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Jeyakumar N, Lerch M, Dale RC, Ramanathan S. MOG antibody-associated optic neuritis. Eye (Lond) 2024; 38:2289-2301. [PMID: 38783085 PMCID: PMC11306565 DOI: 10.1038/s41433-024-03108-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 04/04/2024] [Accepted: 04/19/2024] [Indexed: 05/25/2024] Open
Abstract
Myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD) is a demyelinating disorder, distinct from multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD). MOGAD most frequently presents with optic neuritis (MOG-ON), often with characteristic clinical and radiological features. Bilateral involvement, disc swelling clinically and radiologically, and longitudinally extensive optic nerve hyperintensity with associated optic perineuritis on MRI are key characteristics that can help distinguish MOG-ON from optic neuritis due to other aetiologies. The detection of serum MOG immunoglobulin G utilising a live cell-based assay in a patient with a compatible clinical phenotype is highly specific for the diagnosis of MOGAD. This review will highlight the key clinical and radiological features which expedite diagnosis, as well as ancillary investigations such as visual fields, visual evoked potentials and cerebrospinal fluid analysis, which may be less discriminatory. Optical coherence tomography can identify optic nerve swelling acutely, and atrophy chronically, and may transpire to have utility as a diagnostic and prognostic biomarker. MOG-ON appears to be largely responsive to corticosteroids, which are often the mainstay of acute management. However, relapses are common in patients in whom follow-up is prolonged, often in the context of early or rapid corticosteroid tapering. Establishing optimal acute therapy, the role of maintenance steroid-sparing immunotherapy for long-term relapse prevention, and identifying predictors of relapsing disease remain key research priorities in MOG-ON.
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Affiliation(s)
- Niroshan Jeyakumar
- Translational Neuroimmunology Group, Kids Neuroscience Centre and Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Department of Neurology, Westmead Hospital, Sydney, NSW, Australia
| | - Magdalena Lerch
- Translational Neuroimmunology Group, Kids Neuroscience Centre and Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Russell C Dale
- Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Clinical Neuroimmunology Group, Kids Neuroscience Centre and Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- TY Nelson Department of Neurology, Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Sudarshini Ramanathan
- Translational Neuroimmunology Group, Kids Neuroscience Centre and Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
- Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
- Department of Neurology, Concord Hospital, Sydney, NSW, Australia.
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Hagbohm C, Ouellette R, Flanagan EP, Jonsson DI, Piehl F, Banwell B, Wickström R, Iacobaeus E, Granberg T, Ineichen BV. Clinical and neuroimaging phenotypes of autoimmune glial fibrillary acidic protein astrocytopathy: A systematic review and meta-analysis. Eur J Neurol 2024; 31:e16284. [PMID: 38506182 PMCID: PMC11235751 DOI: 10.1111/ene.16284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/13/2024] [Accepted: 03/05/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVE This study was undertaken to provide a comprehensive review of neuroimaging characteristics and corresponding clinical phenotypes of autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A), a rare but severe neuroinflammatory disorder, to facilitate early diagnosis and appropriate treatment. METHODS A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis)-conforming systematic review and meta-analysis was performed on all available data from January 2016 to June 2023. Clinical and neuroimaging phenotypes were extracted for both adult and paediatric forms. RESULTS A total of 93 studies with 681 cases (55% males; median age = 46, range = 1-103 years) were included. Of these, 13 studies with a total of 535 cases were eligible for the meta-analysis. Clinically, GFAP-A was often preceded by a viral prodromal state (45% of cases) and manifested as meningitis, encephalitis, and/or myelitis. The most common symptoms were headache, fever, and movement disturbances. Coexisting autoantibodies (45%) and neoplasms (18%) were relatively frequent. Corticosteroid treatment resulted in partial/complete remission in a majority of cases (83%). Neuroimaging often revealed T2/fluid-attenuated inversion recovery (FLAIR) hyperintensities (74%) as well as perivascular (45%) and/or leptomeningeal (30%) enhancement. Spinal cord abnormalities were also frequent (49%), most commonly manifesting as longitudinally extensive myelitis. There were 88 paediatric cases; they had less prominent neuroimaging findings with lower frequencies of both T2/FLAIR hyperintensities (38%) and contrast enhancement (19%). CONCLUSIONS This systematic review and meta-analysis provide high-level evidence for clinical and imaging phenotypes of GFAP-A, which will benefit the identification and clinical workup of suspected cases. Differential diagnostic cues to distinguish GFAP-A from common clinical and imaging mimics are provided as well as suitable magnetic resonance imaging protocol recommendations.
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Affiliation(s)
- Caroline Hagbohm
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Department of NeuroradiologyKarolinska University HospitalStockholmSweden
| | - Russell Ouellette
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Department of NeuroradiologyKarolinska University HospitalStockholmSweden
| | - Eoin P. Flanagan
- Department of Neurology, Center for Multiple Sclerosis and Autoimmune NeurologyMayo ClinicRochesterMinnesotaUSA
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
| | - Dagur I. Jonsson
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Department of NeurophysiologyKarolinska University HospitalStockholmSweden
| | - Fredrik Piehl
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Centre for Neurology, Academic Specialist CentreKarolinska University HospitalStockholmSweden
| | - Brenda Banwell
- Division of Child Neurology, Children's Hospital of Philadelphia, Department of Neurology and Department of Pediatrics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Ronny Wickström
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- Astrid Lindgren Children's HospitalKarolinska University HospitalStockholmSweden
| | - Ellen Iacobaeus
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Department of NeurologyKarolinska University HospitalStockholmSweden
| | - Tobias Granberg
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Department of NeuroradiologyKarolinska University HospitalStockholmSweden
| | - Benjamin V. Ineichen
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Center for Reproducible ScienceUniversity of ZürichZürichSwitzerland
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Yonesu M, Hosokawa A, Yutani K, Kimura A, Shimohata T, Nakano M. [A case of autoimmune glial fibrillary acidic protein astrocytopathy with various symptoms such as optic disc edema and cerebellar ataxia]. Rinsho Shinkeigaku 2024; 64:408-412. [PMID: 38811204 DOI: 10.5692/clinicalneurol.cn-001949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
A 59-year-old man had developed visual abnormality, nausea, headache, and weight loss since three months before. The ophthalmologist found severe optic disc edema in both eyes, and referred him to our hospital. The patient had mild cerebellar ataxia. Increased cerebrospinal fluid pressure, increased protein and cell counts, positive oligoclonal band, and contrast-enhanced head MRI showed multiple linear perivascular radial gadolinium enhancement around bilateral lateral ventricles. His subjective and objective findings significantly improved with steroid treatment. The cerebrospinal fluid was found to be positive for glial fibrillary acidic protein (GFAP) antibodies, and a diagnosis of GFAP astrocytopathy was obtained. When optic edema or radial contrast effects was observed on contrast-enhanced MRI, GFAP astrocytopathy should be considerd. Prompt immunotherapy is required to circumvent the development of permanent visual impairment.
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Affiliation(s)
| | | | - Kenji Yutani
- Department of Radiology, Suita Municipal Hospital
| | | | | | - Misa Nakano
- Department of Neurology, Suita Municipal Hospital
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Ng CC, Poh MQW, Lim SA, Swaminathan SK, Yeo T. Headache and optic disc oedema revealing autoimmune GFAP-astrocytopathy. QJM 2024; 117:375-377. [PMID: 38229263 DOI: 10.1093/qjmed/hcae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Indexed: 01/18/2024] Open
Affiliation(s)
- Chai Ching Ng
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Mervyn Qi Wei Poh
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Su Ann Lim
- Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Tianrong Yeo
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Villain P, Kerbrat A, Cochard C. [Subacute blindness and aseptic meningitis as presenting signs of autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy]. J Fr Ophtalmol 2024; 47:104194. [PMID: 38761650 DOI: 10.1016/j.jfo.2024.104194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/20/2024] [Accepted: 03/21/2024] [Indexed: 05/20/2024]
Affiliation(s)
- P Villain
- Service d'ophtalmologie, hôpital Pontchaillou, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35000 Rennes, France.
| | - A Kerbrat
- Service de neurologie, hôpital Pontchaillou, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35000 Rennes, France
| | - C Cochard
- Service d'ophtalmologie, hôpital Pontchaillou, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35000 Rennes, France
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Li J, Shen C, Chen Y, Zeng H, Cui L, Feng H. Organ donation after brain death from autoimmune glial fibrillary acidic protein astrocytopathy: A case report. Heliyon 2024; 10:e28558. [PMID: 38590842 PMCID: PMC10999923 DOI: 10.1016/j.heliyon.2024.e28558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 03/11/2024] [Accepted: 03/20/2024] [Indexed: 04/10/2024] Open
Abstract
Background No reports of organ donation have been documented in patients suffering from severe autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy. Case presentation A 27-year-old male patient developed a fever and headache, followed a week later by weakness and unsteadiness in his limbs. He attended his local hospital, but no cause was found. Thirteen days later, he became unconscious and was promptly moved to the intensive care unit for symptomatic support treatment, with no improvement. He was then transferred to our hospital, where he suffered a cardiac arrest on the same day. The family abandoned treatment and opted for organ donation, for financial reasons. Cell-based assays demonstrated GFAP antibodies in the cerebrospinal fluid. Two kidney recipients and one liver recipient showed no abnormal reactions 15 months after receiving organ transplants. Conclusions We report a case of organ donation following brain death in a patient diagnosed with GFAP astrocytopathy, highlighting the need for vigilance regarding the potential occurrence of cardiac arrest in patients with this condition. Considering the potential of GFAP astrocytopathy is crucial when observing deteriorating symptoms, seizures, and consciousness disturbances subsequent to a suspected viral infection. Successful organ donation from patients with GFAP astrocytopathy may be feasible given the exclusion of systemic infection and the absence of peripheral organ involvement.
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Affiliation(s)
| | | | | | | | - Liqian Cui
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, No. 58 Zhong Shan Road 2, Guangzhou, 510080, China
| | - Huiyu Feng
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, No. 58 Zhong Shan Road 2, Guangzhou, 510080, China
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Ke G, Jian S, Yang T, Zhao X. Clinical characteristics and MRI features of autoimmune glial fibrillary acidic protein astrocytopathy: a case series of 34 patients. Front Neurol 2024; 15:1375971. [PMID: 38585352 PMCID: PMC10995392 DOI: 10.3389/fneur.2024.1375971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 03/11/2024] [Indexed: 04/09/2024] Open
Abstract
Objectives To analyze the clinical and imaging characteristics of autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A). Methods Forty-three patients diagnosed with GFAP-A between March 2017 and July 2023 were retrospectively recruited. The clinical characteristics and magnetic resonance imaging (MRI) features were collected. Results Twenty-one patients (61.8%) had a fever and 16 (47.1%) had a headache. Five patients (14.7%) had coexisting neural autoantibodies and one patient (2.9%) had a coexisting neoplasm. The most common presentation was meningoencephalomyelitis (13/34, 38.3%), followed by meningoencephalitis (12/34, 35.3%). The other clinical manifestations included blurred visions (5/34, 14.7%) and peripheral nervous system involvement (4/34, 11.8%). Twenty-six patients (76.5%) had elevated nucleated cell count, predominantly lymphocytes (15/15, 100%), and 27 (79.4%) had elevated protein levels of cerebrospinal fluid. One-half (50%) of the patients presented with hyponatremia. A majority of the patients (30/33, 90.9%) exhibited abnormal hyperintense lesions on T2WI, which were often located in juxtacortical white matter (18/33, 54.5%), followed by periventricular white matter (16/33, 48.5%), basal ganglia (15/ 33, 45.5%), brainstem (11/33, 33.3%), and thalamic lesions (9/33, 27.3%). Twenty-four patients (72.7%) had abnormal brain enhancement, with supratentorial leptomeningeal enhancement being the most frequent enhancement pattern (15/33, 45.5%), followed by linear perivascular radial enhancement (14/33, 42.4%). Nineteen patients (70.4%) had hyperintense intramedullary spinal cord lesions, with long segments (15/27, 55.6%) and transverse lesions (14/27, 51.9%) being the most frequent lesions. Most cases were sensitive to immunotherapy, such as glucocorticoids, intravenous immunoglobulin, and tacrolimus, with three patients (8.8%) experiencing relapses. Patients with brainstem lesions had higher onset modified Rankin scale scores and were more prone to intensive care unit admissions. Linear perivascular radial enhancement was positively associated with poor prognosis (p < 0.05). Conclusion GFAP-A presented with meningoencephalomyelitis and meningoencephalitis. The brain lesions were often located in juxtacortical white matter, periventricular white matter, basal ganglia, brainstem, and thalamus. Long segments and transverse were the most frequent spine lesions. Leptomeningeal enhancement was the most frequent enhancement pattern, followed by linear perivascular radial enhancement, which may provide new insight into the differential diagnosis of GFAP-A.
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Affiliation(s)
| | | | | | - Xu Zhao
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Li X, Chen JJ, Hur M, Paton GR, McKeon A, Zekeridou A. Papillitis associated with IgLON5 autoimmunity: A novel clinical phenotype. J Neuroimmunol 2024; 388:578312. [PMID: 38364528 PMCID: PMC11152446 DOI: 10.1016/j.jneuroim.2024.578312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/22/2024] [Accepted: 02/04/2024] [Indexed: 02/18/2024]
Abstract
OBJECTIVES To describe papillitis as a clinical phenotype of IgLON5 autoimmunity. METHODS We retrospectively reviewed patients with IgLON5 autoimmunity who had optic neuropathy, optic neuritis, or optic disc edema. Sera from patients with recurrent papillitis were tested for IgLON5 antibodies. RESULTS We found two elderly males presenting with papillitis in the presence of IgLON5 antibodies. CSF pleocytosis was present and partial vision improvement occurred in one patient despite immunotherapy. Sera from 18 patients with recurrent papillitis were negative for IgLON5 antibodies. CONCLUSION Papillitis could be a manifestation of IgLON5 disease, with or without accompanying cognitive, sleep, and movement disorders.
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Affiliation(s)
- Xiaoyang Li
- Department of Neurology, Mayo Clinic, Rochester, USA
| | - John J Chen
- Department of Neurology, Mayo Clinic, Rochester, USA; Department of Ophthalmology, Mayo Clinic, Rochester, USA; Center of MS and Autoimmune Neurology, Mayo Clinic, Rochester, USA
| | - Minjun Hur
- Department of Neurology, Mayo Clinic, Rochester, USA; Department of Ophthalmology, Mayo Clinic, Rochester, USA
| | - Gillian R Paton
- Casey Eye Institute Division of Neuro-ophthalmology, Oregon Health & Science University, USA
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, USA; Center of MS and Autoimmune Neurology, Mayo Clinic, Rochester, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, USA
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, USA; Center of MS and Autoimmune Neurology, Mayo Clinic, Rochester, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, USA.
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Liu Y, Cui Y, Xiao H, Cai J, Zeng W, Lu Z. Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy With Visual Field Defect: A Case Report. J Neuroophthalmol 2024; 44:e82-e84. [PMID: 36729821 DOI: 10.1097/wno.0000000000001781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Yang Liu
- Department of Neurology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, PR China
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Greco G, Colombo E, Gastaldi M, Ahmad L, Tavazzi E, Bergamaschi R, Rigoni E. Beyond Myelin Oligodendrocyte Glycoprotein and Aquaporin-4 Antibodies: Alternative Causes of Optic Neuritis. Int J Mol Sci 2023; 24:15986. [PMID: 37958968 PMCID: PMC10649355 DOI: 10.3390/ijms242115986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/27/2023] [Accepted: 11/02/2023] [Indexed: 11/15/2023] Open
Abstract
Optic neuritis (ON) is the most common cause of vision loss in young adults. It manifests as acute or subacute vision loss, often accompanied by retrobulbar discomfort or pain during eye movements. Typical ON is associated with Multiple Sclerosis (MS) and is generally mild and steroid-responsive. Atypical forms are characterized by unusual features, such as prominent optic disc edema, poor treatment response, and bilateral involvement, and they are often associated with autoantibodies against aquaporin-4 (AQP4) or Myelin Oligodendrocyte Glycoprotein (MOG). However, in some cases, AQP4 and MOG antibodies will return as negative, plunging the clinician into a diagnostic conundrum. AQP4- and MOG-seronegative ON warrants a broad differential diagnosis, including autoantibody-associated, granulomatous, and systemic disorders. These rare forms need to be identified promptly, as their management and prognosis are greatly different. The aim of this review is to describe the possible rarer etiologies of non-MS-related and AQP4- and MOG-IgG-seronegative inflammatory ON and discuss their diagnoses and treatments.
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Affiliation(s)
- Giacomo Greco
- Multiple Sclerosis Centre, IRCCS Mondino Foundation, 27100 Pavia, Italy; (G.G.); (E.C.); (L.A.); (E.T.); (R.B.)
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy
| | - Elena Colombo
- Multiple Sclerosis Centre, IRCCS Mondino Foundation, 27100 Pavia, Italy; (G.G.); (E.C.); (L.A.); (E.T.); (R.B.)
| | - Matteo Gastaldi
- Neuroimmunology Research Unit, IRCCS Mondino Foundation, 27100 Pavia, Italy;
| | - Lara Ahmad
- Multiple Sclerosis Centre, IRCCS Mondino Foundation, 27100 Pavia, Italy; (G.G.); (E.C.); (L.A.); (E.T.); (R.B.)
| | - Eleonora Tavazzi
- Multiple Sclerosis Centre, IRCCS Mondino Foundation, 27100 Pavia, Italy; (G.G.); (E.C.); (L.A.); (E.T.); (R.B.)
| | - Roberto Bergamaschi
- Multiple Sclerosis Centre, IRCCS Mondino Foundation, 27100 Pavia, Italy; (G.G.); (E.C.); (L.A.); (E.T.); (R.B.)
| | - Eleonora Rigoni
- Multiple Sclerosis Centre, IRCCS Mondino Foundation, 27100 Pavia, Italy; (G.G.); (E.C.); (L.A.); (E.T.); (R.B.)
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Kraker JA, Chen JJ. An update on optic neuritis. J Neurol 2023; 270:5113-5126. [PMID: 37542657 DOI: 10.1007/s00415-023-11920-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 07/27/2023] [Accepted: 07/30/2023] [Indexed: 08/07/2023]
Abstract
Optic neuritis (ON) is the most common cause of subacute optic neuropathy in young adults. Although most cases of optic neuritis (ON) are classified as typical, meaning idiopathic or associated with multiple sclerosis, there is a growing understanding of atypical forms of optic neuritis such as antibody mediated aquaporin-4 (AQP4)-IgG neuromyelitis optica spectrum disorder (NMOSD) and the recently described entity, myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD). Differentiating typical ON from atypical ON is important because they have different prognoses and treatments. Findings of atypical ON, including severe vision loss with poor recovery with steroids or steroid dependence, prominent optic disc edema, bilateral vision loss, and childhood or late adult onset, should prompt serologic testing for AQP4-IgG and MOG-IgG. Although the traditional division of typical and atypical ON can be helpful, it should be noted that there can be severe presentations of otherwise typical ON and mild presentations of atypical ON that blur these traditional lines. Rare causes of autoimmune optic neuropathies, such as glial fibrillary acidic protein (GFAP) and collapsin response-mediator protein 5 (CRMP5) autoimmunity also should be considered in patients with bilateral painless optic neuropathy associated with optic disc edema, especially if there are other accompanying suggestive neurologic symptoms/signs. Typical ON usually recovers well without treatment, though recovery may be expedited by steroids. Atypical ON is usually treated with intravenous steroids, and some forms, such as NMOSD, often require plasma exchange for acute attacks and long-term immunosuppressive therapy to prevent relapses. Since treatment is tailored to the cause of the ON, elucidating the etiology of the ON is of the utmost importance.
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Affiliation(s)
- Jessica A Kraker
- Department of Ophthalmology, Mayo Clinic Hospital, Rochester, MN, USA
| | - John J Chen
- Department of Ophthalmology, Mayo Clinic Hospital, Rochester, MN, USA.
- Department of Neurology, Mayo Clinic Hospital, Rochester, MN, USA.
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Greco G, Masciocchi S, Diamanti L, Bini P, Vegezzi E, Marchioni E, Colombo E, Rigoni E, Businaro P, Ferraro OE, Bianchi Marzoli S, Bergamaschi R, Franciotta D, Gastaldi M. Visual System Involvement in Glial Fibrillary Acidic Protein Astrocytopathy: Two Case Reports and a Systematic Literature Review. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200146. [PMID: 37582612 PMCID: PMC10427126 DOI: 10.1212/nxi.0000000000200146] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/27/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND AND OBJECTIVES Glial fibrillary acidic protein (GFAP) antibodies can associate with an astrocytopathy often presenting as a meningoencephalitis. Visual involvement has been reported but scarcely defined. We describe 2 cases of GFAP astrocytopathy with predominant visual symptoms and present a systematic review of the literature. METHODS We describe 2 patients with GFAP astrocytopathy from our neurology department. We performed a systematic review of the literature according to PRISMA guidelines, including all patients with this disease and available clinical data, focusing on visual involvement. RESULTS Patient 1 presented with bilateral optic disc edema and severe sudden bilateral loss of vision poorly responsive to therapy. Patient 2 showed bilateral optic disc edema, headache, and mild visual loss with complete recovery after steroids. We screened 275 records and included 84 articles (62 case reports and 22 case series) for a total of 592 patients. Visual involvement was reported in 149/592 (25%), with either clinical symptoms or paraclinical test-restricted abnormalities. Bilateral optic disc edema was found in 80/159 (50%) of patients investigated with fundoscopy, among which 49/80 (61%) were asymptomatic. One hundred (100/592, 17%) reported visual symptoms, often described as blurred vision or transient visual obscurations. Optic neuritis was rare and diagnosed in only 6% of all patients with GFAP astrocytopathy, often without consistent clinical and paraclinical evidence to support the diagnosis. Four patients (including patient 1) manifested a severe, bilateral optic neuritis with poor treatment response. In patients with follow-up information, a relapsing disease course was more frequently observed in those with vs without visual involvement (35% vs 11%, p = 0.0035, OR 3.6 [CI 1.44-8.88]). DISCUSSION Visual system involvement in GFAP astrocytopathy is common and heterogeneous, ranging from asymptomatic bilateral optic disc edema to severe bilateral loss of vision, but optic neuritis is rare. GFAP CSF antibody testing should be considered in patients with encephalitis/meningoencephalitis or myelitis and bilateral optic disc edema, even without visual symptoms, and in patients with severe bilateral optic neuritis, especially when AQP4 antibodies are negative. Visual symptoms might associate with a higher relapse risk and help to identify patients who may require chronic immunosuppression.
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Affiliation(s)
- Giacomo Greco
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Stefano Masciocchi
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Luca Diamanti
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Paola Bini
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Elisa Vegezzi
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Enrico Marchioni
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Elena Colombo
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Eleonora Rigoni
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Pietro Businaro
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Ottavia E Ferraro
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Stefania Bianchi Marzoli
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Roberto Bergamaschi
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Diego Franciotta
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Matteo Gastaldi
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy.
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13
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Jia N, Wang J, He Y, Li Z, Lai C. Isolated optic neuritis with positive glial fibrillary acidic protein antibody. BMC Ophthalmol 2023; 23:184. [PMID: 37101204 PMCID: PMC10131402 DOI: 10.1186/s12886-023-02927-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: 09/13/2022] [Accepted: 04/19/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy (GFAP-A) has been reported as a spectrum of autoimmune, inflammatory central nervous system disorders. Linear perivascular radial gadolinium enhancement patterns on brain magnetic resonance imaging (MRI) are a hallmark of these disorders. GFAP-A is associated with cerebrospinal fluid (CSF) GFAP antibody (GFAP-Ab), while the association with serum GFAP-Ab is less clear. This study aimed to observe the clinical characteristic and MRI changes of GFAP-Ab-positive optic neuritis (ON). METHODS We performed a retrospective, observational case study at the department of neurology, Beijing Tongren Hospital, from December 2020 to December 2021. The serum of 43 patients and CSF samples of 38 patients with ON were tested for GFAP-Ab by cell-based indirect immune-fluorescence test. RESULTS Four patients (9.3%) were detected GFAP-Ab positive, and in three out of the four patients, GFAP-Abs were detected only in serum. All of them demonstrated unilateral optic neuritis. Three patients (1, 2, and 4) experienced severe visual loss (best corrected visual acuity ≤ 0.1). Two patients (2 and 4) had experienced more than one episode of ON at the time of sampling. MRI showed optic nerve hyperintensity on T2 FLAIR images in all GFAP-Ab positive patients, and orbital section involvement was the most common. During follow-up (mean 4.5 ± 1 months), only Patient 1 had a recurrent ON, and no patient developed new other neurological events or systemic symptoms. CONCLUSION GFAP-Ab is rare in patients with ON and may manifest as isolated, relapsing ON. This supports the notion that the GFAP-A spectrum should comprise isolated ON.
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Affiliation(s)
- Nan Jia
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Jiawei Wang
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yuhong He
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Zhong Li
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chuntao Lai
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China.
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14
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Bennett JL, Costello F, Chen JJ, Petzold A, Biousse V, Newman NJ, Galetta SL. Optic neuritis and autoimmune optic neuropathies: advances in diagnosis and treatment. Lancet Neurol 2023; 22:89-100. [PMID: 36155661 DOI: 10.1016/s1474-4422(22)00187-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 04/14/2022] [Accepted: 04/22/2022] [Indexed: 01/04/2023]
Abstract
Optic neuritis is an inflammatory optic neuropathy that is commonly indicative of autoimmune neurological disorders including multiple sclerosis, myelin-oligodendrocyte glycoprotein antibody-associated disease, and neuromyelitis optica spectrum disorder. Early clinical recognition of optic neuritis is important in determining the potential aetiology, which has bearing on prognosis and treatment. Regaining high-contrast visual acuity is common in people with idiopathic optic neuritis and multiple sclerosis-associated optic neuritis; however, residual deficits in contrast sensitivity, binocular vision, and motion perception might impair vision-specific quality-of-life metrics. In contrast, recovery of visual acuity can be poorer and optic nerve atrophy more severe in individuals who are seropositive for antibodies to myelin oligodendrocyte glycoprotein, AQP4, and CRMP5 than in individuals with typical optic neuritis from idiopathic or multiple-sclerosis associated optic neuritis. Key clinical, imaging, and laboratory findings differentiate these disorders, allowing clinicians to focus their diagnostic studies and optimise acute and preventive treatments. Guided by early and accurate diagnosis of optic neuritis subtypes, the timely use of high-dose corticosteroids and, in some instances, plasmapheresis could prevent loss of high-contrast vision, improve contrast sensitivity, and preserve colour vision and visual fields. Advancements in our knowledge, diagnosis, and treatment of optic neuritis will ultimately improve our understanding of autoimmune neurological disorders, improve clinical trial design, and spearhead therapeutic innovation.
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Affiliation(s)
- Jeffrey L Bennett
- Department of Neurology and Department of Ophthalmology, Programs in Neuroscience and Immunology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
| | - Fiona Costello
- Departments of Clinical Neurosciences and Surgery, University of Calgary, Calgary, AB, Canada
| | - John J Chen
- Department of Ophthalmology and Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Axel Petzold
- National Hospital for Neurology and Neurosurgery, University College London Hospital, London, UK; Moorfields Eye Hospital, London, UK; Neuro-ophthalmology Expert Centre, Amsterdam, Netherlands
| | - Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Nancy J Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurological Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Steven L Galetta
- Department of Neurology and Department of Opthalmology, NYU Langone Medical Center, New York, NY, USA
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15
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GFAP astrocytopathy presenting with profound intracranial hypertension and vision loss. J Neuroimmunol 2022; 373:577976. [PMID: 36270079 DOI: 10.1016/j.jneuroim.2022.577976] [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: 08/19/2022] [Revised: 09/17/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Glial fibrillary acidic protein (GFAP) astrocytopathy is a steroid-responsive autoimmune meningoencephalomyelitis commonly preceded by a viral illness. It is clinically characterized by encephalopathy, myelopathy and papillitis without significant effect on visual acuity. It can be associated with an underlying malignancy or autoimmune condition. OBJECTIVE To report a novel case of GFAP astrocytopathy presenting with profound intracranial hypertension and bilateral vision loss. METHODS Case report. RESULTS AND CONCLUSION GFAP astrocytopathy should be considered when evaluating patients with intracranial hypertension or bilateral vision loss, particularly when other features of autoimmune encephalitis are present.
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16
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Eide PK, Hansson HA. A New Perspective on the Pathophysiology of Idiopathic Intracranial Hypertension: Role of the Glia-Neuro-Vascular Interface. Front Mol Neurosci 2022; 15:900057. [PMID: 35903170 PMCID: PMC9315230 DOI: 10.3389/fnmol.2022.900057] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a neurological disease characterized by symptoms and signs of increased intracranial pressure (ICP) of unknown cause. Most attention has been given to the role of cerebrospinal fluid (CSF) disturbance and intracranial venous hypertension caused by sinus vein stenosis. We previously proposed that key pathophysiological processes take place within the brain at the glia-neuro-vascular interface. However, the relative importance of the proposed mechanisms in IIH disease remains unknown. Modern treatment regimens aim to reduce intracranial CSF and venous pressures, but a substantial proportion of patients experience lasting complaints. In 2010, the first author established a database for the prospective collection of information from individuals being assessed for IIH. The database incorporates clinical, imaging, physiological, and biological data, and information about treatment/outcome. This study retrieved information from the database, asking the following research questions: In IIH subjects responding to shunt surgery, what is the occurrence of signs of CSF disturbance, sinus vein stenosis, intracranial hypertension, and microscopic evidence of structural abnormalities at the glia-neuro-vascular interface? Secondarily, do semi-quantitative measures of abnormal ultrastructure at the glia-neurovascular differ between subjects with definite IIH and non-IIH (reference) subjects? The study included 13 patients with IIH who fulfilled the diagnostic criteria and who improved following shunt surgery, i.e., patients with definite IIH. Comparisons were done regarding magnetic resonance imaging (MRI) findings, pulsatile and static ICP scores, and immune-histochemistry microscopy. Among these 13 IIH subjects, 6/13 (46%) of patients presented with magnetic resonance imaging (MRI) signs of CSF disturbance (empty sella and/or distended perioptic subarachnoid spaces), 0/13 (0%) of patients with IIH had MRI signs of sinus vein stenosis, 13/13 (100%) of patients with IIH presented with abnormal preoperative pulsatile ICP [overnight mean ICP wave amplitude (MWA) above thresholds], 3/13 (23%) patients showed abnormal static ICP (overnight mean ICP above threshold), and 12/13 (92%) of patients with IIH showed abnormal structural changes at the glia-neuro-vascular interface. Comparisons of semi-quantitative structural variables between IIH and aged- and gender-matched reference (REF) subjects showed IIH abnormalities in glial cells, neurons, and capillaries. The present data suggest a key role of disease processes affecting the glia-neuro-vascular interface.
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Affiliation(s)
- Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital—Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- *Correspondence: Per Kristian Eide
| | - Hans-Arne Hansson
- Institute of Biomedicine, University of Gothenburg, Göteborg, Sweden
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17
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De Lott LB, Bennett JL, Costello F. The changing landscape of optic neuritis: a narrative review. J Neurol 2022; 269:111-124. [PMID: 33389032 PMCID: PMC8253868 DOI: 10.1007/s00415-020-10352-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 12/02/2020] [Accepted: 12/04/2020] [Indexed: 01/03/2023]
Abstract
Optic neuritis (ON) is an inflammatory optic neuropathy that is often a harbinger of central nervous system (CNS) demyelinating disorders. ON is frequently misdiagnosed in the clinical arena, leading to either inappropriate management or diagnostic delays. As a result, patients may fail to achieve optimal recovery. The treatment response to corticosteroids and long term risk of multiple sclerosis was established in the first clinical trials conducted roughly 30 years ago. Spontaneous resolution was observed in the vast majority of patients and intravenous high-dose corticosteroids hastened recovery; half of the patients eventually developed multiple sclerosis. Over the ensuing decades, the number of inflammatory conditions associated with ON has significantly expanded exposing substantial variability in the prognosis, treatment, and management of ON patients. ON subtypes can frequently be distinguished by distinct clinical, serological, and radiological profiles allowing expedited and specialized treatment. Guided by an increased understanding of the immunopathology underlying optic nerve and associated CNS injuries, novel disease management strategies are emerging to minimize vision loss, improve long-term surveillance strategies, and minimize CNS injury and disability. Knowledge regarding the clinical signs and symptoms of different ON subtypes is essential to guide acute therapy, prognosticate recovery, accurately identify underlying CNS inflammatory disorders, and facilitate study design for the next generation of clinical and translational trials.
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Affiliation(s)
- Lindsey B. De Lott
- Departments of Neurology, and Ophthalmology and Visual
Sciences, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeffrey L. Bennett
- Departments of Neurology and Ophthalmology, Programs in
Neuroscience and Immunology, University of Colorado, Denver, Colorado, USA
| | - Fiona Costello
- Departments of Clinical Neurosciences and Surgery
(Ophthalmology), University of Calgary, Calgary, Alberta, Canada
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18
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Xie JS, Donaldson L, Margolin E. Papilledema: A review of etiology, pathophysiology, diagnosis, and management. Surv Ophthalmol 2021; 67:1135-1159. [PMID: 34813854 DOI: 10.1016/j.survophthal.2021.11.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/05/2021] [Accepted: 11/15/2021] [Indexed: 02/06/2023]
Abstract
Papilledema is optic nerve head edema secondary to raised intracranial pressure (ICP). It is distinct from other causes of optic disk edema in that visual function is usually normal in the acute phase. Papilledema is caused by transmission of elevated ICP to the subarachnoid space surrounding the optic nerve that hinders axoplasmic transport within ganglion cell axons. There is ongoing controversy as to whether axoplasmic flow stasis is produced by physical compression of axons or microvascular ischemia. The most common cause of papilledema, especially in patients under the age of 50, is idiopathic intracranial hypertension (IIH); however, conditions that decrease cerebrospinal fluid (CSF) outflow by either causing CSF derangements or mechanically blocking CSF outflow channels, and rarely conditions that increase CSF production, can be the culprit. When papilledema is suspected clinically, blood pressure should be measured, and pseudopapilledema should be ruled out. Magnetic resonance imaging of the brain and orbits with venography sequences is the preferred neuroimaging modality that should be performed next to look for indirect imaging signs of increased ICP and to rule out nonidiopathic causes. Lumbar puncture with measurement of opening pressure and evaluation of CSF composition should then be performed. In patients not in a typical demographic group for IIH, further investigations should be conducted to assess for underlying causes of increased ICP. Magnetic resonance imaging of the neck and spine, magnetic resonance angiography of the brain, computed tomography of the chest, complete blood count, and creatinine testing should be able to identify most secondary causes of intracranial hypertension. Treatment for patients with papilledema should be targeted toward the underlying etiology. Most patients with IIH respond to weight loss and oral acetazolamide. For patients with decreased central acuity and constricted visual fields at presentation, as well as patients who do not respond to treatment with acetazolamide, surgical treatments should be considered, with ventriculoperitoneal shunting being the typical procedure of choice.
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Affiliation(s)
- Jim Shenchu Xie
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Laura Donaldson
- Faculty of Medicine, Department of Ophthalmology and Visual Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Edward Margolin
- Faculty of Medicine, Department of Ophthalmology and Visual Sciences, University of Toronto, Toronto, Ontario, Canada; Faculty of Medicine, Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.
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19
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Dumonceau AG, Ameli R, Rogemond V, Ruiz A, Joubert B, Muñiz-Castrillo S, Vogrig A, Picard G, Ambati A, Benaiteau M, Rulquin F, Ciron J, Deiva K, de Broucker T, Kremer L, Kerschen P, Sellal F, Bouldoires B, Genet R, Biberon J, Bigot A, Duval F, Issa N, Rusu EC, Goudot M, Dutray A, Devoize JL, Hopes L, Kaminsky AL, Philbert M, Chanson E, Leblanc A, Morvan E, Andriuta D, Diraison P, Mirebeau G, Derollez C, Bourg V, Bodard Q, Fort C, Grigorashvili-Coin I, Rieul G, Molinier-Tiganas D, Bonnan M, Tchoumi T, Honnorat J, Marignier R. Glial Fibrillary Acidic Protein Autoimmunity: A French Cohort Study. Neurology 2021; 98:e653-e668. [PMID: 34799461 PMCID: PMC8829963 DOI: 10.1212/wnl.0000000000013087] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 11/12/2021] [Indexed: 11/21/2022] Open
Abstract
Background and Objectives To report the clinical, biological, and imaging features and clinical course of a French cohort of patients with glial fibrillary acidic protein (GFAP) autoantibodies. Methods We retrospectively included all patients who tested positive for GFAP antibodies in the CSF by immunohistochemistry and confirmed by cell-based assay using cells expressing human GFAPα since 2017 from 2 French referral centers. Results We identified 46 patients with GFAP antibodies. Median age at onset was 43 years, and 65% were men. Infectious prodromal symptoms were found in 82%. Other autoimmune diseases were found in 22% of patients, and coexisting neural autoantibodies in 11%. Tumors were present in 24%, and T-cell dysfunction in 23%. The most frequent presentation was subacute meningoencephalitis (85%), with cerebellar dysfunction in 57% of cases. Other clinical presentations included myelitis (30%) and visual (35%) and peripheral nervous system involvement (24%). MRI showed perivascular radial enhancement in 32%, periventricular T2 hyperintensity in 41%, brainstem involvement in 31%, leptomeningeal enhancement in 26%, and reversible splenial lesions in 4 cases. A total of 33 of 40 patients had a monophasic course, associated with a good outcome at last follow-up (Rankin Score ≤2: 89%), despite a severe clinical presentation. Adult and pediatric features are similar. Thirty-two patients were treated with immunotherapy. A total of 11/22 patients showed negative conversion of GFAP antibodies. Discussion GFAP autoimmunity is mainly associated with acute/subacute meningoencephalomyelitis with prodromal symptoms, for which tumors and T-cell dysfunction are frequent triggers. The majority of patients followed a monophasic course with a good outcome.
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Affiliation(s)
- Alice Gravier Dumonceau
- Service de neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677 Lyon/Bron, France
| | - Roxana Ameli
- Service d'imagerie médicale, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677 Lyon/Bron, France
| | - Veronique Rogemond
- Centre de référence des syndromes neurologiques paranéoplasiques et encéphalites auto-immunes, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677 Lyon/Bron, France ; Institut NeuroMyoGène, INSERM 1217 et CNRS UMR5310, 69008 Lyon, France ; Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, 69008 Lyon, France
| | - Anne Ruiz
- Centre de Recherche en Neurosciences de Lyon, INSERM 1028 et CNRS UMR5292, 69003 Lyon, France
| | - Bastien Joubert
- Centre de référence des syndromes neurologiques paranéoplasiques et encéphalites auto-immunes, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677 Lyon/Bron, France ; Institut NeuroMyoGène, INSERM 1217 et CNRS UMR5310, 69008 Lyon, France ; Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, 69008 Lyon, France
| | - Sergio Muñiz-Castrillo
- Centre de référence des syndromes neurologiques paranéoplasiques et encéphalites auto-immunes, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677 Lyon/Bron, France ; Institut NeuroMyoGène, INSERM 1217 et CNRS UMR5310, 69008 Lyon, France ; Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, 69008 Lyon, France
| | - Alberto Vogrig
- Centre de référence des syndromes neurologiques paranéoplasiques et encéphalites auto-immunes, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677 Lyon/Bron, France ; Institut NeuroMyoGène, INSERM 1217 et CNRS UMR5310, 69008 Lyon, France ; Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, 69008 Lyon, France
| | - Geraldine Picard
- Centre de référence des syndromes neurologiques paranéoplasiques et encéphalites auto-immunes, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677 Lyon/Bron, France ; Institut NeuroMyoGène, INSERM 1217 et CNRS UMR5310, 69008 Lyon, France ; Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, 69008 Lyon, France
| | - Aditya Ambati
- Stanford University Center for Sleep Sciences and Medecine, Palo Alto, CA, USA
| | - Marie Benaiteau
- Service de neurologie cognitive, épilepsie, sommeil et mouvements anormaux, Hôpital Pierre-Paul Riquet, Hôpitaux de Toulouse, 31059 Toulouse, France
| | - Florence Rulquin
- Service de neurologie inflammatoire et neuro-oncologie, Hôpital Pierre-Paul Riquet, Hôpitaux de Toulouse, 31059 Toulouse, France
| | - Jonathan Ciron
- Service de neurologie inflammatoire et neuro-oncologie, Hôpital Pierre-Paul Riquet, Hôpitaux de Toulouse, 31059 Toulouse, France
| | - Kumaran Deiva
- Service de neuropédiatrie, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, 94270 Le Kremlin-Bicêtre, France
| | - Thomas de Broucker
- Service de neurologie, Hôpital Delafontaine, Centre Hospitalier de Saint-Denis, 93205 Saint-Denis, France
| | - Laurent Kremer
- Service de neurologie, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 67200 Strasbourg, France
| | - Philippe Kerschen
- Service de neurologie, Centre Hospitalier de Luxembourg, 1210 Luxembourg, Luxembourg
| | - François Sellal
- Service de neurologie, Hôpitaux Civils de Colmar, 68000 Colmar, France ; Unité INSERM U-1118, Faculté de Médecine, Université de Strasbourg
| | - Bastien Bouldoires
- Service de médecine interne, Hôpitaux civils de Colmar, 68000 Colmar, France
| | - Roxana Genet
- Service de médecine interne, Hôpital d'Instruction des Armées Legouest, 57000 Metz, France
| | - Jonathan Biberon
- Service de neurologie, Centre Hospitalier Régional Universitaire de Tours, 37044 Tours, France
| | - Adrien Bigot
- Service de médecine interne et immunologie clinique, Centre Hospitalier Régional Universitaire de Tours, 37044 Tours, France
| | - Fanny Duval
- Service de neurologie et maladies neuromusculaires, Groupe Hospitalier Pellegrin, Hôpitaux de Bordeaux, 33000 Bordeaux, France
| | - Nahema Issa
- Service de médecine intensive et réanimation, Hôpital Saint André, 33000 Bordeaux, France
| | - Elena-Camelia Rusu
- Service de neurologie, Hôpital Sainte Musse, Centre Hospitalier Intercommunal de Toulon, 83056 Toulon, France
| | - Mathilde Goudot
- Service de neurologie, Hôpital Emile Muller, 68100 Mulhouse, France
| | - Anais Dutray
- Service de neurologie, Centre Hospitalier de Perpignan, 66046 Perpignan, France
| | - Jean Louis Devoize
- Pôle Cardio-vasculaire et métabolique, Centre hospitalier de Cayenne, 97300 Cayenne, France
| | - Lucie Hopes
- Service de neurologie, Hôpital Central, CHRU Nancy, 54035 Nancy, France
| | - Anne-Laure Kaminsky
- Service de neurologie, CHU de Saint-Etienne, 42270 Saint-Priest-en-Jarez, France
| | - Marion Philbert
- Service de neuropédiatrie, Site Mère Enfant, CHU Martinique, 97200 Fort-de-France, France
| | - Eve Chanson
- Service de neurologie, CHU Gabriel-Montpied, CHU de Clermont-Ferrand, 63003 Clermont-Ferrand, France
| | - Amelie Leblanc
- Service de neurologie, Hôpital d'Instruction des Armées Clermont-Tonnerre, 29240 Brest, France
| | - Erwan Morvan
- Service de neurologie, Hôpital Fondation Adolphe de Rothschild, 75019 Paris, France
| | - Daniela Andriuta
- Service de Neurologie et Laboratoire de Neurosciences Fonctionnelles et Pathologies, Centre Hospitalier universitaire d'Amiens et Université de Picardie Jules Verne, Amiens, France
| | - Philippe Diraison
- Service de neurologie, Hôpital Laënnec, Centre Hospitalier de Cornouaille, 29107 Quimper, France
| | - Gabriel Mirebeau
- Service de neurologie, Centre Hospitalier Universitaire de La Réunion, 97410 Saint Pierre, France
| | - Celine Derollez
- Service de neurologie, Hôpital Roger Salengro, Centre Hospitalier Universitaire de Lille, 59037 Lille, France
| | - Veronique Bourg
- Service de neurologie, Hôpital Pasteur 2, Centre Hospitalier Universitaire de Nice, 06000 Nice, France
| | - Quentin Bodard
- Service de médecine interne et maladies infectieuses, Centre Hospitalier d'Angoulême, 16959 Angoulême, France
| | - Clementine Fort
- Service de neurologie pédiatrique, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 69677 Lyon/Bron, France
| | | | - Guillaume Rieul
- Service de réanimation, Centre Hospitalier de Saint-Brieuc, 22027 Saint-Brieuc, France
| | - Daniela Molinier-Tiganas
- Service de médecine polyvalente et de médecine interne, Centre Hospitalier Le Mans, 72037 Le Mans, France
| | - Mickaël Bonnan
- Service de neurologie, Centre Hospitalier de Pau, 64046 Pau, France
| | - Thierry Tchoumi
- Service de neurologie/UNV, Centre Hospitalier de Saintonge, 17100 Saintes, France
| | - Jérôme Honnorat
- Centre de référence des syndromes neurologiques paranéoplasiques et encéphalites auto-immunes, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677 Lyon/Bron, France ; Institut NeuroMyoGène, INSERM 1217 et CNRS UMR5310, 69008 Lyon, France ; Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, 69008 Lyon, France
| | - Romain Marignier
- Service de neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677 Lyon/Bron, France.,Centre de Recherche en Neurosciences de Lyon, INSERM 1028 et CNRS UMR5292, 69003 Lyon, France
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Vision Loss Associated With Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy. J Neuroophthalmol 2021; 42:e485-e487. [PMID: 34348360 DOI: 10.1097/wno.0000000000001323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Ducloyer JB, Marignier R, Wiertlewski S, Lebranchu P. Optic neuritis classification in 2021. Eur J Ophthalmol 2021; 32:11206721211028050. [PMID: 34218696 DOI: 10.1177/11206721211028050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Optic neuritis (ON) can be associated with inflammatory disease of the central nervous system or can be isolated, with or without relapse. It can also be associated with infectious or systemic disease. These multiple associations based on a variety of clinical, radiological, and biological criteria that have changed over time have led to overlapping phenotypes: a single ON case can be classified in several ways simultaneously or over time. As early, intensive treatment is often required, its diagnosis should be rapid and precise. In this review, we present the current state of knowledge about diagnostic criteria for ON aetiologies in adults and children, we discuss overlapping phenotypes, and we propose a homogeneous classification scheme. Even if distinctions between typical and atypical ON are relevant, their phenotypes are largely overlapping, and clinical criteria are neither sensitive enough, nor specific enough, to assure a diagnosis. For initial cases of ON, clinicians should perform contrast enhanced MRI of the brain and orbits, cerebral spinal fluid analysis, and biological analyses to exclude secondary infectious or inflammatory ON. Systematic screening for MOG-IgG and AQP4-IgG IgG is recommended in children but is still a matter of debate in adults. Early recognition of neuromyelitis optica spectrum disorder, MOG-IgG-associated disorder, and chronic relapsing idiopathic optic neuritis is required, as these diagnoses require therapies for relapse prevention that are different from those used to treat multiple sclerosis.
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Affiliation(s)
| | - Romain Marignier
- Centre de référence des maladies inflammatoires rares du cerveau et de la moelle (MIRCEM), Service de neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Lyon, Auvergne-Rhône-Alpes, France
| | | | - Pierre Lebranchu
- Department of Ophthalmology, University Hospital of Nantes, Nantes, France
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22
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Abstract
Discovery and characterization of serologic biomarkers has revolutionized the diagnostic framework of systemic and paraneoplastic autoimmune neuro-ophthalmic diseases. Expanding recognition of the multiple ocular and visual manifestations of these conditions highlights the important role of the referring provider in identifying potential cases. Increasing ease of access to serologic testing also enables these practitioners to initiate the diagnostic work-up in suspected cases. We aimed to provide an update on the current knowledge surrounding and use of relevant autoimmune biomarkers by correlating specific clinical neuro-ophthalmic manifestations with autoantibody biomarkers. The utility of select biomarkers for myasthenia gravis, neuromyelitis optica spectrum disorder, myelin oligodendrocyte glycoprotein-IgG-associated disorder, opsoclonus-myoclonus syndrome, anti-collapsin-response mediator protein-5 optic neuropathy, and glial fibrillary acidic protein-IgG-associated disease are discussed with particular focus on the clinical contexts in which to consider testing.
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Affiliation(s)
- Devon A Cohen
- Department of Ophthalmology, Harvard Medical School, Boston.,Department of Ophthalmology, Massachusetts Eye and Ear, Boston
| | - Ryan Gise
- Department of Ophthalmology, Harvard Medical School, Boston.,Department of Ophthalmology, Massachusetts Eye and Ear, Boston.,Department of Ophthalmology, Boston Children's Hospital, Boston
| | - Eric D Gaier
- Department of Ophthalmology, Harvard Medical School, Boston.,Department of Ophthalmology, Massachusetts Eye and Ear, Boston.,Department of Ophthalmology, Boston Children's Hospital, Boston.,Picower Institute for Learning and Memory, Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge
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23
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Bouffard MA, Chwalisz BK, Romero JM, Arrillaga-Romany IC, Massoth LR. Case 6-2021: A 65-Year-Old Man with Eye Pain and Decreased Vision. N Engl J Med 2021; 384:745-753. [PMID: 33626257 DOI: 10.1056/nejmcpc2027089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Marc A Bouffard
- From the Department of Neurology, Beth Israel Deaconess Medical Center (M.A.B.), the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Harvard Medical School - all in Boston
| | - Bart K Chwalisz
- From the Department of Neurology, Beth Israel Deaconess Medical Center (M.A.B.), the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Harvard Medical School - all in Boston
| | - Javier M Romero
- From the Department of Neurology, Beth Israel Deaconess Medical Center (M.A.B.), the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Harvard Medical School - all in Boston
| | - Isabel C Arrillaga-Romany
- From the Department of Neurology, Beth Israel Deaconess Medical Center (M.A.B.), the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Harvard Medical School - all in Boston
| | - Lucas R Massoth
- From the Department of Neurology, Beth Israel Deaconess Medical Center (M.A.B.), the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Harvard Medical School - all in Boston
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24
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25
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Enlarged and Enhancing Optic Nerves in Advanced Glial Fibrillary Acidic Protein Meningoencephalomyelitis. J Neuroophthalmol 2020; 39:411-415. [PMID: 31397693 DOI: 10.1097/wno.0000000000000842] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 36-year-old woman presented with intermittent fever, nausea and vomiting, generalized polyarthralgias, and bilateral optic disc swelling. She had a history of difficult-to-control myasthenia gravis since the age of 18 years. Lumbar puncture demonstrated a normal opening pressure; cerebrospinal fluid (CSF) was remarkable for high protein, low glucose, and a mononuclear pleocytosis. Although initial MRI of the brain was normal, a repeat study 8 weeks later revealed enlarged and enhancing bilateral intraorbital and intracranial optic nerves. After a nondiagnostic brain biopsy, a CSF sample tested positive for antibodies to glial fibrillary acidic protein (GFAP). Findings in this case indicate that optic nerve swelling encountered in GFAP meningoencephalomyelitis is more likely due to optic nerve inflammation rather than elevated intracranial pressure.
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26
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Rocca MA, Cacciaguerra L, Filippi M. Moving beyond anti-aquaporin-4 antibodies: emerging biomarkers in the spectrum of neuromyelitis optica. Expert Rev Neurother 2020; 20:601-618. [DOI: 10.1080/14737175.2020.1764352] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Maria A. Rocca
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Cacciaguerra
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Neurophysiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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27
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Yetimler B, Tzartos J, Şengül B, Dursun E, Ulukan Ç, Karagiorgou K, Gezen-Ak D, Sezgin M, Papaconstantinou A, Tzartos S, Orhan EK, Ekizoğlu E, Küçükali Cİ, Baykan B, Tüzün E. Serum glial fibrillary acidic protein (GFAP)-antibody in idiopathic intracranial hypertension. Int J Neurosci 2020; 131:775-779. [PMID: 32303142 DOI: 10.1080/00207454.2020.1758084] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AIM Idiopathic intracranial hypertension (IIH), a disease of obscure origin, is characterized by headache and visual disturbances due to increased intracranial pressure. Recent line of evidence has suggested involvement of inflammation in IIH pathogenesis thus bringing forward anti-glial autoimmunity as a potential contributor of IIH. Glial fibrillary acidic protein (GFAP) is a major astrocytic autoantigen associated with a specific form of meningoencephalitis. MATERIALS AND METHODS In this study, we investigated the presence of GFAP-antibody in 65 sera (49 obtained during active disease and 16 during remission) and in 15 cerebrospinal fluid (CSF) samples of 58 consecutively recruited IIH patients using cell based assay and indirect immunohistochemistry. RESULTS GFAP-antibody was found in active period sera of 2 IIH patients with classical symptoms and good treatment response. Two remission period sera obtained at different time points from one of these cases showed lower titers of GFAP-antibody positivity. IgG from positive samples yielded an astrocytic immunoreactivity pattern. None of the CSF samples showed GFAP-antibodies. CONCLUSIONS These results suggest that anti-astrocyte autoimmunity might be present in a fraction of IIH patients. Exact pathogenic significance of this association needs to be further studied.
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Affiliation(s)
- Berrak Yetimler
- Department of Neuroscience, Aziz Sancar Institute for Experimental Medical Research, Istanbul University, Istanbul, Turkey
| | - John Tzartos
- Tzartos NeuroDiagnostics, Athens, Greece.,1st Department of Neurology, Eginition Hospital, Medical School, University of Athens, Athens, Greece
| | - Büşra Şengül
- Department of Medical Biology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Erdinç Dursun
- Department of Medical Biology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey.,Department of Neuroscience, Institute of Neurological Sciences, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Çağrı Ulukan
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Duygu Gezen-Ak
- Department of Medical Biology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Mine Sezgin
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Socrates Tzartos
- Tzartos NeuroDiagnostics, Athens, Greece.,Hellenic Pasteur Institute, Athens, Greece
| | - Elif Kocasoy Orhan
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Esme Ekizoğlu
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Cem İsmail Küçükali
- Department of Neuroscience, Aziz Sancar Institute for Experimental Medical Research, Istanbul University, Istanbul, Turkey
| | - Betül Baykan
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Erdem Tüzün
- Department of Neuroscience, Aziz Sancar Institute for Experimental Medical Research, Istanbul University, Istanbul, Turkey
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Abstract
The current management of acute optic neuritis (ON) is focused on expediting visual recovery through the use of high-dose intravenous corticosteroids. The recent identification of specific autoantibodies associated with central nervous system inflammatory disorders has provided novel insights into immune targets and mechanisms that impact the prognosis, treatment, and recurrence of ON. Therefore, neurologists and ophthalmologists need to be aware of clinical, laboratory, and imaging findings that may provide important clues to the etiology of ON and the potential need for aggressive management. Moving forward, rapid and accurate diagnosis of inflammatory ON will likely be critical for implementing clinical care that optimizes short-term and long-term therapeutic outcomes.
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Abstract
PURPOSE OF REVIEW This article discusses the clinical presentation, evaluation, and management of the patient with optic neuritis. Initial emphasis is placed on clinical history, examination, diagnostic testing, and medical decision making, while subsequent focus is placed on examining specific inflammatory optic neuropathies. Clinical clues, examination findings, neuroimaging, and laboratory testing that differentiate autoimmune, granulomatous, demyelinating, infectious, and paraneoplastic causes of optic neuritis are assessed, and current treatments are evaluated. RECENT FINDINGS Advances in technology and immunology have enhanced our understanding of the pathologies driving inflammatory optic nerve injury. Clinicians are now able to interrogate optic nerve structure and function during inflammatory injury, rapidly identify disease-relevant autoimmune targets, and deliver timely therapeutics to improve visual outcomes. SUMMARY Optic neuritis is a common clinical manifestation of central nervous system inflammation. Depending on the etiology, visual prognosis and the risk for recurrent injury may vary. Rapid and accurate diagnosis of optic neuritis may be critical for limiting vision loss, future neurologic disability, and organ damage. This article will aid neurologists in formulating a systematic approach to patients with optic neuritis.
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Abstract
Purpose of review To describe a recently characterized autoimmune, inflammatory central nervous system (CNS) disorder known as autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy. Recent findings Affected patients present with symptoms of one or more of meningitis (headache and neck ache), encephalitis (delirium, tremor, seizures, or psychiatric symptoms), and myelitis (sensory symptoms and weakness). Optic disc papillitis (blurred vision) is common. CNS inflammation is evident in characteristic T1 postgadolinium enhancement of GFAP-enriched CNS regions, and lymphocytic cerebrospinal fluid (CSF) white cell count elevation. CSF is more reliable than serum for GFAP-immunoglobulin G (IgG) testing. Ovarian teratoma commonly coexists, particularly among patients with accompanying N-methyl-D-aspartate receptor or aquaporin-4 autoimmunity. Parainfectious autoimmunity is suspected in some other patients, though the culprit organism is rarely verified. Pathophysiologic relevance of T cells is underscored by neuropathology and cases of dysregulated T-cell function (HIV or checkpoint inhibitor cancer therapy). Corticosteroid-responsiveness is a hallmark of the disease. Relapses occur in approximately 20% of patients, necessitating transition to a steroid-sparing drug. Reported outcomes vary, though in the authors’ experience, early and sustained intervention usually portends recovery. Summary Autoimmune GFAP astrocytopathy is a treatable autoimmune CNS disease diagnosable by GFAP-IgG testing in CSF. This disease presents opportunities to explore novel mechanisms of CNS autoimmunity and inflammation.
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Flanagan EP. Neuromyelitis Optica Spectrum Disorder and Other Non-Multiple Sclerosis Central Nervous System Inflammatory Diseases. Continuum (Minneap Minn) 2019; 25:815-844. [PMID: 31162318 DOI: 10.1212/con.0000000000000742] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW This article reviews the clinical features, diagnostic approach, treatment, and prognosis of central nervous system inflammatory diseases that mimic multiple sclerosis (MS), including those defined by recently discovered autoantibody biomarkers. RECENT FINDINGS The discovery of autoantibody biomarkers of inflammatory demyelinating diseases of the central nervous system (aquaporin-4 IgG and myelin oligodendrocyte glycoprotein IgG) and the recognition that, despite some overlap, their clinical phenotypes are distinct from MS have revolutionized this field of neurology. These autoantibody biomarkers assist in diagnosis and have improved our understanding of the underlying disease pathogenesis. This has allowed targeted treatments to be translated into clinical trials, three of which are now under way in aquaporin-4 IgG-seropositive neuromyelitis optica (NMO) spectrum disorder. SUMMARY Knowledge of the clinical attributes, MRI findings, CSF parameters, and accompanying autoantibody biomarkers can help neurologists distinguish MS from its inflammatory mimics. These antibody biomarkers provide critical diagnostic and prognostic information and guide treatment decisions. Better recognition of the clinical, radiologic, and laboratory features of other inflammatory MS mimics that lack autoantibody biomarkers has allowed us to diagnose these disorders faster and initiate disease-specific treatments more expeditiously.
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Glial Fibrillary Acidic Protein Antibody: Another Antibody in the Multiple Sclerosis Diagnostic Mix. J Neuroophthalmol 2018; 38:281-284. [PMID: 29923872 DOI: 10.1097/wno.0000000000000689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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