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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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Thevarkalam M, Kannoth S, Nambiar V, Gopinath S, Mathai A, Anandakuttan A, Krishnan S, Bhaskaran R. Neurological Manifestations of Glutamic Acid Decarboxylase Autoimmunity in Indian Patients. Ann Indian Acad Neurol 2023; 26:663-671. [PMID: 38022450 PMCID: PMC10666894 DOI: 10.4103/aian.aian_392_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/05/2023] [Accepted: 06/23/2023] [Indexed: 12/01/2023] Open
Abstract
Objective To study the neurological manifestations of glutamic acid decarboxylase (GAD 65) autoimmunity in Indian patients. Methods Retrospective study conducted in a tertiary care referral hospital in South India. Patients who tested positive for GAD 65 antibodies from February 2013 to July 2019 were included. Results We identified 922 patients who underwent GAD 65 testing, of which 81 tested positive (8.78%) [mean age 55.42 years (SD 17.39, range 9-86 years, median age 57 years)]. Males (n = 47) outnumbered the females (n = 34). All the GAD values measured were <5000 IU/ml. There were 34 cases (42%) of atypical parkinsonism (16/34, 47% fulfilled the diagnostic criteria for autoimmune atypical parkinsonism) in our series forming the most common group with GAD 65 positivity, followed by autoimmune encephalitis (8 cases, 9.88%). Men were more affected with atypical parkinsonism (22/34; 64.70%), stiff person syndrome (2/3; 66.66%), and neuropathy (4/7; 57.1%) while women were more with autoimmune encephalitis (6/8; 75%). Eighteen (22.6%) had underlying autoimmunity (three had type 1 diabetes mellitus). Six (7.4%) had underlying neoplasm. Thirty-three out of 43 patients responded to immunotherapy (76.74%). Five had spontaneous improvement. Conclusion Glutamic acid decarboxylase65 antibody values were much lower in our study population. Male-dominant autoimmunity was seen unlike that in Western literature. The most striking was the high preponderance of atypical parkinsonism in GAD 65-positive patients. We also found that GAD 65 positivity is a useful marker for a positive response to immunotherapy in suspected autoimmune neurological syndromes irrespective of their titers.
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Affiliation(s)
- Meena Thevarkalam
- Department of Biochemistry, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Sudheeran Kannoth
- Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
- Department of Neuroimmunology Laboratory, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Vivek Nambiar
- Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Siby Gopinath
- Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Annamma Mathai
- Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
- Department of Neuroimmunology Laboratory, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Anandkumar Anandakuttan
- Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Sajitha Krishnan
- Department of Biochemistry, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Renjitha Bhaskaran
- Department of Biostatistics, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
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Warren N, Freier K, Siskind D, O'Gorman C, Blum S, Gillis D, Scott JG. Anti-glutamic acid decarboxylase antibody screening in first-episode psychosis. Aust N Z J Psychiatry 2023; 57:603-612. [PMID: 35362325 DOI: 10.1177/00048674221089560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The Royal Australian and New Zealand College of Psychiatrists recommends screening for a range of antibodies in first-episode psychosis, including anti-glutamic acid decarboxylase antibodies. Glutamic acid decarboxylase antibody-associated encephalitis occurs with high antibody titres and may cause cognitive dysfunction, seizures and psychiatric symptoms. However, glutamic acid decarboxylase antibodies are more frequently found in lower titre in association with other autoimmune disorders (such as diabetes mellitus type 1) and in healthy individuals. The utility of testing unselected populations of consumers with psychosis is unclear. The psychiatric manifestations of this disorder are also poorly described. METHODS First, systematic review of cohort and case-control studies that tested for IgG glutamic acid decarboxylase antibodies in psychiatric populations was conducted. Random-effects meta-analysis of odds ratio for antibody positivity in cases with psychosis and controls assessed prevalence. Second, literature review of all published cases and case series of glutamic acid decarboxylase antibody-associated limbic encephalitis was assessed for frequency and description of psychotic symptoms. RESULTS There were 17 studies, in which 2754 individuals with psychotic disorders were tested for glutamic acid decarboxylase IgG antibodies. Thirty-one consumers with psychosis (0.7%) had positive glutamic acid decarboxylase antibodies compared to 24 controls (1.0%), all at low titre and not fulfilling diagnostic criteria for autoimmune encephalitis. Meta-analysis found no significant difference in rates of glutamic acid decarboxylase antibody positivity (odds ratio = 1.8, 95% confidence interval: [0.90, 3.63]). Literature review found 321 cases of glutamic acid decarboxylase antibody-associated limbic encephalitis, with psychosis in 15 (4.3%) cases. Clinical screening would have identified all cases that presented to psychiatric services. CONCLUSION Glutamic acid decarboxylase antibodies were uncommon in consumers with psychosis, with no significant difference in prevalence from controls and no cases of encephalitis identified. In cases with established glutamic acid decarboxylase antibody-associated limbic encephalitis, psychotic symptoms were uncommon and identifiable by clinical assessment. Targeted antibody testing guidelines should be further considered.
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Affiliation(s)
- Nicola Warren
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Karen Freier
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Dan Siskind
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Cullen O'Gorman
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Neurology, The Princess Alexandra Hospital, Brisbane, QLD, Australia
- Mater Centre for Clinical Neurosciences, Mater Hospital, Brisbane, QLD, Australia
| | - Stefan Blum
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Neurology, The Princess Alexandra Hospital, Brisbane, QLD, Australia
- Mater Centre for Clinical Neurosciences, Mater Hospital, Brisbane, QLD, Australia
| | - David Gillis
- Pathology Queensland Central Laboratory, Division of Immunology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - James G Scott
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
- Metro North Mental Health Service, Brisbane, QLD, Australia
- Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
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Mueller C, Elben S, Day GS, Alves P, Hebert J, Tang-Wai DF, Holtmann O, Iorio R, Perani D, Titulaer MJ, Hansen N, Bartsch T, Johnen A, Illes Z, Borm L, Willison AG, Wiendl H, Meuth SG, Kovac S, Bölte J, Melzer N. Review and meta-analysis of neuropsychological findings in autoimmune limbic encephalitis with autoantibodies against LGI1, CASPR2, and GAD65 and their response to immunotherapy. Clin Neurol Neurosurg 2022; 224:107559. [PMID: 36549220 DOI: 10.1016/j.clineuro.2022.107559] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES It is assumed that autoimmune limbic encephalitis (ALE) demonstrates distinct neuropsychological manifestations with differential responses to immunotherapy according to which associated autoantibody (AAB), if any, is identified. Towards investigating whether this is the case, this study aims to summarize respective findings from the primary literature on ALE with AABs binding to cell surface neural antigens and ALE with AABs against intracellular neural antigens. METHODS We chose ALE with AABs against leucine-rich, glioma inactivated protein 1 (LGI1) and contactin-associated protein-like 2 (CASPR2) as the most frequent cell surface membrane antigens, and ALE with AABs to Embryonic Lethal, Abnormal Vision, Like 1 (ELAVL) proteins (anti-Hu) and glutamic acid decarboxylase 65 (GAD65) as the most frequent intracellular neural antigens. The PubMed and Scopus databases were searched on March 1st, 2021 for neuropsychological test and -screening data from patients with ALE of these AAB-types. Findings were reviewed according to AAB-type and immunotherapy status and are presented in a review section and are further statistically evaluated and presented in a meta-analysis section in this publication. RESULTS Of the 1304 initial hits, 32 studies on ALE with AABs against LGI1, CASPR2, and GAD65 reporting cognitive screening data could be included in a review. In ALE with AABs against LGI1, CASPR2 and GAD65, memory deficits are the most frequently reported deficits. However, deficits in attention and executive functions including working memory, fluency, and psychological function have also been reported. This review shows that ALE patients with AABs against both LGI1 and CASPR2 show higher percentages of neuropsychological deficits compared to ALE patients with AABs against GAD65 before and after initiation of immunotherapy. However, the methodologies used in these studies were heterogenous, and longitudinal studies were not comparable. Moreover, 21 studies including ALE patients with AABs against LGI1 and GAD65 were also suitable for meta-analysis. No suitable study on ALE with AABs against ELAVL proteins could be identified. Meta-Analyses could be executed for cognitive screening data and only partially, due to the small number of studies. However, in statistical analysis no consistent effect of AAB or immunotherapy on performance in cognitive screening tests could be found. CONCLUSION Currently, there is no definite evidence supporting the notion that different AAB-types of ALE exhibit distinct neuropsychological manifestations and respond differently to immunotherapy. Overall, we could not identify evidence for any effect of immunotherapy on cognition in ALE. More systematic, in-depth and longitudinal neuropsychological assessments of patients with different AAB-types of ALE are required in the future to investigate these aspects.
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Affiliation(s)
- Christoph Mueller
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Saskia Elben
- Department of Neurology, Medical Faculty, Heinrich-Heine University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.
| | - Gregory S Day
- Department of Neurology, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, United States.
| | - Pedro Alves
- Serviço de Neurologia, Departamento de Neurociências e Saúde Mental, Hospital de Santa Maria, CHULN, Lisboa, Portugal; Laboratório de Estudos de Linguagem, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Portugal.
| | - Julien Hebert
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Canada.
| | - David F Tang-Wai
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Canada; Memory Clinic, Toronto Western Hospital (University Health Network), Toronto, Canada.
| | - Olga Holtmann
- Institute of Medical Psychology and Systems Neuroscience, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Raffaele Iorio
- Neurology Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Daniela Perani
- Division of Neuroscience, University Vita-Salute San Raffaele, Via Olgettina, 58, 20132 Milano, MI, Italy.
| | - Maarten J Titulaer
- Department of Neurology, Neuropsychology and Immunology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
| | - Niels Hansen
- Department of Psychiatry and Psychotherapy, University of Göttingen, Von-Siebold-Str. 5, 37075 Göttingen, Germany.
| | - Thorsten Bartsch
- Department of Neurology, University Medical Center Schleswig-Holstein, Rosalind-Franklin-Straße 10, 24105 Kiel, Germany.
| | - Andreas Johnen
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Zslot Illes
- Department of Neurology with Institute of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 4, 5000 Odense, Denmark.
| | - Leah Borm
- Institute of Psychology, Westfälische Wilhelms-University of Münster, Fliednerstraße 21, 48149 Münster, Germany.
| | - Alice G Willison
- Department of Neurology, Medical Faculty, Heinrich-Heine University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany; Department of Neurology, Medical Faculty, Heinrich-Heine University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.
| | - Stjepana Kovac
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Jens Bölte
- Institute of Psychology, Westfälische Wilhelms-University of Münster, Fliednerstraße 21, 48149 Münster, Germany.
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany; Department of Neurology, Medical Faculty, Heinrich-Heine University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.
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5
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Li G, Liu X, Yu T, Ren J, Wang Q. Positron emission tomography in autoimmune encephalitis: Clinical implications and future directions. Acta Neurol Scand 2022; 146:708-715. [PMID: 36259555 DOI: 10.1111/ane.13717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/04/2022] [Accepted: 10/08/2022] [Indexed: 11/28/2022]
Abstract
18 F-fluoro-deoxyglucose position emission tomography (18 F-FDG-PET) has been proven as a sensitive and reliable tool for diagnosis of autoimmune encephalitis (AE). More attention was paid to this kind of imaging because of the shortage of MRI, EEG, and CSF findings. FDG-PET has been assessed in a few small studies and case reports showing apparent abnormalities in cases where MRI does not. Here, we summarized the patterns (specific or not) in AE with different antibodies detected and the clinical outlook for the wide application of FDG-PET considering some limitations. Specific patterns based on antibody subtypes and clinical symptoms were critical for identifying suspicious AE, the most common of which was the anteroposterior gradient in anti- N -methyl- d -aspartate receptor (NMDAR) encephalitis and the medial temporal lobe hypermetabolism in limbic encephalitis. And the dynamic changes of metabolic presentations in different phases provided us the potential to inspect the evolution of AE and predict the functional outcomes. Except for the visual assessment, quantitative analysis was recently reported in some voxel-based studies of regions of interest, which suggested some clues of the future evaluation of metabolic abnormalities. Large prospective studies need to be conducted controlling the time from symptom onset to examination with the same standard of FDG-PET scanning.
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Affiliation(s)
- Gongfei Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiao Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Tingting Yu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jiechuan Ren
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Institute for Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
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6
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Bai L, Ren H, Liang M, Lu Q, Lin N, Liu M, Fan S, Cui R, Guan H. Neurological disorders associated with glutamic acid decarboxylase 65 antibodies: Clinical spectrum and prognosis of a cohort from China. Front Neurol 2022; 13:990553. [PMID: 36277926 PMCID: PMC9581312 DOI: 10.3389/fneur.2022.990553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
Objective To describe clinical phenotypes and prognosis of neurological autoimmunity related to glutamic acid decarboxylase 65 (GAD65) antibodies in China. Method In this retrospective observational study from Peking Union Medical College Hospital, we identified patients with neurological disorders related to GAD65 antibodies (cell-based assay) from May 2015 to September 2021. Clinical manifestations, immunotherapy responsiveness, and outcomes were collected after obtaining informed consent from all patients. Results Fifty-five patients were included: 40 (72.73%) were women and initial neurological symptoms developed at 42(34-55) years of age. The median time to the nadir of the disease was 5 months (range from 1 day to 48 months). The clinical syndromes included limbic encephalitis (LE) or epilepsy (Ep) (n = 34, 61.82%), stiff-person syndromes (SPS) (n = 18, 32.73%), autoimmune cerebellar ataxia (ACA) (n = 11, 20%), and overlap syndrome in eight (14.55%) patients. Thirty-two (58.2%) patients had comorbidities of other autoimmune diseases, including Hashimoto thyroiditis (n = 17, 53.13%), T1DM (n = 11, 34.78%), vitiligo (n = 6, 18.75%), and others (n=5, 15.63%). Two (3.64%) patients had tumors, including thymoma and small cell lung cancer. Fifty-one (92.7%) patients received first-line immunotherapy (glucocorticoids and/or IV immunoglobulin), and 4 (7.3%) received second-line immunotherapy (rituximab). Long-term immunotherapy (mycophenolate mofetil) was administered to 23 (41.8%) patients. At the median time of 15 months (IQR 6–33.75 month, range 3–96 month) of follow-up, the patients' median modified Rankin Score (mRS) had declined from 2 to 1. Thirty-eight (70.4%) patients experienced clinical improvement (mRS declined ≥1), 47 (87%) had favorable clinical outcomes (mRS ≤2), and nine were symptom-free (16.7%). The sustained response to immunotherapy ranged from 7/15 (63.63%) in ACA patients and 22/34 (64.7%) in LE/Ep patients to 14/17 (82.35%) in SPS patients. Conclusions LE/Ep was the most common neurological phenotype of GAD65 antibody neurological autoimmunity in our cohort. Most patients had comorbidities of other autoimmune diseases, but underlying tumors were rare. Most patients responded to immunotherapy. However, the long-term prognosis varied among different clinical phenotypes.
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Affiliation(s)
- Lin Bai
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Menglin Liang
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Qiang Lu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Nan Lin
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Mange Liu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ruixue Cui
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Hongzhi Guan
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7
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Abstract
The term limbic encephalitis has been used with an oncological precedent for over 50 years and, since then, has been applied in relation to multiple antibodies found in its etiological process. Over the last decade, the psychiatric community has brought paraneoplastic autoimmune limbic encephalitis (PALE) to a new light, scattering the once known relationships between said screened antibodies responsible for causing limbic encephalitis. Due to the fact that some individuals with this condition have a psychiatric syndrome as an initial manifestation, the aim of this updated scoping review is to reestablish a causal relationship between the onconeuronal autoantibodies, both intracellular and extracellular, possible underlying malignancies and subsequent neuropsychiatric syndrome. In pair with it, there is the idea of sketching a cleaner thorough picture of what poses as psychiatric symptoms as well as possible therapeutics. Even though the always evolving epistemology of the neurosciences achieved a significant unveiling of what includes PALE in its relevant pathological subgroups, the amount of gray literature still is much superior, appealing to a further research with more randomized controlled trials, with larger populations, so that the results corroborate the small amount of data that already exist and posteriorly be applied in the general population.
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8
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Ball C, Fisicaro R, Morris L, White A, Pacicco T, Raj K, Agarwal A, Lee WC, Yu FF. Brain on fire: an imaging-based review of autoimmune encephalitis. Clin Imaging 2022; 84:1-30. [DOI: 10.1016/j.clinimag.2021.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/28/2021] [Accepted: 12/16/2021] [Indexed: 12/28/2022]
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Harmon A, Stingl C, Rikhi A, Tran L, Pizoli C, Malinzak M, Van Mater H. Pediatric GAD-65 Autoimmune Encephalitis: Assessing Clinical Characteristics and Response to Therapy With a Novel Assessment Scale. Pediatr Neurol 2022; 128:25-32. [PMID: 35032887 DOI: 10.1016/j.pediatrneurol.2021.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 12/11/2021] [Accepted: 12/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Glutamic acid decarboxylase (GAD) encephalitis is a neuroinflammatory disease characterized by a broad range of symptoms including cognitive deficits, behavioral changes, and seizures. Children with this disorder have heterogeneous presentations, and little is known about symptom progression over time and response to immunotherapy. METHODS This study reports 10 pediatric GAD encephalitis cases and symptoms found at presentation and follow-up. In addition, symptom severity was reported utilizing a novel scale evaluating functional outcomes across the domains affected by autoimmune encephalitis including cognition, language, seizures, psychiatric symptoms, sleep, and movement. Retrospective chart review was conducted for 10 patients aged <18 years, diagnosed with GAD encephalitis, and followed for one year or more. Chart review included clinical, imaging, and laboratory findings at time of diagnosis and at six- and 12-month follow-ups. RESULTS At presentation, cognitive deficits were found in all patients, seizures in six of 10, and language decline in seven of 10. Psychiatric symptoms were prominent for all but one patient with three of nine patients presenting with psychosis. Fatigue, sleep disruption, and movement disorders were less prominent symptoms, occurring in approximately half of the cohort. Cognition and fatigue improved significantly over time when compared with symptom severity, whereas seizures, psychiatric symptoms, and sleep did not. Language and sleep showed improvement only in early stages. Analysis of seizure frequency and type noted variability mirroring trends noted in adult studies of GAD encephalitis. CONCLUSIONS This study demonstrated the variability of symptom profiles of pediatric GAD encephalitis and benefits of symptom severity scales. Symptom profiles and progression vary in this population.
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Affiliation(s)
- Alexis Harmon
- Duke University School of Medicine, Durham, North Carolina
| | - Cory Stingl
- Division of Rheumatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Aruna Rikhi
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Linh Tran
- Division of Child Neurology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Carolyn Pizoli
- Division of Child Neurology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Michael Malinzak
- Division of Neuroradiology, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Heather Van Mater
- Division of Rheumatology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina.
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10
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Murashko AA, Pavlov KA, Pavlova OV, Gurina OI, Shmukler A. Antibodies against N-Methyl D-Aspartate Receptor in Psychotic Disorders: A Systematic Review. Neuropsychobiology 2022; 81:1-18. [PMID: 34000730 DOI: 10.1159/000515930] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 03/15/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The objective of this study was to provide comprehensive evidence synthesis including all available up-to-date data about the prevalence of N-methyl D-aspartate receptor (NMDAR) antibodies (ABs) in psychotic patients in order to evaluate the clinical relevance of ABs as well as to specify potential explanations of the heterogeneity of the findings and determine areas for further research. METHODS A literature search was conducted using the PubMed/Medline, Web of Knowledge, and Scopus databases. RESULTS Forty-seven studies and 4 systematic reviews (including 2 meta-analyses) were included in the present review. Studies that used cell-based assays (CBAs) provided heterogeneous results on AB prevalence, obviously depending on the type of detection assay and sample characteristics. Improvement of AB detection methods is necessary to determine the real prevalence of ABs across different groups of patients and healthy people. Live CBAs seem to have better sensitivity but probably poorer specificity than fixed CBAs. Moreover, some links between AB-positive status and acute symptoms are possible. A small amount of data on immunotherapy in AB-positive patients raises the possibility of its effectiveness but obviously require further research. CONCLUSIONS NMDAR ABs are definitely present in a subset of psychotic patients. NMDAR ABs might shape psychosis and underlie some symptoms, and immunotherapy might be regarded as a treatment option for patients failing to respond to other therapies.
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Affiliation(s)
- Alexey A Murashko
- Department of Translational Psychiatry, Moscow Research Institute of Psychiatry, The Branch of V. Serbsky National Medical Research Centre for Psychiatry and Narcology, Moscow, Russian Federation
| | - Konstantin A Pavlov
- Department of Fundamental and Applied Neurobiology, V. Serbsky National Medical Research Centre for Psychiatry and Narcology, Moscow, Russian Federation
| | - Olga V Pavlova
- Department of Fundamental and Applied Neurobiology, V. Serbsky National Medical Research Centre for Psychiatry and Narcology, Moscow, Russian Federation
| | - Olga I Gurina
- Department of Fundamental and Applied Neurobiology, V. Serbsky National Medical Research Centre for Psychiatry and Narcology, Moscow, Russian Federation
| | - Alexander Shmukler
- Department of Translational Psychiatry, Moscow Research Institute of Psychiatry, The Branch of V. Serbsky National Medical Research Centre for Psychiatry and Narcology, Moscow, Russian Federation
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11
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Dimova P, Minkin K. Case Report: Multisystem Autoimmune and Overlapping GAD65-Antibody-Associated Neurological Disorders With Beneficial Effect of Epilepsy Surgery and Rituximab Treatment. Front Neurol 2022; 12:756668. [PMID: 35126284 PMCID: PMC8810502 DOI: 10.3389/fneur.2021.756668] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 12/13/2021] [Indexed: 12/18/2022] Open
Abstract
Glutamic acid decarboxylase (GAD) antibodies are associated with disabling conditions such as stiff person syndrome, temporal lobe epilepsy (TLE), limbic encephalitis, cerebellar ataxia (CA), and ocular movement disorders, which are usually chronic and difficult to treat. GAD-related TLE has poor response to anti-seizure medications and immune therapies, and epilepsy surgery is rarely successful. We report on a 47-year-old female with history of migraine, autoimmune thyroid disease, ankylosing spondylitis, and drug-resistant TLE. A video electroencephalography recorded frequent seizures with temporo-insular semiology, correlating to left temporal epileptiform activity and left mesiotemporal hyperintensity on magnetic resonance imaging. GAD autoimmunity was confirmed by very high GAD antibody titers in serum and cerebrospinal fluid. Steroids, immunoglobulins, and cyclophosphamide had no effect, and selective left amygdalectomy was performed based on very restricted hypermetabolism on positron-emission tomography. After transient seizure freedom, significant epilepsy improvement was observed in spite of memory decline. Transient worsening was noted 1 year later during diabetes mellitus manifestation and 5 years later during presentation of progressive CA, which stabilized on rituximab treatment. We believe this case illustrates the diversity and the frequent overlap of GAD-associated disorders, the need of early and aggressive immunotherapy in severe patients, as well as the possible benefit from epilepsy surgery in some GAD-TLE.
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Affiliation(s)
- Petia Dimova
- Epileptology Unit at Epilepsy Surgery Center, Department of Neurosurgery, St. Ivan Rilski University Hospital, Sofia, Bulgaria
- *Correspondence: Petia Dimova
| | - Krassimir Minkin
- Functional and Epilepsy Surgery Center, Department of Neurosurgery, St. Ivan Rilski University Hospital, Sofia, Bulgaria
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12
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Wang J, Gong S, Kong F, Cai D, Huang B, Zheng H, Lin S, Li J, Zhang T. Psychotic Symptoms as the Initial Presentation of a Long-Lasting Misdiagnosed Anti-GAD65 Autoimmune Encephalitis: An Emblematic Case and Literature Review. Front Psychiatry 2022; 13:754938. [PMID: 35280166 PMCID: PMC8905188 DOI: 10.3389/fpsyt.2022.754938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/20/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To present a long-lasting misdiagnosed case of anti-GAD65 autoimmune encephalitis (AE) and promote the early identification of reversible psychotic symptoms in AE. METHODS The case report was generated through detailed assessment of clinical characteristics, cerebral magnetic resonance images, and laboratory results. Meanwhile, a literatures review related to the topic was conducted. RESULTS Psychotic symptoms could be presented in the early stage of anti-GAD65 autoimmune encephalitis. Even though there exists a transdisciplinary gap that hinder the timely recognition of early psychiatric symptoms as components of organic disease, a few strategies could be introduced to enable the earlier recognition and appropriate treatment. CONCLUSIONS Our report intends to raise awareness to promote the early identification of immune-mediated "symptomatic" forms of psychosis.
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Affiliation(s)
- Jianjun Wang
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China.,Global Clinical Scholars Research Training (GCSRT), Harvard Medical School, Boston, MA, United States
| | - Shenglan Gong
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Shenzhen Hospital (Futian) of Guangzhou University of Chinese Medicine, Shenzhen, China.,Sixth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Fanxin Kong
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Dongbin Cai
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Binqing Huang
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Haotao Zheng
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Songjun Lin
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Jinfang Li
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Tianfeng Zhang
- Shenzhen Hospital (Futian) of Guangzhou University of Chinese Medicine, Shenzhen, China.,Sixth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China
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13
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Morales-Ruiz V, Juárez-Vaquera VH, Rosetti-Sciutto M, Sánchez-Muñoz F, Adalid-Peralta L. Efficacy of intravenous immunoglobulin in autoimmune neurological diseases. Literature systematic review and meta-analysis. Autoimmun Rev 2021; 21:103019. [PMID: 34920107 DOI: 10.1016/j.autrev.2021.103019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 12/12/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Corticosteroids are the first-line treatment for several common autoimmune neurological diseases. Other therapeutic approaches, including intravenous immunoglobulin (IVIg) and plasmapheresis, have shown mixed results in patient improvement. OBJECTIVE To compare the efficacy of IVIg administration with that of corticosteroids, plasmapheresis, and placebo in autoimmune neurological diseases like Guillain-Barré syndrome, myasthenia gravis, chronic inflammatory demyelinating polyneuropathy, optic neuritis, and multiple sclerosis. METHODS A systematic review was performed on the databases PubMed, MEDLINE, Embase, and Cochrane. Controlled, randomized studies comparing the efficacy of IVIg with placebo, plasmapheresis, and/or glucocorticoid administration were selected. Only studies reporting the number of patients who improved after treatment were included, irrespective of language or publication year. In total, 23 reports were included in the meta-analysis study. RESULTS Our meta-analysis showed a beneficial effect of IVIg administration on patient improvement over placebo (OR = 2.79, CI [95%] = 1.40-5.55, P = 0.01). Meanwhile, IVIg administration showed virtually identical effects to plasmapheresis (OR = 0.83, CI [95%] = 0.45-1.55, P < 0.01). Finally, no significant differences were found in the efficacy of IVIg and glucocorticoid administration (OR = 0.98, Cl [95%] = 0.58-1.68, P = 0.13). CONCLUSION IVIg can be regarded as a viable therapeutic approach, either as a first- or second-line therapy, and as an adjuvant therapy for autoimmune neurological diseases.
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Affiliation(s)
- Valeria Morales-Ruiz
- Unidad Periférica para el Estudio de la Neuroinflamación en Patologías Neurológicas del Instituto de Investigaciones Biomédicas de la UNAM en el Instituto Nacional de Neurología y Neurocirugía, Insurgentes Sur 3877, Col. La Fama, Ciudad de México 14269, Mexico; Posgrado en Ciencias Biológicas, Universidad Nacional Autónoma de México, Av. Ciudad Universitaria 3000, Coyoacán, Ciudad de México 04510, Mexico
| | - Víctor Hugo Juárez-Vaquera
- Unidad Periférica para el Estudio de la Neuroinflamación en Patologías Neurológicas del Instituto de Investigaciones Biomédicas de la UNAM en el Instituto Nacional de Neurología y Neurocirugía, Insurgentes Sur 3877, Col. La Fama, Ciudad de México 14269, Mexico
| | - Marcos Rosetti-Sciutto
- Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Ciudad de México 04510, Mexico; Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, México-Xochimilco 101, Col. Huipulco, Ciudad de México 14370, Mexico
| | - Fausto Sánchez-Muñoz
- Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Col. Belisario Domínguez Secc. 16, Ciudad de México 14080, Mexico
| | - Laura Adalid-Peralta
- Unidad Periférica para el Estudio de la Neuroinflamación en Patologías Neurológicas del Instituto de Investigaciones Biomédicas de la UNAM en el Instituto Nacional de Neurología y Neurocirugía, Insurgentes Sur 3877, Col. La Fama, Ciudad de México 14269, Mexico; Instituto Nacional de Neurología y Neurocirugía, Insurgentes Sur 3877, Col. La Fama, Ciudad de México 14269, Mexico.
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14
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McLaughlin J, Young T. Neurology in the psychiatric patient: how to think about differentials in altered mental status and diagnoses not to miss. BJPSYCH ADVANCES 2021. [DOI: 10.1192/bja.2021.67] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
SUMMARY
A wide variety of neurological conditions may present first to a psychiatrist and it is important to be aware of these in differential diagnosis. A careful history, examination and a broad differential diagnosis can help set up an appropriate management plan – with room to change if things change in unexpected ways. In this article we explore common ground shared by psychiatry and neurology and show how incorporation of neurological knowledge can improve the practice of psychiatry. Using four fictional case vignettes of altered mental status we explore important neurological differential diagnoses which could present to the Psychiatrist.
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15
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Gomathy SB, Das A, Pandit AK, Srivastava AK. Enoxaparin-induced Wunderlich syndrome in a young patient with anti-GAD 65-associated opsoclonus and limbic encephalitis: a rare complication in a rare disease. BMJ Case Rep 2021; 14:e244916. [PMID: 34620636 PMCID: PMC8499240 DOI: 10.1136/bcr-2021-244916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2021] [Indexed: 11/04/2022] Open
Abstract
Wunderlich syndrome is a rare condition characterised by acute spontaneous non-traumatic renal haemorrhage into the subcapsular and perirenal spaces. Our case of anti-GAD65-associated autoimmune encephalitis (AE), aged 30 years, developed this complication following use of enoxaparin and was managed by selective glue embolisation of subsegmental branches of right renal cortical arteries. Our case had opsoclonus as one of the clinical manifestations, which has till now been described in only two patients of this AE. This patient received all forms of induction therapies (steroids, plasmapheresis, intravenous immunoglobulin and rituximab) following which she had good improvement in her clinical condition. The good response to immunotherapy is also a point of discussion as this has been rarely associated with anti-GAD65 AE.
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Affiliation(s)
- Saranya B Gomathy
- Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, Delhi, India
| | - Animesh Das
- Neurology, All India Institute of Medical Sciences, New Delhi, India
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16
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Akkari M, Messelmani M, Souissi W, Derbali H, Mrissa R. Subacute dementia revealing a limbic encephalitis with anti-GAD 65 antibodies in a young woman. Acta Neurol Belg 2021; 122:1651-1652. [PMID: 34562261 DOI: 10.1007/s13760-021-01766-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/26/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Manel Akkari
- Department of Neurology, Military Hospital of Tunis, Tunis, Tunisia.
| | | | - Wala Souissi
- Department of Neurology, Military Hospital of Tunis, Tunis, Tunisia
| | - Hajer Derbali
- Department of Neurology, Military Hospital of Tunis, Tunis, Tunisia
| | - Ridha Mrissa
- Department of Neurology, Military Hospital of Tunis, Tunis, Tunisia
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17
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Piepgras J, Müller A, Steffen F, Lotz J, Loquai C, Zipp F, Dresel C, Bittner S. Neurofilament light chain levels reflect outcome in a patient with glutamic acid decarboxylase 65 antibody-positive autoimmune encephalitis under immune checkpoint inhibitor therapy. Eur J Neurol 2021; 28:1086-1089. [PMID: 33556229 DOI: 10.1111/ene.14692] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 12/15/2020] [Indexed: 11/29/2022]
Abstract
Neurological immune-mediated side effects are rare but often severe complications of immune checkpoint inhibitor (ICI) treatment. This report describes a severe case of nivolumab/ipilimumab-associated glutamic acid decarboxylase 65-positive autoimmune encephalitis. It proposes neurofilament light chain levels, a biomarker indicating axonal damage, in the cerebrospinal fluid and serum as a putative novel biomarker for this diagnostically and therapeutically challenging entity with an often unfavorable outcome. Additionally, we provide an overview of previous reports of patients developing autoimmune encephalitis under ICI treatment.
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Affiliation(s)
- Johannes Piepgras
- Department of Neurology, Focus Program Translational Neuroscience and Immunotherapy, Rhine-Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Aneka Müller
- Department of Neurology, Focus Program Translational Neuroscience and Immunotherapy, Rhine-Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Falk Steffen
- Department of Neurology, Focus Program Translational Neuroscience and Immunotherapy, Rhine-Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Johannes Lotz
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Carmen Loquai
- Department of Dermatology, Skin Cancer Center, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience and Immunotherapy, Rhine-Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Christian Dresel
- Department of Neurology, Focus Program Translational Neuroscience and Immunotherapy, Rhine-Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Stefan Bittner
- Department of Neurology, Focus Program Translational Neuroscience and Immunotherapy, Rhine-Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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18
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Etemadifar M, Aghababaei A, Nouri H, Kargaran PK, Mohammadi S, Salari M. Autoimmune encephalitis: the first observational study from Iran. Neurol Sci 2021; 43:1239-1248. [PMID: 34328580 DOI: 10.1007/s10072-021-05400-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 06/08/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Even within the most populous countries in the Middle East, such as Iran, autoimmune encephalitis cases have been rarely reported. OBJECTIVE We aimed to describe the demographic, clinical, and paraclinical characteristics of Iranian patients with autoimmune encephalitis positive for anti-neuronal autoantibodies. METHODS This cross-sectional study included all patients diagnosed with autoimmune encephalitis and referred to our hospital, in Isfahan, Iran, from March 2016 to May 2020. Patients' demographic, clinical, laboratory, radiological, and electroencephalographic features were obtained from their medical records. RESULTS We identified a total of 39 (21 females, 53.8%) patients with autoimmune encephalitis (mean age = 34.9 ± 12.8 years). The most commonly detected antibody was anti-NMDAR (n = 26, 66.7%), followed by anti-GABABR (n = 8, 20.5%), anti-Zic4 (n = 4, 10.3%), and anti-GAD65 (n = 1, 2.6%) antibodies, in descending order of frequency. Two anti-NMDAR-positive patients had a history of systemic lupus erythematosus (SLE), and four had a prior history of herpes simplex encephalitis. Clinical presentations in patients positive for anti-Zic4 antibodies included cognitive decline (n = 4, 100%), seizures (n = 3, 75%), parkinsonism (n = 1, 25%), and stiff-person syndrome (n = 1, 25%). CONCLUSION This was the first case series of Iranian patients with autoimmune encephalitis with some interesting observations, including SLE-associated anti-NMDAR encephalitis, as well as an unusual concurrence of anti-Zic4 antibody positivity and cognitive problems, seizures, parkinsonism, and stiff-person syndrome.
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Affiliation(s)
- Masoud Etemadifar
- Department of Neurosurgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.,Al-Zahra Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Aghababaei
- Al-Zahra Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Hosein Nouri
- Al-Zahra Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.,Network of Immunity in Infection, Malignancy, and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Isfahan, Iran
| | - Parisa K Kargaran
- Department of Cardiovascular Medicine, Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shaghayegh Mohammadi
- Al-Zahra Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehri Salari
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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19
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The Influence of Virus Infection on Microglia and Accelerated Brain Aging. Cells 2021; 10:cells10071836. [PMID: 34360004 PMCID: PMC8303900 DOI: 10.3390/cells10071836] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/15/2021] [Accepted: 07/16/2021] [Indexed: 12/12/2022] Open
Abstract
Microglia are the resident immune cells of the central nervous system contributing substantially to health and disease. There is increasing evidence that inflammatory microglia may induce or accelerate brain aging, by interfering with physiological repair and remodeling processes. Many viral infections affect the brain and interfere with microglia functions, including human immune deficiency virus, flaviviruses, SARS-CoV-2, influenza, and human herpes viruses. Especially chronic viral infections causing low-grade neuroinflammation may contribute to brain aging. This review elucidates the potential role of various neurotropic viruses in microglia-driven neurocognitive deficiencies and possibly accelerated brain aging.
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20
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Ren C, Ren H, Ren X, Zhang W, Li J, Dai L, Guan H, Fang F. Case Report: Autoimmune Encephalitis Associated With Anti-glutamic Acid Decarboxylase Antibodies: A Pediatric Case Series. Front Neurol 2021; 12:641024. [PMID: 33912125 PMCID: PMC8072212 DOI: 10.3389/fneur.2021.641024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Antibodies against glutamic acid decarboxylase (GAD) are associated with various neurologic conditions described in patients, including stiff person syndrome, cerebellar ataxia, refractory epilepsy, and limbic and extralimbic encephalitis. There have been some case reports and investigations regarding anti-GAD65 antibody-associated encephalitis in adult populations, but pediatric cases are rare. We retrospectively analyzed the clinical data of three anti-GAD65 antibody-positive patients to explore the diversity and clinical features of anti-GAD65 antibody-associated pediatric autoimmune encephalitis. Methods: The clinical data of a series of three patients positive for anti-GAD65 antibody were retrospectively analyzed. GAD65 antibodies were determined in serum and CSF using a cell-based assay. Results: All three patients were female, and the onset ages were 4 years and 9 months, 6 years, and 16 years old. Their clinical phenotypes included autoimmune limbic encephalitis, extralimbic encephalitis, and encephalitis combining limbic and extralimbic encephalitis. The clinical symptoms included seizures, memory deficits, drowsiness, dysautonomia, and headache. All patients had abnormal carinal MRI and EEG. All patients received immunotherapy and had transiently good responsiveness, but one patient then experienced relapse. In follow-up, one patient with extralimbic encephalitis recovered completely, while two patients with limbic involvement had poor outcomes with refractory focal epilepsy. Conclusion: In addition to limbic encephalitis, extralimbic encephalitis is also an important phenotype in patients who are positive for anti-GAD65 antibodies. Early diagnosis and immunotherapy can improve the symptoms. However, patients with limbic encephalitis often have refractory epilepsy in the chronic phase and have a poor long-term outcome.
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Affiliation(s)
- Changhong Ren
- Department of Neurology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaotun Ren
- Department of Neurology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Weihua Zhang
- Department of Neurology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jiuwei Li
- Department of Neurology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Lifang Dai
- Department of Neurology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fang Fang
- Department of Neurology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
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21
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Goudot M, Frismand S, Hopes L, Verger A, Joubert B, Honnorat J, Tyvaert L. Recurrent seizures of autoimmune origin: emerging phenotypes. J Neurol 2021; 268:3000-3010. [PMID: 33638022 DOI: 10.1007/s00415-021-10457-1] [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: 09/12/2020] [Revised: 01/15/2021] [Accepted: 02/09/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Recurrent seizures of autoimmune origin (AEp) are one of the most frequent causes of recurrent seizures or suspected epilepsy of unknown cause. The aim of this study was to identify specific phenotypes corresponding to AEp. METHODS We retrospectively reviewed features of patients with recurrent seizures of unknown cause and investigated for suspected AEp (January 2015-May 2018). Patients were separated in: (1) AEpAb+: AEp with positive autoantibodies; (2) AEpAb-: suspected AEp (inflammatory central nervous system (CNS) profile) without autoantibodies; (3) NAEp: epilepsy without CNS inflammation. RESULTS Eighty-nine epileptic patients underwent a CSF antibody detection. From the remaining 57 epileptic patients (32 excluded for a differential diagnosis), 61.4% were considered as AEp. 21% were AEpAb+ (4 NMDAR, 2 GABAbR, 3 GAD-Ab, 2 LGi1, 1 CASPR2), 40.4% AEpAb-, and 38.6% NAE. AE (AEpAb+ and AEpAb-) was significantly associated with antibody prevalence in epilepsy (APE) score ≥ 4 (80%), encephalitic phase (71.4%), psychiatric involvement (64.7%), cognitive impairment (50%), and status epilepticus (41.2%). Within the group of 29 patients without encephalitic phase and with chronic epilepsy (NEPp), 34.5% were defined as AEp. 10.4% were AEpAb+ (2 GAD, 1 CASPR2) and 24.1% were AEpAb-. NEP AEp was associated with non-cerebral autoimmune disorders, short epileptic disease duration, and cognitive impairment. CONCLUSIONS Autoimmune cause (AEp) should be assessed in patient suffering from recurrent seizures of unknown cause. Acute encephalitis is clearly the main AEp phenotype. AEp was also defined in more than one-third of chronic epilepsy patients (NEP) of unknown cause. Then, AEp may be combined with other autoimmune comorbidities, a shorter evolution of recurrent seizures, and cognitive impairment.
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Affiliation(s)
- Mathilde Goudot
- Department of Neurology, University Hospital of Nancy, Nancy, France
| | - Solène Frismand
- Department of Neurology, University Hospital of Nancy, Nancy, France
| | - Lucie Hopes
- Department of Neurology, University Hospital of Nancy, Nancy, France
| | - Antoine Verger
- Department of Nuclear Medicine, IADI, INSERM U1254, University Hospital of Nancy, Nancy, France
| | - Bastien Joubert
- Department of Neurology, French Reference Center of Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, INSERM U1217/CNRS, UMR5310, Lyon, France
| | - Jérôme Honnorat
- Department of Neurology, French Reference Center of Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, INSERM U1217/CNRS, UMR5310, Lyon, France
| | - Louise Tyvaert
- Department of Neurology, University Hospital of Nancy, Nancy, France. .,Faculty of Medicine, CRAN CNRS UMR 7039, University of Lorraine, Nancy, France. .,Epilepsy Unit, Department of Neurology, Nancy University Medical Centre, Central Hospital, 54000, Nancy, France.
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Kao YC, Lin MI, Weng WC, Lee WT. Neuropsychiatric Disorders Due to Limbic Encephalitis: Immunologic Aspect. Int J Mol Sci 2020; 22:ijms22010389. [PMID: 33396564 PMCID: PMC7795533 DOI: 10.3390/ijms22010389] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/26/2020] [Accepted: 12/28/2020] [Indexed: 12/16/2022] Open
Abstract
Limbic encephalitis (LE) is a rare cause of encephalitis presenting as an acute and subacute onset of neuropsychiatric manifestations, particularly with memory deficits and confusion as core features, along with seizure occurrence, movement disorders, or autonomic dysfunctions. LE is caused by neuronal antibodies targeting the cellular surface, synaptic, and intracellular antigens, which alter the synaptic transmission, especially in the limbic area. Immunologic mechanisms involve antibodies, complements, or T-cell-mediated immune responses in different degree according to different autoantibodies. Sensitive cerebrospinal fluid markers of LE are unavailable, and radiographic findings may not reveal a typical mesiotemporal involvement at neurologic presentations; therefore, a high clinical index of suspicions is pivotal, and a neuronal antibody testing is necessary to make early diagnosis. Some patients have concomitant tumors, causing paraneoplastic LE; therefore, tumor survey and treatment are required in addition to immunotherapy. In this study, a review on the molecular and immunologic aspects of LE was conducted to gain awareness of its peculiarity, which we found quite different from our knowledge on traditional psychiatric illness.
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Affiliation(s)
- Yu-Chia Kao
- Department of Pediatrics, E-Da Hospital, Kaohsiung 82445, Taiwan;
| | - Ming-I Lin
- Department of Pediatrics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 11101, Taiwan;
| | - Wen-Chin Weng
- Department of Pediatrics, National Taiwan University Hospital, Taipei 100226, Taiwan;
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei 100233, Taiwan
| | - Wang-Tso Lee
- Department of Pediatrics, National Taiwan University Hospital, Taipei 100226, Taiwan;
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei 100233, Taiwan
- Graduate Institute of Brain and Mind Sciences, National Taiwan University College of Medicine, Taipei 100233, Taiwan
- Correspondence: ; Tel.: +886-2-23123456 (ext. 71545); Fax: +886-2-23147450
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Mansoor S, Murphy K. Anti-GAD-associated limbic encephalitis: an unusual clinical manifestation from northwest of Ireland. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2020. [DOI: 10.1186/s41983-020-0160-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractWe report an unusual manifestation of anti-GAD-associated limbic encephalitis in a 59-year-old man following pacemaker insertion for cardiac pauses. Clinically, the association of anti-GAD antibody with limbic encephalitis is rare. He presented with a complex constellation of symptoms, posing a diagnostic and therapeutic challenge.
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24
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Jaafar F, Haddad L, Koleilat N, Sharara-Chami R, Shbarou R. Super refractory status epilepticus secondary to anti-GAD antibody encephalitis successfully treated with aggressive immunotherapy. Epilepsy Behav Rep 2020; 14:100396. [PMID: 33305253 PMCID: PMC7710630 DOI: 10.1016/j.ebr.2020.100396] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 11/29/2022] Open
Abstract
Antibodies against glutamic acid decarboxylase are reported in association with a number of neurological conditions including limbic encephalitis. We report a case of anti-GAD-antibody associated encephalitis presenting with super-refractory status epilepticus. We describe the clinical course, management, and the outcome. In addition, we review the presentation and outcomes of reported cases of anti-GAD encephalitis. Similar to the reported cases of anti-GAD encephalitis, our case was refractory to treatment with conventional antiseizure medication. Treatment with intravenous immune globulin (IVIG), high dose corticosteroids, and plasmapheresis had partial response, but escalation of treatment to the use of tocilizumab was associated with significant clinical improvement.
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Key Words
- AED, antiepileptic drug
- Autoimmune encephalitis
- CSF, cerebrospinal fluid
- EEG, electroencephalogram
- GABA, gamma-aminobutyric acid
- GAD, glutamic acid decarboxylase
- Glutamic acid decarboxylase antibodies
- IVIG, intravenous immunoglobulin
- Limbic encephalitis
- MDZ, midazolam
- MP, methylprednisolone
- MRI, magnetic resonance imaging
- NMDA, N-methyl-d-aspartate
- PCR, polymerase chain reaction
- PLEX, plasma exchange
- RNA, ribonucleic acid
- Status epilepticus
- Tocilizumab
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Affiliation(s)
- Fatima Jaafar
- Division of Child Neurology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Laith Haddad
- Division of Child Neurology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nadia Koleilat
- Division of Child Neurology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rana Sharara-Chami
- Division of Pediatric Critical Care, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rolla Shbarou
- Division of Child Neurology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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25
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Psychiatric symptoms in anti glutamic acid decarboxylase associated limbic encephalitis in adults: a systematic review. Neurosci Biobehav Rev 2020; 119:128-137. [PMID: 33022299 DOI: 10.1016/j.neubiorev.2020.08.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 07/13/2020] [Accepted: 08/22/2020] [Indexed: 01/17/2023]
Abstract
Autoimmune Limbic Encephalitis (LE) is a relatively new category of immune-mediated diseases with a wide range of neuropsychiatric symptoms. LE associated with Glutamic Acid Decarboxylase (GAD) antibodies is difficult to diagnose due to its possible atypical presentation with neuropsychiatric and behavioral features. We performed a systematic review of literature and retrieved 21 cases of anti GAD-associated LE with neuropsychiatric signs. Median age at onset was 27 years with a female predominance (81.0 %) and median diagnostic delay of 6 months. Clinical presentation included typical LE symptoms such as anterograde amnesia (95.2 %) and temporal lobe or tonico-clonic seizures (95.2 %). Psychiatric symptoms were described in 61.9 % of patients, presenting as anxiety, depressive symptoms, apathy and behavioral changes. Extra-limbic symptoms were present in 14.3 % of patients. No neoplasia associated was found. Some patients had poor epileptic, cognitive and psychiatric outcomes requiring prolonged immunosuppressive treatment. The description of the neuropsychiatric spectrum of anti-GAD LE and its specificities aims to improve our understanding of this entity, and may lead to earlier diagnosis as well as better outcome.
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26
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Zhu F, Shan W, Lv R, Li Z, Wang Q. Clinical characteristics of GAD 65-associated autoimmune encephalitis. Acta Neurol Scand 2020; 142:281-293. [PMID: 32416610 DOI: 10.1111/ane.13281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To examine the clinical characteristics of autoimmune encephalitis associated with the glutamate decarboxylase 65 (GAD 65) antibody. MATERIALS AND METHODS Medical records of all patients that diagnosed with GAD 65 antibody-associated encephalitis were retrospectively analyzed. Data regarding demographics and symptoms, neurological signs, laboratory and imaging results, treatment and prognosis were collected. RESULTS We collected a total of seven patients, mainly young or middle-aged women with a subacute or chronic course. The main clinical symptoms mainly included chronic epilepsy, cerebellar ataxia, stiff-person syndrome, and limbic encephalitis. Three of seven (43%) patients had high CSF (cerebrospinal fluid) protein levels. Oligoclonal IgG bands (including IgG 1) and 24 hours intrathecal synthesis of IgG were detected in CSF and serum in six patients, five patients (83%) reported increased distribution of oligoclonal IgG bands (including IgG 1) and 24 hours intrathecal synthesis of IgG in serum and CSF. And six of seven patients (86%) had abnormal thyroid function or were positive for thyroid antibodies. By electroencephalogram examination, sharp or slow waves in the temporal region were often observed for six of seven patients (86%). Abnormal imaging signals (six of seven patients, 86%) of the temporal lobe and hippocampus were detected by brain magnetic resonance imaging, and decreased metabolism of the temporal lobe was detected by positron emission tomography/computed tomography (six of six patients, 100%). These patients were mainly treated with corticosteroid and gamma globulin. The clinical symptoms of the patients were alleviated. CONCLUSIONS The course of GAD 65 antibody-associated encephalitis is longer than other autoimmune encephalitides. The clinical symptoms of GAD 65 autoimmune encephalitis mainly manifested as chronic epilepsy, cerebellar ataxia, stiff-person syndrome, and limbic encephalitis, and combined with or without thyroid autoimmune diseases, type 1 diabetes, and thymoma. A comprehensive understanding of the disease is a way to prevent misdiagnosis and delayed treatment.
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Affiliation(s)
- Fei Zhu
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
| | - Wei Shan
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Beijing Institute for Brain Disorders Beijing China
| | - Ruijuan Lv
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
| | - Zhimei Li
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
| | - Qun Wang
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Beijing Institute for Brain Disorders Beijing China
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Chengyu L, Weixiong S, Chao C, Songyan L, Lin S, Zhong Z, Hua P, Fan J, Na C, Tao C, Jianwei W, Haitao R, Hongzhi G, Xiaoqiu S. Clinical features and immunotherapy outcomes of anti-glutamic acid decarboxylase 65 antibody-associated neurological disorders. J Neuroimmunol 2020; 345:577289. [PMID: 32563127 DOI: 10.1016/j.jneuroim.2020.577289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 06/07/2020] [Accepted: 06/07/2020] [Indexed: 02/07/2023]
Abstract
We described the clinical and neuroimaging characteristics of seven Chinese patients with anti-GAD65 antibody-associated neurological disorders of whom epileptic seizures were the initial and main symptoms. All patients were given immunotherapy and followed up monthly. The outcome demonstrates that immunotherapy is helpful for non-seizure manifestations of anti-GAD65-associated neurological autoimmunity and is less effective in the treatment of seizures, yet partial responses can still occur in the early stage. Taken together we suggest a trial with immunotherapy in all patients in the early stage of the disease, and in patients with non-epilepsy symptoms in the later stage.
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Affiliation(s)
- Li Chengyu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China.
| | - Shi Weixiong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Chen Chao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Liu Songyan
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Sang Lin
- Epilepsy Center, Medical Alliance of Beijing Tian Tan Hospital, Peking University First Hospital Fengtai Hospital, Beijing 100071, China
| | - Zheng Zhong
- Epilepsy Center, Medical Alliance of Beijing Tian Tan Hospital, Peking University First Hospital Fengtai Hospital, Beijing 100071, China
| | - Pan Hua
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Jian Fan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Chen Na
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Cui Tao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Wu Jianwei
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Ren Haitao
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Guan Hongzhi
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Shao Xiaoqiu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China.
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28
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Immune-mediated epilepsy with GAD65 antibodies. J Neuroimmunol 2020; 341:577189. [PMID: 32087461 DOI: 10.1016/j.jneuroim.2020.577189] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 02/11/2020] [Accepted: 02/11/2020] [Indexed: 12/18/2022]
Abstract
Anti-GAD65 antibodies have been identified in both acute/subacute seizures (limbic encephalitis and extralimbic encephalitis) and chronic isolated epilepsy. The evidence of high serum titers and intrathecal synthesis play a fundamental role in diagnosis but poorly correlate with disease severity or response to therapies. It remains controversial whether anti-GAD65 Abs are the pathogenic entity or only serve as a surrogate marker for autoimmune disorders mediated by cytotoxic T cells. Unlike other immune-mediated epilepsy, although multiple combinations of therapeutics are used, the efficacy and prognosis of patients with GAD65-epilepsy patients are poor. Besides, GAD65-epilepsy is more prone to relapse and potentially evolve into a more widespread CNS inflammatory disorder. This article reviews the recent advances of GAD65-epilepsy, focusing on the diagnosis, epidemiology, pathophysiology, clinical features, and treatment, to better promote the recognition and provide proper therapy for this condition.
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Li TR, Zhang YD, Wang Q, Shao XQ, Li ZM, Lv RJ. Intravenous methylprednisolone or immunoglobulin for anti-glutamic acid decarboxylase 65 antibody autoimmune encephalitis: which is better? BMC Neurosci 2020; 21:13. [PMID: 32228575 PMCID: PMC7106675 DOI: 10.1186/s12868-020-00561-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 03/21/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Patients positive for anti-glutamic acid decarboxylase 65 (GAD65) antibodies have attracted increasing attention. Their clinical manifestations are highly heterogeneous and can be comorbid with tumors. Currently, there is no consensus on the therapeutic regimen for anti-GAD65-associated neurological diseases due to the clinical complexity, rarity and sporadic distribution. We reported six anti-GAD65 autoimmune encephalitis (AE) patients who received intravenous methylprednisolone (IVMP) or immunoglobulin (IVIG) or both. Then, we evaluated the therapeutic effect of both by summarizing results in previous anti-GAD65 AE patients from 70 published references. RESULTS Our six patients all achieved clinical improvements in the short term. Unfortunately, there was no significant difference between IVMP and IVIG in terms of therapeutic response according to the previous references, and the effectiveness of IVMP and IVIG was 45.56% and 36.71%, respectively. We further divided the patients into different subgroups according to their prominent clinical manifestations. The response rates of IVMP and IVIG were 42.65% and 32.69%, respectively, in epilepsy patients; 60.00% and 77.78%, respectively, in patients with stiff-person syndrome; and 28.57% and 55.56%, respectively, in cerebellar ataxia patients. Among 29 anti-GAD65 AE patients with tumors, the response rates of IVMP and IVIG were 29.41% and 42.11%, respectively. There was no significant difference in effectiveness between the two regimens among the different subgroups. CONCLUSION Except for stiff-person syndrome, we found that this kind of AE generally has a poor response to IVMP or IVIG. Larger prospective studies enrolling large numbers of patients are required to identify the optimal therapeutic strategy in the future.
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Affiliation(s)
- Tao-Ran Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China.,Department of Neurology, Xuanwu Hospital of Capital Medical University, 45 Chang Chun Road, Xicheng District, Beijing, 100053, People's Republic of China
| | - Yu-Di Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China.,Department of Neurology, the Second Hospital of Hebei Medical University, Hebei Medical University, 215 Heping West Road, Xinhua District, Shijiazhuang, 050000, People's Republic of China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China
| | - Xiao-Qiu Shao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China
| | - Zhi-Mei Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China
| | - Rui-Juan Lv
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China.
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Abstract
Paraneoplastic neurological syndromes are nonmetastatic complications of malignancy secondary to immune-mediated neuronal dysfunction or death. Pathogenesis may occur from cell surface binding of antineuronal antibodies leading to dysfunction of the target protein, or from antibodies binding against intracellular antigens which ultimately leads to cell death. There are several classical neurological paraneoplastic phenotypes including subacute cerebellar degeneration, limbic encephalitis, encephalomyelitis, and dorsal sensory neuropathy. The patient’s clinical presentations may be suggestive to the treating clinician as to the specific underlying paraneoplastic antibody. Specific antibodies often correlate with the specific underlying tumor type, and malignancy screening is essential in all patients with paraneoplastic neurological disease. Prompt initiation of immunotherapy is essential in the treatment of patients with paraneoplastic neurological disease, often more effective in cell surface antibodies in comparison to intracellular antibodies, as is removal of the underlying tumor.
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Affiliation(s)
- Jonathan Galli
- Department of Neurology, University of Utah, Salt Lake City, UT, 84108, USA.,2. George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - John Greenlee
- Department of Neurology, University of Utah, Salt Lake City, UT, 84108, USA
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31
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Di Giacomo R, Deleo F, Pastori C, Didato G, Andreetta F, Del Sole A, de Curtis M, Villani F. Predictive value of high titer of GAD65 antibodies in a case of limbic encephalitis. J Neuroimmunol 2019; 337:577063. [PMID: 31525619 DOI: 10.1016/j.jneuroim.2019.577063] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/27/2019] [Accepted: 09/09/2019] [Indexed: 12/18/2022]
Abstract
We report the case of a 42-year-old woman who presented with vertigo and migraine and rapidly developed cognitive decline and seizures. Both serum and cerebro-spinal fluid samples showed high titer of anti-glutamic acid decarboxylase (anti-GAD65) antibodies (998,881 IU/ml and 54,687 IU/ml respectively). Limbic encephalitis was diagnosed and high dose steroids treatment started. During one-year follow-up, without further immunomodulatory therapy, the patient became seizure free, and cognitive functions returned to normal. Serum anti-GAD65 antibodies titer decreased significantly but remained elevated (192,680 IU/ml). We discuss the prognostic and pathogenic value of high titer anti-GAD65 antibodies and its variations in a case of autoimmune limbic encephalitis.
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Affiliation(s)
- Roberta Di Giacomo
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Francesco Deleo
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Chiara Pastori
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Giuseppe Didato
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Francesca Andreetta
- UO Neurologia IV, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Angelo Del Sole
- Nuclear Medicine Unit, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Italy.
| | - Marco de Curtis
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Flavio Villani
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Division of Clinical Neurophysiology, Policlinico IRCCS San Martino, Genova, Italy.
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Abstract
Autoimmune encephalitis is a severe inflammatory disorder of the brain with diverse causes and a complex differential diagnosis. Recent advances in the past decade have led to the identification of new syndromes and biological markers of limbic encephalitis, the commonest presentation of autoimmune encephalitis. The successful use of serum and intrathecal antibodies to diagnose affected patients has resulted in few biopsy and postmortem examinations. In those available, there can be variable infiltrating inflammatory T cells with cytotoxic granules in close apposition to neurons, consistent with an inflammatory autoimmune basis, but true vasculitis is rarely seen. The exception is Hashimoto encephalopathy.
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Affiliation(s)
- David S Younger
- Department of Neurology, Division of Neuro-Epidemiology, New York University School of Medicine, New York, NY 10016, USA; School of Public Health, City University of New York, New York, NY, USA.
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Nagai K, Maekawa T, Terashima H, Kubota M, Ishiguro A. Severe anti-GAD antibody-associated encephalitis after stem cell transplantation. Brain Dev 2019; 41:301-304. [PMID: 30381136 DOI: 10.1016/j.braindev.2018.10.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/07/2018] [Accepted: 10/16/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND General features of anti-glutamic acid decarboxylase (GAD) antibody-associated limbic encephalitis are seizures, cognitive impairment, and imaging findings at the medial temporal lobes. We report a patient affected with remarkably severe anti-GAD antibody-positive encephalitis after hematopoietic stem cell transplantation (HSCT). CASE REPORT A 5-year-old girl received HSCT due to pineoblastoma. Thirteen months after HSCT, she showed seizure clustering and altered mental status. Her anti-GAD antibody level was high, 65,100 U/mL (reference range < 1.5 U/mL). Her disease was diagnosed as autoimmune encephalitis and she received intravenous immunoglobulin (IVIG) and methylprednisolone. After the therapy, she partially recovered. Encephalitis later relapsed, however, and she showed extremely high anti-GAD antibody, 27 months after HSCT. Although lesions were located in the temporal and occipital lobes by MRI at 5 days after the relapse, very severe whole brain encephalitis was revealed at 13 days after the relapse. Seizures and abnormal encephalogram were resistant to IVIG and methylprednisolone. After plasma exchange, these findings were resolved. MRI revealed diffuse cerebral atrophy, 57 months after the relapse. No relapse has occurred for the past 5 years with decreased anti-GAD antibody after starting bimonthly administration of IVIG. CONCLUSION This may be the first case of severe and recurrent anti-GAD antibody-associated autoimmune encephalitis after HSCT with specific MRI findings. No relapse has occurred since starting maintenance IVIG.
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Affiliation(s)
- Koki Nagai
- Department of Postgraduate Education and Training, National Center for Child Health and Development, Japan
| | - Takanobu Maekawa
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Japan
| | - Hiroshi Terashima
- Division of Neurology, National Center for Child Health and Development, Japan
| | - Masaya Kubota
- Division of Neurology, National Center for Child Health and Development, Japan
| | - Akira Ishiguro
- Department of Postgraduate Education and Training, National Center for Child Health and Development, Japan.
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Autoimmune encephalitis and psychiatric disorders. Rev Neurol (Paris) 2018; 174:228-236. [DOI: 10.1016/j.neurol.2017.11.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/15/2017] [Accepted: 11/29/2017] [Indexed: 12/20/2022]
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