neurology, Technical University of Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany
| | - Thanos Tsaktanis
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Achim Berthele
- Department of Neurology, Technical University of Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany
| | - Thomas Korn
- Department of Neurology, Technical University of Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany.
- Institute for Experimental Neuroimmunology, Technical University of Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany.
- Munich Cluster for Systems Neurology (SyNergy), Feodor-Lynen-Str. 17, 81377, Munich, Germany.
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31
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Valencia-Cifuentes V, Cañas CA, Rivas JC. Major depression associated with a levonorgestrel-releasing intrauterine system mimicking frontotemporal dementia: a case report. Front Psychiatry 2023; 14:1266419. [PMID: 37779626 PMCID: PMC10535084 DOI: 10.3389/fpsyt.2023.1266419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/28/2023] [Indexed: 10/03/2023] Open
Abstract
This case illustrates the adverse cognitive and affective effects associated with the use of an intrauterine hormonal contraceptive, which could be confused with symptoms of early onset dementia. We present a case of a 42-year-old woman diagnosed with seronegative spondyloarthropathy who subsequently developed anxiety and depressive symptoms after the implantation of a Levonorgestrel-Releasing Intrauterine System (LNG-IUS). Three years later, she began to experience memory and attentional failures, refractory pain, and severe depression. The progression of psychiatric symptoms led to a diagnosis of bipolar affective disorder and treatment with antidepressants and anxiolytics. Due to cognitive and psychiatric symptoms, autoimmune encephalitis was considered, but no improvement was shown with treatment. Early onset dementia was suspected, and a brain PET scan revealed frontal lobe hypometabolism. An adverse effect of LNG-IUS was considered; after its removal, mood and cognitive function improvements were observed. This case report emphasizes the importance of considering organic causes of unexplained psychiatric manifestations and highlights the potential impact of hormonal interventions on mental health.
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Affiliation(s)
- Valeria Valencia-Cifuentes
- Department of Neurology, Fundación Valle del Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Carlos A. Cañas
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Universidad ICESI, CIRAT: Centro de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional, Cali, Colombia
- Department of Rheumatology, Fundación Valle del Lili, Cali, Colombia
| | - Juan Carlos Rivas
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Department of Psychiatry, Fundación Valle del Lili, Cali, Colombia
- Department of Psychiatry, Universidad del Valle, Cali, Colombia
- Hospital Departamental Psiquiátrico, Universitario del Valle, Cali, Colombia
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Venkatesan A, Probasco JC. Autoimmune encephalitis: chasing a moving target. Lancet Neurol 2023; 22:460-462. [PMID: 37210088 DOI: 10.1016/s1474-4422(23)00165-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/22/2023]
Affiliation(s)
- Arun Venkatesan
- Johns Hopkins Encephalitis Center, Department of Neurology, Johns Hopkins University School of Medicine, MD 21287, USA.
| | - John C Probasco
- Johns Hopkins Encephalitis Center, Department of Neurology, Johns Hopkins University School of Medicine, MD 21287, USA
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