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Nair P, Iype T, Panicker P. Painful Itch in a Fidgety Girl. Ann Indian Acad Neurol 2024; 27:208-209. [PMID: 38751911 PMCID: PMC11093180 DOI: 10.4103/aian.aian_651_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 12/01/2023] [Accepted: 12/17/2023] [Indexed: 05/18/2024] Open
Affiliation(s)
- Poornima Nair
- Department of Neurology, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Thomas Iype
- Department of Neurology, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Praveen Panicker
- Department of Neurology, Government Medical College, Thiruvananthapuram, Kerala, India
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Gadoth A, Nisnboym M, Alcalay Y, Zubkov A, Schwartz I, Schwartz D, Abboud M, Rubinek T, Yossepowitch O, Weinstein T. Electrolyte Imbalance in Anti-LGI1 Encephalitis: It Is Not All in Your Head. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200155. [PMID: 37591767 PMCID: PMC10434828 DOI: 10.1212/nxi.0000000000200155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 06/27/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Antileucine-rich glioma-inactivated 1 (anti-LGI1) autoimmune encephalitis was first described in 2010 and is today the most common type of limbic encephalitis. During the course of the disease, 60%-88% of the patients develop hyponatremia. The etiology of the sodium disorder is unclear, often presumed to be the result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Other electrolyte abnormalities have not been reported in association with anti-LGI1 antibody encephalitis. Due to the presence of hypomagnesemia and hypophosphatemia in our patients, we set out to try to find the expression of LGI1 protein in the kidney as an explanation for these abnormalities. METHODS We reviewed the medical files of all patients diagnosed with anti-LGI1 antibody encephalitis, at the Department of Neurology in the Tel Aviv Medical Center between January 2011 and December 2020, exploring for electrolyte abnormalities. Using tissue staining, Western blot, mass spectrometry, and RNA expression techniques, we tried to demonstrate the expression of LGI1 protein in the human kidney. RESULTS We identified 15 patients diagnosed with anti-LGI1 antibody encephalitis. Their average age was 65 years (44-80), and 9 were male individuals. Thirteen of the 15 patients (87%) developed varying degrees of hyponatremia. Laboratory studies demonstrated low serum osmolality, low serum blood urea nitrogen, and low uric acid, with a high urinary sodium and inappropriately high urine osmolality, supporting the presumable diagnosis of SIADH. One patient with hyponatremia that was tested, had high levels of copeptin, supporting the diagnosis of SIADH. In addition to hyponatremia, 7 patients (47%) exhibited other electrolyte abnormalities; 5 patients (33%) had overt hypophosphatemia, 4 patients (27%) had overt hypomagnesemia, and 2 other patients (13%) had borderline low magnesium levels. Western blot analysis of human kidney lysate, mass spectrometry, and qRT-PCR failed to demonstrate the expression of LGI1 protein in the kidney. DISCUSSION Hyponatremia in patients with anti-LGI1 antibody encephalitis is due to SIADH as previously assumed. Other electrolyte abnormalities such as hypomagnesemia and hypophosphatemia occur in at least 40% of patients and may be another clue for the diagnosis of anti-LGI1 antibody encephalitis. Because we failed to demonstrate LGI1 expression in the kidney, the results of our study suggest that renal losses lead to these disturbances, most probably due to SIADH.
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Affiliation(s)
- Avi Gadoth
- From the Department of Neurology (A.G.), Encephalitis Center, Tel-Aviv Medical Center; Department of Neurology (M.N.Z.), Sourasky Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University; Encephalitis Center (Y.A.), Immunology Laboratory, Sourasky Tel Aviv Medical Center; Department of Pathology (A.Z.), Tel Aviv Medical Center; Department of Nephrology (I.S., D.S., T.W.); Oncology Division (M.A., T.R.); and Department of Urology (O.Y.), Sourasky, Tel-Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Israel.
| | - Michal Nisnboym
- From the Department of Neurology (A.G.), Encephalitis Center, Tel-Aviv Medical Center; Department of Neurology (M.N.Z.), Sourasky Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University; Encephalitis Center (Y.A.), Immunology Laboratory, Sourasky Tel Aviv Medical Center; Department of Pathology (A.Z.), Tel Aviv Medical Center; Department of Nephrology (I.S., D.S., T.W.); Oncology Division (M.A., T.R.); and Department of Urology (O.Y.), Sourasky, Tel-Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Yifat Alcalay
- From the Department of Neurology (A.G.), Encephalitis Center, Tel-Aviv Medical Center; Department of Neurology (M.N.Z.), Sourasky Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University; Encephalitis Center (Y.A.), Immunology Laboratory, Sourasky Tel Aviv Medical Center; Department of Pathology (A.Z.), Tel Aviv Medical Center; Department of Nephrology (I.S., D.S., T.W.); Oncology Division (M.A., T.R.); and Department of Urology (O.Y.), Sourasky, Tel-Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Asia Zubkov
- From the Department of Neurology (A.G.), Encephalitis Center, Tel-Aviv Medical Center; Department of Neurology (M.N.Z.), Sourasky Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University; Encephalitis Center (Y.A.), Immunology Laboratory, Sourasky Tel Aviv Medical Center; Department of Pathology (A.Z.), Tel Aviv Medical Center; Department of Nephrology (I.S., D.S., T.W.); Oncology Division (M.A., T.R.); and Department of Urology (O.Y.), Sourasky, Tel-Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Idit Schwartz
- From the Department of Neurology (A.G.), Encephalitis Center, Tel-Aviv Medical Center; Department of Neurology (M.N.Z.), Sourasky Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University; Encephalitis Center (Y.A.), Immunology Laboratory, Sourasky Tel Aviv Medical Center; Department of Pathology (A.Z.), Tel Aviv Medical Center; Department of Nephrology (I.S., D.S., T.W.); Oncology Division (M.A., T.R.); and Department of Urology (O.Y.), Sourasky, Tel-Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Doron Schwartz
- From the Department of Neurology (A.G.), Encephalitis Center, Tel-Aviv Medical Center; Department of Neurology (M.N.Z.), Sourasky Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University; Encephalitis Center (Y.A.), Immunology Laboratory, Sourasky Tel Aviv Medical Center; Department of Pathology (A.Z.), Tel Aviv Medical Center; Department of Nephrology (I.S., D.S., T.W.); Oncology Division (M.A., T.R.); and Department of Urology (O.Y.), Sourasky, Tel-Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Marana Abboud
- From the Department of Neurology (A.G.), Encephalitis Center, Tel-Aviv Medical Center; Department of Neurology (M.N.Z.), Sourasky Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University; Encephalitis Center (Y.A.), Immunology Laboratory, Sourasky Tel Aviv Medical Center; Department of Pathology (A.Z.), Tel Aviv Medical Center; Department of Nephrology (I.S., D.S., T.W.); Oncology Division (M.A., T.R.); and Department of Urology (O.Y.), Sourasky, Tel-Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Tamar Rubinek
- From the Department of Neurology (A.G.), Encephalitis Center, Tel-Aviv Medical Center; Department of Neurology (M.N.Z.), Sourasky Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University; Encephalitis Center (Y.A.), Immunology Laboratory, Sourasky Tel Aviv Medical Center; Department of Pathology (A.Z.), Tel Aviv Medical Center; Department of Nephrology (I.S., D.S., T.W.); Oncology Division (M.A., T.R.); and Department of Urology (O.Y.), Sourasky, Tel-Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Ofer Yossepowitch
- From the Department of Neurology (A.G.), Encephalitis Center, Tel-Aviv Medical Center; Department of Neurology (M.N.Z.), Sourasky Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University; Encephalitis Center (Y.A.), Immunology Laboratory, Sourasky Tel Aviv Medical Center; Department of Pathology (A.Z.), Tel Aviv Medical Center; Department of Nephrology (I.S., D.S., T.W.); Oncology Division (M.A., T.R.); and Department of Urology (O.Y.), Sourasky, Tel-Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Talia Weinstein
- From the Department of Neurology (A.G.), Encephalitis Center, Tel-Aviv Medical Center; Department of Neurology (M.N.Z.), Sourasky Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University; Encephalitis Center (Y.A.), Immunology Laboratory, Sourasky Tel Aviv Medical Center; Department of Pathology (A.Z.), Tel Aviv Medical Center; Department of Nephrology (I.S., D.S., T.W.); Oncology Division (M.A., T.R.); and Department of Urology (O.Y.), Sourasky, Tel-Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
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De Stefano G, Pulitano P, Di Bonaventura C, Zuliani L, Morano A. Anti-LGI1 encephalitis: A family affair. J Neuroimmunol 2023; 378:578084. [PMID: 37037125 DOI: 10.1016/j.jneuroim.2023.578084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 04/01/2023] [Accepted: 04/01/2023] [Indexed: 04/08/2023]
Abstract
Here we describe the second ever-reported case of familial anti-leucine-rich glioma-inactivated protein 1 (LGI1) limbic encephalitis (LE). Two elderly Caucasian sisters presented with psychiatric symptoms and cognitive impairment, followed by faciobrachial dystonic seizures. Anti-LGI1 antibodies were detected in their serum. Considering they had been living in distant regions for decades, environmental factors could be ruled out. Human leukocyte antigen (HLA) genotyping revealed that both carried HLA-DRB1*07, found in 90% of anti-LGI1 encephalitis patients, HLA-DQA1*02:01 and HLA-DQB1*03:03, commonly associated with DRB1*07:01. Considering the exceptional nature of familial cases, as-yet-unknown genetic contributors other than HLA might play a role in our siblings.
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Huang P. Epidemic Japanese B encephalitis combined with contactin-associated protein-like 2 antibody-positive autoimmune encephalitis: A case report. World J Clin Cases 2023; 11:1379-1384. [PMID: 36926141 PMCID: PMC10013120 DOI: 10.12998/wjcc.v11.i6.1379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/19/2022] [Accepted: 02/07/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND It is not uncommon to develop viral encephalitis. Epidemic Japanese B encephalitis infection combined with contactin-associated protein-like 2 (CASPR-2) antibody-positive autoimmune encephalitis has not been reported at present. In clinical work, we need to consider more options.
CASE SUMMARY A 32-year-old male worker presented with headache, fever and call-unresponsive presentation. Complete cranial magnetic resonance image showed symmetrical abnormal signals in bilateral medial temporal lobe, bilateral thalamus and basal ganglia. Improved lumbar puncture showed that cerebrospinal fluid protein and cell count increased significantly. Viral encephalitis was considered, and the patient's consciousness still increased rapidly after antiviral treatment. Further detection of Cerebrospinal fluid Japanese B encephalitis virus Polymerase Chain Reaction positive, serum autoimmune encephalitis antibody showed CASPR-2 antibody positive (1:320), the patient's condition gradually improved after plasma exchange treatment. 3 mo later, the serum CASPR-2 antibody was negative and the patient's condition was stable.
CONCLUSION This article reports the world’s first case of Epidemic Japanese B encephalitis infection combined with CASPR-2 antibody-positive autoimmune encephalitis, with a view to raising awareness.
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Affiliation(s)
- Pan Huang
- Department of Neurology, People’s Hospital of Deyang City, Deyang 618000, Sichuan Province, China
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Kong DL. Anti-leucine-rich glioma inactivated protein 1 encephalitis with sleep disturbance as the first symptom: A case report and review of literature. World J Clin Cases 2023; 11:408-416. [PMID: 36686352 PMCID: PMC9850984 DOI: 10.12998/wjcc.v11.i2.408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 11/20/2022] [Accepted: 12/05/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Anti-leucine-rich glioma inactivated protein 1 (anti-LGI1) encephalitis is an infrequent type of autoimmune encephalitis (AE) characterized by acute or subacute cognitive and psychiatric disturbance, facio-brachial dystonic seizures (FBDSs), and hyponatremia. Anti-LGI1 AE has increasingly been considered a primary form of AE. Early identification and treatment of this disease are clearly very important.
CASE SUMMARY Here, we report that a male patient developed severe anti-LGI1 encephalitis, which was initially misdiagnosed as a sleep disturbance. He was hospitalized for epileptic seizures and typical FBDSs half a month after he developed sleep disturbances. LGI1 antibodies were detected in his cerebrospinal fluid and serum (1:100 and 1:3.2, respectively), which led to the diagnosis of classic anti-LGI1 AE. No obvious abnormality was observed on brain computed tomography images. T2-weighted fluid-attenuated inversion recovery and T2-weighted scans of brain magnetic resonance imaging (MRI) showed slightly elevated signals within the left basal ganglia area. No tumor was detected within the brain of this patient using MRI. After hormone and antiepileptic drug treatment, the patient’s symptoms improved significantly.
CONCLUSION Anti-LGI1 antibody-associated encephalitis has characteristic clinical manifestations, such as cognitive impairment, psychiatric symptoms, seizures, sleep disorders, hyponatremia, and FBDSs. LGI1 antibodies are present in the serum and/or cerebrospinal fluid, but their production is sensitive to immunosuppressants, and this disease has a relatively good prognosis. In particular, we should be aware of the possibility of anti-LGI1 antibody-associated encephalitis in adolescents with sleep disorders to avoid missed diagnoses and misdiagnoses.
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Affiliation(s)
- De-Lian Kong
- Department of Neurology, The Affiliated Jiangning Hospital with Nanjing Medical University, Nanjing 211000, Jiangsu Province, China
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Liu X, Li G, Yu T, Lv R, Cui T, Hogan RE, Wang Q. Prognostic significance and extra-hypothalamus dysfunction of hyponatremia in anti-leucine-rich glioma-inactivated protein 1 encephalitis. J Neuroimmunol 2022; 373:578000. [PMID: 36410057 DOI: 10.1016/j.jneuroim.2022.578000] [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: 05/23/2022] [Revised: 10/21/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022]
Abstract
This study aimed to investigate prognostic significance and brain metabolic mechanism of hyponatremia in anti-leucine-rich glioma-inactivated protein 1 (LGI1) encephalitis. After adjusting for confounders, patients with moderate and severe hyponatremia had significantly increased risk of poor functional outcome and sequelae of seizures. In addition, serum sodium was negatively correlated with normalized ratio of the standardized uptake value of medial temporal lobe (MTL), basal ganglia (BG), and hypothalamus on positron emission tomography (PET) and which was further validated using voxel-wise analysis, suggesting an extra-hypothalamus (BG and MTL) localization for hyponatremia.
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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
| | - Gongfei Li
- 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
| | - Ruijuan Lv
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Tao Cui
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - R Edward Hogan
- Department of Neurology, Washington University School of Medicine in St Louis, MO, USA.
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China.
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Prasertpan T, Phuenpathom W, Bhidayasiri R, Sringean J. An Elderly Man With Chaotic Sleep Behaviors and Rapidly Progressive Ataxia. Mov Disord Clin Pract 2022; 9:S36-S40. [PMID: 36118510 PMCID: PMC9464990 DOI: 10.1002/mdc3.13537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 02/22/2022] [Accepted: 02/28/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Tittaya Prasertpan
- Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Faculty of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital. Thai Red Cross SocietyBangkokThailand
| | - Warongporn Phuenpathom
- Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Faculty of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital. Thai Red Cross SocietyBangkokThailand
| | - Roongroj Bhidayasiri
- Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Faculty of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital. Thai Red Cross SocietyBangkokThailand
- The Academy of ScienceThe Royal Society of ThailandBangkokThailand
| | - Jirada Sringean
- Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Faculty of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital. Thai Red Cross SocietyBangkokThailand
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Baumgartner T, Pitsch J, Olaciregui-Dague K, Hoppe C, Racz A, Rüber T, Becker A, von Wrede R, Surges R. Seizure underreporting in LGI1 and CASPR2 antibody encephalitis. Epilepsia 2022; 63:e100-e105. [PMID: 35735209 DOI: 10.1111/epi.17338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 11/28/2022]
Abstract
Patients with anti-leucine-rich glioma-inactivated 1 protein (LGI1) or anti-contactin-associated protein 2 (CASPR2) antibody encephalitis typically present with frequent epileptic seizures. The seizures generally respond well to immunosuppressive therapy and the long-term seizure outcome seems to be favorable. Consequentially, diagnosing acute symptomatic seizures secondary to autoimmune encephalitis instead of autoimmune epilepsy was proposed. However, published data on long-term seizure outcomes in CASPR2 and LGI1 antibody encephalitis are mostly based on patient reports and seizure underreporting is a recognized issue. Clinical records from our tertiary epilepsy center were screened retrospectively for patients with LGI1 and CASPR2 antibody encephalitis who reported seizure freedom for at least three months and received video-EEG for >24 hours at follow-up visits. Twenty (LGI1: n=15; CASPR2: n=5) out of thirty-two patients with LGI1 (n=24) and CASPR2 (n=8) antibody encephalitis fulfilled these criteria. We recorded focal aware and impaired awareness seizures in four of these patients (20%) with reported seizure-free intervals ranging from 3 to 27 months. Our results question the favorable seizure outcome in patients with CASPR2 and LGI1 antibody encephalitis and suggest that the proportion of patients who have persistent seizures may be greater. Our findings underline the importance of prolonged video-EEG telemetry in this population.
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Affiliation(s)
| | - Julika Pitsch
- Dept. of Epileptology, University Hospital Bonn, Germany
| | | | | | - Attila Racz
- Dept. of Epileptology, University Hospital Bonn, Germany
| | - Theodor Rüber
- Dept. of Epileptology, University Hospital Bonn, Germany
| | - Albert Becker
- Section for Translational Epilepsy Research, Dept. of Neuropathology, University Hospital Bonn, Germany
| | | | - Rainer Surges
- Dept. of Epileptology, University Hospital Bonn, Germany
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Pan J, Lv R, Zhou G, Si R, Wang Q, Zhao X, Liu J, Ai L. The Detection of Invisible Abnormal Metabolism in the FDG-PET Images of Patients With Anti-LGI1 Encephalitis by Machine Learning. Front Neurol 2022; 13:812439. [PMID: 35711267 PMCID: PMC9197115 DOI: 10.3389/fneur.2022.812439] [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: 11/10/2021] [Accepted: 04/27/2022] [Indexed: 12/12/2022] Open
Abstract
Objective This study aims to detect the invisible metabolic abnormality in PET images of patients with anti-leucine-rich glioma-inactivated 1 (LGI1) encephalitis using a multivariate cross-classification method. Methods Participants were divided into two groups, namely, the training cohort and the testing cohort. The training cohort included 17 healthy participants and 17 patients with anti-LGI1 encephalitis whose metabolic abnormality was able to be visibly detected in both the medial temporal lobe and the basal ganglia in their PET images [completely detectable (CD) patients]. The testing cohort included another 16 healthy participants and 16 patients with anti-LGI1 encephalitis whose metabolic abnormality was not able to be visibly detected in the medial temporal lobe and the basal ganglia in their PET images [non-completely detectable (non-CD) patients]. Independent component analysis (ICA) was used to extract features and reduce dimensions. A logistic regression model was constructed to identify the non-CD patients. Results For the testing cohort, the accuracy of classification was 90.63% with 13 out of 16 non-CD patients identified and all healthy participants distinguished from non-CD patients. The patterns of PET signal changes resulting from metabolic abnormalities related to anti-LGI1 encephalitis were similar for CD patients and non-CD patients. Conclusion This study demonstrated that multivariate cross-classification combined with ICA could improve, to some degree, the detection of invisible abnormal metabolism in the PET images of patients with anti-LGI1 encephalitis. More importantly, the invisible metabolic abnormality in the PET images of non-CD patients showed patterns that were similar to those seen in CD patients.
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Affiliation(s)
- Jian Pan
- School of Computer and Information Technology, Beijing Jiaotong University, Beijing, China
| | - Ruijuan Lv
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Guifei Zhou
- School of Computer and Information Technology, Beijing Jiaotong University, Beijing, China
| | - Run Si
- School of Computer and Information Technology, Beijing Jiaotong University, Beijing, China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaobin Zhao
- Department of Nuclear Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiangang Liu
- School of Computer and Information Technology, Beijing Jiaotong University, Beijing, China.,Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Engineering Medicine, Beihang University, Beijing, China.,Key Laboratory of Big Data-Based Precision Medicine (Beihang University), Ministry of Industry and Information Technology of the People's Republic of China, Beijing, China
| | - Lin Ai
- Department of Nuclear Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Dalakas MC. Autoimmune Neurological Disorders with IgG4 Antibodies: a Distinct Disease Spectrum with Unique IgG4 Functions Responding to Anti-B Cell Therapies. Neurotherapeutics 2022; 19:741-752. [PMID: 35290608 PMCID: PMC9294117 DOI: 10.1007/s13311-022-01210-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2022] [Indexed: 11/26/2022] Open
Abstract
The main IgG4 antibody-mediated neurological disorders (IgG4-ND) include MuSK myasthenia; CIDP with nodal/paranodal antibodies to Neurofascin-155, contactin-1/caspr-1, or pan-neurofascins; anti-LGI1 and CASPR2-associated limbic encephalitis, Morvan syndrome, or neuromyotonia; and several cases of the anti-IgLON5 and anti-DPPX-spectrum CNS diseases. The paper is centered on the clinical spectrum of IgG4-ND and their immunopathogenesis highlighting the unique functional effects of the IgG4 subclass compared to IgG1-3 antibody subclasses. The IgG4 antibodies exert pathogenic effects on their targeted antigens by blocking enzymatic activity or disrupting protein-protein interactions affecting signal transduction pathways, but not by activating complement, binding to inhibitory FcγRIIb receptor or engaging in cross-linking of the targeted antigen with immune complex formation as the IgG1-IgG3 antibody subclasses do. IgG4 can even inhibit the classical complement pathway by affecting the affinity of IgG1-2 subclasses to C1q binding. Because the IgG4 antibodies do not trigger inflammatory processes or complement-mediated immune responses, the conventional anti-inflammatory therapies, especially with IVIg, immunosuppressants, and plasmapheresis, are ineffective or not sufficiently effective in inducing long-term remissions. In contrast, aiming at the activated plasmablasts connected with IgG4 antibody production is a meaningful therapeutic target in IgG4-ND. Indeed, data from large series of patients with MuSK myasthenia, CIDP with nodal/paranodal antibodies, and anti-LGI1 and CASPR2-associated syndromes indicate that B cell depletion therapy with rituximab exerts long-lasting clinical remissions by targeting memory B cells and IgG4-producing CD20-positive short-lived plasma cells. Because IgG4 antibody titers seem reduced in remissions and increased in exacerbation, they may serve as potential biomarkers of treatment response supporting further the pathogenic role of self-reacting B cells. Controlled trials are needed in IgG4-ND not only with rituximab but also with the other anti-B cell agents that target CD19/20, especially those like obexelimab and obinutuzumab, that concurrently activate the inhibitory FcγRIIb receptors which have low binding affinity to IgG4, exerting a more prolonged anti-B cell action affecting also antigen presentation and cytotoxic T cells. Antibody therapies targeting FcRn, testing those anti-FcRn inhibitors that effectively catabolize the IgG4 antibody subclass, may be especially promising.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit National and Kapodistrian University of Athens Medical School, Athens, Greece.
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Guo K, Liu X, Lin J, Gong X, Li A, Liu Y, Zhou D, Hong Z. Clinical characteristics, long-term functional outcomes and relapse of anti-LGI1/Caspr2 encephalitis: a prospective cohort study in Western China. Ther Adv Neurol Disord 2022; 15:17562864211073203. [PMID: 35069805 PMCID: PMC8777345 DOI: 10.1177/17562864211073203] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/22/2021] [Indexed: 02/05/2023] Open
Abstract
Objective: To study the clinical characteristics of anti-leucine-rich glioma-inactivated 1 (LGI1) encephalitis and anti-contactin-associated protein-like 2 (Caspr2) encephalitis and to investigate factors associated with poor long-term neurological functional outcomes and relapse among patients in western China. Methods: In this single-center prospective cohort study, we consecutively enrolled patients with anti-LGI1 encephalitis and anti-Caspr2 encephalitis from April 2014 to February 2021. Patient outcomes were assessed using the modified Rankin scale. Predictors of long-term functional outcomes and relapse were analyzed. Results: Forty-four anti-LGI1 encephalitis patients [median age: 44 years, range: 18–82 years; females: 25 (56.8%)], 35 anti-Caspr2 encephalitis patients [median age: 43 years, range: 14–80 years; females: 19 (54.3%)], and 5 dual-positive patients [median age: 44 years, range: 36–58 years; females: 5 (100%)] were enrolled. Overall, 86.4% anti-LGI1 encephalitis patients and 80% anti-Caspr2 encephalitis had a favorable neurological functional outcome (mRS 0-2). Tumor occurrence and weight loss were associated with poor long-term functional outcomes in anti-LGI1 encephalitis, whereas in anti-Caspr2 encephalitis, predictors included behavioral disorder at acute phase, abnormalities in brain magnetic resonance imaging, higher modified Rankin scale scores at onset, poor response to the initial immunotherapy at 4 weeks, age at onset<30 years, and relapse ( p<0.05). Overall, 13.6% of anti-LGI1 encephalitis patients and 20% of anti-Caspr2 encephalitis patients had at least one relapse. Sleep disorder at the acute phase was the risk factor of relapse in anti-LGI1 encephalitis, while female, age at onset <30 years, and behavioral disorder at acute phase were the risk factors of relapse in anti-Caspr2 encephalitis (log rank p<0.05). Conclusion: The clinical characteristics such as age, gender, and tumor occurrence rates of anti-LGI1 encephalitis and anti-Caspr2 encephalitis in western China are different from those in the Western countries. Most patients in our study had favorable long-term functional outcomes. The relapse rates are still high in both types of encephalitis, which warrants caution.
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Affiliation(s)
- Kundian Guo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
- Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Xu Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
- Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Jingfang Lin
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
- Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Xue Gong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
- Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Aiqing Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
- Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Yue Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
- Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
- Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Zhen Hong
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu 610041, Sichuan, People’s Republic of China
- Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, People’s Republic of China
- Department of Neurology, Chengdu Shangjin Nanfu Hospital, Chengdu, People’s Republic of China
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12
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Garrido Sanabria ER, Zahid A, Britton J, Kraus GJ, López-Chiriboga AS, Zekeridou A, Flanagan EP, McKeon A, Mills JR, Pittock SJ, Dubey D. CASPR2-IgG-associated autoimmune seizures. Epilepsia 2022; 63:709-722. [PMID: 35032032 DOI: 10.1111/epi.17164] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 12/26/2021] [Accepted: 12/28/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE This study was undertaken to report clinical presentations and outcomes of CASPR2-IgG-associated seizures. METHODS Mayo Clinic Neuroimmunology database was queried to identify CASPR2-IgG-seropositive (CASPR2-IgG+) patients evaluated at our institution (2009-2019). RESULTS Of the 53 CASPR2-IgG+ patients (titer ≥ 1:10), 20 had seizures (38%). All seizure patients were male, with median onset age of 68 years. Eighteen (90%) had seizures at initial presentation. One patient was found to have malignancy (colon adenocarcinoma). Two patients had coexisting LGI1-IgG. Twelve patients had archived sera, which on titration had CASPR2-IgG titers ≥ 1:100. Fifteen patients (75%) met criteria for autoimmune encephalitis. Patients most commonly presented with focal onset, nonmotor seizures with impaired awareness (n = 14, 70%). Eleven patients also had focal motor and/or sensory seizures as one of the seizure semiologies. The majority of patients (n = 11, 55%) developed generalized tonic-clonic seizures during their disease course. Seizure clusters occurred in 12 patients. In addition to seizures, patients developed cognitive disturbance (n = 16, 80%), episodic emotional lability (n = 13, 65%), paroxysmal dizziness (n = 9, 45%), episodic ataxia (n = 6, 30%), and chronic ataxia (n = 9, 45%). Only three patients (15%) had coexisting peripheral nervous system involvement. Frontotemporal or temporal ictal and/or interictal electroencephalographic abnormalities were present among nine patients, and three had multifocal epileptiform abnormalities. Eight patients (40%) had medial temporal T2/fluid-attenuated inversion recovery hyperintensity on brain magnetic resonance imaging. Elevated cerebrospinal fluid protein and/or lymphocytic pleocytosis was present in most cases (13/14, 93%). Thirteen patients reached seizure freedom following initiation of antiseizure medication (ASM; n = 4) or a combination of immunotherapy and ASM (n = 9). Median duration of follow-up was 25 months (range = 2-136 months). SIGNIFICANCE CASPR2-IgG evaluation should be considered among older male patients with new onset focal seizures and impaired awareness often occurring in clusters with/without features of encephalitis. Coexisting neurological manifestations, including episodic emotional lability, ataxia, and paroxysmal dizziness, also aid in the diagnosis.
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Affiliation(s)
| | - Anza Zahid
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey Britton
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gregory J Kraus
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - John R Mills
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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13
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Endmayr V, Tunc C, Ergin L, De Rosa A, Weng R, Wagner L, Yu TY, Fichtenbaum A, Perkmann T, Haslacher H, Kozakowski N, Schwaiger C, Ricken G, Hametner S, Klotz S, Dutra LA, Lechner C, de Simoni D, Poppert KN, Müller GJ, Pirker S, Pirker W, Angelovski A, Valach M, Maestri M, Guida M, Ricciardi R, Frommlet F, Sieghart D, Pinter M, Kircher K, Artacker G, Höftberger R, Koneczny I. Anti-Neuronal IgG4 Autoimmune Diseases and IgG4-Related Diseases May Not Be Part of the Same Spectrum: A Comparative Study. Front Immunol 2022; 12:785247. [PMID: 35095860 PMCID: PMC8795769 DOI: 10.3389/fimmu.2021.785247] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/15/2021] [Indexed: 12/18/2022] Open
Abstract
Background IgG4 is associated with two emerging groups of rare diseases: 1) IgG4 autoimmune diseases (IgG4-AID) and 2) IgG4-related diseases (IgG4-RLD). Anti-neuronal IgG4-AID include MuSK myasthenia gravis, LGI1- and Caspr2-encephalitis and autoimmune nodo-/paranodopathies (CNTN1/Caspr1 or NF155 antibodies). IgG4-RLD is a multiorgan disease hallmarked by tissue-destructive fibrotic lesions with lymphocyte and IgG4 plasma cell infiltrates and increased serum IgG4 concentrations. It is unclear whether IgG4-AID and IgG4-RLD share relevant clinical and immunopathological features. Methods We collected and analyzed clinical, serological, and histopathological data in 50 patients with anti-neuronal IgG4-AID and 19 patients with IgG4-RLD. Results A significantly higher proportion of IgG4-RLD patients had serum IgG4 elevation when compared to IgG4-AID patients (52.63% vs. 16%, p = .004). Moreover, those IgG4-AID patients with elevated IgG4 did not meet the diagnostic criteria of IgG4-RLD, and their autoantibody titers did not correlate with their serum IgG4 concentrations. In addition, patients with IgG4-RLD were negative for anti-neuronal/neuromuscular autoantibodies and among these patients, men showed a significantly higher propensity for IgG4 elevation, when compared to women (p = .005). Last, a kidney biopsy from a patient with autoimmune paranodopathy due to CNTN1/Caspr1-complex IgG4 autoantibodies and concomitant nephrotic syndrome did not show fibrosis or IgG4+ plasma cells, which are diagnostic hallmarks of IgG4-RLD. Conclusion Our observations suggest that anti-neuronal IgG4-AID and IgG4-RLD are most likely distinct disease entities.
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Affiliation(s)
- Verena Endmayr
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Cansu Tunc
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Lara Ergin
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Anna De Rosa
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Pisa, Italy
| | - Rosa Weng
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Lukas Wagner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thin-Yau Yu
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Andreas Fichtenbaum
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Perkmann
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Helmuth Haslacher
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Carmen Schwaiger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gerda Ricken
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Simon Hametner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Sigrid Klotz
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Lívia Almeida Dutra
- Department of Neurology and Neurosurgery, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Christian Lechner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Pediatric Neurology, Department of Pediatric and Adolescent Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Désirée de Simoni
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Department of Neurology, University Hospital St. Poelten, St. Poelten, Austria
| | - Kai-Nicolas Poppert
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Georg Johannes Müller
- Department of Neurology and Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Disorders, Klinik Donaustadt, Vienna, Austria
| | - Susanne Pirker
- Department of Neurology, Klinik Hietzing, Vienna, Austria
| | - Walter Pirker
- Department of Neurology, Klinik Ottakring, Vienna, Austria
| | | | - Matus Valach
- Department of Pathology, Klinik Landstrasse, Vienna, Austria
| | - Michelangelo Maestri
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Pisa, Italy
| | - Melania Guida
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Pisa, Italy
| | - Roberta Ricciardi
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Pisa, Italy
| | - Florian Frommlet
- Center for Medical Statistics, Informatics and Intelligent Systems, Section for Medical Statistics, Medical University of Vienna, Vienna, Austria
| | - Daniela Sieghart
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Miklos Pinter
- Wiener Privatklinik – Health Center, Vienna, Austria
| | - Karl Kircher
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - Gottfried Artacker
- Department of Pediatrics and Adolescent Medicine, Klinik Donaustadt, Vienna, Austria
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Inga Koneczny
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
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14
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Jiang Y, Tan C, Li T, Song X, Ma J, Yao Z, Hong S, Li X, Jiang L, Luo Y. Phenotypic Spectrum of CASPR2 and LGI1 Antibodies Associated Neurological Disorders in Children. Front Pediatr 2022; 10:815976. [PMID: 35463890 PMCID: PMC9021408 DOI: 10.3389/fped.2022.815976] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/11/2022] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The clinical data of patients with double-positive for leucine-rich glioma-inactivated protein 1 (LGI1) and contactin-associated protein-like 2 (CASPR2) antibodies is limited, particularly for children. This study aimed to investigate and summarize the clinical features and long-term prognosis of children's LGI1 and CASPR2 antibodies related to neurological disorders. METHODS We collected the clinical data and prognosis of patients with dual positive antibodies of CASPR2 and LGI1, hospitalized in the Department of Neurology, Children's Hospital of Chongqing Medical University. Furthermore, we summarized the clinical phenotypes of this disorder in children by reviewing the published literature. RESULTS Two patients presenting with variable neurological symptoms including pain, hypertension, profuse sweating, irritability, and dyssomnia from Children's Hospital of Chongqing Medical University were enrolled in this study. Together with the two patients, we identified 17 children with dual CASPR2 and LGI1 antibodies, including 12 males and 5 females. At the onset, the median age was 4.1 years (range 1-16, interquartile range 2.5-13.5), with 9 children younger than 5 years and 6 adolescents. Of the 17 patients, 11 were diagnosed with Morvan syndrome, 4 with acquired neuromyotonia, 1 with Guillain-Barré syndrome, and 1 with Guillain-Barré syndrome combined with Morvan syndrome. Dysautonomia (14/17, 82.3%), pain (13/17, 76.4%), sleep disorders (13/17, 76.4%), encephalopathy (12/17, 70.5%), and weight loss (10/17, 58.8%) were the most frequently described symptoms overall. No tumors were identified. Of the 17 patients, 13 received immunotherapy comprising IVIG combination of IVMP during the acute symptomatic phase followed by oral prednisolone to maintain remission (n = 7), the combination of IVIG, IVMP, oral prednisolone and methotrexate (n = 1), the combination of IVIG, IVMP, and mycophenolate mofetil (n = 1), the combination of IVIG, IVMP, oral prednisolone, and rituximab (n = 1), IVIG only (n = 2), IVMP only (n = 1). Median modified Rankin Scale (mRS) scores in the acute phase were 3 (range 1-4) and improved gradually. Over the follow-up (median 8.6 months, range 1-36 months), 52.9% (9/17) of the patients recovered completely; one patient relapsed and showed immunotherapy-dependent. CONCLUSION LGI1 and CASPR2 double-positive antibodies associated with the neurological diseases can occur in children of all ages and involve multiple nervous systems. Morvan syndrome is the most common phenotype of this disorder. The long-term outcomes are mostly favorable upon immunotherapy.
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Affiliation(s)
- Yan Jiang
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing, China
| | - Chengbing Tan
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing, China
| | - Tingsong Li
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing, China
| | - Xiaojie Song
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing, China
| | - Jiannan Ma
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing, China
| | - Zhengxiong Yao
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing, China
| | - Siqi Hong
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing, China
| | - Xiujuan Li
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing, China
| | - Li Jiang
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing, China
| | - Yuanyuan Luo
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing, China
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15
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Dalakas MC. IgG4-Mediated Neurologic Autoimmunities: Understanding the Pathogenicity of IgG4, Ineffectiveness of IVIg, and Long-Lasting Benefits of Anti-B Cell Therapies. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2022; 9:9/1/e1116. [PMID: 34845096 PMCID: PMC8630661 DOI: 10.1212/nxi.0000000000001116] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/08/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Describe the unique functions of immunoglobulin G4 (IgG4) in IgG4-neurologic disorders (IgG4-ND) and explain why, in contrast to their IgG1-counterparts, they respond poorly to intravenous immune globulin (IVIg) but effectively to anti-B cell therapies. METHODS The IgG4 structure and isotype switch, B cells and plasmablasts relevant to IgG4 production, and IgG4-induced disruption of the targeted antigens are reviewed and compared with IgG1-mediated autoimmune ND, where IVIg inhibits IgG1-triggered inflammatory effects. RESULTS The main IgG4-ND include muscle-specific kinase myasthenia; nodal/paranodal chronic inflammatory demyelinating polyradiculoneuropathy with antibodies to neurofascin-155, contactin-1/caspr-1, or pan-neurofascins; antileucine-rich, glioma-inactivated-1 and contactin-associated protein-like 2 associated-limbic encephalitis, Morvan syndrome, or neuromyotonia; and anti-IgLON5 disorder. The IgG4, because of its unique structural features in the hinge region, has noninflammatory properties being functionally monovalent and bispecific, unable to engage in cross-linking and internalization of the targeted antigen. In contrast to IgG1 subclass which is bivalent and monospecific, IgG4 does not activate complement and cannot bind to inhibitory Fcγ receptor (FcγRIIb) to activate cellular and complement-mediated immune responses, the key functions inhibited by IVIg. Because IVIg contains only 0.7%-2.6% IgG4, its idiotypes are of IgG1 subclass and cannot effectively neutralize IgG4 or sufficiently enhance IgG4 catabolism by saturating FcRn. In contrast, rituximab, by targeting memory B cells and IgG4-producing CD20-positive short-lived plasma cells, induces long-lasting clinical benefits. DISCUSSION Rituximab is the preferred treatment in IgG4-ND patients with severe disease by effectively targeting the production of pathogenic IgG-4 antibodies. In contrast, IVIG is ineffective because it inhibits immunoinflammatory functions irrelevant to the mechanistic effects of IgG4 and contains IgG-1 idiotypes that cannot sufficiently neutralize or possibly catabolize IgG4. Controlled studies with anti-CD19/20 monoclonals that also activate FcγRIIb may be more promising in treating IgG4-ND.
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Affiliation(s)
- Marinos C Dalakas
- From Thomas Jefferson University, Philadelphia, PA; and the University of Athens Medical School, Greece.
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16
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Piffer S, Cantalupo G, Filipponi S, Poretto V, Pellegrini M, Tanel R, Buganza M, Giometto B. Agrypnia excitata as the main feature in anti-leucine-rich glioma-inactivated 1 encephalitis: a detailed clinical and polysomnographic semiological analysis. Eur J Neurol 2021; 29:890-894. [PMID: 34679240 DOI: 10.1111/ene.15152] [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: 05/16/2021] [Revised: 08/09/2021] [Accepted: 10/14/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE The core manifestations of leucine-rich glioma-inactivated 1 (LGI1) autoantibody-mediated encephalitis are limbic encephalitis and faciobrachial dystonic seizures. Agrypnia excitata (AE) is a rare syndrome characterized by sleep-wake cycle disruption, autonomic hyperactivation and episodes of oneiric stupor. Only a few diseases are known to present with AE. An autoimmune etiology must be considered when accompanied by neuromyotonia. A case of anti-LGI1 encephalitis presenting with AE is reported. METHODS Detailed clinical, video-polysomnographic, laboratory, radiological and long-term follow-up assessments were performed. RESULTS A previously healthy 58-year-old man was referred for a rapidly progressive change in mental status, characterized by persistent drowsiness and confusion, accompanied by frequent episodes of unconscious gestures ranging from simple stereotyped movements to more complex actions mimicking various daily activities. Other symptoms included tachycardia, hyperhidrosis, mild hyponatremia, rare faciobrachial dystonic seizures, and a single generalized tonic-clonic seizure, but no neuromyotonia. Prolonged video-polysomnography excluded epileptic activity and showed continuous monomorphic slowing of background activity not consistent with a regular wakefulness or sleep state. A brain magnetic resonance imaging scan was unremarkable. Brain fluorodeoxyglucose positron emission tomography revealed hypermetabolism of the hippocampi, amygdala and basal ganglia. Anti-LGI1 antibodies were detected in the cerebrospinal fluid. The sleep disorder resolved progressively after starting immunotherapy. CONCLUSIONS Agrypnia excitata can be a dominant, treatable manifestation of anti-LGI1 encephalitis. Oneiric stupor episodes are a useful clinical feature for establishing diagnostic suspicion and could provide a window to understanding the mechanisms behind some movement disorders in autoimmune encephalitis.
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Affiliation(s)
- Silvio Piffer
- Department of Emergency, Neurology Unit, Santa Chiara Hospital, Trento, Italy
| | | | - Stefania Filipponi
- Department of Emergency, Neurology Unit, Santa Chiara Hospital, Trento, Italy
| | - Valentina Poretto
- Department of Emergency, Neurology Unit, Santa Chiara Hospital, Trento, Italy
| | - Maria Pellegrini
- Department of Emergency, Neurology Unit, Santa Chiara Hospital, Trento, Italy
| | - Raffaella Tanel
- Department of Emergency, Neurology Unit, Santa Chiara Hospital, Trento, Italy
| | - Manuela Buganza
- Department of Emergency, Neurology Unit, Santa Chiara Hospital, Trento, Italy
| | - Bruno Giometto
- Department of Emergency, Neurology Unit, Santa Chiara Hospital, Trento, Italy
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17
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Swayang PS, Nalini A, Preethish-Kumar V, Udupa K, Yadav R, Vengalil S, Reshma SS, Polavarapu K, Nashi S, Sathyaprabha TN, Treesa Thomas P, Maya B, Jamuna R, Mahadevan A, Netravathi M. CASPR2-Related Morvan Syndrome: Autonomic, Polysomnographic, and Neuropsychological Observations. Neurol Clin Pract 2021; 11:e267-e276. [PMID: 34484901 DOI: 10.1212/cpj.0000000000000978] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 08/07/2020] [Indexed: 12/16/2022]
Abstract
Objective Morvan syndrome is characterized by central, autonomic, and peripheral hyperexcitability due to contactin-associated protein 2 (CASPR2) antibody. Our objective was to study the clinical spectrum, electrophysiologic, autonomic, polysomnographic, and neuropsychological profile in patients with CASPR2-related Morvan syndrome. Methods Serum and CSF samples that were CASPR2 antibody positive from 2016 to 2019 were assessed. Among them, patients with Morvan syndrome diagnosed based on clinical and electrophysiologic basis were included. Results Fourteen (M:F = 10:4) patients with Morvan syndrome were included with age at onset of 37.1 ± 17.5 years. The clinical features were muscle twitching (12), insomnia (12), pain (11), paresthesias (9), hyperhidrosis (7), hypersalivation (6), double incontinence (3), spastic speech (2), dysphagia (2), behavioral disturbances (2), seizures (1), and cold intolerance (1). Neurologic examination revealed myokymia (12), hyperactive tendon reflexes (10), and tremor (6). EMG revealed neuromyotonia (12) and increased spontaneous activity (7). Autonomic function tests conducted in 8 patients revealed definite autonomic dysfunction (4), orthostatic hypotension (2), early dysfunction (1), and postural orthostatic tachycardia syndrome (1). Polysomnography findings in 6 patients revealed insomnia (3), absence of deep sleep (1), high-frequency beta activity (1), REM behavior disorder (1), and periodic leg movements (1). Neuropsychological evaluation showed subtle involvement of the left frontal and temporal lobe. Malignancy workup was negative. All patients were treated with steroids. There was complete neurologic resolution in follow-up with persistent neuropathic pain in 5 patients. Conclusions This study has contributed to the growing knowledge on CASPR2-related Morvan syndrome. It is important for an increased awareness and early recognition as it is potentially treatable by immunotherapy.
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Affiliation(s)
- Panda Sudha Swayang
- Departments of Neurology (PSS, AN, VP-K, KU, RY, SV, SSR, KP, SN, MN), Neurophysiology (TNS), Psychiatric Social Work (PTT), Neuroimaging & Interventional Neuroradiology (NIIR) (BM), Neuropsychology (RJ), and Neuropathology (AM), National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India
| | - Atchayaram Nalini
- Departments of Neurology (PSS, AN, VP-K, KU, RY, SV, SSR, KP, SN, MN), Neurophysiology (TNS), Psychiatric Social Work (PTT), Neuroimaging & Interventional Neuroradiology (NIIR) (BM), Neuropsychology (RJ), and Neuropathology (AM), National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India
| | - Veeramani Preethish-Kumar
- Departments of Neurology (PSS, AN, VP-K, KU, RY, SV, SSR, KP, SN, MN), Neurophysiology (TNS), Psychiatric Social Work (PTT), Neuroimaging & Interventional Neuroradiology (NIIR) (BM), Neuropsychology (RJ), and Neuropathology (AM), National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India
| | - Kaviraja Udupa
- Departments of Neurology (PSS, AN, VP-K, KU, RY, SV, SSR, KP, SN, MN), Neurophysiology (TNS), Psychiatric Social Work (PTT), Neuroimaging & Interventional Neuroradiology (NIIR) (BM), Neuropsychology (RJ), and Neuropathology (AM), National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India
| | - Ravi Yadav
- Departments of Neurology (PSS, AN, VP-K, KU, RY, SV, SSR, KP, SN, MN), Neurophysiology (TNS), Psychiatric Social Work (PTT), Neuroimaging & Interventional Neuroradiology (NIIR) (BM), Neuropsychology (RJ), and Neuropathology (AM), National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India
| | - Seena Vengalil
- Departments of Neurology (PSS, AN, VP-K, KU, RY, SV, SSR, KP, SN, MN), Neurophysiology (TNS), Psychiatric Social Work (PTT), Neuroimaging & Interventional Neuroradiology (NIIR) (BM), Neuropsychology (RJ), and Neuropathology (AM), National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India
| | - Sheikh Sultana Reshma
- Departments of Neurology (PSS, AN, VP-K, KU, RY, SV, SSR, KP, SN, MN), Neurophysiology (TNS), Psychiatric Social Work (PTT), Neuroimaging & Interventional Neuroradiology (NIIR) (BM), Neuropsychology (RJ), and Neuropathology (AM), National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India
| | - Kiran Polavarapu
- Departments of Neurology (PSS, AN, VP-K, KU, RY, SV, SSR, KP, SN, MN), Neurophysiology (TNS), Psychiatric Social Work (PTT), Neuroimaging & Interventional Neuroradiology (NIIR) (BM), Neuropsychology (RJ), and Neuropathology (AM), National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India
| | - Saraswati Nashi
- Departments of Neurology (PSS, AN, VP-K, KU, RY, SV, SSR, KP, SN, MN), Neurophysiology (TNS), Psychiatric Social Work (PTT), Neuroimaging & Interventional Neuroradiology (NIIR) (BM), Neuropsychology (RJ), and Neuropathology (AM), National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India
| | - T N Sathyaprabha
- Departments of Neurology (PSS, AN, VP-K, KU, RY, SV, SSR, KP, SN, MN), Neurophysiology (TNS), Psychiatric Social Work (PTT), Neuroimaging & Interventional Neuroradiology (NIIR) (BM), Neuropsychology (RJ), and Neuropathology (AM), National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India
| | - Priya Treesa Thomas
- Departments of Neurology (PSS, AN, VP-K, KU, RY, SV, SSR, KP, SN, MN), Neurophysiology (TNS), Psychiatric Social Work (PTT), Neuroimaging & Interventional Neuroradiology (NIIR) (BM), Neuropsychology (RJ), and Neuropathology (AM), National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India
| | - Bhat Maya
- Departments of Neurology (PSS, AN, VP-K, KU, RY, SV, SSR, KP, SN, MN), Neurophysiology (TNS), Psychiatric Social Work (PTT), Neuroimaging & Interventional Neuroradiology (NIIR) (BM), Neuropsychology (RJ), and Neuropathology (AM), National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India
| | - Rajeshwaran Jamuna
- Departments of Neurology (PSS, AN, VP-K, KU, RY, SV, SSR, KP, SN, MN), Neurophysiology (TNS), Psychiatric Social Work (PTT), Neuroimaging & Interventional Neuroradiology (NIIR) (BM), Neuropsychology (RJ), and Neuropathology (AM), National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India
| | - Anita Mahadevan
- Departments of Neurology (PSS, AN, VP-K, KU, RY, SV, SSR, KP, SN, MN), Neurophysiology (TNS), Psychiatric Social Work (PTT), Neuroimaging & Interventional Neuroradiology (NIIR) (BM), Neuropsychology (RJ), and Neuropathology (AM), National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India
| | - M Netravathi
- Departments of Neurology (PSS, AN, VP-K, KU, RY, SV, SSR, KP, SN, MN), Neurophysiology (TNS), Psychiatric Social Work (PTT), Neuroimaging & Interventional Neuroradiology (NIIR) (BM), Neuropsychology (RJ), and Neuropathology (AM), National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India
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18
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Li Y, Song F, Liu W, Wang Y. Clinical features of nine cases of leucine-rich glioma inactivated 1 protein antibody-associated encephalitis. Acta Neurol Belg 2021; 121:889-897. [PMID: 32232701 DOI: 10.1007/s13760-020-01336-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 03/18/2020] [Indexed: 01/11/2023]
Abstract
To investigate clinical features of leucine-rich glioma inactivated 1 protein (LGI1) antibody-associated autoimmune encephalitis (AE). The clinical data were collected and analyzed in nine patients with LGI1 AE. All nine patients (100%) presented acute/subacute onset, had seizures, cognitive impairment, mental/behavioral abnormalities, six had sleep disorders and seven showed hyponatremia. Seizures manifested in three types: faciobranchial dystonia seizure (FBDS) (44%), mesial temporal lobe epilepsy (MTLE)-like seizure (66%), and focal to bilateral tonic-clonic seizure (FBTCS) (77%). Six of nine cases (66%) showed abnormalities in brain MRI, among them four showed high T2/flair signal on unilateral/bilateral hippocampus, two showed high T1/T2 signal on unilateral basal ganglia. All nine patients (100%) showed abnormalities in EEG, among them 1 (11%) showed diffuse slow waves, 8 (88%) showed focal slow waves; 6 (66%) revealed interictal epileptic discharges; ictal EEG was recorded in five patients, two were FBDS, three were MTLE-like seizure.LGI1 antibodies in serum and cerebrospinal fluid were both positive. No signs of tumor were found in all patients. Eight of nine patients received immunotherapy and antiepileptic drug (AED) treatment, one only treated with AED without immunotherapy. Eight patients improved significantly with seizure-free after immunotherapy, only one still had FBDS after immunotherapy and AED treatment. In LGI1 AE hippocampus and basal ganglia were two main targets, the corresponding seizure type was MTLE-like seizure and FBDS respectively. Diagnosis depended on detection of LGI1 antibodies in CSF. The incidence of tumor was low. The effect of immunotherapy was good and AEDs should be considered as add-on symptomatic treatment.
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Affiliation(s)
- Ying Li
- Department of Neurology, The First Affiliated Hospital of DaLian Medical University, DaLian, China
| | - Fan Song
- Department of Neurology, The First Affiliated Hospital of DaLian Medical University, DaLian, China
| | - Wei Liu
- Department of Neurology, The First Affiliated Hospital of DaLian Medical University, DaLian, China
| | - Ying Wang
- Department of Neurology, The First Affiliated Hospital of DaLian Medical University, DaLian, China.
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19
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Li TR, Zhang YD, Wang Q, Shao XQ, Lv RJ. Recognition of seizure semiology and semiquantitative FDG-PET analysis of anti-LGI1 encephalitis. CNS Neurosci Ther 2021; 27:1173-1181. [PMID: 34291554 PMCID: PMC8446218 DOI: 10.1111/cns.13707] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 05/31/2021] [Accepted: 07/06/2021] [Indexed: 12/11/2022] Open
Abstract
Aims Anti‐leucine‐rich glioma‐inactivated 1 (LGI1) autoimmune encephalitis (AE) is characterized by complex manifestations of seizures. Here, we report a new seizure semiology, attempt to classify the disease by semiology type, and explore the metabolic pattern of each group. Methods Anti‐LGI1 AE patients were retrospectively screened between May 2014 and September 2019 in our tertiary epilepsy center. All enrolled patients had seizures during long‐range video electroencephalogram (EEG) recordings, and all patients (except one) underwent [18F] fluoro‐2‐deoxyglucose (FDG) positron emission tomography (PET) scans. Voxel‐based metabolic analysis and z‐distribution analysis were carried out to determine the metabolic pattern. Results Thirty‐three patients were enrolled. According to the patients’ seizure semiology, we divided the patients into four groups: focal impaired awareness seizures (FIAS, n = 17), faciobrachial dystonic seizures (FBDS)‐only (n = 6), FBDS‐plus (n = 8), and focal aware motor seizures (FAMS) (n = 2). No significant differences were found in the clinical manifestations or accessory tests except for the onset age (FIAS < FBDS‐plus) and seizure semiology. This was the first study to extensively describe the clinical manifestations and EEG of FAMS in anti‐LGI1 AE patients. In addition, we found that the patients with different semiologies all showed a wide range of abnormal metabolism, which is not limited to the temporal regions and basal ganglia, and extends far beyond our previous interpretation of FDG‐PET data. Conclusion Our results showed that FAMS can serve as a rare indicative seizure semiology of anti‐LGI1 AE and that individuals with this disease exhibited widespread functional network alterations.
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Affiliation(s)
- Tao-Ran Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, China.,Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Yu-Di Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, China.,Department of Neurology, the Second Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiao-Qiu Shao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Rui-Juan Lv
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, China
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20
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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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21
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Lu XJ, Li R, Chen YX, Xu XK, Shi BL. Meningioma preceding CASPR2 antibody limbic encephalitis with a stroke mimic: A case report. Medicine (Baltimore) 2021; 100:e26241. [PMID: 34115012 PMCID: PMC8202617 DOI: 10.1097/md.0000000000026241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/19/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Todd paralysis (a stroke-like presentation in some patients with epilepsy) caused by limbic encephalitis (LE) is not easily distinguished from acute ischemic stroke by clinicians in the emergency room. PATIENT CONCERNS We report a contactin-associated protein-like 2-antibody (CASPR2-Ab)-positive patient who presented with atypical LE. DIAGNOSES CASPR2-Ab-positive LE was the presumed diagnosis. Re-evaluation of cerebrospinal fluid (CSF) samples revealed autoantibodies targeting CASPR2 at an immunoglobulin G titer of 1:1. The clinical presentation of subacute onset seizures, abnormal electroencephalography, hypermetabolism on positron emission tomography, good immunotherapy response, and the presence of specific antibodies in serum supports a diagnosis of autoimmune LE. INTERVENTION The patient received glucocorticoids (1 g for 3 days and 500 mg for 3 days), immunoglobulin (25 g for 3 days), sodium valproate (1 g for 3 days), and clonazepam (1 mg for 3 days). OUTCOMES Remission of temporal lobe epilepsy symptoms and cognitive dysfunction was observed. Follow-up analysis of CSF and serological examination were not approved by the patient. His Mini-Mental State Examination score improved to 21/30. Stable remission of symptoms was achieved throughout the follow-up period of 50 days. LESSONS Autoimmune encephalitis (AE) should be considered in cases of late-onset epilepsy following meningioma peritumoral brain edema and resection. A diagnosis of AE should be considered in patients presenting with stroke-like symptoms if the magnetic resonance imaging abnormality does not match a known vascular territory. Early and correct diagnosis is crucial because immunotherapy is usually effective for this disease.
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Affiliation(s)
- Xiao-Jin Lu
- Department of Neurology, School of Clinical, Weifang Medical University
| | - Ran Li
- Department of Neurology, Affiliated Traditional Chinese Medicine Hospital of Weifang Medical University
| | - Yong-Xing Chen
- Department of Neurology, Weifang People's Hospital (The First Affiliated Hospital of Weifang Medical University), Weifang, Shandong, China
| | - Xian-Kai Xu
- Department of Neurology, School of Clinical, Weifang Medical University
| | - Bao-Lin Shi
- Department of Neurology, Weifang People's Hospital (The First Affiliated Hospital of Weifang Medical University), Weifang, Shandong, China
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22
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Koneczny I, Yilmaz V, Lazaridis K, Tzartos J, Lenz TL, Tzartos S, Tüzün E, Leypoldt F. Common Denominators in the Immunobiology of IgG4 Autoimmune Diseases: What Do Glomerulonephritis, Pemphigus Vulgaris, Myasthenia Gravis, Thrombotic Thrombocytopenic Purpura and Autoimmune Encephalitis Have in Common? Front Immunol 2021; 11:605214. [PMID: 33584677 PMCID: PMC7878376 DOI: 10.3389/fimmu.2020.605214] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/08/2020] [Indexed: 12/20/2022] Open
Abstract
IgG4 autoimmune diseases (IgG4-AID) are an emerging group of autoimmune diseases that are caused by pathogenic autoantibodies of the IgG4 subclass. It has only recently been appreciated, that members of this group share relevant immunobiological and therapeutic aspects even though different antigens, tissues and organs are affected: glomerulonephritis (kidney), pemphigus vulgaris (skin), thrombotic thrombocytopenic purpura (hematologic system) muscle-specific kinase (MuSK) in myasthenia gravis (peripheral nervous system) and autoimmune encephalitis (central nervous system) to give some examples. In all these diseases, patients’ IgG4 subclass autoantibodies block protein-protein interactions instead of causing complement mediated tissue injury, patients respond favorably to rituximab and share a genetic predisposition: at least five HLA class II genes have been reported in individual studies to be associated with several different IgG4-AID. This suggests a role for the HLA class II region and specifically the DRβ1 chain for aberrant priming of autoreactive T-cells toward a chronic immune response skewed toward the production of IgG4 subclass autoantibodies. The aim of this review is to provide an update on findings arguing for a common pathogenic mechanism in IgG4-AID in general and to provide hypotheses about the role of distinct HLA haplotypes, T-cells and cytokines in IgG4-AID.
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Affiliation(s)
- Inga Koneczny
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Vuslat Yilmaz
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Konstantinos Lazaridis
- Department of Immunology, Laboratory of Immunology, Hellenic Pasteur Institute, Athens, Greece
| | - John Tzartos
- Tzartos NeuroDiagnostics, Athens, Greece.,1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Tobias L Lenz
- Research Group for Evolutionary Immunogenomics, Max Planck Institute for Evolutionary Biology, Plön, Germany
| | - Socrates Tzartos
- Tzartos NeuroDiagnostics, Athens, Greece.,Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece
| | - Erdem Tüzün
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Frank Leypoldt
- Neuroimmunology, Institute of Clinical Chemistry and Department of Neurology, Medical Faculty, Christian-Albrechts-University Kiel, Kiel, Germany
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23
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Wu Y, Shi J, Gao J, Hu Y, Ren H, Guan H, Li J, Huang Y, Cui L, Guan Y. Peripheral nerve hyperexcitability syndrome: A clinical, electrophysiological, and immunological study. Muscle Nerve 2021; 63:697-702. [PMID: 33501683 DOI: 10.1002/mus.27188] [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: 03/10/2020] [Revised: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Peripheral nerve hyperexcitability syndrome (PNHS) is characterized by muscle fasciculations and spasms. Nerve hyperexcitability and after-discharges can be observed in electrophysiological studies. Autoimmune mechanisms play a major role in the pathophysiology of primary PNHS. METHODS We retrospectively conducted a case-control study recruiting patients with clinical and electrophysiological features of PNHS. Control patients were diagnosed with other neuronal or muscular diseases. Contactin-associated protein2 (CASPR2) and leucine-rich glioma-inactivated1 (LGI1) antibodies were examined. RESULTS A total of 19 primary PNHS patients and 39 control patients were analyzed. The most common symptoms for the case group were fasciculations (11/19) and muscle spasms (13/19). Case group patients were likely to demonstrate electrodiagnostic findings of nerve hyperexcitability (17/19) and after-discharges in the tibial nerve (19/19). We found high prevalence of CASPR2 (9/19) and LGI1 (6/19) antibodies in the case group. DISCUSSION Primary PNHS patients were likely to show after-discharges in the tibial nerve. The pathogenesis of PNHS is autoimmune CASPR2 and LGI1 antibodies are possible pathogenic antibodies for primary PNHS.
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Affiliation(s)
- Yimin Wu
- Neurology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiayu Shi
- Neurology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Juhua Gao
- Neurology Department, People's Hospital of Hunan Province, Changsha, China
| | - Youfang Hu
- Neurology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Haitao Ren
- Neurology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hongzhi Guan
- Neurology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jing Li
- Neurology Department, The First Hospital of Tsinghua University, Beijing, China
| | - Yangyu Huang
- Neurology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Liying Cui
- Neurology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuzhou Guan
- Neurology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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24
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Vasconcelos GDA, Barreira RM, Antoniollo KENT, Pinheiro AMN, Maia CFR, Alves DMBS, Nóbrega PR, Braga-Neto P. Autoimmune Encephalitis in Latin America: A Critical Review. Front Neurol 2021; 11:606350. [PMID: 33551968 PMCID: PMC7859257 DOI: 10.3389/fneur.2020.606350] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/10/2020] [Indexed: 11/18/2022] Open
Abstract
Autoimmune encephalitis is an increasingly recognized cause of encephalitis. The majority of case series report patients residing in developed countries in the northern hemisphere. The epidemiologic features of autoimmune encephalitis in Latin America are still unclear. The aim of the study was to perform a review of the clinical presentation of autoimmune encephalitis in Latin America and compare to world literature. References were identified by an in-depth literature search and selected on the basis of relevance to the topic and authors' judgment. We selected clinical studies and case reports published from 2007 to July, 2020 including patients from Latin American countries. Of the 379 patients included, the majority were cases of anti-NMDA receptor encephalitis (93.14%), followed by anti-VGKC-complex encephalitis (N = 17; 4.48%), anti-GAD encephalitis (N = 9; 2.37%), anti-AMPA receptor encephalitis (N = 1; 0.26%), anti-GABA receptor encephalitis (N = 1; 0. 26%), anti-mGluR5 encephalitis (N = 1; 0. 26%), and anti-mGluR1 encephalitis (N = 1; 0. 26%). Reported cases of Anti-NMDA encephalitis in Latin-America had a very slight female predominance, lower prevalence of associated tumors and a lower incidence of extreme delta brush on electroencephalogram. Autoimmune encephalitis is possibly underdiagnosed in underdeveloped countries. Its outcome after treatment, however, appears to be similarly favorable in Latin American patients as has been reported in developed countries based on available case reports and case series. Regional specificities in the manifestation of autoimmune encephalitis could be related to epidemiologic factors, such as the presence of different triggers and different genetic and immunologic background, that need to be studied by future research.
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Affiliation(s)
| | | | | | | | | | | | - Paulo Ribeiro Nóbrega
- Division of Neurology, Department of Clinical Medicine, Fortaleza, Brazil.,Neurology Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | - Pedro Braga-Neto
- Center of Health Sciences, Universidade Estadual do Ceará, Fortaleza, Brazil.,Division of Neurology, Department of Clinical Medicine, Fortaleza, Brazil
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25
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Kuehn JC, Scheuerle A, Bauer J, Becker AJ, Wirtz R, Lewerenz J. A 64-Year-Old Patient With a Mesiotemporal Mass and Symptomatic Epilepsy. Brain Pathol 2021; 30:413-414. [PMID: 32100436 DOI: 10.1111/bpa.12818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Julia C Kuehn
- Department of Neuropathology, Section for Translational Epilepsy Research, University of Bonn Medical Center, Bonn, Germany
| | - Angelika Scheuerle
- Department of Neuropathology, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Jan Bauer
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Albert J Becker
- Department of Neuropathology, Section for Translational Epilepsy Research, University of Bonn Medical Center, Bonn, Germany
| | - Rainer Wirtz
- Department of Neurosurgery, Ulm University, Ulm, Germany
| | - Jan Lewerenz
- Department of Neurology, Ulm University, Ulm, Germany
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26
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Tan C, Jiang Y, Zhong M, Hu Y, Hong S, Li X, Jiang L. Clinical Features and Outcomes in Pediatric Autoimmune Encephalitis Associated With CASPR2 Antibody. Front Pediatr 2021; 9:736035. [PMID: 34660491 PMCID: PMC8518709 DOI: 10.3389/fped.2021.736035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 08/30/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Contactin-associated protein-like 2 (CASPR2) neurological autoimmunity has been associated with various clinical syndromes involving central and peripheral nervous system. CASPR2 antibody-associated autoimmune encephalitis is mostly reported in adults. Analysis of the clinical presentation and prognostic data of CASPR2 antibody-associated autoimmune encephalitis in children remains important. Methods: A single-center retrospective review of children diagnosed with CASPR2 antibody-associated autoimmune encephalitis from June 1st, 2018 to October 31st, 2020. Results: Six patients were identified. The median age was 12 years (range 1.8-14), with an overall male predominance of 83% (5/6). Commonest clinical features were psychiatric symptoms (6/6), movement disorders (4/6), altered consciousness (3/6), sleep disorders (3/6), and headache (3/6). Four patients (4/6) received first-line therapy alone (steroids combined with intravenous immunoglobulins), and two patients (2/6) received second-line therapy (rituximab, mycophenolate mofetil, or cyclophosphamide). All patients showed no peripheral nervous system involvement. One patient had comorbidities with systemic lupus erythematosus. No evidence of neoplastic disease was found in the whole cohort. All patients had favorable outcomes (modified Rankin Score 0-2) with recurrence rate at 0%, respectively. Conclusion: CASPR2 antibody-associated autoimmune encephalitis is rare in children. Our findings suggest that this type of encephalitis seems to occur more frequently in older children. Patients respond well to immunotherapy and usually demonstrate a favorable clinical outcome. Associated tumors are extremely rare.
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Affiliation(s)
- Chengbing Tan
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing, China
| | - Yan Jiang
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing, China
| | - Min Zhong
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing, China
| | - Yue Hu
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing, China
| | - Siqi Hong
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing, China
| | - Xiujuan Li
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing, China
| | - Li Jiang
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing, China
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27
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Kao YC, Lin MI, Weng WC, Lee WT. Neuropsychiatric Disorders Due to Limbic Encephalitis: Immunologic Aspect. Int J Mol Sci 2020; 22:ijms22010389. [PMID: 33396564 PMCID: PMC7795533 DOI: 10.3390/ijms22010389] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/26/2020] [Accepted: 12/28/2020] [Indexed: 12/16/2022] Open
Abstract
Limbic encephalitis (LE) is a rare cause of encephalitis presenting as an acute and subacute onset of neuropsychiatric manifestations, particularly with memory deficits and confusion as core features, along with seizure occurrence, movement disorders, or autonomic dysfunctions. LE is caused by neuronal antibodies targeting the cellular surface, synaptic, and intracellular antigens, which alter the synaptic transmission, especially in the limbic area. Immunologic mechanisms involve antibodies, complements, or T-cell-mediated immune responses in different degree according to different autoantibodies. Sensitive cerebrospinal fluid markers of LE are unavailable, and radiographic findings may not reveal a typical mesiotemporal involvement at neurologic presentations; therefore, a high clinical index of suspicions is pivotal, and a neuronal antibody testing is necessary to make early diagnosis. Some patients have concomitant tumors, causing paraneoplastic LE; therefore, tumor survey and treatment are required in addition to immunotherapy. In this study, a review on the molecular and immunologic aspects of LE was conducted to gain awareness of its peculiarity, which we found quite different from our knowledge on traditional psychiatric illness.
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Affiliation(s)
- Yu-Chia Kao
- Department of Pediatrics, E-Da Hospital, Kaohsiung 82445, Taiwan;
| | - Ming-I Lin
- Department of Pediatrics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 11101, Taiwan;
| | - Wen-Chin Weng
- Department of Pediatrics, National Taiwan University Hospital, Taipei 100226, Taiwan;
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei 100233, Taiwan
| | - Wang-Tso Lee
- Department of Pediatrics, National Taiwan University Hospital, Taipei 100226, Taiwan;
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei 100233, Taiwan
- Graduate Institute of Brain and Mind Sciences, National Taiwan University College of Medicine, Taipei 100233, Taiwan
- Correspondence: ; Tel.: +886-2-23123456 (ext. 71545); Fax: +886-2-23147450
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28
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Fernandes D, Santos SD, Coutinho E, Whitt JL, Beltrão N, Rondão T, Leite MI, Buckley C, Lee HK, Carvalho AL. Disrupted AMPA Receptor Function upon Genetic- or Antibody-Mediated Loss of Autism-Associated CASPR2. Cereb Cortex 2020; 29:4919-4931. [PMID: 30843029 DOI: 10.1093/cercor/bhz032] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 02/01/2019] [Accepted: 02/08/2019] [Indexed: 12/22/2022] Open
Abstract
Neuropsychiatric disorders share susceptibility genes, suggesting a common origin. One such gene is CNTNAP2 encoding contactin-associated protein 2 (CASPR2), which harbours mutations associated to autism, schizophrenia, and intellectual disability. Antibodies targeting CASPR2 have also been recently described in patients with several neurological disorders, such as neuromyotonia, Morvan's syndrome, and limbic encephalitis. Despite the clear implication of CNTNAP2 and CASPR2 in neuropsychiatric disorders, the pathogenic mechanisms associated with alterations in CASPR2 function are unknown. Here, we show that Caspr2 is expressed in excitatory synapses in the cortex, and that silencing its expression in vitro or in vivo decreases the synaptic expression of α-amino-3-hydroxy-5-methylisoxazole-4-propionic acid (AMPA) receptors and the amplitude of AMPA receptor-mediated currents. Furthermore, Caspr2 loss of function blocks synaptic scaling in vitro and experience-dependent homoeostatic synaptic plasticity in the visual cortex. Patient CASPR2 antibodies decrease the dendritic levels of Caspr2 and synaptic AMPA receptor trafficking, and perturb excitatory transmission in the visual cortex. These results suggest that mutations in CNTNAP2 may contribute to alterations in AMPA receptor function and homoeostatic plasticity, and indicate that antibodies from anti-CASPR2 encephalitis patients affect cortical excitatory transmission.
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Affiliation(s)
- Dominique Fernandes
- Synapse Biology Group, CNC-Centre for Neuroscience and Cell Biology, University of Coimbra, 3004-504 Coimbra, Portugal.,PDBEB, Doctoral Programme in Experimental Biology and Biomedicine, CNC & Institute for Interdisciplinary Research, University of Coimbra (IIIUC), 3004-504 Coimbra, Portugal.,Solomon Snyder Department of Neurosciences, Zanvyl Krieger Mind/Brain Institute, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Sandra D Santos
- Synapse Biology Group, CNC-Centre for Neuroscience and Cell Biology, University of Coimbra, 3004-504 Coimbra, Portugal
| | - Ester Coutinho
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - Jessica L Whitt
- Solomon Snyder Department of Neurosciences, Zanvyl Krieger Mind/Brain Institute, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Nuno Beltrão
- Synapse Biology Group, CNC-Centre for Neuroscience and Cell Biology, University of Coimbra, 3004-504 Coimbra, Portugal
| | - Tiago Rondão
- Synapse Biology Group, CNC-Centre for Neuroscience and Cell Biology, University of Coimbra, 3004-504 Coimbra, Portugal.,Department of Life Sciences, Faculty of Sciences and Technology, University of Coimbra, 3004-504 Coimbra, Portugal
| | - M Isabel Leite
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - Camilla Buckley
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - Hey-Kyoung Lee
- Solomon Snyder Department of Neurosciences, Zanvyl Krieger Mind/Brain Institute, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Ana Luísa Carvalho
- Synapse Biology Group, CNC-Centre for Neuroscience and Cell Biology, University of Coimbra, 3004-504 Coimbra, Portugal.,Department of Life Sciences, Faculty of Sciences and Technology, University of Coimbra, 3004-504 Coimbra, Portugal
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29
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Koneczny I. Update on IgG4-mediated autoimmune diseases: New insights and new family members. Autoimmun Rev 2020; 19:102646. [PMID: 32801046 DOI: 10.1016/j.autrev.2020.102646] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 03/08/2020] [Indexed: 12/23/2022]
Abstract
Antibodies of IgG4 subclass are exceptional players of the immune system, as they are considered to be immunologically inert and functionally monovalent, and as such may be part of classical tolerance mechanisms. IgG4 antibodies are found in a range of different diseases, including IgG4-related diseases, allergy, cancer, rheumatoid arthritis, helminth infection and IgG4 autoimmune diseases, where they may be pathogenic or protective. IgG4 autoimmune diseases are an emerging new group of diseases that are characterized by pathogenic, antigen-specific autoantibodies of IgG4 subclass, such as MuSK myasthenia gravis, pemphigus vulgaris and thrombotic thrombocytopenic purpura. The list of IgG4 autoantigens is rapidly growing and to date contains 29 candidate antigens. Interestingly, IgG4 autoimmune diseases are restricted to four distinct organs: 1) the central and peripheral nervous system, 2) the kidney, 3) the skin and mucous membranes and 4) the vascular system and soluble antigens in the blood circulation. The pathogenicity of IgG4 can be validated using our classification system, and is usually excerted by functional blocking of protein-protein interaction.
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Affiliation(s)
- Inga Koneczny
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Währingergürtel 18-20, 1090 Vienna, Austria.
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30
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Spatial navigation in early multiple sclerosis: a neglected cognitive marker of the disease? J Neurol 2020; 268:77-89. [PMID: 32700011 DOI: 10.1007/s00415-020-10079-z] [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: 04/23/2020] [Revised: 07/06/2020] [Accepted: 07/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cognitive deficits are common in early multiple sclerosis (MS), however, spatial navigation changes and their associations with brain pathology remain poorly understood. OBJECTIVE To characterize the profile of spatial navigation changes in two main navigational strategies, egocentric (self-centred) and allocentric (world-centred), and their associations with demyelinating and neurodegenerative changes in early MS. METHODS Participants with early MS after the first clinical event (n = 51) and age-, gender- and education-matched controls (n = 42) underwent spatial navigation testing in a real-space human analogue of the Morris water maze task, comprehensive neuropsychological assessment, and MRI brain scan with voxel-based morphometry and volumetric analyses. RESULTS The early MS group had lower performance in the egocentric (p = 0.010), allocentric (p = 0.004) and allocentric-delayed (p = 0.038) navigation tasks controlling for age, gender and education. Based on the applied criteria, lower spatial navigation performance was present in 26-29 and 33-41% of the participants with early MS in the egocentric and the allocentric task, respectively. Larger lesion load volume in cortical, subcortical and cerebellar regions (ß ≥ 0.29; p ≤ 0.032) unlike brain atrophy was associated with less accurate allocentric navigation performance. CONCLUSION Lower spatial navigation performance is present in up to 41% of the participants with early MS. Demyelinating lesions in early MS may disrupt neural network forming the basis of allocentric navigation.
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31
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Gillespie LE, Dave A, Goldstein A. A Tale of Two Brothers: Familial Voltage-Gated Potassium Channel Autoimmune Encephalitis. Cureus 2020; 12:e8723. [PMID: 32699718 PMCID: PMC7372199 DOI: 10.7759/cureus.8723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
This is the first reported case of familial voltage-gated potassium channel (VGKC) autoimmune encephalitis. The symptoms of autoimmune encephalitis can mimic infectious encephalitis with headache, fatigue, and neuropsychiatric symptoms. Autoimmunity is emerging as a distinct cause of encephalitis in the children. Prompt recognition, diagnosis, and treatment are important to prevent brain damage. Two brothers presented two years apart with different symptoms. The explanation for their distinct symptoms lies in the multifactorial development of autoimmunity. The presentation of autoimmune encephalitis can depend on the offending antibodies. The most common are antibodies against the N-methyl-D-aspartic acid (NMDA) receptor and the VGKC complex. Antibodies to the VGKC complex are divided into three different groups depending on their antigenic target: leucine-rich glioma-inactivated protein 1 (LGI1), contactin-associated protein-like 2 (CASPR2), or neither. Anti-VGKC antibodies in children are associated with neuroinflammation and encephalitis. Autoimmunity to LGI1 and CASPR2 antigens is associated with distinct human leukocyte antigen (HLA) alleles. Different HLA isotypes are involved in antigen processing and presentation and can lead to a genetic predisposition to autoimmunity. VGKC autoimmune encephalitis can present with memory changes, psychiatric symptoms, and motor abnormalities. Both brothers presented with these symptoms in their own unique way. Efficient diagnosis and immunosuppression helped improve their outcomes.
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Affiliation(s)
| | - Amanda Dave
- Pediatrics, University of Nebraska Medical Center, Omaha, USA
| | - Amy Goldstein
- Pediatrics, University of Nebraska Medical Center, Omaha, USA
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32
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Spanò G, Pizzamiglio G, McCormick C, Clark IA, De Felice S, Miller TD, Edgin JO, Rosenthal CR, Maguire EA. Dreaming with hippocampal damage. eLife 2020; 9:e56211. [PMID: 32508305 PMCID: PMC7279885 DOI: 10.7554/elife.56211] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/05/2020] [Indexed: 01/20/2023] Open
Abstract
The hippocampus is linked with both sleep and memory, but there is debate about whether a salient aspect of sleep - dreaming - requires its input. To address this question, we investigated if human patients with focal bilateral hippocampal damage and amnesia engaged in dreaming. We employed a provoked awakening protocol where participants were woken up at various points throughout the night, including during non-rapid eye movement and rapid eye movement sleep, to report their thoughts in that moment. Despite being roused a similar number of times, dream frequency was reduced in the patients compared to control participants, and the few dreams they reported were less episodic-like in nature and lacked content. These results suggest that hippocampal integrity may be necessary for typical dreaming to occur, and aligns dreaming with other hippocampal-dependent processes such as episodic memory that are central to supporting our mental life.
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Affiliation(s)
- Goffredina Spanò
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, University College LondonLondonUnited Kingdom
| | - Gloria Pizzamiglio
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, University College LondonLondonUnited Kingdom
| | - Cornelia McCormick
- Department of Neurodegenerative Diseases and Geriatric Psychiatry, University Hospital BonnBonnGermany
| | - Ian A Clark
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, University College LondonLondonUnited Kingdom
| | - Sara De Felice
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, University College LondonLondonUnited Kingdom
| | - Thomas D Miller
- Department of Neurology, Royal Free HospitalLondonUnited Kingdom
| | - Jamie O Edgin
- Department of Psychology, University of ArizonaTucsonUnited States
| | - Clive R Rosenthal
- Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
| | - Eleanor A Maguire
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, University College LondonLondonUnited Kingdom
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33
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Wang Y, Yu Y, Hu Y, Li Y, Song F, Wang Y. Clinical and Electroencephalographic Features of the Seizures in Neuronal Surface Antibody-Associated Autoimmune Encephalitis. Front Neurol 2020; 11:280. [PMID: 32431657 PMCID: PMC7214674 DOI: 10.3389/fneur.2020.00280] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 03/25/2020] [Indexed: 12/12/2022] Open
Abstract
Objectives: To investigate clinical and electroencephalographic features of the seizures in different types of neuronal surface antibody (NSAb)-associated autoimmune encephalitis (AE). Methods: The clinical data of the seizures were analyzed in 18 patients with NSAb-associated AEs diagnosed in the First Affiliated Hospital of Dalian Medical University. Results: From May 2013 to April 2019, a total of 18 cases of NSAb-associated AE were diagnosed, including 9 cases of leucine-rich glioma-inactivated 1 protein (LGI1) antibody-associated encephalitis, 7 cases of anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis, and 2 cases of anti-γ-aminobutyric acid B receptor (GABABR) encephalitis. All nine cases (100%) with LGI1 AE had seizures manifesting in three types: faciobranchial dystonia seizure (FBDS) (44.4%), mesial temporal lobe epilepsy (MTLE)-like seizure (66.7%), and focal to bilateral tonic–clonic seizure (FBTCS) (77.8%). Six of nine (66.7%) showed abnormal signal on hippocampus or basal ganglia in brain MRI. Five of seven cases (71%) with anti-NMDAR encephalitis had seizures manifesting in three types: focal aware seizure (40%), focal-impaired awareness seizure (20%), generalized tonic–clonic seizure (GTCS) (100%), and status epilepticus (SE) (40%). Three of seven (42.8%) showed abnormalities in brain MRI. Both patients with anti-GABABR encephalitis had seizures manifesting in two types: GTCS and MTLE-like seizure, one with SE. One showed abnormal signal on left hippocampus in brain MRI. All patients (100%) with three types of AE had abnormalities in electroencephalogram (EEG), showing diffuse (4/18) or focal slow waves (14/18) in background, interictal (10/18), or ictal (6/18) epileptic discharges in the temporal or other regions; two patients with anti-NMDAR encephalitis showed delta activity or rhythm in frontotemporal region. All patients with seizures showed good response to immunotherapy except one with LGI1 AE. Conclusions: Most patients with NSAb-associated AE had seizures; seizure types varied between different types of AE. In LGI1 AE, the hippocampus and basal ganglia were two main targets; the corresponding seizure type was MTLE-like seizure and FBDS, respectively. Anti-NMDAR encephalitis had more generalized than focal seizures. Delta activity or rhythm in the frontotemporal region in EEG was helpful for diagnosis. Anti-GABABR encephalitis was characterized by refractory seizures as initial symptom, mainly GTCS or MTLE-like seizure. Most seizures in NSAb-associated AE showed good response to immunotherapy, and antiepileptic drugs should be considered as an add-on symptomatic treatment.
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Affiliation(s)
- Yan Wang
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian, China.,Department of Neurology, The First People's Hospital in Jinzhou, Dalian, China
| | - Yi Yu
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yaping Hu
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ying Li
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Fan Song
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ying Wang
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
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34
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Conrad K, Shoenfeld Y, Fritzler MJ. Precision health: A pragmatic approach to understanding and addressing key factors in autoimmune diseases. Autoimmun Rev 2020; 19:102508. [PMID: 32173518 DOI: 10.1016/j.autrev.2020.102508] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 11/06/2019] [Indexed: 02/07/2023]
Abstract
The past decade has witnessed a significant paradigm shift in the clinical approach to autoimmune diseases, lead primarily by initiatives in precision medicine, precision health and precision public health initiatives. An understanding and pragmatic implementation of these approaches require an understanding of the drivers, gaps and limitations of precision medicine. Gaining the trust of the public and patients is paramount but understanding that technologies such as artificial intelligences and machine learning still require context that can only be provided by human input or what is called augmented machine learning. The role of genomics, the microbiome and proteomics, such as autoantibody testing, requires continuing refinement through research and pragmatic approaches to their use in applied precision medicine.
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Affiliation(s)
- Karsten Conrad
- Institute of Immunology, Medical Faculty "Carl Gustav Carus", Technical University of Dresden, Dresden, Germany
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel; Department of Medicine, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Marvin J Fritzler
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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35
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Spanò G, Weber FD, Pizzamiglio G, McCormick C, Miller TD, Rosenthal CR, Edgin JO, Maguire EA. Sleeping with Hippocampal Damage. Curr Biol 2020; 30:523-529.e3. [PMID: 31956024 PMCID: PMC6997880 DOI: 10.1016/j.cub.2019.11.072] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/16/2019] [Accepted: 11/25/2019] [Indexed: 12/22/2022]
Abstract
The hippocampus plays a critical role in sleep-related memory processes [1-3], but it is unclear which specific sleep features are dependent upon this brain structure. The examination of sleep physiology in patients with focal bilateral hippocampal damage and amnesia could supply important evidence regarding these links. However, there is a dearth of such studies, despite these patients providing compelling insights into awake cognition [4, 5]. Here, we sought to identify the contribution of the hippocampus to the sleep phenotype by characterizing sleep via comprehensive qualitative and quantitative analyses in memory-impaired patients with selective bilateral hippocampal damage and matched control participants using in-home polysomnography on 4 nights. We found that, compared to control participants, patients had significantly reduced slow-wave sleep-likely due to decreased density of slow waves-as well as slow-wave activity. In contrast, slow and fast spindles were indistinguishable from those of control participants. Moreover, patients expressed slow oscillations (SOs), and SO-fast spindle coupling was observed. However, on closer scrutiny, we noted that the timing of spindles within the SO cycle was delayed in the patients. The shift of patients' spindles into the later phase of the up-state within the SO cycle may indicate a mismatch in timing across the SO-spindle-ripple events that are associated with memory consolidation [6, 7]. The substantial effect of selective bilateral hippocampal damage on large-scale oscillatory activity in the cortex suggests that, as with awake cognition, the hippocampus plays a significant role in sleep physiology, which may, in turn, be necessary for efficacious episodic memory.
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Affiliation(s)
- Goffredina Spanò
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, University College London, London WC1N 3AR, UK
| | - Frederik D Weber
- Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen 6525 EN, the Netherlands
| | - Gloria Pizzamiglio
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, University College London, London WC1N 3AR, UK
| | - Cornelia McCormick
- Department of Neurodegenerative Diseases and Geriatric Psychiatry, University Hospital Bonn, Bonn 53127, Germany
| | - Thomas D Miller
- Department of Neurology, Royal Free Hospital, London NW3 2QG, UK
| | - Clive R Rosenthal
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK
| | - Jamie O Edgin
- Department of Psychology, University of Arizona, Tucson, AZ 85721, USA
| | - Eleanor A Maguire
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, University College London, London WC1N 3AR, UK.
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36
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Lad M, Mullally SL, Houston AL, Kelly T, Griffiths TD. Characterizing memory loss in patients with autoimmune limbic encephalitis hippocampal lesions. Hippocampus 2019; 29:1114-1120. [PMID: 31472008 PMCID: PMC6852518 DOI: 10.1002/hipo.23150] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 08/05/2019] [Accepted: 08/09/2019] [Indexed: 12/29/2022]
Abstract
Since the publication of Scoville and Milner's (1957) seminal paper, the precise functional role played by the hippocampus in support of human memory has been fiercely debated. For instance, the single question of whether the hippocampus plays a time-limited or an indelible role in the recollection of personal memories led to a deep and tenacious schism within the field. Similar polarizations arose between those who debated the precise nature of the role played by the hippocampus in support of semantic relative to episodic memories and in recall/recollection relative to familiarity-based recognition. At the epicenter of these divisions lies conflicting neuropsychological findings. These differences likely arise due to the consistent use of heterogeneous patient populations to adjudicate between these positions. Here we utilized traditional neuropsychological measures in a homogenous patient population with a highly discrete hippocampal lesion (i.e., VGKCC-Ab related autoimmune limbic encephalitis patients). We observed consistent impairment of recent episodic memories, a present but less striking impairment of remote episodic memories, preservation of personal semantic memory, and recall but not recognition memory deficits. We conclude that this increasingly well-characterized patient group may represent an important homogeneous population in which the functional role played by the hippocampus may be more precisely delineated.
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Affiliation(s)
- Meher Lad
- Institute of NeuroscienceNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Sinéad L. Mullally
- Institute of NeuroscienceNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | | | - Tom Kelly
- The Neuropsychology DepartmentRoyal Victoria InfirmaryNewcastle upon TyneUnited Kingdom
| | - Timothy D. Griffiths
- Institute of NeuroscienceNewcastle UniversityNewcastle upon TyneUnited Kingdom
- Wellcome Trust Centre for NeuroimagingUniversity College LondonLondonUnited Kingdom
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37
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Alexopoulos H, Dalakas MC. The immunobiology of autoimmune encephalitides. J Autoimmun 2019; 104:102339. [PMID: 31611142 DOI: 10.1016/j.jaut.2019.102339] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 09/25/2019] [Indexed: 12/17/2022]
Abstract
Autoimmune encephalitides, with an estimated incidence of 1.5 per million population per year, although described only 15 years ago, have already had a remarkable impact in neurology and paved the field to autoimmune neuropsychiatry. Many patients traditionally presented with aberrant behavior, especially of acute or subacute onset, and treated with anti-psychotic therapies, turn out to have a CNS autoimmune disease with pathogenic autoantibodies against synaptic antigens responding to immunotherapies. The review describes the clinical spectrum of these disorders, and the pathogenetic role of key autoantibodies directed against: a) cell surface synaptic antigens and receptors, including NMDAR, GABAa, GABAb, AMPA and glycine receptors; b) channels such as AQP4 water-permeable channel or voltage-gated potassium channels; c) proteins that stabilize voltage-gated potassium channel complex into the membrane, like the LGI1 and CASPR2; and d) enzymes that catalyze the formation of neurotransmitters such as Glutamic Acid Decarboxylase (GAD). These antibodies, effectively target excitatory or inhibitory synapses in the limbic system, basal ganglia or brainstem altering synaptic function and resulting in uncontrolled neurological excitability disorder clinically manifested with psychosis, agitation, behavioral alterations, depression, sleep disturbances, seizure-like phenomena, movement disorders such as ataxia, chorea and dystonia, memory changes or coma. Some of the identified triggering factors include: viruses, especially herpes simplex, accounting for the majority of relapses occurring after viral encephalitis, which respond to immunotherapy rather than antiviral agents; tumors especially teratoma, SCLC and thymomas; and biological cancer therapies (immune-check-point inhibitors). As anti-synaptic antibodies persist after viral infections or tumor removal, augmentation of autoreactive B cells which release autoantigens to draining lymph nodes, molecular mimicry and infection-induced bystander immune activation products play a role in autoimmunization process or perpetuating autoimmune neuroinflammation. The review stresses the importance of early detection, clinical recognition, proper antibody testing and early therapy initiation as these disorders, regardless of a known or not trigger, are potentially treatable responding to systemic immunotherapy with intravenous steroids, IVIg, rituximab or even bortezomid.
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Affiliation(s)
- Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C Dalakas
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece; Department of Neurology, Thomas Jefferson University, Philadelphia, USA.
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Yao L, Yue W, Xunyi W, Jianhong W, Guoxing Z, Zhen H. Clinical features and long-term outcomes of seizures associated with autoimmune encephalitis: A follow-up study in East China. J Clin Neurosci 2019; 68:73-79. [DOI: 10.1016/j.jocn.2019.07.049] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 07/08/2019] [Indexed: 11/29/2022]
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Galetta KM, Bhattacharyya S. Multiple Sclerosis and Autoimmune Neurology of the Central Nervous System. Med Clin North Am 2019; 103:325-336. [PMID: 30704684 DOI: 10.1016/j.mcna.2018.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Autoimmune disorders of the central nervous system are common and often affect people in the most productive years of their lives. Among primary autoimmune diseases of the central nervous system, multiple sclerosis is most prevalent in the United States. Many other autoantibody-mediated neurologic syndromes have been identified within the past 2 to 3 decades, including neuromyelitis optica and anti-N-methyl-D aspartate receptor encephalitis. Finally, the central nervous system can also be affected by systemic autoimmune diseases such as sarcoidosis. Many of these diseases are treatable when detected early.
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Affiliation(s)
- Kristin M Galetta
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA; Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Shamik Bhattacharyya
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Macher S, Zimprich F, De Simoni D, Höftberger R, Rommer PS. Management of Autoimmune Encephalitis: An Observational Monocentric Study of 38 Patients. Front Immunol 2018; 9:2708. [PMID: 30524441 PMCID: PMC6262885 DOI: 10.3389/fimmu.2018.02708] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 11/01/2018] [Indexed: 12/30/2022] Open
Abstract
Over the last years the clinical picture of autoimmune encephalitis has gained importance in neurology. The broad field of symptoms and syndromes poses a great challenge in diagnosis for clinicians. Early diagnosis and the initiation of the appropriate treatment is the most relevant step in the management of the patients. Over the last years advances in neuroimmunology have elucidated pathophysiological basis and improved treatment concepts. In this monocentric study we compare demographics, diagnostics, treatment options and outcomes with knowledge from literature. We present 38 patients suffering from autoimmune encephalitis. Antibodies were detected against NMDAR and LGI1 in seven patients, against GAD in 6 patients) one patient had coexisting antibodies against GABAA and GABAB), against CASPR2, IGLON5, YO, Glycine in 3 patients, against Ma-2 in 2 patients, against CV2 and AMPAR in 1 patient; two patients were diagnosed with hashimoto encephalitis with antibodies against TPO/TG. First, we compare baseline data of patients who were consecutively diagnosed with autoimmune encephalitis from a retrospective view. Further, we discuss when to stop immunosuppressive therapy since how long treatment should be performed after clinical stabilization or an acute relapse is still a matter of debate. Our experiences are comparable with data from literature. However, in contrary to other experts in the field we stop treatment and monitor patients very closely after tumor removal and after rehabilitation from first attack.
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Affiliation(s)
- Stefan Macher
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Desiree De Simoni
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paulus S Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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Feyissa AM, Lamb C, Pittock SJ, Gadoth A, McKeon A, Klein CJ, Britton JW. Antiepileptic drug therapy in autoimmune epilepsy associated with antibodies targeting the leucine-rich glioma-inactivated protein 1. Epilepsia Open 2018; 3:348-356. [PMID: 30187005 PMCID: PMC6119747 DOI: 10.1002/epi4.12226] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2018] [Indexed: 01/17/2023] Open
Abstract
Objective To characterize seizure semiology and the utility of antiepileptic drug (AED) therapy in leucine‐rich glioma inactivated‐1 ( LGI1‐Ab) autoimmune epilepsy (AE). Methods Patients with voltage‐gated potassium channel complex (VGKCc) titers higher than 0.02 nmol/L who were evaluated between May 2008 and June 2016 at the 3 Mayo Clinic sites (Arizona, Florida, or Minnesota) were identified. We then performed a retrospective review of those who were LGI1‐Ab positive and were treated for seizures. Results A total of 1,095 patients with VGKCc titers higher than 0.02 nmol/L were identified, in which 77 were LGI1 positive. Of these, 56 patients with seizures were included in the analysis. Mean age at symptom onset was 62.9 years; 66% (n = 37) were male. The most common seizure semiology was focal faciobrachial dystonic seizures with preserved awareness (FBDS) (n = 35, 63%), followed by focal with impaired awareness (FIA) (n = 29, 52%), generalized tonic–clonic (GTCs) (n = 28, 50%), and focal non‐motor seizures with preserved awareness (n = 28, 50%). The majority had more than one seizure type (n = 49, 88%; median = 2.5). Thirty‐eight patients (68%) became seizure free: 29 (76%) with immunotherapy, 3 (5%) with AEDs alone, 2 (3%) with AEDs before any immunotherapy, and 4 (7%) with AEDs after immunotherapy. Levetiracetam (n = 47, 84%) and valproic acid (n = 21, 38%) were the most commonly used AEDs, but neither were associated with seizure freedom. Sodium channel blocking (NCB) AEDs were associated with seizure freedom in 4 patients compared to none treated with non‐NCB AEDs. Regardless of class, AEDs prior to or apart from immunotherapy were associated with seizure freedom in only five patients (9%). In patients with FBDS, seizure freedom was more often associated with immunotherapy than AEDs (20/30 vs. 3/34, p = 0.001). Significance Although FBDS are the most characteristic seizure type seen in LGI1‐Ab AE, other seizure types including FIA and GTCs also occur. Immunotherapy was the treatment most frequently associated with seizure freedom in LGI1‐Ab AE. In general, AEDs seemed to confer a very low chance for seizure freedom, although AEDs with NCB‐blocking properties were associated with seizure freedom in a limited number. Levetiracetam in particular appears to be ineffective in this patient population.
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Affiliation(s)
| | | | - Sean J Pittock
- Department of Neurology Mayo Clinic Rochester Minnesota U.S.A.,Department of Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota U.S.A
| | - Avi Gadoth
- Department of Neurology Mayo Clinic Rochester Minnesota U.S.A.,Department of Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota U.S.A
| | - Andrew McKeon
- Department of Neurology Mayo Clinic Rochester Minnesota U.S.A.,Department of Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota U.S.A
| | - Christopher J Klein
- Department of Neurology Mayo Clinic Rochester Minnesota U.S.A.,Department of Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota U.S.A
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18F-FDG-PET and MRI in autoimmune encephalitis: a systematic review of brain findings. Clin Transl Imaging 2018. [DOI: 10.1007/s40336-018-0275-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Huijbers MG, Plomp JJ, van der Maarel SM, Verschuuren JJ. IgG4-mediated autoimmune diseases: a niche of antibody-mediated disorders. Ann N Y Acad Sci 2018; 1413:92-103. [PMID: 29377160 DOI: 10.1111/nyas.13561] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 10/19/2017] [Accepted: 10/30/2017] [Indexed: 12/11/2022]
Abstract
Immunoglobulin 4 (IgG4) is one of four human IgG subclasses and has several unique functional characteristics. It exhibits low affinity for complement and for most Fc receptors. It furthermore has generally high affinity for its antigen, with binding occurring in a monovalent fashion, as IgG4 can exchange Fab-arms with other IgG4 molecules. Because of these characteristics, IgG4 is believed to block its targets and prevent inflammation, which, depending on the setting, can have a protective or pathogenic effect. One example of IgG4 pathogenicity is muscle-specific kinase (MuSK) myasthenia gravis (MG), in which patients develop IgG4 MuSK autoantibodies, resulting in muscle weakness. As a consequence of the distinct IgG4 characteristics, the pathomechanism of MuSK MG is very different from IgG1-and IgG3-mediated autoimmune diseases, such as acetylcholine receptor MG. In recent years, new autoantibodies in a spectrum of autoimmune diseases have been discovered. Interestingly, some were found to be predominantly IgG4. These IgG4-mediated autoimmune diseases share many pathomechanistic aspects with MuSK MG, suggesting that IgG4-mediated autoimmunity forms a separate niche among the antibody-mediated disorders. In this review, we summarize the group of IgG4-mediated autoimmune diseases, discuss the role of IgG4 in MuSK MG, and highlight interesting future research questions for IgG4-mediated autoimmunity.
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Affiliation(s)
- Maartje G Huijbers
- Departments of Neurology, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Human Genetics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jaap J Plomp
- Departments of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Jan J Verschuuren
- Departments of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
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A Genetic Disposition for Autoimmune Encephalitis: Searching for Human Leukocyte Antigen (HLA) Complex Subtypes. Epilepsy Curr 2017; 17:273-274. [PMID: 29225536 DOI: 10.5698/1535-7597.17.5.273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Singer HS. Autoantibody-Associated Movement Disorders in Children: Proven and Proposed. Semin Pediatr Neurol 2017; 24:168-179. [PMID: 29103424 DOI: 10.1016/j.spen.2017.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Movement disorders secondary to autoantibodies in children represent a rapidly expanding group of conditions. Once considered to be limited to poststreptococcal Sydenham's chorea or rare cases of childhood systemic lupus erythematosus, a variety of antibody-related movement abnormalities are now seen as part of noninfectious autoimmune encephalitis or within an expanding list of postinfectious disorders. In this article, several proposed autoantibody-mediated movement disorders in children are reviewed. In each one, there is a hypothesized antibody biomarker that is believed to be pathogenic and cause the clinical symptoms. As will be discussed, in some, such as anti-NMDA receptor encephalitis, the strength of supporting evidence is strong. In others, antibodies have been identified, but their role as the pathophysiological mechanism remains undetermined. Lastly, there are proposed disorders, such as PANDAS, that are controversial on both a clinical and autoimmune basis.
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Affiliation(s)
- Harvey S Singer
- Departments of Neurology and Pediatrics, Johns Hopkins University, Baltimore MD.
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