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Irani SR. Autoimmune Encephalitis. Continuum (Minneap Minn) 2024; 30:995-1020. [PMID: 39088286 DOI: 10.1212/con.0000000000001448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
OBJECTIVE This article focuses on the clinical features and diagnostic evaluations that accurately identify patients with ever-expanding forms of antibody-defined encephalitis. Forms of autoimmune encephalitis are more prevalent than infectious encephalitis and represent treatable neurologic syndromes for which early immunotherapies lead to the best outcomes. LATEST DEVELOPMENTS A clinically driven approach to identifying many autoimmune encephalitis syndromes is feasible, given the typically distinctive features associated with each antibody. Patient demographics alongside the presence and nature of seizures, cognitive impairment, psychiatric disturbances, movement disorders, and peripheral features provide a valuable set of clinical tools to guide the detection and interpretation of highly specific antibodies. In turn, these clinical features in combination with serologic findings and selective paraclinical testing, direct the rationale for the administration of immunotherapies. Observational studies provide the mainstay of evidence guiding first- and second-line immunotherapy administration in autoimmune encephalitis and, whereas these typically result in some clinical improvements, almost all patients have residual neuropsychiatric deficits, and many experience clinical relapses. An improved pathophysiologic understanding and ongoing clinical trials can help to address these unmet medical needs. ESSENTIAL POINTS Antibodies against central nervous system proteins characterize various autoimmune encephalitis syndromes. The most common targets include leucine-rich glioma inactivated protein 1 (LGI1), N-methyl-d-aspartate (NMDA) receptors, contactin-associated proteinlike 2 (CASPR2), and glutamic acid decarboxylase 65 (GAD65). Each antibody-associated autoimmune encephalitis typically presents with a recognizable blend of clinical and investigation features, which help differentiate each from alternative diagnoses. The rapid expansion of recognized antibodies and some clinical overlaps support panel-based antibody testing. The clinical-serologic picture guides the immunotherapy regime and offers valuable prognostic information. Patient care should be delivered in conjunction with autoimmune encephalitis experts.
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Segal Y, Rotschild O, Mina Y, Maayan Eshed G, Levinson T, Paran Y, Dekel M, Cohen-Poradosu R, Ashkenazi A, Moreno I, Aizenstein O, Halutz O, Alcalay Y, Gadoth A. Epidemiology of autoimmune encephalitis and comparison to infectious causes-Experience from a tertiary center. Ann Clin Transl Neurol 2024. [PMID: 39030965 DOI: 10.1002/acn3.52147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 05/29/2024] [Accepted: 06/21/2024] [Indexed: 07/22/2024] Open
Abstract
OBJECTIVES The incidence of autoimmune encephalitis (AIE) has risen in the last decade, yet recent studies are lacking. We compared the epidemiology of autoimmune and infectious encephalitis cases in Tel-Aviv Sourasky Medical Center (TASMC) between 2010 and 2020. METHODS All encephalitis cases, aged 18 and above, admitted to TASMC between the years 2010 and 2020 were reviewed for demographic, clinical, laboratory, and imaging data and categorized based on etiology. RESULTS Two hundred and twenty-five patients with encephalitis were identified. The most common identifiable cause was viral (42%), followed by autoimmune encephalitis (35%), bacterial (18%), and fungal/parasitic (5%). The incidence of AIE cases out of the yearly admitted cases increased substantially, from 3.8/100 K in 2010 to 18.8/100 K in 2020. The incidence of viral cases also increased while those of bacterial and fungal/parasitic infections remained stable. Patients with AIE were younger compared to infectious patients (p-value <0.001) and had lower markers of systemic and cerebrospinal fluid inflammation (p-value for all <0.001). Seizures were more common among AIE patients (p-value <0.001), yet one-year mortality rates were higher among infectious patients (p-value <0.001). INTERPRETATION AIE incidence has risen significantly in our institution during the past decade, with current rates comparable to those of all infectious causes combined. Based on this cohort, clinical clues for an autoimmune etiology include a non-inflammatory cerebrospinal fluid profile, the presence of seizures, and temporal lobe imaging abnormalities (also common in herpetic encephalitis). In light of its rising incidence and the importance of early treatment, AIE should be considered in the differential diagnosis of all encephalitis cases.
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Affiliation(s)
- Yahel Segal
- Department of Neurology, Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - Ofer Rotschild
- Department of Neurology, Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - Yair Mina
- Department of Neurology, Tel-Aviv Medical Center, Tel-Aviv, Israel
- Encephalitis Center, Tel-Aviv Medical Center, Tel-Aviv, Israel
| | | | - Tal Levinson
- Infectious Diseases Unit, Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - Yael Paran
- Encephalitis Center, Tel-Aviv Medical Center, Tel-Aviv, Israel
- Infectious Diseases Unit, Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - Michal Dekel
- Encephalitis Center, Tel-Aviv Medical Center, Tel-Aviv, Israel
- Infectious Diseases Unit, Tel-Aviv Medical Center, Tel-Aviv, Israel
| | | | - Adi Ashkenazi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Itamar Moreno
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orna Aizenstein
- Encephalitis Center, Tel-Aviv Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Radiology, Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - Ora Halutz
- Encephalitis Center, Tel-Aviv Medical Center, Tel-Aviv, Israel
- Clinical Microbiology Laboratory, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Yifat Alcalay
- Encephalitis Center, Tel-Aviv Medical Center, Tel-Aviv, Israel
- Immunology Laboratory, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Avi Gadoth
- Department of Neurology, Tel-Aviv Medical Center, Tel-Aviv, Israel
- Encephalitis Center, Tel-Aviv Medical Center, Tel-Aviv, Israel
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Segal Y, Zekeridou A. Interest of rare autoantibodies in autoimmune encephalitis and paraneoplastic neurological syndromes: the utility (or futility) of rare antibody discovery. Curr Opin Neurol 2024; 37:295-304. [PMID: 38533672 DOI: 10.1097/wco.0000000000001261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
PURPOSE OF REVIEW The increasing recognition and diagnosis of autoimmune encephalitis (AE) and paraneoplastic neurological syndromes (PNS) is partly due to neural autoantibody testing and discovery. The past two decades witnessed an exponential growth in the number of identified neural antibodies. This review aims to summarize recent rare antibody discoveries in the context of central nervous system (CNS) autoimmunity and evaluate the ongoing debate about their utility. RECENT FINDINGS In the last 5 years alone 15 novel neural autoantibody specificities were identified. These include rare neural antibody biomarkers of autoimmune encephalitis, cerebellar ataxia or other movement disorders, including multifocal presentations. SUMMARY Although the clinical applications of these rare antibody discoveries may be limited by the low number of positive cases, they still provide important diagnostic, prognostic, and therapeutic insights.
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Affiliation(s)
- Yahel Segal
- Department of Laboratory Medicine and Pathology
| | - Anastasia Zekeridou
- Department of Laboratory Medicine and Pathology
- Department of Neurology
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
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Smith KM, Budhram A, Geis C, McKeon A, Steriade C, Stredny CM, Titulaer MJ, Britton JW. Autoimmune-associated seizure disorders. Epileptic Disord 2024. [PMID: 38818801 DOI: 10.1002/epd2.20231] [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: 01/24/2024] [Revised: 03/28/2024] [Accepted: 04/13/2024] [Indexed: 06/01/2024]
Abstract
With the discovery of an expanding number of neural autoantibodies, autoimmune etiologies of seizures have been increasingly recognized. Clinical phenotypes have been identified in association with specific underlying antibodies, allowing an earlier diagnosis. These phenotypes include faciobrachial dystonic seizures with LGI1 encephalitis, neuropsychiatric presentations associated with movement disorders and seizures in NMDA-receptor encephalitis, and chronic temporal lobe epilepsy in GAD65 neurologic autoimmunity. Prompt recognition of these disorders is important, as some of them are highly responsive to immunotherapy. The response to immunotherapy is highest in patients with encephalitis secondary to antibodies targeting cell surface synaptic antigens. However, the response is less effective in conditions involving antibodies binding intracellular antigens or in Rasmussen syndrome, which are predominantly mediated by cytotoxic T-cell processes that are associated with irreversible cellular destruction. Autoimmune encephalitides also may have a paraneoplastic etiology, further emphasizing the importance of recognizing these disorders. Finally, autoimmune processes and responses to novel immunotherapies have been reported in new-onset refractory status epilepticus (NORSE) and febrile infection-related epilepsy syndrome (FIRES), warranting their inclusion in any current review of autoimmune-associated seizure disorders.
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Affiliation(s)
- Kelsey M Smith
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Adrian Budhram
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Christian Geis
- Department of Neurology and Section Translational Neuroimmunology, Jena University Hospital, Jena, Germany
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Claude Steriade
- Department of Neurology, New York University Langone Health, New York, New York, USA
| | - Coral M Stredny
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Maarten J Titulaer
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
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Lamblin F, Kerstens J, Muñiz-Castrillo S, Vogrig A, Goncalves D, Rogemond V, Picard G, Villard M, Pinto AL, Van Coevorden-Hameete MH, De Bruijn MA, De Vries JM, Schreurs M, Tyvaert L, Hopes L, Aupy J, Marchal C, Psimaras D, Kremer L, Bourg V, Antoine JCG, Wang A, Kahane P, Demeret S, Ahle G, Sempere VP, Timestit N, Nourredine M, Maureille A, Benaiteau M, Joubert B, Mignot E, Titulaer MJ, Honnorat J. Comparative Study of Paraneoplastic and Nonparaneoplastic Autoimmune Encephalitis With GABA BR Antibodies. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200229. [PMID: 38657198 PMCID: PMC11087025 DOI: 10.1212/nxi.0000000000200229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/29/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND AND OBJECTIVES While patients with paraneoplastic autoimmune encephalitis (AE) with gamma-aminobutyric-acid B receptor antibodies (GABABR-AE) have poor functional outcomes and high mortality, the prognosis of nonparaneoplastic cases has not been well studied. METHODS Patients with GABABR-AE from the French and the Dutch Paraneoplastic Neurologic Syndromes Reference Centers databases were retrospectively included and their data collected; the neurologic outcomes of paraneoplastic and nonparaneoplastic cases were compared. Immunoglobulin G (IgG) isotyping and human leukocyte antigen (HLA) genotyping were performed in patients with available samples. RESULTS A total of 111 patients (44/111 [40%] women) were enrolled, including 84 of 111 (76%) paraneoplastic and 18 of 111 (16%) nonparaneoplastic cases (cancer status was undetermined for 9 patients). Patients presented with seizures (88/111 [79%]), cognitive impairment (54/111 [49%]), and/or behavioral disorders (34/111 [31%]), and 54 of 111 (50%) were admitted in intensive care unit (ICU). Nonparaneoplastic patients were significantly younger (median age 54 years [range 19-88] vs 67 years [range 50-85] for paraneoplastic cases, p < 0.001) and showed a different demographic distribution. Nonparaneoplastic patients more often had CSF pleocytosis (17/17 [100%] vs 58/78 [74%], p = 0.02), were almost never associated with KTCD16-abs (1/16 [6%] vs 61/70 [87%], p < 0.001), and were more frequently treated with second-line immunotherapy (11/18 [61%] vs 18/82 [22%], p = 0.003). However, no difference of IgG subclass or HLA association was observed, although sample size was small (10 and 26 patients, respectively). After treatment, neurologic outcome was favorable (mRS ≤2) for 13 of 16 (81%) nonparaneoplastic and 37 of 84 (48%) paraneoplastic cases (p = 0.03), while 3 of 18 (17%) and 42 of 83 (51%) patients had died at last follow-up (p = 0.008), respectively. Neurologic outcome no longer differed after adjustment for confounding factors but seemed to be negatively associated with increased age and ICU admission. A better survival was associated with nonparaneoplastic cases, a younger age, and the use of immunosuppressive drugs. DISCUSSION Nonparaneoplastic GABABR-AE involved younger patients without associated KCTD16-abs and carried better neurologic and vital prognoses than paraneoplastic GABABR-AE, which might be due to a more intensive treatment strategy. A better understanding of immunologic mechanisms underlying both forms is needed.
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Affiliation(s)
- Florian Lamblin
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Jeroen Kerstens
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Sergio Muñiz-Castrillo
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Alberto Vogrig
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - David Goncalves
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Veronique Rogemond
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Geraldine Picard
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Marine Villard
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Anne-Laurie Pinto
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Marleen H Van Coevorden-Hameete
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Marienke A De Bruijn
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Juna M De Vries
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Marco Schreurs
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Louise Tyvaert
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Lucie Hopes
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Jerome Aupy
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Cecile Marchal
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Dimitri Psimaras
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Laurent Kremer
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Veronique Bourg
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Jean-Christophe G Antoine
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Adrien Wang
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Philippe Kahane
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Sophie Demeret
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Guido Ahle
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Vicente Peris Sempere
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Noemie Timestit
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Mikail Nourredine
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Aurelien Maureille
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Marie Benaiteau
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Bastien Joubert
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Emmanuel Mignot
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Maarten J Titulaer
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Jerome Honnorat
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
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6
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Hahn C, Budhram A, Alikhani K, AlOhaly N, Beecher G, Blevins G, Brooks J, Carruthers R, Comtois J, Cowan J, de Robles P, Hébert J, Kapadia RK, Lapointe S, Mackie A, Mason W, McLane B, Muccilli A, Poliakov I, Smyth P, Williams KG, Uy C, McCombe JA. Canadian Consensus Guidelines for the Diagnosis and Treatment of Autoimmune Encephalitis in Adults. Can J Neurol Sci 2024:1-21. [PMID: 38312020 DOI: 10.1017/cjn.2024.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Abstract
Autoimmune encephalitis is increasingly recognized as a neurologic cause of acute mental status changes with similar prevalence to infectious encephalitis. Despite rising awareness, approaches to diagnosis remain inconsistent and evidence for optimal treatment is limited. The following Canadian guidelines represent a consensus and evidence (where available) based approach to both the diagnosis and treatment of adult patients with autoimmune encephalitis. The guidelines were developed using a modified RAND process and included input from specialists in autoimmune neurology, neuropsychiatry and infectious diseases. These guidelines are targeted at front line clinicians and were created to provide a pragmatic and practical approach to managing such patients in the acute setting.
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Affiliation(s)
- Christopher Hahn
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Adrian Budhram
- Clinical Neurological Sciences, London Health Sciences Centre, London, ON, Canada
- Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada
| | - Katayoun Alikhani
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Nasser AlOhaly
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Grayson Beecher
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - Gregg Blevins
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - John Brooks
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Robert Carruthers
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Jacynthe Comtois
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Juthaporn Cowan
- Division of Infectious Diseases, Department of Medicine Ottawa Hospital, Ottawa, ON, Canada
| | - Paula de Robles
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Julien Hébert
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Ronak K Kapadia
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Sarah Lapointe
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Aaron Mackie
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Warren Mason
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Brienne McLane
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | | | - Ilia Poliakov
- Division of Neurology, University of Saskatchewan College of Medicine, Saskatoon, SK, Canada
| | - Penelope Smyth
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | | | - Christopher Uy
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
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7
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Wagner B, Irani S. Autoimmune and paraneoplastic seizures. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:151-172. [PMID: 38494275 DOI: 10.1016/b978-0-12-823912-4.00009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Seizures are a common feature of autoimmune encephalitis and are especially prevalent in patients with the commonest autoantibodies, against LGI1, CASPR2 and the NMDA, GABAB, and GABAA receptors. In this chapter, we discuss the classification, clinical, investigation, and treatment aspects of patients with these, and other autoantibody-mediated and -associated, illnesses. We highlight distinctive and common seizure semiologies which, often alongside other features we outline, can help the clinical diagnosis of an autoantibody-associated syndrome. Next, we classify these syndromes by either focusing on whether they represent underlying causative autoantibodies or T-cell-mediated syndromes and on the distinction between acute symptomatic seizures and a more enduring tendency to autoimmune-associated epilepsy, a practical and valuable distinction for both patients and clinicians which relates to the pathogenesis. We emphasize the more effective immunotherapy response in patients with causative autoantibodies, and discuss the emerging evidence for various first-, second-, and third-line immunotherapies. Finally, we highlight available clinical rating scales which can guide autoantibody testing and immunotherapy in patients with seizures of unknown etiology. Throughout, we relate the clinical and therapeutic observations to the immunobiology and neuroscience which drive these seizures.
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Affiliation(s)
- Barbara Wagner
- Neuroscience Department, NDCN, University of Oxford and Oxford University Hospitals, Oxford, United Kingdom; Kantonsspital Aarau Switzerland, Tellstrasse, Aarau, Switzerland
| | - Sarosh Irani
- Neuroscience Department, NDCN, University of Oxford and Oxford University Hospitals, Oxford, United Kingdom.
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8
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Graus F. Clinical approach to diagnosis of paraneoplastic neurologic syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:79-96. [PMID: 38494298 DOI: 10.1016/b978-0-12-823912-4.00007-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
The correct diagnosis of a paraneoplastic neurologic syndrome (PNS) first requires the identification of the syndrome as one of those defined as high-risk (previously called classical) or intermediate-risk for cancer in the 2021 PNS diagnostic criteria. Testing for neuronal antibodies should be restricted to these syndromes as indiscriminate request decreases the diagnostic value of the antibodies. Identifying onconeural (high-risk for cancer) or intermediate-risk for cancer antibodies supports the paraneoplastic diagnosis and mandates the search for an underlying cancer. Tumor screening must follow the published guidelines. Repeated screening is indicated in neurologic syndromes with onconeural antibodies and patients with high-risk for cancer neurologic syndromes unless they present neuronal antibodies which are not associated with cancer. Neuronal antibodies should be screened by immunohistochemistry and confirmed by immunoblot (intracellular antigens) or cell-based assay (CBA) (surface antigens). Positive results only by immunoblot or CBA should be taken with caution. Although the 2021 diagnostic criteria for PNS do not capture all PNS, as they do not allow to diagnose definite PNS neurologic syndromes without neuronal antibodies, the updated criteria represent a step forward to differentiate true PNS from neurologic syndromes that coincide in time with cancer diagnosis without having a pathogenic link.
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Affiliation(s)
- Francesc Graus
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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9
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Kadish R, Clardy SL. Epidemiology of paraneoplastic neurologic syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:57-77. [PMID: 38494297 DOI: 10.1016/b978-0-12-823912-4.00011-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes (PNS), initially depicted as seemingly cryptic remote manifestations of malignancy, were first described clinically in the early 20th century, with pathophysiologic correlates becoming better elucidated in the latter half of the century. There remain many questions not only about the pathophysiology but also regarding the epidemiology of these conditions. The continuous discovery of novel autoantigens and related neurologic disease has broadened the association in classical PNS to include conditions such as paraneoplastic cerebellar degeneration. It has also brought into focus several other neurologic syndromes with a putative neoplastic association. These conditions are overall rare, making it difficult to capture large numbers of patients to study, and raising the question of whether incidence is increasing over time or improved identification is driving the increased numbers of cases. With the rise and increasing use of immunotherapy for cancer treatment, the incidence of these conditions is additionally expected to rise and may present with various clinical symptoms. As we enter an era of clinical trial intervention in these conditions, much work is needed to capture more granular data on population groups defined by socioeconomic characteristics such as age, ethnicity, economic resources, and gender to optimize care and clinical trial planning.
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Affiliation(s)
- Robert Kadish
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Stacey L Clardy
- Department of Neurology, University of Utah, Salt Lake City, UT, United States; George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States.
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10
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Jean MJ, Samkoff L, Mohile N. Management of Paraneoplastic Syndromes in the Era of Immune Checkpoint Inhibitors. Curr Treat Options Oncol 2024; 25:42-65. [PMID: 38198120 DOI: 10.1007/s11864-023-01157-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 01/11/2024]
Abstract
OPINION STATEMENT Our understanding of paraneoplastic neurologic syndromes (PNS) has blossomed over the past few decades. Clinicians have access to more robust diagnostic criteria and have a heightened index of suspicion for these disorders. Nonetheless, treatment, which typically includes immunosuppression, and response to treatment, varies. Due to persistent difficulty in making a definitive diagnosis, we favor empiric treatment when a possible diagnosis of PNS is suspected, and other alternative causes have substantially been excluded (e.g., infections, toxic-metabolic derangements, metastasis, or leptomeningeal disease). Treatment of the underlying cancer, if identified, is the first therapeutic step and can prevent disease worsening and in rare cases, can reverse neurologic symptoms. In addition to anti-cancer treatment, first line immunotherapies, which include corticosteroids, intravenous immunoglobulins (IVIG), or plasma exchange (PLEX) are typically used. If partial or no benefit is seen, second line immunotherapeutic agents such as rituximab are considered. Additionally, the severity of the initial presentation and possible risk for relapse influences the use of the latter agents. Symptomatic management is also an important component in our practice and will depend on the syndrome being treated. One of the more novel entities we are facing currently is the management of immune checkpoint (ICI)-induced PNS. In those cases, current American Society of Clinical Oncology (ASCO) guidelines are followed.
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Affiliation(s)
- Maxime Junior Jean
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Lawrence Samkoff
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Nimish Mohile
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA.
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11
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Budhram A, Sechi E. Antibodies to neural cell surface and synaptic proteins in paraneoplastic neurologic syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:347-364. [PMID: 38494289 DOI: 10.1016/b978-0-12-823912-4.00006-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Among patients with paraneoplastic neurologic syndromes (PNS), emphasis has historically been placed on neural antibodies against intracellular proteins that have a strong association with malignancy. Because of the intracellular location of their antigenic targets, these antibodies are typically considered to be non-pathogenic surrogate markers of immune cell-mediated neural injury. Unfortunately, patients with these antibodies often have suboptimal response to immunotherapy and poor prognosis. Over the last two decades, however, dramatic advancements have been made in the discovery and clinical characterization of neural antibodies against extracellular targets. These antibodies are generally considered to be pathogenic, given their potential to directly alter antigen structure or function, and patients with these antibodies often respond favorably to prompt immunotherapy. These antibodies also associate with tumors and may thus occur as PNS, albeit more variably than neural antibodies against intracellular targets. The updated 2021 PNS diagnostic criteria, which classifies antibodies as high-risk, intermediate-risk, or lower-risk for an associated cancer, better clarifies how neural antibodies against extracellular targets relate to PNS. Using this recently created framework, the clinical presentations, ancillary test findings, oncologic associations, and treatment responses of syndromes associated with these antibodies are discussed.
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Affiliation(s)
- Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, ON, Canada; Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada.
| | - Elia Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
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12
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Quinot V, Höftberger R. Pathogenesis and immunopathology of paraneoplastic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:33-54. [PMID: 38494287 DOI: 10.1016/b978-0-12-823912-4.00027-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes (PNS) represent a rare group of immune-mediated complications associated with an underlying tumor. Ectopic protein expression in neoplastic cells or an aberrant immune regulation in the course of hematooncologic diseases or thymomas trigger an autoimmune response that may affect any part of the central and/or peripheral nervous system. Recent advances in drug therapies as well as novel animal models and neuropathologic studies have led to further insights on the immune pathomechanisms of PNS. Although the syndromes share common paths in pathogenesis, they may differ in the disease course, prognosis, and therapy targets, depending on the localization and type of antibody epitope. Neuropathologic hallmarks of PNS associated with antibodies directed against intracellular epitopes are characterized by T cell-dominated inflammation, reactive gliosis including microglial nodules, and neuronal degeneration. By contrast, the neuropathology of cell surface antibody-mediated PNS strongly depends on the targeted antigen and varies from B cell/plasma cell-dominated inflammation and well-preserved neurons together with a reduced expression of the target antigen in anti-NMDAR encephalitis to irreversible Purkinje cell loss in anti-P/Q-type VGCC antibody-associated paraneoplastic cerebellar degeneration. The understanding of different pathomechanisms in PNS is important because they strongly correspond with therapy response and prognosis, and should guide treatment decisions.
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Affiliation(s)
- Valérie Quinot
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria.
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13
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Waters P, Mills JR, Fox H. Evolution of methods to detect paraneoplastic antibodies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:113-130. [PMID: 38494273 DOI: 10.1016/b978-0-12-823912-4.00010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
An adaptive immune response in less than 1% of people who develop cancer produces antibodies against neuronal proteins. These antibodies can be associated with paraneoplastic syndromes, and their accurate detection should instigate a search for a specific cancer. Over the years, multiple systems, from indirect immunofluorescence to live cell-based assays, have been developed to identify these antibodies. As the specific antigens were identified, high throughput, multi-antigen substrates such as line blots and ELISAs were developed for clinical laboratories. However, the evolution of assays required to identify antibodies to membrane targets has shone a light on the importance of antigen conformation for antibody detection. This chapter discusses the early antibody assays used to detect antibodies to nuclear and cytosolic targets and how new approaches are required to detect antibodies to membrane targets. The chapter presents recent data that support international recommendations against the sole use of line blots for antibody detection and highlights a new antigen-specific approach that appears promising for the detection of submembrane targets.
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Affiliation(s)
- Patrick Waters
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Hannah Fox
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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14
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Masciocchi S, Businaro P, Scaranzin S, Morandi C, Franciotta D, Gastaldi M. General features, pathogenesis, and laboratory diagnostics of autoimmune encephalitis. Crit Rev Clin Lab Sci 2024; 61:45-69. [PMID: 37777038 DOI: 10.1080/10408363.2023.2247482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/09/2023] [Indexed: 10/02/2023]
Abstract
Autoimmune encephalitis (AE) is a group of inflammatory conditions that can associate with the presence of antibodies directed to neuronal intracellular, or cell surface antigens. These disorders are increasingly recognized as an important differential diagnosis of infectious encephalitis and of other common neuropsychiatric conditions. Autoantibody diagnostics plays a pivotal role for accurate diagnosis of AE, which is of utmost importance for the prompt recognition and early treatment. Several AE subgroups can be identified, either according to the prominent clinical phenotype, presence of a concomitant tumor, or type of neuronal autoantibody, and recent diagnostic criteria have provided important insights into AE classification. Antibodies to neuronal intracellular antigens typically associate with paraneoplastic neurological syndromes and poor prognosis, whereas antibodies to synaptic/neuronal cell surface antigens characterize many AE subtypes that associate with tumors less frequently, and that are often immunotherapy-responsive. In addition to the general features of AE, we review current knowledge on the pathogenic mechanisms underlying these disorders, focusing mainly on the potential role of neuronal antibodies in the most frequent conditions, and highlight current theories and controversies. Then, we dissect the crucial aspects of the laboratory diagnostics of neuronal antibodies, which represents an actual challenge for both pathologists and neurologists. Indeed, this diagnostics entails technical difficulties, along with particularly interesting novel features and pitfalls. The novelties especially apply to the wide range of assays used, including specific tissue-based and cell-based assays. These assays can be developed in-house, usually in specialized laboratories, or are commercially available. They are widely used in clinical immunology and in clinical chemistry laboratories, with relevant differences in analytic performance. Indeed, several data indicate that in-house assays could perform better than commercial kits, notwithstanding that the former are based on non-standardized protocols. Moreover, they need expertise and laboratory facilities usually unavailable in clinical chemistry laboratories. Together with the data of the literature, we critically evaluate the analytical performance of the in-house vs commercial kit-based approach. Finally, we propose an algorithm aimed at integrating the present strategies of the laboratory diagnostics in AE for the best clinical management of patients with these disorders.
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Affiliation(s)
- Stefano Masciocchi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, Università degli Studi di Pavia, Pavia, Italy
| | - Pietro Businaro
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, Università degli Studi di Pavia, Pavia, Italy
| | - Silvia Scaranzin
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Chiara Morandi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Diego Franciotta
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Matteo Gastaldi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
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15
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Kerstens J, Titulaer MJ. Overview of treatment strategies in paraneoplastic neurological syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:97-112. [PMID: 38494299 DOI: 10.1016/b978-0-12-823912-4.00015-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Treatment strategies in paraneoplastic neurological syndromes rely on the three pillars of tumor treatment, immunotherapy, and symptomatic treatment, the first one being by far the most important in the majority of patients and syndromes. Classically, antibodies against extracellular antigens are directly pathogenic, and patients with these syndromes are more responsive to immunomodulatory or immunosuppressive treatments than the ones with antibodies against intracellular targets. This chapter first discusses some general principles of tumor treatment and immunotherapy, followed by a closer look at specific treatment options for different clinical syndromes, focusing on symptomatic treatments.
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Affiliation(s)
- Jeroen Kerstens
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Maarten J Titulaer
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands.
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16
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Broers MC, Wieske L, Erdag E, Gürlek C, Bunschoten C, van Doorn PA, Eftimov F, Kuitwaard K, de Vries JM, de Wit MCY, Nagtzaam MM, Franken SC, Zhu L, Paunovic M, de Wit M, Schreurs MW, Lleixà C, Martín-Aguilar L, Pascual-Goñi E, Querol L, Jacobs BC, Huizinga R, Titulaer MJ. Clinical relevance of distinguishing autoimmune nodopathies from CIDP: longitudinal assessment in a large cohort. J Neurol Neurosurg Psychiatry 2023; 95:52-60. [PMID: 37879898 DOI: 10.1136/jnnp-2023-331378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 07/28/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND The aim of this study was to determine treatment response and whether it is associated with antibody titre change in patients with autoimmune nodopathy (AN) previously diagnosed as chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), and to compare clinical features and treatment response between AN and CIDP. METHODS Serum IgG antibodies to neurofascin-155 (NF155), contactin-1 (CNTN1) and contactin-associated protein 1 (CASPR1) were detected with cell-based assays in patients diagnosed with CIDP. Clinical improvement was determined using the modified Rankin scale, need for alternative and/or additional treatments and assessment of the treating neurologist. RESULTS We studied 401 patients diagnosed with CIDP and identified 21 patients with AN (10 anti-NF155, 6 anti-CNTN1, 4 anti-CASPR1 and 1 anti-NF155/anti-CASPR1 double positive). In patients with AN ataxia (68% vs 28%, p=0.001), cranial nerve involvement (34% vs 11%, p=0.012) and autonomic symptoms (47% vs 22%, p=0.025) were more frequently reported; patients with AN improved less often after intravenous immunoglobulin treatment (39% vs 80%, p=0.002) and required additional/alternative treatments more frequently (84% vs 34%, p<0.001), compared with patients with CIDP. Antibody titres decreased or became negative in patients improving on treatment. Treatment withdrawal was associated with a titre increase and clinical deterioration in four patients. CONCLUSIONS Distinguishing CIDP from AN is important, as patients with AN need a different treatment approach. Improvement and relapses were associated with changes in antibody titres, supporting the pathogenicity of these antibodies.
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Affiliation(s)
- Merel C Broers
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Luuk Wieske
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Ece Erdag
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Cemre Gürlek
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Carina Bunschoten
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Filip Eftimov
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Krista Kuitwaard
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Juna M de Vries
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Marie-Claire Y de Wit
- Department of Pediatric Neurology, Erasmus MC, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Mariska Mp Nagtzaam
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Suzanne C Franken
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Louisa Zhu
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Manuela Paunovic
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Maurice de Wit
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Marco Wj Schreurs
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Cinta Lleixà
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Lorena Martín-Aguilar
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Elba Pascual-Goñi
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luis Querol
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro para la de Investigación Biomédica en Red en Enfermedades Raras, CIBERER, Madrid, Spain
| | - Bart C Jacobs
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Ruth Huizinga
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Maarten J Titulaer
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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17
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Huang T, Liu F, Wang B, Wang C, Hao M, Guo S. Clinical characteristics and prognosis in patients with neuronal surface antibody-mediated autoimmune encephalitis: a single-center cohort study in China. Front Immunol 2023; 14:1213532. [PMID: 38152405 PMCID: PMC10751914 DOI: 10.3389/fimmu.2023.1213532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 11/22/2023] [Indexed: 12/29/2023] Open
Abstract
Objective This retrospective observational study primarily aimed to analyse the clinical characteristics of patients with neuronal surface antibody-mediated autoimmune encephalitis (AE) in China and report their prognosis after immunotherapy. Methods Clinical characteristics, laboratory or imaging examinations, and treatment outcomes of 103 patients diagnosed with AE between 1 September 2014 and 31 December 2020 were collected. Univariate and multivariate logistic regression analyses were performed to determine the predictors of poor prognosis. Results Overall, 103 patients were enrolled in the study. The main clinical symptoms included seizures (74.8%), psychiatric and behavior disorders (66.0%), cognitive deficits (51.5%), disturbances of consciousness (45.6%), and movement disorders/involuntary movements (26.2%). The distribution of clinical syndromes also differed for different AE subtypes. The efficacy rates of first-line immunotherapy for anti-NMDAR, anti-LGI1, anti-GABABR, and anti-CASPR2 encephalitis were 70.2%, 92.3%, 70%, and 83.3%, respectively, and rituximab was administered to 21 patients as second-line immunotherapy, including 14 patients with anti-NMDAR encephalitis, 4 with anti-LGI1 encephalitis, 2 with anti-GABABR encephalitis, and 1 with anti-CASPR2 encephalitis. Five patients with poor effect of the second-line treatment received bortezomib. According to the results of the last follow-up, 78 patients had a good prognosis (mRS 0-2), and 21 patients had a poor prognosis (mRS 3-6). The proportion of patients with a poor prognosis was significantly higher in anti-GABABR encephalitis compared to the other AE subtypes (p<0.001). Multivariate analysis indicated that elevated neutrophil-to-lymphocyte ratio (NLR) and tumour presence were independent risk factors for poor prognosis. The regression equation of the model was logit(P)=-3.480 + 0.318 NLR+2.434 with or without tumour (with assignment =1, without assignment =0). The prediction probability generated by the regression model equation was used as the independent variable for receiver operating curve (ROC) analysis. The results showed that the area under the curve (AUC) of the prediction probability was 0.847 (95% CI, 0.733-0.961; p < 0.001). Conclusions Different AE subtypes demonstrated different clinical symptom spectra throughout the disease stage. Anti-LGI1 encephalitis and anti-CASPR2 encephalitis were more sensitive to first-line and second-line treatments. Anti-GABABR encephalitis had the worst prognosis among the abovementioned subtypes. The regression equation constructed using NLR and tumour presence effectively predicted the poor prognosis.
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Affiliation(s)
- Teng Huang
- Department of Neurology, Shandong Provincial Hospital, Shandong University, Jinan, China
- Department of Neurology, Shandong Second Provincial General Hospital, Jinan, China
| | - Fei Liu
- Department of Neurology, Shandong Second Provincial General Hospital, Jinan, China
| | - Baojie Wang
- Department of Neurology, Shandong Second Provincial General Hospital, Jinan, China
| | - Chunjuan Wang
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Maolin Hao
- Department of Neurology, Shandong Second Provincial General Hospital, Jinan, China
| | - Shougang Guo
- Department of Neurology, Shandong Provincial Hospital, Shandong University, Jinan, China
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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18
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Vogrig A, Pegat A, Villagrán-García M, Wucher V, Attignon V, Sohier E, Brevet M, Rogemond V, Pinto AL, Muñiz-Castrillo S, Peter E, Robert M, Picard G, Hopes L, Psimaras D, Terra A, Perrin C, Cogne D, Tabone-Eglinger S, Martinez S, Jury D, Valantin J, Gadot N, Auclair-Perrossier J, Viari A, Dubois B, Desestret V, Honnorat J. Different Genetic Signatures of Small-Cell Lung Cancer Characterize Anti-GABA B R and Anti-Hu Paraneoplastic Neurological Syndromes. Ann Neurol 2023; 94:1102-1115. [PMID: 37638563 DOI: 10.1002/ana.26784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/27/2023] [Accepted: 08/24/2023] [Indexed: 08/29/2023]
Abstract
OBJECTIVE Small-cell lung cancer (SCLC) is the malignancy most frequently associated with paraneoplastic neurological syndromes (PNS) and can trigger different antibody responses against intracellular (Hu) or neuronal surface (GABAB R) antigens. Our aim was to clarify whether the genomic and transcriptomic features of SCLC are different in patients with anti-GABAB R or anti-Hu PNS compared with SCLC without PNS. METHODS A total of 76 SCLC tumor samples were collected: 34 anti-Hu, 14 anti-GABAB R, and 28 SCLC without PNS. The study consisted of 4 steps: (1) pathological confirmation; (2) next generation sequencing using a panel of 98 genes, including those encoding the autoantibodies targets ELAVL1-4, GABBR1-2, and KCTD16; (3) genome-wide copy number variation (CNV); and (4) whole-transcriptome RNA sequencing. RESULTS CNV analysis revealed that patients with anti-GABAB R PNS commonly have a gain in chromosome 5q, which contains KCTD16, whereas anti-Hu and control patients often harbor a loss. No significantly different number of mutations regarding any onconeural genes was observed. Conversely, the transcriptomic profile of SCLC was different, and the differentially expressed genes allowed effective clustering of the samples into 3 groups, reflecting the antibody-based classification, with an overexpression of KCTD16 specific to anti-GABAB R PNS. Pathway analysis revealed that tumors of patients with anti-GABAB R encephalitis were enriched in B-cell signatures, as opposed to those of patients with anti-Hu, in which T-cell- and interferon-γ-related signatures were overexpressed. INTERPRETATION SCLC genetic and transcriptomic features differentiate anti-GABAB R, anti-Hu, and non-PNS tumors. The role of KCTD16 appears to be pivotal in the tumor immune tolerance breakdown of anti-GABAB R PNS. ANN NEUROL 2023;94:1102-1115.
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Affiliation(s)
- Alberto Vogrig
- French Reference Center of Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Mechanisms in integrated life sciences Institute, (MeLiS), INSERM U1314, CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Clinical Neurology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Antoine Pegat
- Service ENMG et Pathologies Neuromusculaires, Hôpital Neurologique P. Wertheimer, Hospices Civils de Lyon, Bron, France
- Pathophysiology and Genetics of Neuron and Muscle, CNRS UMR 5261, INSERM U1315, INMG, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est, Lyon, France
| | - Macarena Villagrán-García
- French Reference Center of Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Mechanisms in integrated life sciences Institute, (MeLiS), INSERM U1314, CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Valentin Wucher
- French Reference Center of Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Mechanisms in integrated life sciences Institute, (MeLiS), INSERM U1314, CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Valéry Attignon
- Cancer Genomic Platform, Cancer Research Center of Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS, Centre Léon Bérard, Lyon, France
| | - Emilie Sohier
- Gilles Thomas Bioinformatics Platform, Cancer Research Center of Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS, Centre Léon Bérard, Lyon, France
- Fondation Synergie Lyon Cancer, Centre Léon Bérard, Lyon, France
| | - Marie Brevet
- Department of Pathology, Lyon Est Hospital, Hospices Civils de Lyon, Bron, France
| | - Veronique Rogemond
- French Reference Center of Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Mechanisms in integrated life sciences Institute, (MeLiS), INSERM U1314, CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Anne-Laurie Pinto
- French Reference Center of Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Mechanisms in integrated life sciences Institute, (MeLiS), INSERM U1314, CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Sergio Muñiz-Castrillo
- French Reference Center of Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Mechanisms in integrated life sciences Institute, (MeLiS), INSERM U1314, CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Stanford Center for Sleep Sciences and Medicine, Stanford University, Palo Alto, CA, USA
| | - Elise Peter
- French Reference Center of Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Mechanisms in integrated life sciences Institute, (MeLiS), INSERM U1314, CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Melisse Robert
- French Reference Center of Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Mechanisms in integrated life sciences Institute, (MeLiS), INSERM U1314, CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Géraldine Picard
- French Reference Center of Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Mechanisms in integrated life sciences Institute, (MeLiS), INSERM U1314, CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Lucie Hopes
- Department of Neurology, CHRU Nancy, Nancy, France
| | - Dimitri Psimaras
- Neurology 2 Department Mazarin, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
- Sorbonne Université, INSERM, CNRS, Paris Brain Institute, Institut du Cerveau et de la Moelle Épinière, ICM, Paris, France
| | - Anthony Terra
- Centre de Ressources Biologiques Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
| | - Corinne Perrin
- Centre de Ressources Biologiques Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
| | - Dominique Cogne
- Plateforme de Gestion des Echantillons Biologique, Cancer Research Center of Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS, Centre Léon Bérard, Lyon, France
| | - Severine Tabone-Eglinger
- Plateforme de Gestion des Echantillons Biologique, Cancer Research Center of Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS, Centre Léon Bérard, Lyon, France
| | - Séverine Martinez
- Plateforme de Gestion des Echantillons Biologique, Cancer Research Center of Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS, Centre Léon Bérard, Lyon, France
| | - Delphine Jury
- Plateforme de Gestion des Echantillons Biologique, Cancer Research Center of Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS, Centre Léon Bérard, Lyon, France
| | - Julie Valantin
- Plateforme Anatomopathologie Recherche, Cancer Research Center of Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS Centre Léon Bérard, Lyon, France
| | - Nicolas Gadot
- Plateforme Anatomopathologie Recherche, Cancer Research Center of Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS Centre Léon Bérard, Lyon, France
| | - Jessie Auclair-Perrossier
- Cancer Genomic Platform, Cancer Research Center of Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS, Centre Léon Bérard, Lyon, France
| | - Alain Viari
- Gilles Thomas Bioinformatics Platform, Cancer Research Center of Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS, Centre Léon Bérard, Lyon, France
| | - Bertrand Dubois
- Cancer Immune Surveillance and Therapeutic Targeting Team, Cancer Research Center of Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS, Centre Léon Bérard, Lyon, France
- Lyon Immunotherapy for Cancer Laboratory, Cancer Research Center of Lyon, Lyon, France
| | - Virginie Desestret
- French Reference Center of Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Mechanisms in integrated life sciences Institute, (MeLiS), INSERM U1314, CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Jérôme Honnorat
- French Reference Center of Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Mechanisms in integrated life sciences Institute, (MeLiS), INSERM U1314, CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
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Matsui N, Tanaka K, Ishida M, Yamamoto Y, Matsubara Y, Saika R, Iizuka T, Nakamura K, Kuriyama N, Matsui M, Arisawa K, Nakamura Y, Kaji R, Kuwabara S, Izumi Y. Prevalence, Clinical Profiles, and Prognosis of Stiff-Person Syndrome in a Japanese Nationwide Survey. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200165. [PMID: 37739810 PMCID: PMC10519438 DOI: 10.1212/nxi.0000000000200165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/17/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND AND OBJECTIVES To elucidate current epidemiologic, clinical, and immunologic profiles and treatments of stiff-person syndrome (SPS) in Japan. METHODS A nationwide mail survey was conducted using an established method. Data processing sheets were sent to randomly selected departments of internal medicine, neurology, pediatrics, psychiatry, and neurosurgery in hospitals and clinics throughout Japan to identify patients with SPS who were seen between January 2015 and December 2017. RESULTS Thirty cases were identified as glutamic acid decarboxylase 65 (GAD65)-positive SPS cases on the basis of detailed clinical data of 55 cases. Four patients had α1 subunit of glycine receptor (GlyR) antibodies, and 1 patient had both GAD65 and GlyR antibodies. The total estimated number of patients with GAD65-positive SPS was 140, and the estimated prevalence was 0.11 per 100,000 population. The median age at onset was 51 years (range, 26-83 years), and 23 (76%) were female. Of these, 70% had classic SPS, and 30% had stiff-limb syndrome. The median time from symptom onset to diagnosis was significantly longer in the high-titer GAD65 antibody group than in the low-titer group (13 months vs 2.5 months, p = 0.01). The median modified Rankin Scale (mRS) at baseline was 4, and the median mRS at the last follow-up was 2. Among the 29 GAD65-positive patients with ≥1 year follow-up, 7 received only symptomatic treatment, 9 underwent immunotherapy without long-term immunotherapy, and 13 received long-term immunotherapy such as oral prednisolone. The coexistence of type 1 diabetes mellitus and the lack of long-term immunotherapy were independent risk factors for poor outcome (mRS ≥3) in the GAD65-positive patients (odds ratio, 15.0; 95% CI 2.6-131.6; p = 0.001; odds ratio, 19.8; 95% CI 3.2-191.5; p = 0.001, respectively). DISCUSSION This study provides the current epidemiologic and clinical status of SPS in Japan. The symptom onset to the diagnosis of SPS was longer in patients with high-titer GAD65 antibodies than in those with low-titer GAD65 antibodies. The outcome of patients with SPS was generally favorable, but more aggressive immunotherapies are necessary for GAD65-positive patients with SPS.
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Affiliation(s)
- Naoko Matsui
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Keiko Tanaka
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Mitsuyo Ishida
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Yohei Yamamoto
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Yuri Matsubara
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Reiko Saika
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Takahiro Iizuka
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Koshi Nakamura
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Nagato Kuriyama
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Makoto Matsui
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Kokichi Arisawa
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Yosikazu Nakamura
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Ryuji Kaji
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Satoshi Kuwabara
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Yuishin Izumi
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
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Van Steenhoven RW, de Vries JM, Bruijstens AL, Paunovic M, Nagtzaam MM, Franken SC, Bastiaansen AE, De Bruijn MA, Van Sonderen A, Schreurs MWJ, Gardeniers M, Verdijk RM, Balvers RK, Sillevis Smitt PA, Neuteboom RF, Titulaer MJ. Mimics of Autoimmune Encephalitis: Validation of the 2016 Clinical Autoimmune Encephalitis Criteria. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200148. [PMID: 37582614 PMCID: PMC10427145 DOI: 10.1212/nxi.0000000000200148] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/27/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND AND OBJECTIVES The clinical criteria for autoimmune encephalitis (AE) were proposed by Graus et al. in 2016. In this study, the AE criteria were validated in the real world, and common AE mimics were described. In addition, criteria for probable anti-LGI1 encephalitis were proposed and validated. METHODS In this retrospective cohort study, patients referred to our national referral center with suspicion of AE and specific neuroinflammatory disorders with similar clinical presentations were included from July 2016 to December 2019. Exclusion criteria were pure cerebellar or peripheral nerve system disorders. All patients were evaluated according to the AE criteria. RESULTS In total, 239 patients were included (56% female; median age 42 years, range 1-85). AE was diagnosed in 104 patients (44%) and AE mimics in 109 patients (46%). The most common AE mimics and misdiagnoses were neuroinflammatory CNS disorders (26%), psychiatric disorders (19%), epilepsy with a noninflammatory cause (13%), CNS infections (7%), neurodegenerative diseases (7%), and CNS neoplasms (6%). Common confounding factors were mesiotemporal lesions on brain MRI (17%) and false-positive antibodies in serum (12%). Additional mesiotemporal features (involvement extralimbic structures, enhancement, diffusion restriction) were observed more frequently in AE mimics compared with AE (61% vs 24%; p = 0.005). AE criteria showed the following sensitivity and specificity: possible AE, 83% (95% CI 74-89) and 27% (95% CI 20-36); definite autoimmune limbic encephalitis (LE), 10% (95% CI 5-17) and 98% (95% CI 94-100); and probable anti-NMDAR encephalitis, 50% (95% CI 26-74) and 96% (95% CI 92-98), respectively. Specificity of the criteria for probable seronegative AE was 99% (95% CI 96-100). The newly proposed criteria for probable anti-LGI1 encephalitis showed a sensitivity of 66% (95% CI 47-81) and specificity of 96% (95% CI 93-98). DISCUSSION AE mimics occur frequently. Common pitfalls in AE misdiagnosis are mesiotemporal lesions (predominantly with atypical features) and false-positive serum antibodies. As expected, the specificity of the criteria for possible AE is low because these criteria represent the minimal requirements for entry in the diagnostic algorithm for AE. Criteria for probable AE (-LGI1, -NMDAR, seronegative) and definite autoimmune LE are applicable for decisions on immunotherapy in early disease stage, as specificity is high.
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Affiliation(s)
- Robin W Van Steenhoven
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Juna M de Vries
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Arlette L Bruijstens
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Manuela Paunovic
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Mariska M Nagtzaam
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Suzanne C Franken
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Anna E Bastiaansen
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marienke A De Bruijn
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Agnes Van Sonderen
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marco W J Schreurs
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Mayke Gardeniers
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Robert M Verdijk
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Rutger K Balvers
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Peter A Sillevis Smitt
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Rinze F Neuteboom
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Maarten J Titulaer
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
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Qin M, Chen J, Guo X, Xiang X, Nie L, Wang Y, Mao L. Movement disorders in autoimmune encephalitis: an update. J Neurol 2023; 270:5288-5302. [PMID: 37523063 DOI: 10.1007/s00415-023-11881-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/13/2023] [Accepted: 07/13/2023] [Indexed: 08/01/2023]
Abstract
Autoimmune encephalitis (AE) is a form of encephalitis resulting from an immune response targeting central nervous system antigens, which is characterized by cognitive impairment, neuropsychiatric symptoms, seizures, movement disorders (MDs), and other encephalopathy symptoms. MDs frequently manifest throughout the progression of the disease, with recurrent involuntary movements leading to discomfort and, in some cases, necessitating admission to the intensive care unit. Prompt identification and management of MDs can aid in the diagnosis and prognosis of AE. This review synthesizes current knowledge on the characteristics, underlying mechanisms, and treatment options for MDs in the context of AE.
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Affiliation(s)
- Mengting Qin
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiaojiao Chen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoqing Guo
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuying Xiang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lei Nie
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yong Wang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Ling Mao
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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McKeon A, Lesnick C, Vorasoot N, Buckley MW, Dasari S, Flanagan EP, Gilligan M, Lafrance-Corey R, Miske R, Pittock SJ, Scharf M, Yang B, Zekeridou A, Dubey D, Mills J. Utility of Protein Microarrays for Detection of Classified and Novel Antibodies in Autoimmune Neurologic Disease. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200145. [PMID: 37550073 PMCID: PMC10406426 DOI: 10.1212/nxi.0000000000200145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/01/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Neural antibodies are detected by tissue-based indirect immunofluorescence assay (IFA) in Mayo Clinic's Neuroimmunology Laboratory practice, but the process of characterizing and validating novel antibodies is lengthy. We report our assessment of human protein arrays. METHODS Assessment of arrays (81% human proteome coverage) was undertaken using diverse known positive samples (17 serum and 14 CSF). Samples from patients with novel neural antibodies were reflexed from IFA to arrays. Confirmatory assays were cell-based (CBA) or line blot. Epitope mapping was undertaken using phage display immunoprecipitation sequencing (PhiPSeq). RESULTS Control positive samples known to be reactive with linear epitopes of intracellular antigens (e.g., ANNA-1 [anti-Hu]) were readily identified by arrays in 20 of 21 samples. By contrast, 10 positive controls known to be enriched with antibodies against cell surface protein conformational epitopes (e.g., GluN1 subunit of NMDA-R) were indistinguishable from background signal. Three antibodies, previously characterized by other investigators (but unclassified in our laboratory), were unmasked in 4 patients using arrays (July-December 2022): Neurexin-3α, 1 patient; regulator of gene protein signaling (RGS)8, 1 patient; and seizure-related homolog like 2 (SEZ6L2), 2 patients. All were accompanied by previously reported phenotypes (encephalitis, 1; cerebellar ataxia, 3). Patient 1 had subacute onset of seizures and encephalopathy. Neurexin-3α ranked high in CSF (second ranked neural protein) but low in serum (660th overall). Neurexin-3α CBA was positive in both samples. Patient 2 presented with rapidly progressive cerebellar ataxia. RGS8 ranked the highest neural protein in available CSF sample by array (third overall). RGS8-specific line blot was positive. Patients 3 and 4 had rapidly progressive cerebellar ataxia. SEZ6L2 was the highest ranked neural antigen by arrays in all samples (CSF, 1, serum, 2; Patient 3, ranked 9th overall in CSF, 11th in serum; Patient 4, 6th overall in serum]). By PhIPSeq, diverse neurexin-3α epitopes (including cell surface) were detected in CSF from patient 1, but no SEZ6L2 peptides were detected for serum or CSF samples from Patient 3. DISCUSSION Individualized autoimmune neurologic diagnoses may be accelerated using protein arrays. They are optimal for detection of intracellular antigen-reactive antibodies, though certain cell surface-directed antibodies (neurexin-3α and SEZ6L2) may also be detected.
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Affiliation(s)
- Andrew McKeon
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany.
| | - Connie Lesnick
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Nisa Vorasoot
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Monica W Buckley
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Surendra Dasari
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Eoin P Flanagan
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Michael Gilligan
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Reghann Lafrance-Corey
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Ramona Miske
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Sean J Pittock
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Madeleine Scharf
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Binxia Yang
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Anastasia Zekeridou
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Divyanshu Dubey
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - John Mills
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
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23
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Sun T, Zhao D, Zhang G, Huang Y, Guo J, Jiang W, Jia R, Maimaiti M, Liu J, Bu N, Li Z, Yan Y, Zhang X, Sun C, Zhao C, Jia X, Mao B, Tian H, Liu Y, Chen Z, Fan Z, Guo X, Lu J, Ren K, Li H, Guo J. Late-Onset Anti-GABA B Receptor Encephalitis: Clinical Characteristics and Outcomes Differing From Early-Onset Patients. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:10/4/e200131. [PMID: 37230544 DOI: 10.1212/nxi.0000000000200131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/13/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Existing evidence indicates anti-GABAB receptor encephalitis (GABABR-E) seems to occur more commonly later in life, yet the age-associated differences in clinical features and outcomes are not well determined. This study aims to explore the demographic, clinical characteristics, and prognostic differences between late-onset and early-onset GABABR-E and identify predictors of favorable long-term outcomes. METHODS This is an observational retrospective study conducted in 19 centers from China. Data from 62 patients with GABABR-E were compared between late-onset (aged 50 years or older) and early-onset (younger than 50 years) groups and between groups with favorable outcomes (modified Rankin scale (mRS) ≤ 2) and poor outcomes (mRS >2). Logistic regression analyses were applied to identify factors affecting long-term outcomes. RESULTS Forty-one (66.1%) patients experienced late-onset GABABR-E. A greater proportion of males, a higher mRS score at onset, higher frequencies of ICU admission and tumors, and a higher risk of death were demonstrated in the late-onset group than in the early-onset group. Compared with poor outcomes, patients with favorable outcomes had a younger onset age, a lower mRS score at onset, lower frequencies of ICU admission and tumors, and a greater proportion with immunotherapy maintenance for at least 6 months. On multivariate regression analysis, age at onset (OR, 0.849, 95% CI 0.739-0.974, p = 0.020) and the presence of underlying tumors (OR, 0.095, 95% CI 0.015-0.613, p = 0.013) were associated with poorer long-term outcomes, whereas immunotherapy maintenance for at least 6 months was associated with favorable outcomes (OR, 10.958, 95% CI 1.469-81.742, p = 0.020). DISCUSSION These results demonstrate the importance of risk stratification of GABABR-E according to age at onset. More attention should be paid to older patients especially with underlying tumors, and immunotherapy maintenance for at least 6 months is recommended to achieve a favorable outcome.
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Affiliation(s)
- Tangna Sun
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Daidi Zhao
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Gejuan Zhang
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yue Huang
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jia Guo
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China.
| | - Wen Jiang
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Rui Jia
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Maynur Maimaiti
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jianguo Liu
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ning Bu
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Zunbo Li
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yaping Yan
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaoyan Zhang
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Chenjing Sun
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Cong Zhao
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaotao Jia
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Baoyi Mao
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Hui Tian
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Liu
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Zheng Chen
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Zilian Fan
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaoyan Guo
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China.
| | - Jiarui Lu
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Kaixi Ren
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Hongzeng Li
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jun Guo
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China.
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24
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Edridge A, Namazzi R, Tebulo A, Mfizi A, Deijs M, Koekkoek S, de Wever B, van der Ende A, Umiwana J, de Jong MD, Jans J, Verhoeven-Duif N, Titulaer M, van Karnebeek C, Seydel K, Taylor T, Asiimwe-Kateera B, van der Hoek L, Kabayiza JC, Mallewa M, Idro R, Boele van Hensbroek M, van Woensel JBM. Viral, Bacterial, Metabolic, and Autoimmune Causes of Severe Acute Encephalopathy in Sub-Saharan Africa: A Multicenter Cohort Study. J Pediatr 2023; 258:113360. [PMID: 36828342 DOI: 10.1016/j.jpeds.2023.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 02/11/2023] [Accepted: 02/19/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVES To assess whether viral, bacterial, metabolic, and autoimmune diseases are missed by conventional diagnostics among children with severe acute encephalopathy in sub-Saharan Africa. STUDY DESIGN One hundred thirty-four children (6 months to 18 years) presenting with nontraumatic coma or convulsive status epilepticus to 1 of 4 medical referral centers in Uganda, Malawi, and Rwanda were enrolled between 2015 and 2016. Locally available diagnostic tests could be supplemented in 117 patients by viral, bacterial, and 16s quantitative polymerase chain reaction testing, metagenomics, untargeted metabolomics, and autoimmune immunohistochemistry screening. RESULTS Fourteen (12%) cases of viral encephalopathies, 8 (7%) cases of bacterial central nervous system (CNS) infections, and 4 (4%) cases of inherited metabolic disorders (IMDs) were newly identified by additional diagnostic testing as the most likely cause of encephalopathy. No confirmed cases of autoimmune encephalitis were found. Patients for whom additional diagnostic testing aided causal evaluation (aOR 3.59, 90% CI 1.57-8.36), patients with a viral CNS infection (aOR 7.91, 90% CI 2.49-30.07), and patients with an IMD (aOR 9.10, 90% CI 1.37-110.45) were at increased risk for poor outcome of disease. CONCLUSIONS Viral and bacterial CNS infections and IMDs are prevalent causes of severe acute encephalopathy in children in Uganda, Malawi, and Rwanda that are missed by conventional diagnostics and are associated with poor outcome of disease. Improved diagnostic capacity may increase diagnostic yield and might improve outcome of disease.
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Affiliation(s)
- Arthur Edridge
- Amsterdam Centre for Global Child Health, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Medical Microbiology & Infection Prevention, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Ruth Namazzi
- Department of Paediatrics, Makerere University, Kampala, Uganda
| | - Andrew Tebulo
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Anan Mfizi
- Department of Paediatrics, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Martin Deijs
- Department of Medical Microbiology & Infection Prevention, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sylvie Koekkoek
- Department of Medical Microbiology & Infection Prevention, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bob de Wever
- Department of Medical Microbiology & Infection Prevention, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Arie van der Ende
- Department of Medical Microbiology & Infection Prevention, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeanine Umiwana
- Department of Paediatrics, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Menno D de Jong
- Department of Medical Microbiology & Infection Prevention, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Judith Jans
- Laboratory of Metabolic Diseases, UMC Utrecht, Utrecht, The Netherlands
| | | | | | - Clara van Karnebeek
- Departments of Pediatrics and Human Genetics, Emma Center for Personalized Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Karl Seydel
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI
| | - Terrie Taylor
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI
| | | | - Lia van der Hoek
- Department of Medical Microbiology & Infection Prevention, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jean-Claude Kabayiza
- Department of Paediatrics, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Macpherson Mallewa
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Richard Idro
- Department of Paediatrics, Makerere University, Kampala, Uganda
| | - Michael Boele van Hensbroek
- Amsterdam Centre for Global Child Health, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Job B M van Woensel
- Amsterdam Centre for Global Child Health, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Paediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam UMC, Amsterdam, The Netherlands
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25
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Vaišvilas M, Ciano-Petersen NL, Macarena Villagrán-García MD, Muñiz-Castrillo S, Vogrig A, Honnorat J. Paraneoplastic encephalitis: clinically based approach on diagnosis and management. Postgrad Med J 2023; 99:669-678. [PMID: 37389581 DOI: 10.1136/postgradmedj-2022-141766] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/25/2022] [Indexed: 11/04/2022]
Abstract
Paraneoplastic neurological syndromes (PNSs) comprise a subset of immune-mediated nervous system diseases triggered by an underlying malignancy. Each syndrome usually shows a distinct clinical presentation and outcome according to the associated neural antibodies. PNSs generally have a subacute onset with rapid progression and severe neurological disability. However, some patients may have hyperacute onset or even show chronic progression mimicking neurodegenerative diseases. Updated diagnostic criteria for PNS have been recently established in order to increase diagnostic specificity and to encourage standardisation of research initiatives related to PNS. Treatment for PNS includes oncological therapy and immunomodulation to halt neurological deterioration although current treatment options are seldom effective in reversing disability. Nevertheless, growing knowledge and better understanding of PNS pathogenesis promise better recognition, earlier diagnosis and novel treatment strategies. Considering that PNSs provide a model of effective anticancer immunity, the impact of these studies will extend far beyond the field of neurology.
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Affiliation(s)
- Mantas Vaišvilas
- Department of Neuro-oncology Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Department of Neuro-oncology, Université Claude Bernard Lyon 1 Villeurbanne, Lyon, France
| | - Nicolás Lundahl Ciano-Petersen
- Department of Neuro-oncology Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Department of Neuro-oncology, Université Claude Bernard Lyon 1 Villeurbanne, Lyon, France
| | - M D Macarena Villagrán-García
- Department of Neuro-oncology Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Department of Neuro-oncology, Université Claude Bernard Lyon 1 Villeurbanne, Lyon, France
| | - Sergio Muñiz-Castrillo
- Department of Neuro-oncology Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Department of Neuro-oncology, Université Claude Bernard Lyon 1 Villeurbanne, Lyon, France
| | - Alberto Vogrig
- Department of Neuro-oncology Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Department of Neuro-oncology, Université Claude Bernard Lyon 1 Villeurbanne, Lyon, France
| | - Jérôme Honnorat
- Department of Neuro-oncology, Université Claude Bernard Lyon 1 Villeurbanne, Lyon, France
- Department of Neuro-oncology, Hospices Civils de Lyon, Bron, France
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26
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Hiesgen J, Schutte C. Autoimmune encephalitis : Part 1 (Epidemiology, Pathophysiology and Clinical spectrum). S Afr Med J 2023; 113:116-121. [PMID: 36876355 DOI: 10.7196/samj.2023.v113i3.780] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Indexed: 03/06/2023] Open
Abstract
Since the identification of anti-N-methyl-D-aspartate (NMDA) receptor antibodies about 15 years ago, many patients with rapidly progressing psychiatric symptoms, abnormal movements, seizures or unexplained coma, have been diagnosed with autoimmune encephalitis (AE). The symptom onset is often unspecific and might mimic psychiatric disease, but the later course is frequently characterized by severe disease, often requiring intensive care. Clinical and immunological criteria are helpful in identifying the patients, but no biomarkers exist to guide the clinician in therapy or predict outcome. While persons of all ages can be affected by AE, some types of AE affect more children and young adults and are more prevalent in women. This review will focus on encephalitides associated with neuronal cell-surface or synaptic antibodies, which can result in characteristic syndromes, and are often recognizable on clinical grounds. AE subtypes associated with antibodies against extracellular epitopes can occur with or without tumours. Because the antibodies bind and alter the function of the antigen, the effects are often reversible if immunotherapy is initiated, and the prognosis is favourable in most instances. The first part of this series will introduce the topic, provide an overview of current neuronal surface antibodies and how they present, describe the most common subtype, anti-NMDA receptor encephalitis, and discuss the difficulties in recognizing patients with underlying AE amongst patients with new onset psychiatric disorders.
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27
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Wang Y, Ren X, Shen Y, Hua Y, Xu L, Zhang W, Sheng G, Jiang P, Yuan Z, Liu L, Gao F. Case report: Pediatric anti-gamma aminobutyric acid-B receptor encephalitis with benign prognosis. Front Pediatr 2023; 11:1104001. [PMID: 36937947 PMCID: PMC10020610 DOI: 10.3389/fped.2023.1104001] [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] [Received: 11/21/2022] [Accepted: 02/15/2023] [Indexed: 03/06/2023] Open
Abstract
Objective To explore the clinical characteristics of pediatric anti-gamma-aminobutyric acid-B receptor (GABABR) encephalitis to enhance the understanding and improve the diagnostic and therapeutic strategies for this disease. Methods We report a rare case of a female pediatric patient with anti-GABABR encephalitis who was treated at the Children's Hospital of Zhejiang University School of Medicine. Literature search was performed to explore the clinical characteristics of pediatric anti-GABABR encephalitis. Results The patient exhibited recurrent epileptic seizure, status epilepticus, and psychiatric symptoms at the age of 11 years and 10 months. Anti-GABABR antibodies were positive in cerebrospinal fluid and serum. Brain magnetic resonance imaging (MRI) exhibited abnormal signals in the left hippocampus. Symptoms and abnormality of brain MRI were improved after administration of immunosuppressants, anti-seizure and antipsychotic drugs. Two of pediatric anti-GABABR encephalitis with clinical data were identified through literature search. Analysis of these three cases suggested that the pediatric patients primarily experienced limbic encephalitis, with no tumor incidence. A favorable immunotherapy response was demonstrated with a superior prognosis in all the cases. Conclusions We reported a pediatric anti-GABABR encephalitis case with early age of onset. Promt autoimmune antibody testing and tumor screening, as well as immunomodulatory treatment immediately after a definitive diagnosis are warranted to improve prognosis.
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Affiliation(s)
- Yeping Wang
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Department of Pediatric, Jinhua Maternity and Child Health Care Hospital, Jinhua, China
| | - Xiaoyan Ren
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Department of Neurology, Ningbo Women and Children’s Hospital, Ningbo, China
| | - Yu Shen
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Department of Neurology, Ningbo Women and Children’s Hospital, Ningbo, China
| | - Yi Hua
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Lu Xu
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Weiran Zhang
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Guoxia Sheng
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Peifang Jiang
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Zhefeng Yuan
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Liu Liu
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Correspondence: Feng Gao Liu Liu
| | - Feng Gao
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Correspondence: Feng Gao Liu Liu
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Fortunato F, Giugno A, Sammarra I, Labate A, Gambardella A. Epilepsy, Immunity and Neuropsychiatric Disorders. Curr Neuropharmacol 2023; 21:1714-1735. [PMID: 35794773 PMCID: PMC10514543 DOI: 10.2174/1570159x20666220706094651] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/03/2022] [Accepted: 06/13/2022] [Indexed: 11/22/2022] Open
Abstract
Several studies have focused on the emerging role of immunity and inflammation in a wide range of neurological disorders. Autoimmune diseases involving central nervous system share well defined clinical features including epileptic seizures and additional neuropsychiatric symptoms, like cognitive and psychiatric disturbances. The growing evidence about the role of immunity in the pathophysiologic mechanisms underlying these conditions lead to the concept of autoimmune epilepsy. This relatively-new term has been introduced to highlight the etiological and prognostic implications of immunity in epileptogenesis. In this review, we aim to discuss the role of autoimmunity in epileptogenesis and its clinical, neurophysiological, neuroimaging and therapeutic implications. Moreover, we wish to address the close relationship between immunity and additional symptoms, particularly cognitive and psychiatric features, which deeply impact clinical outcomes in these patients. To assess these aspects, we first analyzed Rasmussen's encephalitis. Subsequently, we have covered autoimmune encephalitis, particularly those associated with autoantibodies against surface neuronal antigens, as these autoantibodies express a direct immune-mediated mechanism, different from those against intracellular antigens. Then, we discussed the connection between systemic immune disorders and neurological manifestations. This review aims to highlight the need to expand knowledge about the role of inflammation and autoimmunity in the pathophysiology of neurological disorders and the importance to early recognize these clinical entities. Indeed, early identification may result in faster recovery and a better prognosis.
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Affiliation(s)
- Francesco Fortunato
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
| | - Alessia Giugno
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
| | - Ilaria Sammarra
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
| | - Angelo Labate
- BIOMORF Department, Neurology Unit, University of Messina, Messina, Italy
| | - Antonio Gambardella
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
- Institute of Molecular Bioimaging and Physiology, National Research Council, I-88100 Catanzaro, Italy
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Binks S, Lamquet S, Crawford AH, Meurs A, Irani SR, Pakozdy A. Parallel roles of neuroinflammation in feline and human epilepsies. Vet J 2022; 290:105912. [PMID: 36209994 PMCID: PMC10912827 DOI: 10.1016/j.tvjl.2022.105912] [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: 01/22/2022] [Revised: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
Autoimmune encephalitis refers to a group of disorders characterised by a non-infectious encephalitis, often with prominent seizures and surface neuronal autoantibodies. AE is an important cause of new-onset refractory status epilepticus in humans and is frequently responsive to immunotherapies including corticosteroids, plasma exchange, intravenous immunoglobulin G and rituximab. Recent research suggests that parallel autoantibodies can be detected in non-human mammalian species. The best documented example is leucine-rich glioma-inactivated 1 (LGI1)-antibodies in domestic cats with limbic encephalitis (LE). In this review, we discuss the role of neuroinflammation and autoantibodies in human and feline epilepsy and LE.
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Affiliation(s)
- Sophie Binks
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, OX3 9DU, UK; Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals Foundation Trust, Oxford OX3 9DU, UK.
| | - Simon Lamquet
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Abbe H Crawford
- Clinical Science and Services, The Royal Veterinary College, Hertfordshire AL9 7TA, UK
| | - Alfred Meurs
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, OX3 9DU, UK; Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals Foundation Trust, Oxford OX3 9DU, UK
| | - Akos Pakozdy
- University Clinic for Small Animals, University of Veterinary Medicine Vienna, Austria
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30
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Affiliation(s)
- J Y Shen
- From the Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - G J Ng
- From the Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - T Yeo
- From the Department of Neurology, National Neuroscience Institute, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
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31
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Reis Carneiro D, Maresch Â, Cunha R, Morgadinho A. Sez6l2-associated encephalitis in a patient with small-cell lung cancer. Neurol Sci 2022; 43:6131-6133. [DOI: 10.1007/s10072-022-06244-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 06/21/2022] [Indexed: 11/30/2022]
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32
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Lancaster E. Autoantibody Encephalitis: Presentation, Diagnosis, and Management. J Clin Neurol 2022; 18:373-390. [PMID: 35796263 PMCID: PMC9262450 DOI: 10.3988/jcn.2022.18.4.373] [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] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/22/2022] [Accepted: 04/22/2022] [Indexed: 02/07/2023] Open
Abstract
Autoantibody encephalitis causes distinct clinical syndromes involving alterations in mentation, abnormal movements, seizures, psychiatric symptoms, sleep disruption, spasms, and neuromyotonia. The diagnoses can be confirmed by specific antibody tests, although some antibodies may be better detected in spinal fluid and others in serum. Each disorder conveys a risk of certain tumors which may inform diagnosis and be important for treatment. Autoantibodies to receptors and other neuronal membrane proteins are generally thought to be pathogenic and result in loss of function of the targets, so understanding the pharmacology of the receptors may inform our understanding of the syndromes. Patients may be profoundly ill but the syndromes usually respond to immune therapy, although there are differences in the types of immune therapy that are thought to be most effective for the various disorders.
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Affiliation(s)
- Eric Lancaster
- Department of Neurology, The University of Pennsylvania, Philadelphia, PA, USA.
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Abstract
PURPOSE OF REVIEW Autoimmune encephalitis (AE) refers to immune-mediated neurological syndromes often characterised by the detection of pathogenic autoantibodies in serum and/or cerebrospinal fluid which target extracellular epitopes of neuroglial antigens. There is increasing evidence these autoantibodies directly modulate function of their antigens in vivo. Early treatment with immunotherapy improves outcomes. Yet, these patients commonly exhibit chronic disability. Importantly, optimal therapeutic strategies at onset and during escalation remain poorly understood. In this review of a rapidly emerging field, we evaluate recent studies on larger cohorts, registries, and meta-analyses to highlight existing evidence for contemporary therapeutic approaches in AE. RECENT FINDINGS We highlight acute and long-term treatments used in specific AE syndromes, exemplify how understanding disease pathogenesis can inform precision therapy and outline challenges of defining disability outcomes in AE. SUMMARY Early first-line immunotherapies, including corticosteroids and plasma exchange, improve outcomes, with emerging evidence showing second-line immunotherapies (especially rituximab) reduce relapse rates. Optimal timing of immunotherapy escalation remains unclear. Routine reporting of outcome measures which incorporate cognitive impairment, fatigue, pain, and mental health will permit more accurate quantification of residual disability and comprehensive comparisons between international multicentre cohorts, and enable future meta-analyses with the aim of developing evidence-based therapeutic guidelines.
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Affiliation(s)
- Benjamin P Trewin
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead; Sydney Medical School and Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Isaak Freeman
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Sudarshini Ramanathan
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead; Sydney Medical School and Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Neurology, Concord Hospital, Sydney, Australia
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
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34
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Rare antibody-mediated and seronegative autoimmune encephalitis: An update. Autoimmun Rev 2022; 21:103118. [PMID: 35595048 DOI: 10.1016/j.autrev.2022.103118] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 05/15/2022] [Indexed: 01/14/2023]
Abstract
Paralleling advances with respect to more common antibody-mediated encephalitides, such as anti-N-methyl-D-aspartate receptor (NMDAR) and anti-leucine-rich glioma-inactivated 1 (LGI1) Ab-mediated encephalitis, the discovery and characterisation of novel antibody-mediated encephalitides accelerated over the past decade, adding further depth etiologically to the spectrum of antibody-mediated encephalitis. Herein, we review the major mechanistic, clinical features and management considerations with respect to anti-γ-aminobutyric acid B (GABAB)-, anti-α-amino-3-hydroxy-5-methyl-4-isoxazolepropinoic receptor- (AMPAR), anti-GABAA-, anti-dipeptidyl-peptidase-like protein-6 (DPPX) Ab-mediated encephalitides, delineate rarer subtypes and summarise findings to date regarding seronegative autoimmune encephalitis.
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35
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Gill AJ, Venkatesan A. Pathogenic mechanisms in neuronal surface autoantibody-mediated encephalitis. J Neuroimmunol 2022; 368:577867. [DOI: 10.1016/j.jneuroim.2022.577867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/22/2022] [Accepted: 04/09/2022] [Indexed: 11/16/2022]
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36
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Co DO, Kwon JM. Autoimmune Encephalitis: Distinguishing Features and Specific Therapies. Crit Care Clin 2022; 38:393-412. [DOI: 10.1016/j.ccc.2021.11.007] [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]
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Ciano-Petersen NL, Muñiz-Castrillo S, Vogrig A, Joubert B, Honnorat J. Immunomodulation in the acute phase of autoimmune encephalitis. Rev Neurol (Paris) 2022; 178:34-47. [PMID: 35000790 DOI: 10.1016/j.neurol.2021.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 12/06/2021] [Accepted: 12/13/2021] [Indexed: 12/14/2022]
Abstract
Autoimmune encephalitides constitute an emerging group of diseases for which the diagnosis and management may be challenging, and are usually associated with antibodies against neuroglial antigens used as biomarkers. In this review, we aimed to clarify the diagnostic approach to patients with encephalitis of suspected autoimmune origin in order to initiate early immunotherapy, and to summarize the evidence of current immunotherapies and alternative options assessed for refractory cases. Currently, the general therapeutic approach consists of steroids, IVIG, and/or plasma exchange as first-line medications, which should be prescribed once a diagnosis of possible autoimmune encephalitis is established. For patients not responding to these treatments, rituximab and cyclophosphamide are used as second-line immunotherapy. Additionally, alternative therapies, chiefly tocilizumab and bortezomib, have been reported to be useful in particularly refractory cases. Although the aforementioned approach with first and second-line immunotherapy is widely accepted, the best therapeutic strategy is still unclear since most available evidence is gathered from retrospective non-controlled studies. Moreover, several predictors of good long-term prognosis have been proposed such as response to first-line therapies, modified Rankin score lesser than 4 at the worst neurologic status, no need for admission in intensive care unit, and early escalation to second-line immunotherapy. Thus, the lack of solid evidence underlines the necessity of future well-conducted trials addressing both the best therapeutic regimen and the outcome predictors, but since autoimmune encephalitides have a relatively low incidence, international collaborations seem imperative to reach a reasonable study population size.
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Affiliation(s)
- N L Ciano-Petersen
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; Inserm U1217/CNRS UMR 5310, SynatAc Team, Institute NeuroMyoGène, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Biomedical Research Institute of Málaga-IBIMA, Málaga, Spain; Neurology Department, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - S Muñiz-Castrillo
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; Inserm U1217/CNRS UMR 5310, SynatAc Team, Institute NeuroMyoGène, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - A Vogrig
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; Inserm U1217/CNRS UMR 5310, SynatAc Team, Institute NeuroMyoGène, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - B Joubert
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; Inserm U1217/CNRS UMR 5310, SynatAc Team, Institute NeuroMyoGène, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - J Honnorat
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; Inserm U1217/CNRS UMR 5310, SynatAc Team, Institute NeuroMyoGène, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France.
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Hébert J, Muccilli A, Wennberg RA, Tang-Wai DF. Autoimmune Encephalitis and Autoantibodies: A Review of Clinical Implications. J Appl Lab Med 2022; 7:81-98. [PMID: 34996085 DOI: 10.1093/jalm/jfab102] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 07/29/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Autoimmune encephalitis (AE) is a common cause of encephalitis. We review the most recent evidence on this neuroimmune condition and autoantibody testing currently available. CONTENT Clinical criteria, neuroimaging and electroencephalography can facilitate the diagnosis of AE prior to obtaining autoantibody testing results, and lead to a diagnosis of AE even in the absence of a recognized antibody. Early treatment of AE has been found to correlate with improved long-term functional and cognitive outcomes. We suggest a clinical approach to diagnosis based on the predominant area of nervous system involvement and the results of ancillary testing that are widely available. We also propose a 2-tiered approach to the acute management of probable or definite AE. We, finally, provide guidance on the long-term management of AE-a challenging and understudied area. SUMMARY Much work remains to be done to improve the care of patients with AE. As understanding of the pathophysiology and predisposing factors underlying this condition steadily increases, a more evidence-based, targeted approach to the treatment of AE is still desired. Nonetheless, looking at the progress made over the past 2 decades, since the discovery of the first autoantibodies associated with AE, one cannot help but feel optimistic about the road ahead.
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Affiliation(s)
- Julien Hébert
- Department of Medicine, Division of Neurology, Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Alexandra Muccilli
- Department of Medicine, Division of Neurology, Division of Neurology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Neurology, Multiple Sclerosis Clinic, St. Michael's Hospital, Toronto, ON, Canada
| | - Richard A Wennberg
- Department of Medicine, Division of Neurology, Division of Neurology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Neurology, Epilepsy Clinic and Neurophysiology Lab, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - David F Tang-Wai
- Department of Medicine, Division of Neurology, Division of Neurology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Neurology, Memory Clinic, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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Abstract
Limbic encephalitis (LE) is a clinical syndrome defined by subacutely evolving limbic signs and symptoms with structural and functional evidence of mediotemporal damage in the absence of a better explanation than an autoimmune (or paraneoplastic) cause. There are features common to all forms of LE. In recent years, antibody(ab)-defined subtypes have been established. They are distinct regarding underlying pathophysiologic processes, clinical and magnetic resonance imaging courses, cerebrospinal fluid signatures, treatment responsivity, and likelihood of a chronic course. With immunotherapy, LE with abs against surface antigens has a better outcome than LE with abs to intracellular antigens. Diagnostic and treatment challenges are, on the one hand, to avoid overlooking and undertreatment and, on the other hand, to avoid overdiagnoses and overtreatment. LE can be conceptualized as a model disease for the consequences of new onset mediotemporal damage by different mechanisms in adult life. It may be studied as an example of mediotemporal epileptogenesis.
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Affiliation(s)
- Christian G Bien
- Department of Epileptology (Krankenhaus Mara), Bielefeld University, Bielefeld, Germany; Laboratory Krone, Bad Salzuflen, Germany.
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40
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Liu X, Yu T, Zhao X, Li G, Lv R, Ai L, Wang Q. 18 F-fluorodeoxy-glucose positron emission tomography pattern and prognostic predictors in patients with anti-GABAB receptor encephalitis. CNS Neurosci Ther 2021; 28:269-278. [PMID: 34837479 PMCID: PMC8739043 DOI: 10.1111/cns.13767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 10/21/2021] [Accepted: 11/10/2021] [Indexed: 01/03/2023] Open
Abstract
Aims To identify the metabolic pattern and prognostic predictors in anti‐gamma‐aminobutyric‐acid B (GABAB) receptor encephalitis using 18F‐fluorodeoxy‐glucose positron emission tomography (18F‐FDG‐PET). Methods Twenty‐one patients diagnosed anti‐GABAB receptor encephalitis who underwent 18F‐FDG‐PET at first hospitalization were retrospectively reviewed. 18F‐FDG‐PET images were analyzed in comparison with controls. Further group comparisons of 18F‐FDG‐PET data were carried out between prognostic subgroups. Results 18F‐FDG‐PET was abnormal in 81% patients with anti‐GABAB receptor encephalitis and was more sensitive than MRI (81% vs. 42.9%, p = 0.025). Alter limbic lobe glucose metabolism (mostly hypermetabolism) was observed in 14 patients (66.7%), of whom 10 (10/14, 71.4%) demonstrated hypermetabolism in the medial temporal lobe (MTL). Group analysis also confirmed MTL hypermetabolism in association with relative frontal and parietal hypometabolism was a general metabolic pattern. After a median follow‐up of 33 months, the group comparisons revealed that patients with poor outcome demonstrated increased metabolism in the MTL compared to those with good outcome. Conclusion 18F‐FDG‐PET may be more sensitive than MRI in the early diagnosis of anti‐GABAB receptor encephalitis. MTL hypermetabolism was associated with relative frontal or parietal hypometabolism and may serve as a prognostic biomarker in anti‐GABAB receptor encephalitis.
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Affiliation(s)
- 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
| | - Xiaobin Zhao
- Department of Nuclear Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gongfei Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, 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
| | - Lin Ai
- Department of Nuclear Medicine, Beijing Tiantan Hospital, Capital Medical University, 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.,Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
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41
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Bastiaansen AEM, de Jongste AHC, de Bruijn MAAM, Crijnen YS, Schreurs MWJ, Verbeek MM, Dumoulin DW, Taal W, Titulaer MJ, Sillevis Smitt PAE. Phase II trial of natalizumab for the treatment of anti-Hu associated paraneoplastic neurological syndromes. Neurooncol Adv 2021; 3:vdab145. [PMID: 34693289 PMCID: PMC8528262 DOI: 10.1093/noajnl/vdab145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Paraneoplastic neurological syndromes with anti-Hu antibodies (Hu-PNS) have a very poor prognosis: more than half of the patients become bedridden and median survival is less than 12 months. Several lines of evidence suggest a pathogenic T cell-mediated immune response. Therefore, we conducted a prospective open-label phase II trial with natalizumab. Methods Twenty Hu-PNS patients with progressive disease were treated with a maximum of three monthly natalizumab cycles (300 mg). The primary outcome measure was functional improvement, this was defined as at least one point decrease in modified Rankin Scale (mRS) score at the last treatment visit. In addition, treatment response was assessed wherein a mRS score ≤3 after treatment was defined as treatment responsive. Results The median age at onset was 67.8 years (SD 8.4) with a female predominance (n = 17, 85%). The median time from symptom onset to Hu-PNS diagnosis was 5 months (IQR 2–11). Most patients had subacute sensory neuronopathy (n = 15, 75%), with a median mRS of 4 at baseline. Thirteen patients had a tumor, all small cell lung cancer. After natalizumab treatment, two patients (10%) showed functional improvement. Of the remaining patients, 60% had a stable functional outcome, while 30% showed further deterioration. Treatment response was classified as positive in nine patients (45%). Conclusions Natalizumab may ameliorate the disease course in Hu-PNS, but no superior effects above other reported immunosuppressive and immunomodulatory were observed. More effective treatment modalities are highly needed. Trial registration https://www.clinicaltrialsregister.eu/ctr-search/trial/2014-000675-13/NL
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Affiliation(s)
- Anna E M Bastiaansen
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Adriaan H C de Jongste
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Yvette S Crijnen
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marco W J Schreurs
- Department of Immunology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marcel M Verbeek
- Department of Neurology and Laboratory Medicine, Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Daphne W Dumoulin
- Department of Pulmonary Medicine, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Walter Taal
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Maarten J Titulaer
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Binks S, Uy C, Honnorat J, Irani SR. Paraneoplastic neurological syndromes: a practical approach to diagnosis and management. Pract Neurol 2021; 22:19-31. [PMID: 34510016 DOI: 10.1136/practneurol-2021-003073] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2021] [Indexed: 01/13/2023]
Abstract
Paraneoplastic neurological syndromes (PNS) are the immune-mediated effects of a remote cancer and are characterised by an autoantibody response against antigens expressed by the tumour. Classically, well-characterised 'onconeuronal' antibodies target intracellular antigens and hence cannot access their antigens across intact cell membranes. The pathogenic mediators are likely to be neuronal-specific T cells. There is a variable response to immunotherapies and the clinical syndrome helps to direct the search for a specific set of tumours. By contrast, many newly emerging autoantibodies with oncological associations target cell surface epitopes and can exert direct pathogenic effects on both the central and peripheral nervous systems. Patients with these cell-surface directed autoantibodies often clearly respond to immunotherapies. Overall, the clinical, serological and oncological features in an individual patient helps determine the clinical relevance of the syndrome and hence guide its management. We summarise current knowledge and a practical approach to the investigation, diagnosis, treatment and outcomes of patients with suspected PNS.
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Affiliation(s)
- Sophie Binks
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK.,Department of Neurology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Christopher Uy
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK.,Department of Medicine (Division of Neurology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Jerome Honnorat
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hopital Neurologique, Lyon, France.,SynatAc Team, Institute NeuroMyoGene INSERM U1217/CNRS UMR 5310, Universite de Lyon, Universit Claude Bernard Lyon 1, Lyon, France
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK .,Department of Neurology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Bastiaansen AEM, van Steenhoven RW, de Bruijn MAAM, Crijnen YS, van Sonderen A, van Coevorden-Hameete MH, Nühn MM, Verbeek MM, Schreurs MWJ, Sillevis Smitt PAE, de Vries JM, Jan de Jong F, Titulaer MJ. Autoimmune Encephalitis Resembling Dementia Syndromes. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/5/e1039. [PMID: 34341093 PMCID: PMC8362342 DOI: 10.1212/nxi.0000000000001039] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/19/2021] [Indexed: 11/15/2022]
Abstract
Objective As autoimmune encephalitis (AIE) can resemble neurodegenerative dementia
syndromes, and patients do not always present as encephalitis, this study
evaluates how frequently AIE mimics dementia and provides red flags for AIE
in middle-aged and older patients. Methods In this nationwide observational cohort study, patients with
anti–leucine-rich glioma-inactivated 1 (LGI1), anti–NMDA
receptor (NMDAR), anti–gamma-aminobutyric acid B receptor
(GABABR), or anti–contactin-associated protein-like 2
(CASPR2) encephalitis were included. They had to meet 3 additional criteria:
age ≥45 years, fulfillment of dementia criteria, and no prominent
seizures early in the disease course (≤4 weeks). Results Two-hundred ninety patients had AIE, of whom 175 were 45 years or older.
Sixty-seven patients (38%) fulfilled criteria for dementia without prominent
seizures early in the disease course. Of them, 42 had anti-LGI1 (48%), 13
anti-NMDAR (52%), 8 anti-GABABR (22%), and 4 anti-CASPR2 (15%)
encephalitis. Rapidly progressive cognitive deterioration was seen in 48
patients (76%), whereas a neurodegenerative dementia syndrome was suspected
in half (n = 33). In 17 patients (27%; 16/17 anti-LGI1), subtle
seizures had been overlooked. Sixteen patients (25%) had neither
inflammatory changes on brain MRI nor CSF pleocytosis. At least 1 CSF
biomarker, often requested when dementia was suspected, was abnormal in 27
of 44 tested patients (61%), whereas 8 had positive 14-3-3 results (19%).
Most patients (84%) improved after immunotherapy. Conclusions Red flags for AIE in patients with suspected dementia are: (1) rapidly
progressive cognitive decline, (2) subtle seizures, and (3) abnormalities in
ancillary testing atypical for neurodegeneration. Physicians should be aware
that inflammatory changes are not always present in AIE, and that biomarkers
often requested when dementia was suspected (including 14-3-3) can show
abnormal results. Diagnosis is essential as most patients profit from
immunotherapy.
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Affiliation(s)
- Anna E M Bastiaansen
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Robin W van Steenhoven
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marienke A A M de Bruijn
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Yvette S Crijnen
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Agnes van Sonderen
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marleen H van Coevorden-Hameete
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marieke M Nühn
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marcel M Verbeek
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marco W J Schreurs
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Peter A E Sillevis Smitt
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Juna M de Vries
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Frank Jan de Jong
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Maarten J Titulaer
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
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44
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Ding JB, Dongas J, Hu K, Ding M. Autoimmune Limbic Encephalitis: A Review of Clinicoradiological Features and the Challenges of Diagnosis. Cureus 2021; 13:e17529. [PMID: 34603897 PMCID: PMC8476324 DOI: 10.7759/cureus.17529] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2021] [Indexed: 12/19/2022] Open
Abstract
Limbic encephalitis is an autoimmune cause of encephalitis. In addition to the usual symptoms of encephalitis such as altered consciousness, fever, and focal neurological deficits, limbic encephalitis can present with neuropsychiatric manifestations and seizures. Making a formal diagnosis involves a difficult and prolonged workup phase. The purpose of this review is to help readers delineate limbic encephalitis from other illnesses. This is done by presenting a spectrum of potential organic differential diagnoses and pertinent findings that distinguish them from limbic encephalitis. Instead of presenting a variety of psychiatric differential diagnoses, the authors present a review of psychiatric manifestations known to be associated with limbic encephalitis, as naturally, any psychiatric disorder could be a potential comorbid disease.
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Affiliation(s)
- Jack B Ding
- Internal Medicine, Royal Adelaide Hospital, Adelaide, AUS
- Internal Medicine, University of Adelaide, Adelaide, AUS
| | - John Dongas
- Internal Medicine, Royal Adelaide Hospital, Adelaide, AUS
| | - Kevin Hu
- Internal Medicine, Lyell McEwin Hospital, Adelaide, AUS
| | - Mark Ding
- Internal Medicine, University of Adelaide, Adelaide, AUS
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45
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Lizcano-Meneses A, Watanabe N, von Glehn F, Barbosa R, de Albuquerque M, Yassuda C, Moraes AS, Martínez JW, Santos LM, Cendes F. Clinical variables that help in predicting the presence of autoantibodies in patients with acute encephalitis. Seizure 2021; 90:117-122. [DOI: 10.1016/j.seizure.2021.02.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/03/2021] [Accepted: 02/17/2021] [Indexed: 12/19/2022] Open
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46
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Ruiz-García R, Muñoz-Sánchez G, Naranjo L, Guasp M, Sabater L, Saiz A, Dalmau J, Graus F, Martinez-Hernandez E. Limitations of a Commercial Assay as Diagnostic Test of Autoimmune Encephalitis. Front Immunol 2021; 12:691536. [PMID: 34267758 PMCID: PMC8276168 DOI: 10.3389/fimmu.2021.691536] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/15/2021] [Indexed: 12/24/2022] Open
Abstract
Detection of neuronal surface antibodies (NSAb) is important for the diagnosis of autoimmune encephalitis (AE). Although most clinical laboratories use a commercial diagnostic kit (Euroimmun, Lübeck, Germany) based on indirect immunofluorescence on transfected cells (IIFA), clinical experience suggests diagnostic limitations. Here, we assessed the performance of the commercial IIFA in serum and CSF samples of patients with suspected AE previously examined by rat brain immunohistochemistry (Cohort A). Of 6213 samples, 404 (6.5%) showed brain immunostaining suggestive of NSAb: 163 (40%) were positive by commercial IIFA and 241 (60%) were negative. When these 241 samples were re-assessed with in-house IIFA, 42 (18%) were positive: 21 (9%) had NSAb against antigens not included in the commercial IIFA and the other 21 (9%) had NSAb against antigens included in the commercial kit (false negative results). False negative results occurred more frequently with CSF (29% vs 10% in serum) and predominantly affected GABABR (39%), LGI1 (17%) and AMPAR (11%) antibodies. Results were reproduced in a separate cohort (B) of 54 AE patients with LGI1, GABABR or AMPAR antibodies in CSF which were missed in 30% by commercial IIFA. Patients with discordant GABABR antibody results (positive in-house but negative commercial IIFA) were less likely to develop full-blown clinical syndrome; no significant clinical differences were noted for the other antibodies. Overall, NSAb testing by commercial IIFA led to false negative results in a substantial number of patients, mainly those affected by anti-LG1, GABABR or AMPAR encephalitis. If these disorders are suspected and commercial IIFA is negative, more comprehensive antibody studies are recommended.
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Affiliation(s)
- Raquel Ruiz-García
- Immunology Department, Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona, Spain
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Laura Naranjo
- Immunology Department, Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona, Spain
| | - Mar Guasp
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Neurology Department, Hospital Clinic, and University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Raras (CIBERER), Madrid, Spain
| | - Lidia Sabater
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Albert Saiz
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Neurology Department, Hospital Clinic, and University of Barcelona, Barcelona, Spain
| | - Josep Dalmau
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Neurology Department, Hospital Clinic, and University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Raras (CIBERER), Madrid, Spain
- Neurology Department, University of Pennsylvania, Philadelphia, PA, United States
- Catalan Institution of Research and Advanced Studies (ICREA), Barcelona, Spain
| | - Francesc Graus
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Eugenia Martinez-Hernandez
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Neurology Department, Hospital Clinic, and University of Barcelona, Barcelona, Spain
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47
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Zografou C, Vakrakou AG, Stathopoulos P. Short- and Long-Lived Autoantibody-Secreting Cells in Autoimmune Neurological Disorders. Front Immunol 2021; 12:686466. [PMID: 34220839 PMCID: PMC8248361 DOI: 10.3389/fimmu.2021.686466] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/28/2021] [Indexed: 12/24/2022] Open
Abstract
As B cells differentiate into antibody-secreting cells (ASCs), short-lived plasmablasts (SLPBs) are produced by a primary extrafollicular response, followed by the generation of memory B cells and long-lived plasma cells (LLPCs) in germinal centers (GCs). Generation of IgG4 antibodies is T helper type 2 (Th2) and IL-4, -13, and -10-driven and can occur parallel to IgE, in response to chronic stimulation by allergens and helminths. Although IgG4 antibodies are non-crosslinking and have limited ability to mobilize complement and cellular cytotoxicity, when self-tolerance is lost, they can disrupt ligand-receptor binding and cause a wide range of autoimmune disorders including neurological autoimmunity. In myasthenia gravis with predominantly IgG4 autoantibodies against muscle-specific kinase (MuSK), it has been observed that one-time CD20+ B cell depletion with rituximab commonly leads to long-term remission and a marked reduction in autoantibody titer, pointing to a short-lived nature of autoantibody-secreting cells. This is also observed in other predominantly IgG4 autoantibody-mediated neurological disorders, such as chronic inflammatory demyelinating polyneuropathy and autoimmune encephalitis with autoantibodies against the Ranvier paranode and juxtaparanode, respectively, and extends beyond neurological autoimmunity as well. Although IgG1 autoantibody-mediated neurological disorders can also respond well to rituximab induction therapy in combination with an autoantibody titer drop, remission tends to be less long-lasting and cases where titers are refractory tend to occur more often than in IgG4 autoimmunity. Moreover, presence of GC-like structures in the thymus of myasthenic patients with predominantly IgG1 autoantibodies against the acetylcholine receptor and in ovarian teratomas of autoimmune encephalitis patients with predominantly IgG1 autoantibodies against the N‐methyl‐d‐aspartate receptor (NMDAR) confers increased the ability to generate LLPCs. Here, we review available information on the short-and long-lived nature of ASCs in IgG1 and IgG4 autoantibody-mediated neurological disorders and highlight common mechanisms as well as differences, all of which can inform therapeutic strategies and personalized medical approaches.
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Affiliation(s)
- C Zografou
- Institute of Neuropathology, University of Zurich, Zurich, Switzerland
| | - A G Vakrakou
- First Department of Neurology, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - P Stathopoulos
- First Department of Neurology, National and Kapodistrian University of Athens Medical School, Athens, Greece
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Abstract
Introduction: Paraneoplastic neurological syndromes (PNS) are a rare heterogeneous group of neurological diseases associated with tumors. These syndromes are the result of a cross-reactive immune response against antigens shared by the tumor and the nervous system. The discovery of an increasing number of autoantigens and the identification of tumoral factors leading to a substantial antitumoral immune response makes this topic highly innovative.Areas covered: This review covers the clinical, oncological, pathophysiological aspects of both immunological PNS groups. One is associated with autoantibodies against intracellular onconeural antibodies, which are highly specific for an underlying tumor, although the disease is mainly T-cell mediated. In contrast, PNS associated with pathogenic surface-binding/receptor autoantibodies, which are often responsive to immunosuppressive treatment, may manifest as paraneoplastic and non-paraneoplastic diseases. The most frequent tumors associated with PNS are (small cell) lung cancer, gynecological tumors, thymoma, lymphoma, and, in children, neuroblastoma. A special interest is given to PNS, induced by immune checkpoint-inhibitors (ICIs).Expert opinion: Research in PNS, including the group of ICI-induced PNS provide new insights in both the pathophysiology of PNS and tumor immune interactions and offers new treatment options for this group of severe neurological diseases.
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Affiliation(s)
- Franz Blaes
- Department of Neurology, KKH Gummersbach, Gummersbach, Germany
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49
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Chen T. Clinical Reasoning: A 68-Year-Old Man With Proximal Weakness and Seizures. Neurology 2021; 97:e423-e428. [PMID: 33931546 DOI: 10.1212/wnl.0000000000012137] [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
Affiliation(s)
- Tychicus Chen
- From the Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, Canada.
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50
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Devine MF, Kothapalli N, Elkhooly M, Dubey D. Paraneoplastic neurological syndromes: clinical presentations and management. Ther Adv Neurol Disord 2021; 14:1756286420985323. [PMID: 33796141 PMCID: PMC7970694 DOI: 10.1177/1756286420985323] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 12/11/2020] [Indexed: 12/17/2022] Open
Abstract
We provide an overview of the varied presentations of paraneoplastic neurological syndromes. We also review the onconeural antibodies and their particular oncological and neurological associations. Recognition of these syndromes and their oncological associations is crucial, as early diagnosis and management has been associated with better patient outcomes. Specific management strategies and prognosis vary widely depending on the underlying etiology. An understanding of the relevant clinical details, imaging findings, and other diagnostic information can help tailor treatment approaches. We provide an outline of the diagnostic evaluation and treatment of various paraneoplastic neurological disorders, presenting with central and/or peripheral nervous system involvement. We briefly discuss neurologic immune checkpoint inhibitor-related adverse events, which can occasionally present with paraneoplastic neurological syndrome phenotypes.
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Affiliation(s)
- Michelle F Devine
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Naga Kothapalli
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburg, PA, USA
| | | | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905-0002, USA
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