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Goertzen A, Altawashi AK, Rieck J, Veh RW. Autoimmune processes in neurological patients are much more common than presently suspected. J Neurol 2023; 270:5866-5877. [PMID: 37603074 PMCID: PMC10632246 DOI: 10.1007/s00415-023-11901-0] [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: 06/11/2023] [Revised: 07/23/2023] [Accepted: 07/25/2023] [Indexed: 08/22/2023]
Abstract
Autoimmune encephalitides are seldom diseases. How rare they actually are, however, is not known. The low incidence combined with the problematic identification may dampen efforts of neurologists, to identify patients with unclear symptoms as suffering from autoimmune encephalitis. Here, we aim to obtain a better estimate, how many patients with autoimmune disorders should be expected among 100 inpatients in a conventional neurological department. From a total number of 2603 non-stroke patients attended in a 2-year period (2018-2019) 460 CSFs were obtained. From this collection 187 samples (40.7%, > 500 sections) could be analyzed with our immunocytochemical technique. Autoreactive antibodies were detected in 102 (55%) of these 187 CSF samples. Certainly, the presence of autoreactive antibodies does not necessarily indicate that the patient suffers from an autoimmune disease. Our data indicate that from roughly 2000 patients during 1 year about 125 patients with autoreactive CSF antibodies should be expected in a conventional neurological department. This represents the about 35-fold value of what is generally expected at present. Being aware of this high incidence may intensify the efforts of neurologist to identify patients with any type of autoimmune encephalitis. This will be beneficial for patients, because they often profit from immunomodulatory therapy. Interestingly, some CFSs from our patients react with the CA2 subdivision of the hippocampus. While long neglected, recent research places this area into an important position to influence hippocampal network physiology. Autoreactive antibodies in the CSF may disturb the function of CA2 neurons, thereby explaining some neuropsychiatric symptoms in patients with autoimmune encephalitides.
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Affiliation(s)
- Angelika Goertzen
- AMEOS Klinikum St. Clemens Oberhausen, Wilhelmstrasse 34, D-46145, Oberhausen, Germany
| | | | - Julian Rieck
- Institut für Zell- und Neurobiologie, Centrum 2, Charité - Universitätsmedizin Berlin, Charitéplatz 1, D-10117, Berlin, Germany
| | - Rüdiger W Veh
- Institut für Zell- und Neurobiologie, Centrum 2, Charité - Universitätsmedizin Berlin, Charitéplatz 1, D-10117, Berlin, Germany.
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Detailed morphological analysis of rat hippocampi treated with CSF autoantibodies from patients with anti-NMDAR encephalitis discloses two distinct types of immunostaining patterns. Brain Res 2020; 1747:147033. [DOI: 10.1016/j.brainres.2020.147033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/23/2020] [Accepted: 07/24/2020] [Indexed: 10/23/2022]
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Positive Allosteric Modulation as a Potential Therapeutic Strategy in Anti-NMDA Receptor Encephalitis. J Neurosci 2018; 38:3218-3229. [PMID: 29476014 DOI: 10.1523/jneurosci.3377-17.2018] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/22/2018] [Accepted: 02/12/2018] [Indexed: 02/06/2023] Open
Abstract
N-methyl-d-aspartate receptors (NMDARs) are ionotropic glutamate receptors important for synaptic plasticity, memory, and neuropsychiatric health. NMDAR hypofunction contributes to multiple disorders, including anti-NMDAR encephalitis (NMDARE), an autoimmune disease of the CNS associated with GluN1 antibody-mediated NMDAR internalization. Here we characterize the functional/pharmacological consequences of exposure to CSF from female human NMDARE patients on NMDAR function, and we characterize the effects of intervention with recently described positive allosteric modulators (PAMs) of NMDARs. Incubation (48 h) of rat hippocampal neurons of both sexes in confirmed NMDARE patient CSF, but not control CSF, attenuated NMDA-induced current. Residual NMDAR function was characterized by lack of change in channel open probability, indiscriminate loss of synaptic and extrasynaptic NMDARs, and indiscriminate loss of GluN2B-containing and GluN2B-lacking NMDARs. NMDARs tagged with N-terminal pHluorin fluorescence demonstrated loss of surface receptors. Thus, function of residual NMDARs following CSF exposure was indistinguishable from baseline, and deficits appear wholly accounted for by receptor loss. Coapplication of CSF and PAMs of NMDARs (SGE-301 or SGE-550, oxysterol-mimetic) for 24 h restored NMDAR function following 24 h incubation in patient CSF. Curiously, restoration of NMDAR function was observed despite washout of PAMs before electrophysiological recordings. Subsequent experiments suggested that residual allosteric potentiation of NMDAR function explained the persistent rescue. Further studies of the pathogenesis of NMDARE and intervention with PAMs may inform new treatments for NMDARE and other disorders associated with NMDAR hypofunction.SIGNIFICANCE STATEMENT Anti-N-methyl-d-aspartate receptor encephalitis (NMDARE) is increasingly recognized as an important cause of sudden-onset psychosis and other neuropsychiatric symptoms. Current treatment leaves unmet medical need. Here we demonstrate cellular evidence that newly identified positive allosteric modulators of NMDAR function may be a viable therapeutic strategy.
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Banwell B, Goldberg EM, Ortiz-Gonzalez XR. Jessica Anne Panzer, MD, PhD (1977–2017). Neurology 2017. [DOI: 10.1212/wnl.0000000000004637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Ortiz-Gonzalez X, Goldberg EM, Banwell B. Obituary: Jessica Anne Panzer, MD, PhD. Pediatr Neurol 2017; 75:4-5. [PMID: 28823630 DOI: 10.1016/j.pediatrneurol.2017.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Xilma Ortiz-Gonzalez
- Division of Child Neurology, The Children's Hospital of Philadelphia, Department of Neurology, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ethan M Goldberg
- Division of Child Neurology, The Children's Hospital of Philadelphia, Department of Neurology, The University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Brenda Banwell
- Division of Child Neurology, The Children's Hospital of Philadelphia, Department of Neurology, The University of Pennsylvania, Philadelphia, Pennsylvania
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Anti-N-Methyl-D-aspartate Receptor Encephalitis: A Severe, Potentially Reversible Autoimmune Encephalitis. Mediators Inflamm 2017; 2017:6361479. [PMID: 28698711 PMCID: PMC5494059 DOI: 10.1155/2017/6361479] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 04/04/2017] [Indexed: 02/06/2023] Open
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is potentially lethal, but it is also a treatable autoimmune disorder characterized by prominent psychiatric and neurologic symptoms. It is often accompanied with teratoma or other neoplasm, especially in female patients. Anti-NMDAR antibodies in cerebrospinal fluid (CSF) and serum are characteristic features of the disease, thereby suggesting a pathogenic role in the disease. Here, we summarize recent studies that have clearly documented that both clinical manifestations and the antibodies may contribute to early diagnosis and multidisciplinary care. The clinical course of the disorder is reversible and the relapse could occur in some patients. Anti-NMDAR encephalitis coexisting with demyelinating disorders makes the diagnosis more complex; thus, clinicians should be aware of the overlapping diseases.
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Li Y, Wang Q, Liu C, Wu Y. Anti- N-Methyl-d-Aspartate Receptor Encephalitis in a Patient with Alcoholism: A Rare Case Report. Front Psychiatry 2017; 8:141. [PMID: 28824472 PMCID: PMC5540940 DOI: 10.3389/fpsyt.2017.00141] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 07/20/2017] [Indexed: 12/26/2022] Open
Abstract
Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis, the most common type of autoimmune encephalitis, is characterized by autoantibodies against NMDA receptor. Patients with anti-NMDAR encephalitis also present with various non-specific symptoms, such as flu-like symptoms, neurological, and psychiatric manifestations. Here, we first reported a rare case of anti-NMDAR encephalitis in a 36-year-old male alcohol abuser. The patient presented with acute psychiatric symptoms with no abnormality in neuroimage examination and laboratory test results. Alcoholism was proposed as the most likely diagnosis. However, stopping alcohol drinking and symptomatic treatment were not effective, and 12 days later, the disease progressed with seizures and unconsciousness. Routine analysis of the cerebrospinal fluid (CSF) showed no abnormality. Importantly, anti-NMDA receptor antibodies were detected in his CSF, indicating that the patient has anti-NMDA receptor encephalitis. Consistently, γ-immunoglobulin therapy dramatically improved symptoms, which further confirmed the diagnosis. As anti-NMDAR encephalitis has no unique clinical characteristic and its psychiatric manifestations may overlap with the alcoholism-associated psychiatric symptoms, precaution should be taken to differentiate anti-NMDAR encephalitis from alcoholism in alcohol abusers.
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Affiliation(s)
- Yangyang Li
- Department of Psychiatry, Graduate Program in Psychiatry, Jining Medical University, Jining, China
| | - Qiuling Wang
- Department of Psychiatry, Jining Psychiatric Hospital, Jining, China
| | - Chuanxin Liu
- Department of Psychiatry, Graduate Program in Psychiatry, Jining Medical University, Jining, China.,Collaborative Innovation Center for Birth Defect Research and Transformation of Shandong Province, Jining Medical University, Jining, China
| | - Yili Wu
- Department of Psychiatry, Graduate Program in Psychiatry, Jining Medical University, Jining, China.,Collaborative Innovation Center for Birth Defect Research and Transformation of Shandong Province, Jining Medical University, Jining, China.,Shandong Key Laboratory of Behavioral Medicine, Jining Medical University, Jining, China
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Ultimate Translation: Developing Therapeutics Targeting on N-Methyl-d-Aspartate Receptor. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2016; 76:257-309. [PMID: 27288080 DOI: 10.1016/bs.apha.2016.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
N-Methyl-d-aspartate receptors (NMDARs) are broadly distributed in the central nervous system (CNS), where they mediate excitatory signaling. NMDAR-mediated neurotransmission (NMDARMN) is the molecular engine of learning, memory and cognition, which are the basis for high cortical function. NMDARMN is also critically involved in the development and plasticity of CNS. Due to its essential and critical role, either over- or under-activation of NMDARMN can contribute substantially to the development of CNS disorders. The involvement of NMDARMN has been demonstrated in a variety of CNS disorders, including schizophrenia, depression, posttraumatic stress disorder, aging, mild cognitive impairment and Alzheimer's dementia, amyotrophic lateral sclerosis, and anti-NMDAR encephalitis. Several targets to "correct" or "reset" the NMDARMN in these CNS disorders have been identified and confirmed. With analogy to aminergic treatments, these targets include the glycine/d-serine co-agonist site, channel ionophore, glycine transporter-1, and d-amino acid oxidase. It is still early days in terms of developing novel therapeutics targeting the NMDAR. However, agents modulating NMDARMN hold promise as the next generation of CNS therapeutics.
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Affiliation(s)
- Lloyd Bradley
- Donald Wilson House Neurological Rehabilitation Centre, Western Sussex Hospitals Trust, Chichester, West Sussex, UK
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Autoimmune N-methyl-D-aspartate receptor encephalitis is a differential diagnosis of infectious encephalitis. J Infect 2014; 68:419-25. [DOI: 10.1016/j.jinf.2013.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 12/06/2013] [Accepted: 12/09/2013] [Indexed: 01/17/2023]
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