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Hannich MJ, Konen FF, Gag K, Alkhayer A, Türker SN, Budde K, Nauck M, Wurster U, Dressel A, Skripuletz T, Süße M. Implications of monoclonal gammopathy and isoelectric focusing pattern 5 on the free light chain kappa diagnostics in cerebrospinal fluid. Clin Chem Lab Med 2024; 0:cclm-2023-1468. [PMID: 39039726 DOI: 10.1515/cclm-2023-1468] [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: 12/18/2023] [Accepted: 06/27/2024] [Indexed: 07/24/2024]
Abstract
OBJECTIVES Oligoclonal bands (OCB) analysis is the reference standard for detecting an intrathecal IgG synthesis. Alongside OCB, free light chains kappa (FLCκ) are considered an additional sensitive biomarker for determining patterns 2 or 3, indicating intrathecal Ig synthesis. However, kFLC IF is not suitable for detecting a monoclonal pattern 5. The primary aim of this study was to evaluate the impact of incorporating FLCκ analysis into routine cerebrospinal fluid (CSF) diagnostics instead of OCB testing on the rate of missed monoclonal IgG detection. METHODS A two-center retrospective biomarker study was conducted. OCB were identified using isoelectric focusing in polyacrylamide gels followed by silver staining or in agarose gels followed by immunofixation. FLCκ were quantified using nephelometry and FLCκ assay (Siemens). RESULTS Out of a combined total of 17,755 OCB analyses conducted between 2011 and 2021, a subset of 269 cases (1.5 %) exhibited pattern 5. 98 samples (36 %), which included 18 samples with intrathecal inflammation as determined by additional OCB pattern 2 were included in the FLCκ analysis. Of those, 16 (89 %) had intrathecal FLCκ synthesis. CONCLUSIONS While FLCκ offers a promising avenue for detecting an intrathecal inflammation, the pattern 5, though rare, remains a valuable additional finding of OCB analysis. A combined approach of FLCκ and OCB analysis is recommended for a comprehensive assessment of the humoral intrathecal immune response.
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Affiliation(s)
- Malte J Hannich
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
- Department of Internal Medicine B, 221199 University Medicine Greifswald , Greifswald, Germany
| | - Franz F Konen
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Konrad Gag
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Aiham Alkhayer
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Seda N Türker
- Department of Psychiatry, Hannover Medical School, Hannover, Germany
| | - Kathrin Budde
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Matthias Nauck
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Ulrich Wurster
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Thomas Skripuletz
- Department of Internal Medicine B, 221199 University Medicine Greifswald , Greifswald, Germany
| | - Marie Süße
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
- Department of Neurology, Hannover Medical School, Hannover, Germany
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2
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Belimezi M, Kalliaropoulos A, Mentis AFA, Chrousos GP. Diagnostic significance of IgG and albumin indices versus oligoclonal band types in demyelinating disorders. J Clin Pathol 2023; 76:166-171. [PMID: 34526372 DOI: 10.1136/jclinpath-2021-207766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/29/2021] [Indexed: 11/04/2022]
Abstract
AIMS The laboratory diagnosis of demyelinating inflammatory disorders (DIDs) relies on both intrathecal oligoclonal band (OCB) positivity and IgG index. Although OCB typing remains the gold-standard test for DIDs, it can be laborious and ambiguous, complicating diagnostics, and unduly increasing diagnostic time. We examined whether serum or cerebrospinal fluid (CSF) parameters can classify OCB types and, thus, be used as a replacement test to standard OCB typing. METHODS We retrospectively analysed >1000 prospectively collected samples of patients with DIDs and quantified albumin and IgG levels in the CSF and serum. We determined OCB types by isoelectric focusing combined with immunofixation and evaluated the diagnostic accuracies of IgG and albumin indices in discriminating OCB types by receiver operating characteristic curves and multinomial regression. RESULTS An IgG index cut-off of 0.589 differentiated types 2/3 from types 1/4 (area under the curve 0.780, 95% CI 0.761 to 0.812, p<0.001; specificity: 71.10%, sensitivity: 73.45%). Albumin quotient cut-off values of 6.625 and of 6.707 discriminated type 1 from type 4 and type 2 from type 3, respectively (specificity: <55%, sensitivity: <75%). Female sex, age, IgG index, CSF IgG and serum albumin were associated with different OCB types. CONCLUSIONS Our study reveals that IgG and albumin index can differentiate OCB types with adequate accuracy, especially if refined by age and gender.
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Affiliation(s)
- Maria Belimezi
- Diagnostic Services Laboratory, Hellenic Pasteur Institute, Athens, Greece
| | | | - Alexios-Fotios A Mentis
- Diagnostic Services Laboratory, Hellenic Pasteur Institute, Athens, Greece .,University Research Institute of Maternal and Child Health and Precision Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - George P Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, National and Kapodistrian University of Athens, Athens, Greece
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3
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Cabrera CM. Oligoclonal bands: An immunological and clinical approach. Adv Clin Chem 2022; 109:129-163. [DOI: 10.1016/bs.acc.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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4
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Puthenparampil M, Miante S, Federle L, Zanetta C, Toffanin E, Ruggero S, Rinaldi F, Gallo P. BAFF is decreased in the cerebrospinal fluid of multiple sclerosis at clinical onset. J Neuroimmunol 2016; 297:63-7. [DOI: 10.1016/j.jneuroim.2016.05.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 05/06/2016] [Accepted: 05/11/2016] [Indexed: 12/24/2022]
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5
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Abraira V, Alvarez-Cermeño J, Arroyo R, Cámara C, Casanova B, Cubillo S, de Andrés C, Espejo C, Fernández O, Ferrer J, Figueredo M, García-Merino A, García-Sánchez M, García-Trujillo J, Gómez M, González-Oria C, Gosis A, Izquierdo G, Jímenez J, López-Trascasa M, Montalbán X, Moreno M, Muñoz D, Nuñez V, Muriel A, Navarro J, Olascoaga J, Oreja-Guevara C, Prada A, Ramil E, Ramo-Tello C, Rodríguez C, Rodríguez E, Rodríguez-Frías F, Rodríguez-Antigüedad A, Rodríguez-Molina J, Ruiz E, Saiz A, Sarasola E, Simó M, Yagüe J, Villar L. Utility of oligoclonal IgG band detection for MS diagnosis in daily clinical practice. J Immunol Methods 2011; 371:170-3. [DOI: 10.1016/j.jim.2011.06.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Revised: 06/06/2011] [Accepted: 06/08/2011] [Indexed: 11/29/2022]
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6
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Verbeek MM, Notting EA, Faas B, Claessens-Linskens R, Jongen PJH. Increased cerebrospinal fluid chitotriosidase index in patients with multiple sclerosis. Acta Neurol Scand 2010; 121:309-14. [PMID: 19925532 DOI: 10.1111/j.1600-0404.2009.01242.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate chitotriosidase (CTTS) activity in serum and cerebrospinal fluid (CSF) in multiple sclerosis (MS) patients in relation to disease course and CSF markers for immune activation or inflammation. MATERIALS AND METHODS We studied 80 patients with relapsing-remitting MS (RRMS), 24 with secondary progressive MS (SPMS), 20 with primary progressive MS (PPMS) and 29 patients with other neurological disorders (OND). We measured CTTS activity and studied the correlation with CSF mononuclear cell count (MNC) and intrathecal IgG production. RESULTS CTTS activity was significantly higher in CSF, but not in serum, from the total MS group compared with OND and controls. In RRMS and SPMS CTTS, index was increased compared with controls (RRMS, 0.10 +/- 0.21; SPMS, 0.10 +/- 0.15; controls, 0.021 +/- 0.020), but not in PPMS (0.061 +/- 0.052). CTTS index was higher in MS patients with elevated MNC or CSF-restricted oligoclonal IgG bands than in MS patients without these CSF findings. CONCLUSIONS CTTS index is elevated in RRMS and SPMS. The CTTS index is related to CSF markers of inflammation or immune activation.
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Affiliation(s)
- M M Verbeek
- Department of Neurology, Donders Centre for Brain, Cognition and Behaviour, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
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Leen WG, Weemaes CM, Verbeek MM, Willemsen MA, Rotteveel JJ. Rituximab and intravenous immunoglobulins for relapsing postinfectious opsoclonus-myoclonus syndrome. Pediatr Neurol 2008; 39:213-7. [PMID: 18725071 DOI: 10.1016/j.pediatrneurol.2008.05.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Revised: 05/14/2008] [Accepted: 05/19/2008] [Indexed: 11/29/2022]
Abstract
We describe 2 children with postinfectious opsoclonus-myoclonus syndrome. Although the patients initially responded to monotherapy with methylprednisolone, intravenous immunoglobulins, or rituximab, they manifested persistent neurologic deficits and relapsing signs. Treatment with rituximab in combination with intravenous immunoglobulin, however, resulted in significant longterm clinical improvement.
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Affiliation(s)
- Wilhelmina G Leen
- Department of Pediatric Neurology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
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Mygland A, Trydal T, Vinje BU, Vedeler C. Isoelectric focusing is superior to immunofixation electrophoresis in diagnosing CNS inflammation. Acta Neurol Scand 2007; 115:122-5. [PMID: 17212616 DOI: 10.1111/j.1600-0404.2006.00763.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND A sensitive method to detect intrathecal IgG production is important in diagnosing inflammatory central nervous system (CNS) diseases, including multiple sclerosis (MS). OBJECTIVE To compare cerebrospinal fluid (CSF) electrophoresis with isoelectric focusing (IEF), immunofixation-peroxidase electrophoresis (IFPE) and high-resolution agarose electrophoresis with protein-staining (HRAGE). METHODS Paired serum and CSF samples from 307 consecutive patients attending a general neurology clinic were examined with IEF, IFPE and HRAGE. Clinical diagnosis was based on review of the patients' medical records after an average of 4 years. RESULTS The sensitivity for detecting any inflammatory (autoimmune or infectious) CNS disease (52 patients) was 67% for IEF, 50% for IFPE and 29% for HRAGE. The sensitivity for detecting MS (14 patients) was 93%, 86% and 29% respectively. The sensitivity for detecting clinically isolated syndrome (eight patients) was 75%, 25% and 13% respectively. The number of oligoclonal bands in IEF was higher in inflammatory than in non-inflammatory neurological diseases or symptoms, but similar in MS and other inflammatory diseases. CONCLUSION IEF is the method of choice in diagnosing intrathecal IgG synthesis.
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Affiliation(s)
- A Mygland
- Department of Neurology, Sørlandet Sykehus, Kristiansand, Norway.
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Link H, Huang YM. Oligoclonal bands in multiple sclerosis cerebrospinal fluid: An update on methodology and clinical usefulness. J Neuroimmunol 2006; 180:17-28. [PMID: 16945427 DOI: 10.1016/j.jneuroim.2006.07.006] [Citation(s) in RCA: 244] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2006] [Accepted: 07/03/2006] [Indexed: 12/17/2022]
Abstract
Two or more oligoclonal IgG bands (OB) detected by separation of cerebrospinal fluid (CSF) proteins while not demonstrable in corresponding serum reflect a local B-cell response accompanying central nervous system (CNS) inflammation. Using optimized, standardized methodology, preferentially protein separation by isoelectric focusing followed by immunoblotting, more than 95% of patients with multiple sclerosis (MS) have CSF OB of IgG class not detectable in serum, thereby providing powerful evidence for the diagnosis of MS. Once present, CSF OB persists in the individual patient irrespective of MS course or therapy. Because of the high sensitivity of CSF OB in MS as well as its high specificity in the appropriate clinical setting, examination of CSF for OB of IgG class can be strongly recommended to obtain support for the diagnosis of MS and identify patients with clinically isolated syndrome (CIS) at increased risk of developing MS. The IgG index equal to CSF/serum IgG:CSF/serum albumin is elevated in about 70% of MS patients, but rarely in CSF OB-negative MS. Because of lower diagnostic sensitivity, IgG index cannot be recommended as replacement of CSF OB in the diagnosis of MS but, when elevated, as additional evidence for an augmented B-cell response within the CNS that is compatible with MS. Although the clinical picture as well as findings from magnetic resonance imaging of the brain and spinal cord are essential for an MS diagnosis, this should be re-evaluated in CSF OB-negative patients, keeping in mind the many disease entities imitating MS. Recommended diagnostic criteria for MS must include definitions of the role of lumbar puncture and of clearly specified, optimized and standardized routine CSF investigations including for the presence of CSF IgG OB. There is a need for concerted long-term follow-up studies of the subgroup of MS patients without CSF OB regarding e.g. prognostic and immunologic features. For inclusion in trials of disease-modulating drugs, it is recommended that patients with MS or CIS are selected regarding presence vs. absence of CSF OB. Development and evaluation of new technologies to define local vs. systemic B-cell responses in patients with MS or CIS vs. patients with other inflammatory neurological diseases should shed new light on the role of CSF OB, which remains enigmatic.
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Affiliation(s)
- Hans Link
- Karolinska Institute, 14185 Stockholm, Sweden.
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Franciotta D, Avolio C, Capello E, Lolli F. Consensus recommendations of the Italian Association for Neuroimmunology for immunochemical cerebrospinal fluid examination. J Neurol Sci 2005; 237:5-11. [PMID: 16111707 DOI: 10.1016/j.jns.2005.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2004] [Revised: 06/29/2005] [Accepted: 07/05/2005] [Indexed: 11/29/2022]
Abstract
In 2002-2003, the Italian Association for Neuroimmunology (AINI) ran a program for procedure and method standardization in neuroimmunology. The main purposes of the program were: a) to improve the overall quality of analytical performance and, simultaneously, to reduce costs by resource optimization; b) to establish the bases for clinical guidelines in neurology; c) to promote the formation of laboratory networks and of joint research projects; d) to facilitate the procedures for certification required by governmental/non-governmental agencies. This report summarizes the consensus recommendations of a panel of AINI neuroimmunologists/biochemists involved in the field of cerebrospinal fluid examination. The collection process for said recommendations was guided by "impact-factored" literature and the knowledge of the experts involved. Communication was by email and face-to-face at two dedicated AINI workshops.
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Affiliation(s)
- Diego Franciotta
- Laboratory of Neuroimmunology, IRCCS, Neurological Institute C. Mondino, University of Pavia, via Mondino 2, I-27100 Pavia, Italy.
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Reiber H, Thompson EJ, Grimsley G, Bernardi G, Adam P, Monteiro de Almeida S, Fredman P, Keir G, Lammers M, Liblau R, Menna-Barreto M, Sá MJ, Seres E, Sindic CJM, Teelken A, Trendelenburg C, Trojano M, van Antwerpen MP, Verbeek MM. Quality assurance for cerebrospinal fluid protein analysis: international consensus by an Internet-based group discussion. Clin Chem Lab Med 2003; 41:331-7. [PMID: 12705343 DOI: 10.1515/cclm.2003.053] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A group of neurologists and clinical neurochemists representing twelve countries worked towards a consensus on laboratory techniques to improve the quality of analysis and interpretation of cerebrospinal fluid (CSF) proteins. Consensus was approached via a virtual Lotus Notes-based TeamRoom. This new approach respecting multicultural differences, common views, and minority opinions, is available in http://www.teamspace.net/ CSF, presenting the implicit, complementary version of this explicit, printed consensus. Three key recommendations were made: CSF and (appropriately diluted) serum samples should be analyzed together in one analytical run, i.e., with reference to the same calibration curve. Results are evaluated as CSF/serum quotients, taking into account the non-linear, hyperbolic relation between immunoglobulin (Ig)- and albumin-quotients rather than using the linear IgG index or IgG synthesis rate. Controls should include materials with values within the reference ranges (IgM: 0.5-1.5 mg/l; IgA: 1-3 mg/l; IgG: 10-30 mg/l and albumin: 100-300 mg/l). The physiological, methodological and clinical significance of CSF/serum quotients is reviewed. We confirmed the previous consensus on oligoclonal IgG, in particular the usefulness of the five typical interpretation patterns. The group compared current external and internal quality assurance schemes and encouraged all members to maintain national or local traditions. Values for acceptable imprecision in the CSF quality assurance are proposed.
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Affiliation(s)
- Hansotto Reiber
- Neurochemisches Labor, Universität Göttingen, Göttingen, Germany.
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