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Zhou K, Zhang L, Shen S, Lin JF, Wang JR, Zhou D, Li JM, Sima X. Neurological autoantibody prevalence in chronic epilepsy: Clinical and neuropathologic findings. Seizure 2024; 115:28-35. [PMID: 38183825 DOI: 10.1016/j.seizure.2023.12.018] [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: 09/24/2023] [Revised: 12/18/2023] [Accepted: 12/25/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND We aimed to explore the prevalence of autoimmune antibodies (Abs) in a large consecutive series with "chronic" epilepsy and without symptoms of autoimmune encephalitis; and to compare the immunopathology of brain tissue from drug-resistant epilepsy (DRE) with and without Abs positivity. METHODS Neuronal and glial antibodies were detected in the serum of patients who were admitted to the wards of West China Hospital from October 2016 to September 2019 and had epilepsy by cell-based assays and tissue-based assays. RESULTS Twenty-one (6.8 %) of 328 patients had positive Ab findings for the following: dipeptidyl-peptidase-like protein-6 (n = 7), contactin-associated protein-like 2 (n = 5), glutamic acid decarboxylase 65 (n = 4), gamma aminobutyric acid beta receptor (n = 2), N-methyl-d-aspartate receptor (n = 2), and dopamine D2 receptor (n = 1). Antibodies were detected in 6.9 % (13/187) of epilepsy people with unknown etiology and 5.6 % (8/141) of patients with known etiology, respectively. Among 190 patients with DRE, 14 (7.3 %) patients were Abs-positive. There was no significant difference between individuals with seropositive and seronegative results in clinical manifestations, except that the history of febrile seizure was significantly more frequent in the seropositive group. Moreover, brain samples from 3 patients with Abs-positive DRE (with DPPX in 2 patients, and CASPR2 in 1 patient) and 18 patients with Abs-negative DRE were analyzed for immunopathology. We found higher expression of CD8-positive T-cells in the hippocampus of Abs-positive DRE group. CONCLUSIONS Neuronal antibodies are potentially involved in the process of "chronic" epilepsy, and CD8-positive T-cells may play an important role in this process.
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Affiliation(s)
- Kui Zhou
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan 610041, China
| | - Le Zhang
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Sisi Shen
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan 610041, China
| | - Jing-Fang Lin
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan 610041, China
| | - Jie-Rui Wang
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan 610041, China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan 610041, China
| | - Jin-Mei Li
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan 610041, China.
| | - Xiutian Sima
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Grebenciucova E, VanHaerents S. Interleukin 6: at the interface of human health and disease. Front Immunol 2023; 14:1255533. [PMID: 37841263 PMCID: PMC10569068 DOI: 10.3389/fimmu.2023.1255533] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/11/2023] [Indexed: 10/17/2023] Open
Abstract
Interleukin 6 (IL-6) is a pleiotropic cytokine executing a diverse number of functions, ranging from its effects on acute phase reactant pathways, B and T lymphocytes, blood brain barrier permeability, synovial inflammation, hematopoiesis, and embryonic development. This cytokine empowers the transition between innate and adaptive immune responses and helps recruit macrophages and lymphocytes to the sites of injury or infection. Given that IL-6 is involved both in the immune homeostasis and pathogenesis of several autoimmune diseases, research into therapeutic modulation of IL-6 axis resulted in the approval of a number of effective treatments for several autoimmune disorders like neuromyelitis optica spectrum disorder (NMOSD), rheumatoid arthritis, juvenile idiopathic arthritis, polyarticular juvenile idiopathic arthritis, giant cell arteritis (GCA), and cytokine release syndrome, associated with SARS-CoV2 pneumonia. This review discusses downstream inflammatory pathways of IL-6 expression and therapeutic applications of IL-6 blockade, currently investigated for the treatment of several other autoimmune conditions such as autoimmune encephalitis, autoimmune epilepsy, as well as myelin oligodendrocyte glycoprotein associated demyelination (MOGAD). This review further highlights the need for clinical trials to evaluate IL-6 blockade in disorders such neuropsychiatric lupus erythematosus (SLE), sarcoidosis and Behcet's.
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Affiliation(s)
- Elena Grebenciucova
- Feinberg School of Medicine, Department of Neurology, Northwestern University, Chicago, IL, United States
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3
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CDKL5 Deficiency Disorder-Related Epilepsy: A Review of Current and Emerging Treatment. CNS Drugs 2022; 36:591-604. [PMID: 35633486 PMCID: PMC9876658 DOI: 10.1007/s40263-022-00921-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2022] [Indexed: 01/27/2023]
Abstract
Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder (CDD) is a developmental and epileptic encephalopathy with infantile-onset epilepsy. Most individuals with CDD develop refractory epilepsy with multiple seizure types. Management of seizures in CDD remains challenging for clinicians given the highly refractory nature of seizures and the limited number of disease-specific studies that offer a high level of evidence. Epileptic spasms are the most common seizure type in CDD and are more often refractory to standard first-line treatment than are spasms of other etiologies. In other seizure types, the effectiveness of antiseizure medications is limited and wanes over time. Ketogenic diet and palliative surgical treatments have both had mixed results in observational studies. When treating refractory seizures in CDD, we recommend carefully balancing seizure control and treatment-related side effects to optimize each individual's overall quality of life. Clinical trials of medications targeting epilepsy in CDD have been conducted, and additional investigational small molecules, gene therapy, and other disease-modifying therapies are in development for CDD.
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Wanigasinghe J, Chang T. Autoimmune epilepsy due to N-methyl-D-aspartate receptor antibodies in a child: a case report. J Med Case Rep 2021; 15:516. [PMID: 34666812 PMCID: PMC8527639 DOI: 10.1186/s13256-021-03117-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 09/18/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction Seizures of autoimmune etiology may occur independent of or predate syndromes of encephalitis. We report a child with “pure” autoimmune epilepsy followed up for 7 years to highlight long-term effects of this epilepsy and the importance of early initiation and appropriate escalation of immunosuppression to achieve a good long-term outcome. Case presentation A previously healthy 5-year-old Sri Lankan boy presented with acute, frequent, brief focal seizures of temporal-lobe semiology without clinical and investigatory findings suggestive of central nervous system infection, tumor, structural abnormality, or metabolic causes. His epilepsy showed poor response to increasing doses and combinations of antiseizure medications. Further investigations detected N-methyl-d-aspartate receptor antibodies in serum, but not cerebrospinal fluid. Treatment with intravenous methyl prednisolone and maintenance on mycophenolate resulted in a rapid reduction, with seizure freedom achieved within 5–6 weeks. He relapsed when immunotherapy and anti seizure medications were reduced after seizure freedom for 24 months. This, and subsequent relapses, showed poor response to modification of anti-seizure medications, but treatment with immunotherapy (methyl prednisolone and rituximab) achieved complete seizure freedom. At 7-years of follow-up, he remains free of seizure for over 3 years, and has average academic performance and satisfactory quality of life. Conclusions Autoimmune epilepsy is a recognized independent entity. Diagnostic criteria have been suggested for its early recognition and confirmation of diagnosis. Early diagnosis and initiation of immunosuppression, with prompt escalation of treatment when necessary, remains key to good patient outcome.
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Affiliation(s)
- Jithangi Wanigasinghe
- Department of Paediatrics, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.
| | - Thashi Chang
- Department of Clinical Medicine, University of Colombo, Colombo, Sri Lanka
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5
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Tsiortou P, Alexopoulos H, Dalakas MC. GAD antibody-spectrum disorders: progress in clinical phenotypes, immunopathogenesis and therapeutic interventions. Ther Adv Neurol Disord 2021; 14:17562864211003486. [PMID: 33854562 PMCID: PMC8013924 DOI: 10.1177/17562864211003486] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 02/27/2021] [Indexed: 12/14/2022] Open
Abstract
Antibodies against glutamic acid decarboxylase (GAD), originally linked to stiff person syndrome (SPS), now denote the "GAD antibody-spectrum disorders" (GAD-SD) that also include autoimmune epilepsy, limbic encephalitis, cerebellar ataxia and nystagmus with overlapping symptomatology highlighting autoimmune neuronal excitability disorders. The reasons for the clinical heterogeneity among GAD-antibody associated syndromes remain still unsettled, implicating variable susceptibility of GABAergic neurons to anti-GAD or other still unidentified autoantibodies. Although anti-GAD antibody titers do not correlate with clinical severity, very high serum titers, often associated with intrathecal synthesis of anti-GAD-specific IgG, point to in-situ effects of GAD or related autoantibodies within the central nervous system. It remains, however, uncertain what drives these antibodies, why they persist and whether they are disease markers or have pathogenic potential. The review, focused on these concerns, describes the widened clinical manifestations and overlapping features of all GAD-SD; addresses the importance of GAD antibody titers and potential significance of GAD epitopes; summarizes the biologic basis of autoimmune hyperexcitability; highlights the electrophysiological basis of reciprocal inhibition in muscle stiffness; and provides practical guidelines on symptomatic therapies with gamma-aminobutyric acid-enhancing drugs or various immunotherapies.
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Affiliation(s)
- Popianna Tsiortou
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Philadelphia, PA 19107, USA; Neuroimmunology Unit, National and Kapodistrian University of Athens, Athens, Greece
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Leary LD. Autoimmune Epilepsy in Children: Unraveling the Mystery. Pediatr Neurol 2020; 112:73-77. [PMID: 32920307 DOI: 10.1016/j.pediatrneurol.2020.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 12/29/2022]
Abstract
Although many neurologists are familiar with the clinical presentations of anti-N-methyl-d-aspartate receptor or limbic encephalitides, there remains much mystery surrounding autoimmune etiologies of subacute and chronic epilepsies. In addition, the subtleties and differences in presentation in the pediatric population limit diagnosis and challenge clinicians. In the absence of an acute encephalitic picture, it is likely that many clinicians do not test for autoimmune disorders due to the uncertainty surrounding the selection of appropriate candidates for testing and immunomodulation. Recent developments have expanded the definition of epilepsy related to autoimmune mechanisms. Based on current knowledge, autoimmune epilepsy can best be thought of as a subset of autoimmune encephalitis where seizures and epilepsy are the primary presenting factor. Autoimmune epilepsy has been increasingly recognized as a contributor to drug-resistant epilepsies; however, identification of affected individuals remains challenging, particularly in the pediatric population. Our understanding of autoimmune epilepsy continues to evolve as more individuals with epilepsy are tested for antibodies to neuronal proteins and as additional antibodies are being identified. This article provides an overview of the clinical features most commonly associated with positive antibody testing in epilepsy and the scales that are currently available to screen patients for antibody testing and response to immunotherapy. Literature-based recommendations are presented for the modification and validation of current scales to increase applicability to children.
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Affiliation(s)
- Linda D Leary
- Department of Pediatrics and Neurology, University of Texas Health Science Center San Antonio, San Antonio, Texas.
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Steriade C, Britton J, Dale RC, Gadoth A, Irani SR, Linnoila J, McKeon A, Shao X, Venegas V, Bien CG. Acute symptomatic seizures secondary to autoimmune encephalitis and autoimmune‐associated epilepsy: Conceptual definitions. Epilepsia 2020; 61:1341-1351. [DOI: 10.1111/epi.16571] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 05/10/2020] [Accepted: 05/12/2020] [Indexed: 12/12/2022]
Affiliation(s)
| | - Jeffrey Britton
- Division of Epilepsy Department of Neurology Mayo Clinic Rochester MN USA
| | - Russell C. Dale
- The Children's Hospital at Westmead Kids Neuroscience Centre University of Sydney Sydney NSW Australia
| | - Avi Gadoth
- Department of Neurology Encephalitis Center Tel‐Aviv Medical Center Tel‐Aviv Israel
| | - Sarosh R. Irani
- Oxford Autoimmune Neurology Group Nuffield Department of Clinical Neurosciences University of Oxford Oxford UK
| | - Jenny Linnoila
- Department of Neurology Massachusetts General Hospital Boston MA USA
| | - Andrew McKeon
- Department of Neurology and Immunology Mayo Clinic Rochester MN USA
| | - Xiao‐Qiu Shao
- Department of Neurology Beijing Tiantan HospitalChina National Clinical Research Center for Neurological DiseasesCapital Medical University Beijing China
| | - Viviana Venegas
- Unit of Neuropediatrics Advanced Center of Epilepsy Clinica Alemana de Santiago Chile
- Unit of Neurophysiology Instituto de Neurocirugía Asenjo Santiago Chile
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Epilepsy and autoimmune diseases: Comorbidity in a national patient cohort. Seizure 2019; 75:89-95. [PMID: 31918165 DOI: 10.1016/j.seizure.2019.12.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/05/2019] [Accepted: 12/17/2019] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To examine if autoimmune disorders occur with an increased frequency in patients with epilepsy. An autoimmune etiology of epilepsies has been suggested. By using data from The Norwegian Prescription Database (NorPD) we have surveyed a national cohort of patients with active epilepsy treated with antiepileptic drugs. METHODS NorPD contains all prescriptions of drugs dispensed at pharmacies in Norway since 2004. We received data of all drugs prescribed January 2004 - June 2014 for patients receiving an antiepileptic drug.79 751 patients receiving at least two prescriptions of antiepileptic drugs with the reimbursement code for epilepsy were included. To examine autoimmune comorbidity, medications specific for autoimmune diseases were retrieved. Standardized Incidence Ratios (SIR) with 95 % confidence interval (CI) were used to determine whether the occurrence of the prescribed autoimmune drugs in the epilepsy group deviated from the general population. Subgroups stratified for sex and age were examined. RESULTS The epilepsy patients were more often treated with insulin and insulin analogs, SIR 1.8 (95 % CI 1.7-1.9); thyroid substitution, SIR 1.7 (95 % CI 1.7-1.8); pyridostigmine, SIR 1.5 (95 % CI 1.1-2.1); multiple sclerosis (MS) medications, SIR 4.9 (95 % CI 4.6-5.3); and immunosuppressive drugs SIR 1.2 (95 % CI 1.1-1.2). All epilepsy subgroups were more often than expected treated with thyroid substitution. CONCLUSIONS Based on a large, unselected patient cohort we find that epilepsy patients more often are prescribed medications used to treat type 1 diabetes mellitus, hypothyroidism, myasthenia gravis and MS. This was true for both men and women, and in most age-groups.
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Lee KH, Lee YJ, Seo JH, Baumgartner JE, Westerveld M. Epilepsy Surgery in Children versus Adults. J Korean Neurosurg Soc 2019; 62:328-335. [PMID: 31085959 PMCID: PMC6514317 DOI: 10.3340/jkns.2019.0026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 02/24/2019] [Indexed: 11/29/2022] Open
Abstract
Epilepsy is one of the most common chronic neurological disorder affecting 6–7 per 1000 worldwide. Nearly one-third of patients with newly diagnosed epilepsy continue to have recurrent seizures despite adequate trial of more than two anti-seizure drugs : drug-resistant epilepsy (DRE). Children with DRE often experience cognitive and psychosocial co-morbidities requiring more urgent and aggressive treatment than adults. Epilepsy surgery can result in seizure-freedom in approximately two-third of children with improvement in cognitive development and quality of life. Understanding fundamental differences in etiology, co-morbidity, and neural plasticity between children and adults is critical for appropriate selection of surgical candidates, appropriate presurgical evaluation and surgical approach, and improved overall outcome.
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Affiliation(s)
- Ki Hyeong Lee
- Comprehensive Epilepsy Center, Advent Health for Children, Orlando, FL, USA
| | - Yun-Jin Lee
- Comprehensive Epilepsy Center, Advent Health for Children, Orlando, FL, USA.,Department of Pediatrics, Pusan University College of Medicine, Yangsan, Korea
| | - Joo Hee Seo
- Comprehensive Epilepsy Center, Advent Health for Children, Orlando, FL, USA
| | | | - Michael Westerveld
- Comprehensive Epilepsy Center, Advent Health for Children, Orlando, FL, USA
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Serino D, Santarone ME, Caputo D, Fusco L. Febrile infection-related epilepsy syndrome (FIRES): prevalence, impact and management strategies. Neuropsychiatr Dis Treat 2019; 15:1897-1903. [PMID: 31371963 PMCID: PMC6635824 DOI: 10.2147/ndt.s177803] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 06/13/2019] [Indexed: 12/27/2022] Open
Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a rare catastrophic epileptic encephalopathy with a yet undefined etiology, affecting healthy children. It is characterized by acute manifestation of recurrent seizures or refractory status epilepticus preceded by febrile illness, but without evidence of infectious encephalitis. To date, the absence of specific biomarkers poses a significant diagnostic challenge; nonetheless, early diagnosis is very important for optimal management. FIRES is mostly irreversible and its sequelae include drug-resistant epilepsy and neuropsychological impairments. The treatment of FIRES represents a significant challenge for clinicians and is associated with low success rates. Early introduction of ketogenic diet seems to represent the most effective and promising treatment. This review aims to highlight the most recent insights on clinical features, terminology, epidemiology, pathogenesis, diagnostic challenges and therapeutic options.
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Affiliation(s)
- Domenico Serino
- Department of Child Neurology, Royal Aberdeen Children's Hospital, Aberdeen, UK
| | | | - Davide Caputo
- Neurology Unit, Neuroscience Department, San Paolo Hospital, Milan, Italy
| | - Lucia Fusco
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
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Mycophenolate mofetil, azathioprine and methotrexate usage in paediatric anti-NMDAR encephalitis: A systematic literature review. Eur J Paediatr Neurol 2019; 23:7-18. [PMID: 30318435 DOI: 10.1016/j.ejpn.2018.09.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/12/2018] [Accepted: 09/23/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Available data on mycophenolate mofetil (MMF), azathioprine (AZA) and methotrexate (MTX) for paediatric-onset anti-N-methyl-d-aspartate receptor encephalitis (anti-NMDARE) is limited. METHODS Systematic literature review on patients treated with MMF/AZA/MTX for paediatric-onset anti-NMDARE, with focus on modes of use, efficacy and safety. RESULTS 87 patients were included (age at onset median 11 years, range 0.8-18 years; 69% females). 46% had a relapsing course. 52% received MMF, 27% AZA, 15% MTX, and 6% a combination of MMF/AZA/MTX (7 patients received intrathecal MTX). Before MMF/AZA/MTX, 100% patients received steroids, 83% intravenous immunoglobulin and 45% plasma exchange, and 50% received second-line treatments (rituximab/cyclophosphamide). MMF/AZA/MTX were administered >6 months from onset in 51%, and only after relapse in 40%. Worst mRS before MMF/AZA/MTX was median 4.5 (range 3-5). At last follow-up (median 2 years, range 0.2-8.6), median mRS was 1 (range 0-6). Median annualised relapse rate was 0.4 (range 0-6.7) pre-MMF/AZA/MTX (excluding first events), and 0 on MMF/AZA/MTX (mean 0.03, range 0-0.8). 7% patients relapsed on MMF/AZA/MTX. These relapsing patients had low rate of second-line treatments before MMF/AZA/MTX (25%), long median time between onset and MMF/AZA/MTX usage (18 months), and frequently they were started on MMF/AZA/MTX only after relapse (75%). Relapse rate was lower among patients who received first immune therapy ≤30 days (25%) than later (64%), who received second-line treatments at first event (14%) rather than not (64%), who were started on MMF/AZA/MTX after the first (12%) rather than subsequent events (17%), and who were started on MMF/AZA/MTX ≤3 months from onset (33%) rather than later (53%). Adverse reactions to MMF/AZA/MTX occurred in 2 cases (cytomegalovirus colitis and respiratory infection), of grade 3 Common Terminology Criteria for Adverse Events v4.0. DISCUSSION Our literature review disclosed heterogeneity in the use of MMF/AZA/MTX in paediatric-onset anti-NMDARE. MMF/AZA/MTX usage is mostly restricted to retrospective cohort descriptions. These agents may reduce risk of relapse, and have a reasonable safety profile, however data on larger cohorts are required to definitively determine effect.
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12
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Investigation of neuronal auto-antibodies in children diagnosed with epileptic encephalopathy of unknown cause. Brain Dev 2018; 40:909-917. [PMID: 29935963 DOI: 10.1016/j.braindev.2018.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 05/29/2018] [Accepted: 06/03/2018] [Indexed: 01/13/2023]
Abstract
AIM Cryptogenic forms of epileptic encephalopathies (EE) with their well-known features of drug-resistance, mental deterioration and partial response to immunotherapies are ideal candidates for screening for neuronal autoantibodies (NAA). METHOD Fifty consecutive pediatric patients with a diagnosis of EE of unknown cause were included. Nine NAAs were tested by ELISA, RIA or cell-based assays. Clinical features of seronegative and seropositive patients were compared. RESULTS NAAs were found in 7/50 (14%) patients. They were N-methyl-d-aspartate receptor in two (4%), glycine receptor in two (4%), contactin-associated protein-like 2 in one (2%), glutamic acid decarboxylase in one (2%) and type A gamma aminobutyric acid receptor in one patient (2%). Furthermore, serum IgGs of two patients negative for well-characterized NAAs, showed strong reactivity with the uncharacterized membrane antigens of live hippocampal neurons. There were no significant differences between seropositive and seronegative patients by means of epilepsy duration, anti-epileptic drug resistance, EE type, types of seizures, seizure frequencies, EEG features or coexisting autoimmune diseases. Some seropositive patients gave good-moderate response to immunotherapy. DISCUSSION Potential clues for the possible role of autoimmunity in seropositive patients with EE were atypical prognosis of the classical EE type, atypical progression and unusual neurological findings like dyskinesia.
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13
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Guerin J, Watson RE, Carr CM, Liebo GB, Kotsenas AL. Autoimmune epilepsy: findings on MRI and FDG-PET. Br J Radiol 2018; 92:20170869. [PMID: 30235015 DOI: 10.1259/bjr.20170869] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Autoimmune epilepsy (AE) is becoming increasingly recognized as a potentially reversible cause of frequent or medically intractable seizures and cognitive deterioration. We describe various presentations of autoimmune encephalopathy which have specifically presented with seizure and describe reported imaging findings. This is organized as a review of the more common autoantibodies which can specifically precipitate seizure according to the intracellular or extracellular location of the targeted antigen. For each antibody, we illustrate their pathophysiology, characteristic clinical presentations with typical effective treatments and prognoses and imaging findings on MRI and PET/CT exams. Parenchymal involvement is variable with the limbic structures typically affected; however, non-limbic cortex, cerebellum, brainstem and basal ganglia can also be involved. In the acute setting, affected regions typically demonstrate T2 hyperintensity with mild mass effect from edema and increased 18F-fludeoxyglucose uptake. Chronically involved parenchyma will often undergo atrophy and demonstrate decreased metabolism; mesial temporal sclerosis is often the end result when the limbic system is involved. Without treatment, long-term effects from AE range from ongoing cognitive dysfunction and refractory seizures to death. Familiarity with AE may prompt appropriate antibody screening, particularly in cases of refractory seizure disorders. Early investigation and proper management of AE cases may help to prevent parenchymal and neurologic deterioration in these patients.
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Affiliation(s)
- Julie Guerin
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
| | - Robert E Watson
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
| | - Carrie M Carr
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
| | - Greta B Liebo
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
| | - Amy L Kotsenas
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
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Randell RL, Adams AV, Van Mater H. Tocilizumab in Refractory Autoimmune Encephalitis: A Series of Pediatric Cases. Pediatr Neurol 2018; 86:66-68. [PMID: 30177347 DOI: 10.1016/j.pediatrneurol.2018.07.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/23/2018] [Accepted: 07/28/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Autoimmune encephalitis can result in significant neurological and psychiatric morbidity and mortality in patients of all ages and often does not respond to standard therapies. Recent reports suggest efficacy of tocilizumab, a monoclonal antibody against interleukin 6, in refractory autoimmune encephalitis. RESULTS We describe three children with refractory autoimmune encephalitis who experienced a robust, immediate clinical response following treatment with tocilizumab. CONCLUSION These findings support the efficacy and short-term safety of tocilizumab as a third-line treatment for refractory autoimmune encephalitis in children.
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Affiliation(s)
- Rachel L Randell
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina.
| | - Ashley V Adams
- Duke University School of Medicine, Durham, North Carolina
| | - Heather Van Mater
- Division of Pediatric Rheumatology, Department of Pediatrics, Duke University, Durham, North Carolina
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15
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Veri K, Talvik I, Vaher U, Napa A, Ilves P, Uibo O, Õiglane-Shlik E, Laugesaar R, Rein R, Kolk A, Noormets K, Reimand T, Õunap K, Talvik T. Incidence of Childhood Epilepsy in Estonia. J Child Neurol 2018; 33:587-592. [PMID: 29862897 DOI: 10.1177/0883073818776760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of this prospective epidemiological study was to establish the incidence rate of childhood epilepsy in Estonia, to describe the clinical spectrum and to identify etiology of childhood epilepsy. The overall incidence rate was 86.3/100 000. The incidence rate was the highest (141.9/100 000) in the age group from 5 to 9 years. Specific electroclinical syndromes were identified in 22.8% of cases. Structural or metabolic etiology was identified in 20.0% of cases, presumed genetic origin was identified in 33.9% of cases, and in 46.1% of cases the cause of epilepsy remained unknown. The incidence rate of childhood epilepsy in Estonia (86.3/100 000) is similar to the other European countries. In comparison with the results of the first epidemiological study of childhood epilepsy in Estonia (incidence rate 45/100 000; Beilmann et al), the incidence rate in this study is almost 2 times higher, what can be explained with better case collection and improved diagnostic modalities in Estonia.
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Affiliation(s)
- Kadi Veri
- 1 Department of Pediatrics, University of Tartu, Tartu, Estonia.,2 Tallinn Children's Hospital, Tallinn, Estonia
| | - Inga Talvik
- 1 Department of Pediatrics, University of Tartu, Tartu, Estonia.,2 Tallinn Children's Hospital, Tallinn, Estonia.,3 Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Ulvi Vaher
- 3 Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Aita Napa
- 3 Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Pilvi Ilves
- 4 Department of Radiology, Radiology Clinic, Tartu University Hospital, Tartu, Estonia
| | - Oivi Uibo
- 1 Department of Pediatrics, University of Tartu, Tartu, Estonia.,3 Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Eve Õiglane-Shlik
- 1 Department of Pediatrics, University of Tartu, Tartu, Estonia.,3 Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Rael Laugesaar
- 1 Department of Pediatrics, University of Tartu, Tartu, Estonia.,3 Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Reet Rein
- 3 Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Anneli Kolk
- 1 Department of Pediatrics, University of Tartu, Tartu, Estonia.,3 Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Klari Noormets
- 3 Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Tiia Reimand
- 1 Department of Pediatrics, University of Tartu, Tartu, Estonia.,5 Department of Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia.,6 Institute of Biomedicine and Translational Medicine, Department of Biomedicine, University of Tartu, Tartu, Estonia
| | - Katrin Õunap
- 1 Department of Pediatrics, University of Tartu, Tartu, Estonia.,5 Department of Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia
| | - Tiina Talvik
- 1 Department of Pediatrics, University of Tartu, Tartu, Estonia.,3 Children's Clinic, Tartu University Hospital, Tartu, Estonia.,7 Clinical Ethics Committee of Tartu University Hospital, Tartu, Estonia
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Abraira L, Grau-López L, Jiménez M, Becerra J. Psychiatric manifestations and dysautonomia at the onset of focal epilepsy in adults: Clinical signs indicating autoimmune origin. NEUROLOGÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.nrleng.2016.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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18
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Evaluation and Management of Autoimmune Encephalitis: A Clinical Overview for the Practicing Child Psychiatrist. Child Adolesc Psychiatr Clin N Am 2018; 27:37-52. [PMID: 29157501 DOI: 10.1016/j.chc.2017.08.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Medical conditions that present with psychiatric symptoms are becoming increasingly well-recognized in response to the emergence of the field of neuroimmunology. As the availability of testing for novel antineuronal antibodies has increased, so too has the clinical awareness of this diagnostic spectrum. Psychiatrists may have little exposure to this area of expertise, yet may be called on to assist in the diagnosis and treatment of patients with complex neuropsychiatric syndromes secondary to autoimmune encephalitis. This article summarizes the evaluation and management of patients with autoimmune encephalitis and describes emerging patterns in phenotype recognition.
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Aponte-Puerto A, Rozo-Osorio JD, Guzman-Porras JJ, Patiño-Moncayo AD, Amortegui-Beltrán JA, Uscategui AM. Febrile Infection-Related Epilepsy Syndrome (FIRES), a possible cause of super-refractory status epilepticus. Case report. CASE REPORTS 2018. [DOI: 10.15446/cr.v4n1.61288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción: El estado epiléptico superrefractario (EES) es una patología con importante morbimortalidad que afecta el ambiente neuronal según el tipo y duración de las crisis.Presentación del caso: Se presenta el caso de un escolar con estado epiléptico superrefractario y crisis multifocales. Se descartaron causas metabólicas, estructurales, infecciosas, toxicológicas y autoinmunes y se utilizaron diferentes manejos anticonvulsivantes sin respuesta, lográndose control de las crisis 6 semanas después del ingreso a UCI. Se realizó un seguimiento de 12 años, periodo en el que el paciente presentó múltiples recaídas del estado epiléptico asociadas a la presencia de epilepsia refractaria con múltiples tipos de crisis, en su mayoría vegetativas; además se dio involución cognitiva.Discusión: Esta forma de estado epiléptico corresponde al síndrome de estado epiléptico facilitado por fiebre (FIRES), entidad de posible origen inmunológico conocida por ser refractaria al tratamiento agudo y al manejo cró- nico de la epilepsia y que se presenta como secuela. Su evolución no se ha descrito a largo plazo y por tanto no hay consenso sobre el manejo en la fase crónica.Conclusión: Es importante considerar esta etiología en estado epiléptico superrefractario para utilizar de forma temprana diferentes estrategias terapéuticas, como la dieta cetogénica, que permitan, por un lado, controlar su condición crítica y las crisis epilépticas a largo plazo y, por el otro, mejorar el pronóstico cognitivo, logrando así un impacto en la calidad de vida.
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Saghazadeh A, Rezaei N. Immuno-epileptology. Expert Rev Clin Immunol 2017; 13:845-847. [PMID: 28468517 DOI: 10.1080/1744666x.2017.1327351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Amene Saghazadeh
- a Molecular Immunology Research Center; and Department of Immunology, School of Medicine , Tehran University of Medical Sciences , Tehran , Iran.,b MetaCognition Interest Group (MCIG) , Universal Scientific Education and Research Network (USERN) , Tehran , Iran
| | - Nima Rezaei
- a Molecular Immunology Research Center; and Department of Immunology, School of Medicine , Tehran University of Medical Sciences , Tehran , Iran.,c Research Center for Immunodeficiencies, Children's Medical Center , Tehran University of Medical Sciences , Tehran , Iran.,d Systematic Review and Meta-analysis Expert Group (SRMEG) , Universal Scientific Education and Research Network (USERN) , Tehran , Iran
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21
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Ma J, Zhang T, Jiang L. Japanese encephalitis can trigger anti-N-methyl-d-aspartate receptor encephalitis. J Neurol 2017; 264:1127-1131. [DOI: 10.1007/s00415-017-8501-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 04/26/2017] [Accepted: 04/26/2017] [Indexed: 12/11/2022]
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22
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Abstract
Autoimmune encephalitides may account for epilepsies of so far unknown cause. These "autoimmune epilepsies" may respond well to immunotherapy. More than a dozen autoantibodies have been found with this constellation; therefore, broad autoantibody testing of serum-CSF pairs offers the best diagnostic yield. Several particular features raise the suspicion of an autoimmune cause in otherwise unexplained seizure disorders.
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23
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van Sonderen A, Petit-Pedrol M, Dalmau J, Titulaer MJ. The value of LGI1, Caspr2 and voltage-gated potassium channel antibodies in encephalitis. Nat Rev Neurol 2017; 13:290-301. [DOI: 10.1038/nrneurol.2017.43] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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24
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Zhang L, Wu MQ, Hao ZL, Chiang SMV, Shuang K, Lin MT, Chi XS, Fang JJ, Zhou D, Li JM. Clinical characteristics, treatments, and outcomes of patients with anti-N-methyl-d-aspartate receptor encephalitis: A systematic review of reported cases. Epilepsy Behav 2017; 68:57-65. [PMID: 28109991 DOI: 10.1016/j.yebeh.2016.12.019] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 11/20/2016] [Accepted: 12/17/2016] [Indexed: 12/24/2022]
Abstract
Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is a recently recognized autoimmune disorder which is responsive to immunotherapy. However, the outcomes of different immunotherapies have not been defined and there have been few studies that carried out a comparison among them. To provide an overview of the clinical characteristics, treatments, and outcomes of anti-NMDAR encephalitis, we systematically reviewed the literature in the PubMed, Medline, Embase, Cochrane Library, BioMedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), and Wan-fang databases. Eighty-three studies with a total of 432 patients were included. The median age was 22years. Two hundred ninety-three (68%) patients were female, 87 (21%) of 412 patients had a tumor, including 68 (78%) patients with ovarian teratoma. Pediatric patients had a higher ratio of seizures to psychiatric symptoms as the initial manifestation (p=0.0012), a lower proportion with a tumor (p<0.0001) and CSF pleocytosis (p=0.0163), and a better outcome (p=0.0064) than adults. Patients who died had a higher proportion of CSF pleocytosis than the patients who survived (p=0.0021). There were no significant differences among three first-line immunotherapy used alone (p=0.9172) or among combinations of every two of them (p=0.3059). With regard to the use of corticosteroid and IVIG, there were no significant differences between the outcomes of early combined treatment and sequential treatment (p=0.7277), or between using corticosteroid first and IVIG first (p=0.5422). Our findings suggest that the clinical characteristics and outcomes for pediatric patients were different from adult patients, and no significant differences were found among different immunotherapies.
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Affiliation(s)
- Le Zhang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Meng-Qian Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Zi-Long Hao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Siew Mun Vance Chiang
- West China College of Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Kun Shuang
- West China College of Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Min-Tao Lin
- West China College of Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Xiao-Sa Chi
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Jia-Jia Fang
- Department of Neurology, Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Yiwu, Zhejiang Province, China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
| | - Jin-Mei Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
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25
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Abstract
Pediatric autoimmune epileptic encephalopathies are predominantly characterized by the presence of autoantibodies to the surface of neuronal proteins, for example, N-methyl-d-aspartate (NMDA) receptor antibodies, but also include diseases with non-cell surface antibodies (eg, anti-Hu, glutamic-acid decarboxylase antibodies). In some cases with distinct clinical and para-clinical features, an autoimmune epileptic encephalopathy can be diagnosed without the presence of an antibody and will also respond favorably to immunotherapy. In this review, we summarize the common presentations of pediatric autoimmune epileptic encephalopathies, treatments, and outcomes, and report recent findings in the field of epilepsy, encephalopathy, and the immune system.
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Affiliation(s)
- Sukhvir Wright
- 1 Department of Pediatric Neurology, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Angela Vincent
- 2 Nuffield Department of Clinical Neurosciences, John Radcliffe University Hospital, Oxford, United Kingdom
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Kelley BP, Patel SC, Marin HL, Corrigan JJ, Mitsias PD, Griffith B. Autoimmune Encephalitis: Pathophysiology and Imaging Review of an Overlooked Diagnosis. AJNR Am J Neuroradiol 2017; 38:1070-1078. [PMID: 28183838 DOI: 10.3174/ajnr.a5086] [Citation(s) in RCA: 156] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Autoimmune encephalitis is a relatively new category of immune-mediated disease involving the central nervous system that demonstrates a widely variable spectrum of clinical presentations, ranging from the relatively mild or insidious onset of cognitive impairment to more complex forms of encephalopathy with refractory seizure. Due to its diverse clinical features, which can mimic a variety of other pathologic processes, autoimmune encephalitis presents a diagnostic challenge to clinicians. Imaging findings in patients with these disorders can also be quite variable, but recognizing characteristic findings within limbic structures suggestive of autoimmune encephalitis can be a key step in alerting clinicians to the potential diagnosis and ensuring a prompt and appropriate clinical work-up. In this article, we review antibody-mediated encephalitis and its various subtypes with a specific emphasis on the role of neuroimaging in the diagnostic work-up.
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Affiliation(s)
- B P Kelley
- From the Departments of Neuroradiology (B.P.K., S.C.P., H.L.M., J.J.C., B.G.)
| | - S C Patel
- From the Departments of Neuroradiology (B.P.K., S.C.P., H.L.M., J.J.C., B.G.)
| | - H L Marin
- From the Departments of Neuroradiology (B.P.K., S.C.P., H.L.M., J.J.C., B.G.)
| | - J J Corrigan
- From the Departments of Neuroradiology (B.P.K., S.C.P., H.L.M., J.J.C., B.G.)
| | - P D Mitsias
- Neurology (P.D.M.), Henry Ford Hospital, Detroit, Michigan
| | - B Griffith
- From the Departments of Neuroradiology (B.P.K., S.C.P., H.L.M., J.J.C., B.G.)
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27
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Rom AL, Wu CS, Olsen J, Jawaheer D, Hetland ML, Christensen J, Ottesen B, Mørch LS. Parental rheumatoid arthritis and childhood epilepsy: A nationwide cohort study. Neurology 2016; 87:2510-2516. [PMID: 27856781 DOI: 10.1212/wnl.0000000000003424] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 08/10/2016] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To assess the influence of parental rheumatoid arthritis (RA) on risk of epilepsy. METHODS We performed a nationwide cohort study including all singletons born in Denmark from 1977 to 2008 (n = 1,917,723) through individual linkage to nationwide Danish registries. The children were followed for an average of 16 years. Main outcome measures were adjusted hazard ratios (HRs) for epilepsy with onset in early childhood (29 days-4 years), late childhood (5-15 years), adolescence/adulthood (≥15 years), and at any age until the end of follow-up (December 31, 2010). RESULTS Compared to unexposed children, children exposed to maternal RA had an increased risk of early and late childhood epilepsy (adjusted HRs 1.34 [95% confidence interval (CI) 1.13-1.60] and 1.26 [95% CI 1.13-1.41]), while children exposed to maternal RA had no increased risk of epilepsy in adolescence/adulthood (HR 1.15 [95% CI 0.92-1.45]). Paternal RA was not associated with an overall risk of epilepsy in the offspring (HR 0.96 [95% CI 0.81-1.15]) or at any age. Children exposed to maternal RA in utero had a more pronounced increased risk of early childhood epilepsy than children exposed to mothers who were diagnosed with RA after childbirth (HR 1.90 [95% CI 1.26-2.86] vs HR 1.26 [95% CI 1.03-1.52], respectively [p = 0.16]). CONCLUSIONS Exposure to maternal RA was associated with an increased risk of childhood epilepsy, while exposure to paternal RA was not, which indicates that changes in the intrauterine environment may play a role.
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Affiliation(s)
- Ane Lilleøre Rom
- From the Research Unit, Women's and Children's Health (A.L.R.), and Department of Obstetrics and Gynecology (B.O.), The Juliane Marie Centre, and Gynaecological Clinic (L.S.M.), Copenhagen University Hospital Rigshospitalet; Section for Epidemiology, Department of Public Health (C.S.W.), and Departments of Clinical Epidemiology (J.O.) and Neurology (J.C.), University of Aarhus; Research Unit of Gynecology and Obstetrics (C.S.W.), Institute of Clinical Research, University of Southern Denmark, Odense; Department of Obstetrics and Gynecology (C.S.W.), Odense University Hospital, Denmark; Department of Epidemiology (J.O.), School of Public Health, University of California Los Angeles; Children's Hospital Oakland Research Institute (D.J.), CA; Copenhagen Center for Arthritis Research (M.L.H.), Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup; Department of Clinical Medicine (M.L.H.), Faculty of Health and Medical Sciences, University of Copenhagen; and Danish Cancer Society Research Centre (L.S.M.), Virus, Lifestyle and Genes Unit, Copenhagen, Denmark.
| | - Chun Sen Wu
- From the Research Unit, Women's and Children's Health (A.L.R.), and Department of Obstetrics and Gynecology (B.O.), The Juliane Marie Centre, and Gynaecological Clinic (L.S.M.), Copenhagen University Hospital Rigshospitalet; Section for Epidemiology, Department of Public Health (C.S.W.), and Departments of Clinical Epidemiology (J.O.) and Neurology (J.C.), University of Aarhus; Research Unit of Gynecology and Obstetrics (C.S.W.), Institute of Clinical Research, University of Southern Denmark, Odense; Department of Obstetrics and Gynecology (C.S.W.), Odense University Hospital, Denmark; Department of Epidemiology (J.O.), School of Public Health, University of California Los Angeles; Children's Hospital Oakland Research Institute (D.J.), CA; Copenhagen Center for Arthritis Research (M.L.H.), Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup; Department of Clinical Medicine (M.L.H.), Faculty of Health and Medical Sciences, University of Copenhagen; and Danish Cancer Society Research Centre (L.S.M.), Virus, Lifestyle and Genes Unit, Copenhagen, Denmark
| | - Jørn Olsen
- From the Research Unit, Women's and Children's Health (A.L.R.), and Department of Obstetrics and Gynecology (B.O.), The Juliane Marie Centre, and Gynaecological Clinic (L.S.M.), Copenhagen University Hospital Rigshospitalet; Section for Epidemiology, Department of Public Health (C.S.W.), and Departments of Clinical Epidemiology (J.O.) and Neurology (J.C.), University of Aarhus; Research Unit of Gynecology and Obstetrics (C.S.W.), Institute of Clinical Research, University of Southern Denmark, Odense; Department of Obstetrics and Gynecology (C.S.W.), Odense University Hospital, Denmark; Department of Epidemiology (J.O.), School of Public Health, University of California Los Angeles; Children's Hospital Oakland Research Institute (D.J.), CA; Copenhagen Center for Arthritis Research (M.L.H.), Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup; Department of Clinical Medicine (M.L.H.), Faculty of Health and Medical Sciences, University of Copenhagen; and Danish Cancer Society Research Centre (L.S.M.), Virus, Lifestyle and Genes Unit, Copenhagen, Denmark
| | - Damini Jawaheer
- From the Research Unit, Women's and Children's Health (A.L.R.), and Department of Obstetrics and Gynecology (B.O.), The Juliane Marie Centre, and Gynaecological Clinic (L.S.M.), Copenhagen University Hospital Rigshospitalet; Section for Epidemiology, Department of Public Health (C.S.W.), and Departments of Clinical Epidemiology (J.O.) and Neurology (J.C.), University of Aarhus; Research Unit of Gynecology and Obstetrics (C.S.W.), Institute of Clinical Research, University of Southern Denmark, Odense; Department of Obstetrics and Gynecology (C.S.W.), Odense University Hospital, Denmark; Department of Epidemiology (J.O.), School of Public Health, University of California Los Angeles; Children's Hospital Oakland Research Institute (D.J.), CA; Copenhagen Center for Arthritis Research (M.L.H.), Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup; Department of Clinical Medicine (M.L.H.), Faculty of Health and Medical Sciences, University of Copenhagen; and Danish Cancer Society Research Centre (L.S.M.), Virus, Lifestyle and Genes Unit, Copenhagen, Denmark
| | - Merete Lund Hetland
- From the Research Unit, Women's and Children's Health (A.L.R.), and Department of Obstetrics and Gynecology (B.O.), The Juliane Marie Centre, and Gynaecological Clinic (L.S.M.), Copenhagen University Hospital Rigshospitalet; Section for Epidemiology, Department of Public Health (C.S.W.), and Departments of Clinical Epidemiology (J.O.) and Neurology (J.C.), University of Aarhus; Research Unit of Gynecology and Obstetrics (C.S.W.), Institute of Clinical Research, University of Southern Denmark, Odense; Department of Obstetrics and Gynecology (C.S.W.), Odense University Hospital, Denmark; Department of Epidemiology (J.O.), School of Public Health, University of California Los Angeles; Children's Hospital Oakland Research Institute (D.J.), CA; Copenhagen Center for Arthritis Research (M.L.H.), Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup; Department of Clinical Medicine (M.L.H.), Faculty of Health and Medical Sciences, University of Copenhagen; and Danish Cancer Society Research Centre (L.S.M.), Virus, Lifestyle and Genes Unit, Copenhagen, Denmark
| | - Jakob Christensen
- From the Research Unit, Women's and Children's Health (A.L.R.), and Department of Obstetrics and Gynecology (B.O.), The Juliane Marie Centre, and Gynaecological Clinic (L.S.M.), Copenhagen University Hospital Rigshospitalet; Section for Epidemiology, Department of Public Health (C.S.W.), and Departments of Clinical Epidemiology (J.O.) and Neurology (J.C.), University of Aarhus; Research Unit of Gynecology and Obstetrics (C.S.W.), Institute of Clinical Research, University of Southern Denmark, Odense; Department of Obstetrics and Gynecology (C.S.W.), Odense University Hospital, Denmark; Department of Epidemiology (J.O.), School of Public Health, University of California Los Angeles; Children's Hospital Oakland Research Institute (D.J.), CA; Copenhagen Center for Arthritis Research (M.L.H.), Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup; Department of Clinical Medicine (M.L.H.), Faculty of Health and Medical Sciences, University of Copenhagen; and Danish Cancer Society Research Centre (L.S.M.), Virus, Lifestyle and Genes Unit, Copenhagen, Denmark
| | - Bent Ottesen
- From the Research Unit, Women's and Children's Health (A.L.R.), and Department of Obstetrics and Gynecology (B.O.), The Juliane Marie Centre, and Gynaecological Clinic (L.S.M.), Copenhagen University Hospital Rigshospitalet; Section for Epidemiology, Department of Public Health (C.S.W.), and Departments of Clinical Epidemiology (J.O.) and Neurology (J.C.), University of Aarhus; Research Unit of Gynecology and Obstetrics (C.S.W.), Institute of Clinical Research, University of Southern Denmark, Odense; Department of Obstetrics and Gynecology (C.S.W.), Odense University Hospital, Denmark; Department of Epidemiology (J.O.), School of Public Health, University of California Los Angeles; Children's Hospital Oakland Research Institute (D.J.), CA; Copenhagen Center for Arthritis Research (M.L.H.), Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup; Department of Clinical Medicine (M.L.H.), Faculty of Health and Medical Sciences, University of Copenhagen; and Danish Cancer Society Research Centre (L.S.M.), Virus, Lifestyle and Genes Unit, Copenhagen, Denmark
| | - Lina Steinrud Mørch
- From the Research Unit, Women's and Children's Health (A.L.R.), and Department of Obstetrics and Gynecology (B.O.), The Juliane Marie Centre, and Gynaecological Clinic (L.S.M.), Copenhagen University Hospital Rigshospitalet; Section for Epidemiology, Department of Public Health (C.S.W.), and Departments of Clinical Epidemiology (J.O.) and Neurology (J.C.), University of Aarhus; Research Unit of Gynecology and Obstetrics (C.S.W.), Institute of Clinical Research, University of Southern Denmark, Odense; Department of Obstetrics and Gynecology (C.S.W.), Odense University Hospital, Denmark; Department of Epidemiology (J.O.), School of Public Health, University of California Los Angeles; Children's Hospital Oakland Research Institute (D.J.), CA; Copenhagen Center for Arthritis Research (M.L.H.), Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup; Department of Clinical Medicine (M.L.H.), Faculty of Health and Medical Sciences, University of Copenhagen; and Danish Cancer Society Research Centre (L.S.M.), Virus, Lifestyle and Genes Unit, Copenhagen, Denmark
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Aaberg KM, Bakken IJ, Lossius MI, Lund Søraas C, Håberg SE, Stoltenberg C, Surén P, Chin R. Comorbidity and Childhood Epilepsy: A Nationwide Registry Study. Pediatrics 2016; 138:peds.2016-0921. [PMID: 27482059 DOI: 10.1542/peds.2016-0921] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2016] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Children with epilepsy are at increased risk of other disorders and difficulties, preceding, cooccurring with, or after the diagnosis of epilepsy. Risk estimates vary, few studies are population-based, and few provide comprehensive assessments of comorbidities. We used nationwide registry data to describe frequencies of medical, neurologic, developmental, and psychiatric conditions occurring before and after children are diagnosed with childhood epilepsy. METHODS Data were obtained from the Norwegian Patient Registry, which is an administrative database recording International Classification of Diseases, 10th Revision diagnoses from all government-funded specialist health services in Norway (outpatient consultations and hospitalizations). We included data from the years 2008 through 2013 for all children born in Norway between 1996 and 2013 (0-17 years of age at the end of follow-up). Children with epilepsy were compared with the general child population, adjusting for sex and age. We also compared children with complicated epilepsies (ie, epilepsies with additional neurologic and/or developmental disorders) to children with uncomplicated epilepsies. RESULTS The study population included 1 125 161 children. There were 6635 (0.6%) children with epilepsy. Nearly 80% of children with epilepsy had ≥1 comorbid disorder. All types of disorders were more frequent in children with epilepsy, with additional medical disorders recorded in 55%, neurologic disorders in 41%, and developmental/psychiatric disorders in 43%. Children with complicated epilepsies had the highest overall levels of comorbidity, but the risk of medical and psychiatric comorbidities was also substantial among children with uncomplicated epilepsies. CONCLUSIONS The overall frequency of comorbid disease is high in children with epilepsy, including children with presumably uncomplicated epilepsies.
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Affiliation(s)
- Kari Modalsli Aaberg
- Department of Child Health, Norwegian Institute of Public Health, Oslo, Norway; National Center for Epilepsy, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway;
| | | | - Morten I Lossius
- National Center for Epilepsy, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | - Camilla Lund Søraas
- Department of Child Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Siri Eldevik Håberg
- Department of Child Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Camilla Stoltenberg
- Department of Child Health, Norwegian Institute of Public Health, Oslo, Norway; Department of Global Public Health and Community Care, University of Bergen, Norway; and
| | - Pål Surén
- Department of Child Health, Norwegian Institute of Public Health, Oslo, Norway; National Center for Epilepsy, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | - Richard Chin
- Muir Maxwell Epilepsy Centre, University of Edinburgh, Edinburgh, United Kingdom
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29
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Grilo E, Pinto J, Caetano JS, Pereira H, Cardoso P, Cardoso R, Dinis I, Pereira C, Fineza I, Mirante A. Type 1 diabetes and GAD65 limbic encephalitis: a case report of a 10-year-old girl. J Pediatr Endocrinol Metab 2016; 29:985-90. [PMID: 27115322 DOI: 10.1515/jpem-2016-0016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 03/07/2016] [Indexed: 12/14/2022]
Abstract
Limbic encephalitis is a rare neurological disorder that may be difficult to recognize. Clinical features include memory impairment, temporal lobe seizures and affective disturbance. We report the case of a 10-year-old girl with type 1 diabetes mellitus that presented with seizures, depressed mood and memory changes. The diagnosis of glutamic acid decarboxylase 65 (GAD65) mediated limbic encephalitis relied on cerebral magnetic resonance imaging lesions and high serological and cerebrospinal fluid GAD65-antibodies titers. High-dose steroidal therapy was started with clinical improvement. Relapse led to a second high-dose steroid treatment followed by rituximab with remission. A correlation between serum GAD65-antibodies levels and symptoms was found, demonstrating GAD65-antibodies titers may be useful for clinical follow-up and immunotherapy guidance. This report raises awareness of this serious neurological condition that may be associated with type 1 diabetes, underlining the importance of an early diagnosis and prompt treatment for a better prognosis.
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Dubey D, Farzal Z, Hays R, Brown LS, Vernino S. Evaluation of positive and negative predictors of seizure outcomes among patients with immune-mediated epilepsy: a meta-analysis. Ther Adv Neurol Disord 2016; 9:369-77. [PMID: 27582892 DOI: 10.1177/1756285616656295] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The objective of this study was to analyze published literature on autoimmune epilepsy and assess predictors of seizure outcome. METHODS From PubMed and EMBASE databases, two reviewers independently identified publications reporting clinical presentations, management and outcomes of patients with autoimmune epilepsy. A meta-analysis of 46 selected studies was performed. Demographic/clinical variables (sex, age, clinical presentation, epilepsy focus, magnetic resonance imaging [MRI] characteristics, time to diagnosis and initiation of immunomodulatory therapy, and type of immunomodulatory therapy) were compared between two outcome groups (responders and nonresponders). Clinical response was defined as >50% reduction in seizure frequency. Unstandardized effect sizes were collected for the studies for responder and nonresponder groups. Sample size was used as the weight in the meta-analysis. The random effects model was used to account for heterogeneity in the studies. RESULTS The 46 reports included 186 and 96 patients in responder and nonresponder groups respectively. Mean age of the responders and nonresponders was 43 and 31 years (p < 0.01). Responders were more likely to have cell-surface antibodies (68% versus 39%, p < 0.05), particularly voltage-gated potassium channel complex antibodies (p < 0.01). Mean duration from symptom onset to diagnosis, and symptom onset to initiation of immunomodulation was significantly lower among the responders (75 versus 431 days, p < 0.05, and 80 versus 554, p < 0.01, respectively). There was no outcome difference based on gender, MRI characteristics, seizure type, type of acute immunomodulatory therapy, or use of chronic immunomodulation. CONCLUSIONS Among published cases to date, older age, presence of cell-surface antibodies, early diagnosis and immunomodulatory treatment are associated with better seizure outcomes among patients with autoimmune epilepsy.
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Affiliation(s)
- Divyanshu Dubey
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75235, USA
| | - Zehra Farzal
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Ryan Hays
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, USA
| | - L Steven Brown
- Department of Health Systems Research Parkland Health & Hospital System Dallas, TX, USA
| | - Steven Vernino
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, USA
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Brenton JN, Goodkin HP. Antibody-Mediated Autoimmune Encephalitis in Childhood. Pediatr Neurol 2016; 60:13-23. [PMID: 27343023 DOI: 10.1016/j.pediatrneurol.2016.04.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 03/31/2016] [Accepted: 04/05/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND The differential diagnosis of encephalitis in childhood is vast, and evaluation for an etiology is often unrevealing. Encephalitis by way of autoimmunity has long been suspected, as in cases of acute disseminated encephalomyelitis; however, researchers have only recently reported evidence of antibody-mediated immune dysregulation resulting in clinical encephalitis. MAIN FINDINGS These pathologic autoantibodies, aimed at specific neuronal targets, can result in a broad spectrum of symptoms including psychosis, catatonia, behavioral changes, memory loss, autonomic dysregulation, seizures, and abnormal movements. Autoimmune encephalitis in childhood is often quite different from adult-onset autoimmune encephalitis in clinical presentation, frequency of tumor association, and ultimate prognosis. As many of the autoimmune encephalitides are sensitive to immunotherapy, prompt diagnosis and initiation of appropriate treatment are paramount. CONCLUSIONS Here we review the currently recognized antibody-mediated encephalitides of childhood and will provide a framework for diagnosis and treatment considerations.
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Affiliation(s)
- J Nicholas Brenton
- Division of Pediatric Neurology, Department of Neurology, University of Virginia, Charlottesville, Virginia.
| | - Howard P Goodkin
- Division of Pediatric Neurology, Department of Neurology, University of Virginia, Charlottesville, Virginia
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Abraira L, Grau-López L, Jiménez M, Becerra JL. Psychiatric manifestations and dysautonomia at the onset of focal epilepsy in adults: Clinical signs indicating autoimmune origin. Neurologia 2016; 33:S0213-4853(16)30048-2. [PMID: 27311973 DOI: 10.1016/j.nrl.2016.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 03/15/2016] [Accepted: 04/04/2016] [Indexed: 10/21/2022] Open
Affiliation(s)
- L Abraira
- Departamento de Neurología, Hospital Germans Trias i Pujol, Badalona, Barcelona, España.
| | - L Grau-López
- Departamento de Neurología, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
| | - M Jiménez
- Departamento de Neurología, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
| | - J L Becerra
- Departamento de Neurología, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
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Abstract
Autoantibodies targeting proteins at the neuromuscular junction are known to cause several distinct myasthenic syndromes. Recently, autoantibodies targeting neurotransmitter receptors and associated proteins have also emerged as a cause of severe, but potentially treatable, diseases of the CNS. Here, we review the clinical evidence as well as in vitro and in vivo experimental evidence that autoantibodies account for myasthenic syndromes and autoimmune disorders of the CNS by disrupting the functional or structural integrity of synapses. Studying neurological and psychiatric diseases of autoimmune origin may provide new insights into the cellular and circuit mechanisms underlying a broad range of CNS disorders.
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Affiliation(s)
- Sarah J Crisp
- UCL Institute of Neurology, University College London, Queen Square House, Queen Square, London WC1N 3BG, UK
| | - Dimitri M Kullmann
- UCL Institute of Neurology, University College London, Queen Square House, Queen Square, London WC1N 3BG, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Level 6, West Wing, John Radcliffe Hospital, Oxford OX3 9DU, UK
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Abstract
Autoimmune neurologic diseases are of major clinical importance in children. Antibody-mediated diseases of the central nervous system are now increasingly recognized in childhood, where the antibodies bind to cell surface epitopes on neuronal or glial proteins, and the patients demonstrate either focal or more generalized clinical signs depending on the extent of brain regions targeted by the antibodies. The antibodies are directed towards ion channels, receptors, and membrane proteins; and the diseases include limbic encephalitis and N-methyl-d-aspartate receptor-antibody encephalitis, among many others. Additionally there are conditions where the wider immune system is implicated. Neurologic features like seizures, movement disorders, autonomic dysfunction, and sleep disorders, with neuroimaging and electrophysiologic features, may indicate a specific antibody-mediated or immune disorder. Often, phenotypic overlap is observed between these conditions, and phenotypic variation seen in children with the same condition. Nevertheless, many patients benefit from immunotherapy with substantial improvement, although huge efforts are still required to optimize the outcome for many patients. In many patients no antibodies have yet been identified, even though they respond to immunotherapies. Here we describe the known antibodies and associated diseases, discuss conditions that are thought to be immune-mediated but have no known immunologic biomarker, and provide guidelines for the investigation and classification of these disorders.
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35
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Cyril AC, Nair SS, Mathai A, Kannoth S, Thomas SV. Autoimmune encephalitis: Clinical diagnosis versus antibody confirmation. Ann Indian Acad Neurol 2015; 18:408-11. [PMID: 26713011 PMCID: PMC4683878 DOI: 10.4103/0972-2327.165454] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Context: Autoimmune encephalitis is a heterogeneous disorder which is being diagnosed with increasing frequency. The diagnosis of these disorders is based on the detection of autoantibodies and characteristic clinical profiles. Aims: We aimed to study the antibody profile in encephalitis patients with suspected autoimmune etiology presenting to a tertiary care center. Settings and Design: The subjects were selected by screening all patients with clinical profile suggesting autoimmune encephalitis admitted in the neuromedical intensive care unit (ICU) of a tertiary care center in South India. Materials and Methods: Patients who fulfilled modified Zuliani et al.'s, criteria for autoimmune encephalitis were identified during the period December 2009–June 2013. Blood samples from these subjects were screened for six neuronal antibodies. Statistical analysis used: Chi-square test was applied to compare the antibody positive and negative patients. Results: Out of 1,227 patients screened, 39 subjects (14 males: 25 females) were identified with a mean age of 15.95 years and 19 cases were assessed in the acute and 20 in the convalescent phase of the illness. Seizure (87.8 %) was the most common presenting symptom; status epilepticus occurred in 23 (60.5%) patients during the course of the illness. Fourteen (35.9%) patients were N-methyl-D-aspartate receptor (NMDAR) antibody-positive and all were negative for the other antibodies tested. Conclusions: One-third of patients presenting with acute noninfective encephalitis would be positive for NMDAR antibodies with the remaining two-thirds with clinically suspected autoimmune encephalitis being antibody-negative. There are few markers in the clinical and investigative profiles to distinguish antibody-positive and -negative patients.
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Affiliation(s)
- Asha Caroline Cyril
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Sruthi S Nair
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Annamma Mathai
- Department of Neuroimmunology, Amrita Institute for Medical Sciences, Cochin, Kerala, India
| | - Sudheeran Kannoth
- Department of Neuroimmunology, Amrita Institute for Medical Sciences, Cochin, Kerala, India
| | - Sanjeev V Thomas
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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Abstract
Despite the fact that epilepsy is the third most common chronic brain disorder, relatively little is known about the processes leading to the generation of seizures. Accumulating data support an autoimmune basis in patients with antiepileptic drug-resistant seizures. Besides, recent studies show that epilepsy and autoimmune disease frequently co-occur. Autoimmune epilepsy is increasingly recognized in the spectrum of neurological disorders characterized by detection of neural autoantibodies in serum or spinal fluid and responsiveness to immunotherapy. An autoimmune cause is suspected based on frequent or medically intractable seizures and the presence of at least one neural antibody, inflammatory changes indicated in serum or spinal fluid or on MRI, or a personal or family history of autoimmunity. It is essential that an autoimmune etiology be considered in the initial differential diagnosis of new onset epilepsy, because early immunotherapy assures an optimal outcome for the patient.
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Fauser S, Uttner I, Ariño H, Scherbaum WA, Saiz A, Lewerenz J. Long latency between GAD-antibody detection and development of limbic encephalitis--a case report. BMC Neurol 2015; 15:177. [PMID: 26420440 PMCID: PMC4589124 DOI: 10.1186/s12883-015-0435-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 09/21/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In the pathogenesis of limbic encephalitis other promoting factors besides the pure existence of autoantibodies are increasingly discussed to play a significant role. This is to our knowledge the first described patient in whom the presence of autoantibodies precedes the manifestation of limbic encephalitis for many years. CASE PRESENTATION At the age of 38 years, in the serum of a patient with polyendocrine autoimmunity high titers of cytoplasmic islet cell antibodies and of anti-glutamate decarboxylase (GAD) 65 antibodies were observed as an incidential finding, GAD67 antibodies were negative at that time. After a latency of 18 years, she manifested with refractory temporal lobe epilepsy most likely due to autoimmune limbic encephalitis. After epilepsy onset, the patient underwent magnetic resonance imaging (MRI), electroencephalography, cerebrospinal fluid (CSF), serum and neuropsychological investigations during a follow-up period of 8 years. A pharmacoresistent epilepsy with seizure onset from the right temporal lobe and declarative memory deficits were observed affecting primarily the recall of verbal informations. MRI showed a slightly increased signal in the right amygdala without progression. GAD antibodies could be detected in serum (titre 1: 1000) and CSF (titre 1:1) by immunofluorescence. Both, GAD65 and GAD67 antibodies were observed in cell-based assays. CONCLUSIONS It can be assumed that in addition to a pre-existing systemic T-cell response associated with the longstanding polyendocrine autoimmunity, a delayed intrathecal autoimmunity developed leading to limbic encephalitis. This change might be reflected by the development of GAD67 antibodies in our patient. Besides the contribution of this case report to a better understandig of the pathomechanisms for the development of central nervous system (CNS) autoimmunity, it also has a clinical impact as early treatment of GAD antibody-associated CNS disorders has a better prognosis. Therefore, vigilance for symptoms indicating GAD antibody-associated CNS autoimmunity is mandatory in patients with GAD antibody-associated endocrine dysfunction.
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Affiliation(s)
- Susanne Fauser
- Department of Neurology, University Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany. .,Epilepsiezentrum Bethel, Maraweg, 2133617, Bielefeld, Germany.
| | - Ingo Uttner
- Department of Neurology, University Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany.
| | - Helena Ariño
- Service of Neurology, Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Hospital Clínic, Villarroel 170, Barcelona, 08036, Spain.
| | - Werner A Scherbaum
- Heinrich-Heine University, University Hospital, Moorenstrasse 5, 40225, Duesseldorf, Germany.
| | - Albert Saiz
- Service of Neurology, Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Hospital Clínic, Villarroel 170, Barcelona, 08036, Spain.
| | - Jan Lewerenz
- Department of Neurology, University Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany.
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Akaishi T, Jin K, Kato K, Itabashi H, Misu T, Tateyama M, Iwasaki M, Aoki M, Nakasato N. [Clinical characteristics of four patients with temporal lobe epilepsy associated with elevated anti-GAD antibodies]. Rinsho Shinkeigaku 2015; 55:804-9. [PMID: 26369378 DOI: 10.5692/clinicalneurol.cn-000740] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Anti-glutamic acid decarboxylase (GAD) antibodies are known to be associated with insulin-dependent diabetes mellitus (IDDM), stiff-person syndrome, and other neurological symptoms including temporal lobe epilepsy (TLE), known as autoimmune epilepsy. We treated four patients with TLE who had elevated titers of serum anti-GAD antibody (anti-GAD-Ab), higher than 100 U/ml. Three of the four patients started to have epileptic seizures in their 5th or 6th decade. Characteristic symptoms suggesting encephalitis or encephalopathy were absent at onset of these symptoms, which led to delayed diagnosis. All four patients developed two or three of cerebellar ataxia, neuropsychological impairment, and IDDM, by several years or decades after onset of TLE, even after seizure freedom in two patients. These abnormalities were indicators for suspecting the involvement of anti-GAD-Ab in the pathogenesis. Anti-GAD-Ab levels in the cerebrospinal fluid (CSF) were measured, which detected elevated CSF/serum anti-GAD-Ab ratio (≥ 1.0), suggesting intrathecal anti-GAD-Ab synthesis, in three of the four patients. The TLE symptoms were somewhat prolonged, but three of the four patients eventually achieved seizure freedom after immunotherapies with combinations of two or three anti-epileptic drugs. Serum anti-GAD Ab is recommended to be measured in patients with middle-aged onset TLE. Moreover, immune-modulating therapies including steroid pulse and intravenous immunoglobulin therapies could have ameliorated neurological complications, even in the chronic phase.
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Affiliation(s)
- Tetsuya Akaishi
- Department of Epileptology, Tohoku University, Graduate School of Medicine
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Abstract
BACKGROUND Neurological complications, especially encephalopathy and seizures, are commonly seen in bone marrow transplant patients. Infections, chemotoxicity, graft versus host disease, or secondary central nervous system malignancies are the most common underlying etiologies. There is increased awareness that autoimmune encephalitis may cause neurological dysfunction in immunocompetent children. The potential role of such a mechanism in children undergoing bone marrow transplantation is unknown. METHODS We report a boy who developed autoimmune encephalitis with voltage-gated potassium channel-associated and thyroid autoantibodies subsequent to transplantation. RESULTS A 7-year-old boy presented with a change in behavior, poor attention, cognitive deficits, and abnormal movements 15 months after undergoing transplantation for idiopathic aplastic anemia. He had clinical and subclinical seizures and brain magnetic resonance imaging hyperintensities bilaterally in the uncal regions. His evaluation revealed high titers of voltage-gated potassium channel, leucine-rich glioma-inactivated 1 protein, and thyroglobulin antibodies suggestive of autoimmune limbic encephalitis. He showed significant improvement in behavior and neuropsychological testing and has remained seizure-free on levetiracetam after immunotherapy with corticosteroids and intravenous immunoglobulin. CONCLUSION Systemic autoimmune manifestations in bone marrow transplant patients have been well-documented, but autoimmune encephalitis after transplantation has yet to be described in children.
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Affiliation(s)
- Geetanjali S Rathore
- Department of Neurology and Developmental Neuroscience, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
| | - Kathryn S Leung
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Eyal Muscal
- Department of Pediatric Medicine, Sections of Immunology, Allergy & Rheumatology and Child Neurology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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40
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Abstract
Antibody-mediated diseases of the central nervous system are a relatively new and challenging field in autoimmune neurologic disease and of major clinical importance in children and adults. The antibodies bind to cell-surface epitopes on neuronal or glial proteins, and the patients demonstrate either focal or more generalized clinical signs depending on the extent of brain regions targeted by the antibodies. The presence of seizures, movement disorders, autonomic dysfunction and sleep disorders, alongside neuroimaging and electrophysiological features may indicate a specific antibody-mediated disorder. However, phenotypic variation may be observed in children with the same antibody. Regardless, many patients benefit from immunotherapy with substantial improvement.
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Affiliation(s)
- Ming Lim
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Level 6, West Wing, Oxford 3 9DU, UK; Children's Neurosciences, Evelina Children's Hospital @ Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, Lambeth Palace Road, London SE1 7EH, UK.
| | - Yael Hacohen
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Level 6, West Wing, Oxford 3 9DU, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Level 6, West Wing, Oxford 3 9DU, UK.
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Bello-Espinosa LE, Rajapakse T, Rho JM, Buchhalter J. Efficacy of intravenous immunoglobulin in a cohort of children with drug-resistant epilepsy. Pediatr Neurol 2015; 52:509-16. [PMID: 25882078 DOI: 10.1016/j.pediatrneurol.2014.11.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 11/15/2014] [Accepted: 11/18/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVES We describe the experience of a pediatric epilepsy center regarding the efficacy of intravenous immunoglobulin for drug-resistant seizures in children. METHODS A retrospective chart review of all children in a community-based, children's hospital neurology clinic from 2006 to 2012, inclusive, with intractable epilepsy who were treated with intravenous immunoglobulin for a minimum of six cycles was performed. Data collected included patient demographics, seizure and epilepsy syndrome type, presumed etiology for the seizures, and seizure frequency. Response to intravenous immunoglobulin was defined as "positive" if either seizure freedom or ≥50% reduction of seizures was achieved. RESULTS Twenty-seven children (3-17 years old) were identified and included in the analysis. Following treatment with intravenous immunoglobulin, the following outcomes were noted: four were seizure-free, eight had 90% reduction, five had 75% reduction, and five had 50% reduction. A total of 22 (81%) patients had a positive clinical response to treatment from baseline. Five patients (19%) were not responsive. No clear relationship of responsiveness to intravenous immunoglobulin with regard to age, gender, or epilepsy syndrome was apparent; however, the small numbers in each category precluded meaningful statistical analysis. SIGNIFICANCE Our findings and those of others suggest that intravenous immunoglobulin is a potentially high efficacy, low side effect profile therapy in the treatment of children with drug-resistant epilepsies. Intravenous immunoglobulin was able to reduce multiple seizure types in a variety of epilepsy etiologies, including those of unknown cause.
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Affiliation(s)
- Luis E Bello-Espinosa
- Department of Pediatrics, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
| | - Thilinie Rajapakse
- Department of Pediatrics, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
| | - Jong M Rho
- Department of Pediatrics, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada; Alberta Children's Hospital Research Institute, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
| | - Jeffrey Buchhalter
- Department of Pediatrics, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada; Alberta Children's Hospital Research Institute, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada.
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Suleiman J, Dale RC. The recognition and treatment of autoimmune epilepsy in children. Dev Med Child Neurol 2015; 57:431-40. [PMID: 25483277 DOI: 10.1111/dmcn.12647] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2014] [Indexed: 01/07/2023]
Abstract
There is emerging interest in autoimmune epilepsy, which represents a small but potentially treatable form of epilepsy. Most insights into autoimmune epilepsy derive from the recent descriptions of autoimmune encephalitis that takes two general forms: a focal encephalitis (such as limbic) or a diffuse encephalitis (such as anti-N-methyl-D-aspartate receptor [NMDAR] encephalitis). The features of autoimmune epilepsy include acute or subacute onset of seizures, usually in the context of encephalopathy, and inflammation of the central nervous system on testing cerebrospinal fluid or magnetic resonance imaging. Neuronal antibodies associated with autoimmune encephalitis and seizures in children include NMDAR, voltage-gated potassium channel complex, glycine receptor, γ-Aminobutyric acid type A receptor (GABA(A)R), γ-Aminobutyric acid type B receptor (GABA(B)R), and glutamic acid decarboxylase antibodies. These antibodies support the diagnosis of autoimmune epilepsy, but are not essential for diagnosis. When autoimmune epilepsy is suspected, first-line immune therapy with corticosteroids in addition to intravenous immunoglobulin or plasma exchange should be considered. Second-line therapy with rituximab or cyclophosphamide can be considered if the syndrome is severe. A response to immune therapy supports the diagnosis of autoimmune epilepsy. Neuronal antibodies are increasingly found in patients with focal epilepsy of unknown cause who do not have 'encephalitis'. Recent epidemiological studies support the link between epilepsy and autoimmune diseases. Future studies need to define the spectrum of autoimmune epilepsy and focus on early identification and treatment.
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Affiliation(s)
- Jehan Suleiman
- Department of Paediatrics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates; Paediatrics and Child Health Discipline, Clinical School, The Children's Hospital at Westmead, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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43
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Ramberger M, Peschl P, Schanda K, Irschick R, Höftberger R, Deisenhammer F, Rostásy K, Berger T, Dalmau J, Reindl M. Comparison of diagnostic accuracy of microscopy and flow cytometry in evaluating N-methyl-D-aspartate receptor antibodies in serum using a live cell-based assay. PLoS One 2015; 10:e0122037. [PMID: 25815887 PMCID: PMC4376531 DOI: 10.1371/journal.pone.0122037] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 02/06/2015] [Indexed: 01/17/2023] Open
Abstract
N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune neurological disease, diagnosed by a specific autoantibody against NMDAR. Antibody testing using commercially available cell-based assays (CBA) or immunohistochemistry on rat brain tissue has proven high specificity and sensitivity. Here we compare an immunofluorescence live CBA to a flow cytometry (FACS) based assay to detect NMDAR antibodies by their binding to the surface of HEK293A cells functionally expressing NMDAR. Both assays were first established using a discovery group of 76 individuals and then validated in a group of 32 patients in a blinded manner. In the CBA, 23 of 23 patients with NMDAR encephalitis were positive for NMDAR antibodies and 0 of 85 controls (32 healthy controls and 53 patients with other neurological diseases), resulting in a sensitivity and specificity of 100% (95% confidence intervals (CI) 85.1-100.0 and 95.7-100.0, respectively). The FACS based assay detected NMDAR antibodies in 20 of 23 patients and in 0 of 85 controls. Therefore, with an equally high specificity (95% CI 95.7-100.0) the sensitivity of the FACS based assay was 87% (95% CI 66.4-97.2). Comparing antibody titers from CBA with delta median fluorescence intensities from FACS showed a high concordance (kappa = 0.943, p<0.0001) and correlation (r = 0.697, p<0.0001). In conclusion, evaluation of the FACS based assay revealed a lower sensitivity and high inter-assay variation, making the CBA a more reliable detection method.
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Affiliation(s)
- Melanie Ramberger
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Patrick Peschl
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Kathrin Schanda
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Regina Irschick
- Division of Neuroanatomy, Medical University of Innsbruck, Innsbruck, Austria
| | - Romana Höftberger
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
- Institució Catalana de Recerca i Estudis Avançats (ICREA), IDIBAPS, Hospital Clínic, Barcelona, Spain
| | - Florian Deisenhammer
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Kevin Rostásy
- Pediatric Neurology, Witten/Herdecke University, Children’s Hospital Datteln, Datteln, Germany
| | - Thomas Berger
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Josep Dalmau
- Institució Catalana de Recerca i Estudis Avançats (ICREA), IDIBAPS, Hospital Clínic, Barcelona, Spain
| | - Markus Reindl
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- * E-mail:
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Sánchez Fernández I, Loddenkemper T. Therapeutic choices in convulsive status epilepticus. Expert Opin Pharmacother 2015; 16:487-500. [PMID: 25626010 DOI: 10.1517/14656566.2015.997212] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Convulsive status epilepticus (SE) is one of the most frequent and severe neurological emergencies in both adults and children. A timely administration of appropriate antiepileptic drugs (AEDs) can stop seizures early and markedly improve outcome. AREAS COVERED The main treatment strategies for SE are reviewed with an emphasis on initial treatments. The established first-line treatment consists of benzodiazepines, most frequently intravenous lorazepam. Benzodiazepines that do not require intravenous administration like intranasal midazolam or intramuscular midazolam are becoming more popular because of easier administration in the field. Other benzodiazepines may also be effective. After treatment with benzodiazepines, treatment with fosphenytoin and phenobarbital is usually recommended. Other intravenously available AEDs, such as valproate and levetiracetam, may be as effective and safe as fosphenytoin and phenobarbital, have a faster infusion time and better pharmacokinetic profile. The rationale behind the need for an early treatment of SE is discussed. The real-time delays of AED administration in clinical practice are described. EXPERT OPINION There is limited evidence to support what the best initial benzodiazepine or the best non-benzodiazepine AED is. Recent and developing multicenter trials are evaluating the best treatment options and will likely modify the recommended treatment choices in SE in the near future. Additionally, more research is needed to understand how different treatment options modify prognosis in SE. Timely implementation of care protocols to minimize treatment delays is crucial.
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Affiliation(s)
- Iván Sánchez Fernández
- Boston Children's Hospital, Harvard Medical School, Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Fegan 9 , 300 Longwood Avenue, Boston, MA 02115 , USA
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Sannagowdara K, Willoughby R, Whelan H. Proton Nuclear Magnetic Resonance (NMR) Metabolomics: Future in Etiological Diagnosis of Encephalomyelitis. ACTA ACUST UNITED AC 2015; 6. [PMID: 26339656 DOI: 10.4172/2314-7326.1000184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kumar Sannagowdara
- Department of Pediatric Neurology, Medical College of Wisconsin, Milwaukee WI, USA
| | - Rodney Willoughby
- Department of Pediatric Infectious Diseases, Medical College of Wisconsin, Milwaukee WI, USA
| | - Harry Whelan
- Department of Pediatric Neurology, Medical College of Wisconsin, Milwaukee WI, USA
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Kim SY, Choi SA, Ryu HW, Kim H, Lim BC, Hwang H, Chae JH, Choi J, Kim KJ, Hwang YS, Lee ST, Chu K, Lee SK. Screening Autoimmune Anti-neuronal Antibodies in Pediatric Patients with Suspected Autoimmune Encephalitis. J Epilepsy Res 2014; 4:55-61. [PMID: 25625089 PMCID: PMC4295054 DOI: 10.14581/jer.14012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 09/01/2014] [Indexed: 12/15/2022] Open
Abstract
Background and Purpose: The aim of this study was to identify and describe the pediatric autoimmune encephalitis cases positive for anti-neuronal antibody tests. Methods: Screening of six anti-neuronal antibodies in 23 children with suspected autoimmune encephalitis was performed by cell-based indirect immunofluorescence test with patients’ serum or cerebrospinal fluid. Results: Among the 23 cases enrolled here, eight patients (35%) were positive for the anti-N-methyl-d-aspartate (NMDA) receptor antibody and one patient (4%) was positive for the anti-contactin-associated protein-like 2 (CASPR2) antibody. In the anti-NMDA receptor antibody-positive group, seizure and movement disorders were the most prominent features and were present in all patients. A tumor was present in only one patient. Three patients with infant- and toddler-onset disease did not exhibit a classic multistage illness. In addition to seizure and dyskinesia, aphasia or mutism without severe consciousness impairment was present in all three patients. These atypical clinical presentations may suggest different pathomechanism of anti-NMDA receptor encephalitis among these age groups. The patient who was positive for the anti-CASPR2 antibody was an 8-year-old girl who presented with fever, encephalopathy, and seizure. Neuromyotonia or other dyskinesia was not present. Conclusions: Eight anti-NMDA receptor antibody positive patients and one CASPR2 positive patient were identified from the screening of six anti-neuronal antibodies in pediatric patients suspected with autoimmune encephalitis. Developmental regression specifically for language skills was suggested as one of the atypical clinical features in infants and toddler onset anti-NMDA receptor antibody positive patients.
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Affiliation(s)
- Soo Yeon Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul
| | - Sun Ah Choi
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul
| | - Hye Won Ryu
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam
| | - Hunmin Kim
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam
| | - Byung Chan Lim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul; ; Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul
| | - Hee Hwang
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam
| | - Jong-Hee Chae
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul; ; Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul
| | - Jieun Choi
- Department of Pediatrics, SMG-SNU Boramae Medical Center, Seoul
| | - Ki Joong Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul; ; Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul
| | - Yong Seung Hwang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul; ; Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul
| | - Soon-Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Kon Chu
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Sang Kun Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
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Abstract
The role of immunity and inflammation appears to be an integral part of the pathogenic processes associated with some seizures, particularly with refractory epilepsy. Prompt treatment with immunotherapy may lead to better outcomes. Immune treatment options for treatment of epilepsy include therapies such as corticosteroids, immunoglobulins, plasmapheresis, or steroid-sparing drugs such as azathioprine. Recent alternatives have included even more aggressive treatment with cyclophosphamide, anti-pre-B-lymphocyte monoclonal antibody rituximab, and monoclonal antibodies such as efalizumab or natalizumab, which are presently used for other inflammatory disorders. Randomized controlled trials of immunotherapy in presumed autoimmune epilepsy are needed to provide further support for the rapid use of immunotherapy in patients with immune mediated epilepsy.
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Affiliation(s)
- Joseph J Melvin
- Section of Neurology, St. Christopher's Hospital for Children, Department of Pediatrics, Drexel University College of Medicine, Philadelphia, PA..
| | - H Huntley Hardison
- Section of Neurology, St. Christopher's Hospital for Children, Department of Pediatrics, Drexel University College of Medicine, Philadelphia, PA
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Abstract
There is increasing evidence documenting activation of inflammatory processes in focal epilepsies. This review article summarizes current data regarding immune mediated inflammatory processes in patients with symptomatic partial epilepsies such as mesial temporal sclerosis, focal cortical dysplasia, and Rasmussen's encephalitis. We have also reviewed several neuronal surface antibody-associated syndromes, which have been recently described with focal seizures as an important part of clinical presentation, such as antibody-associated limbic encephalitis and N-methyl-D-aspartic acid receptor antibody syndrome. An autoimmune mechanism may be one pathogenic factor in some symptomatic epilepsies acting as a triggering event in the process leading to the development of epilepsy.
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Irani SR, Gelfand JM, Al-Diwani A, Vincent A. Cell-surface central nervous system autoantibodies: clinical relevance and emerging paradigms. Ann Neurol 2014; 76:168-84. [PMID: 24930434 PMCID: PMC4141019 DOI: 10.1002/ana.24200] [Citation(s) in RCA: 139] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 06/13/2014] [Accepted: 06/13/2014] [Indexed: 01/17/2023]
Abstract
The recent discovery of several potentially pathogenic autoantibodies has helped identify patients with clinically distinctive central nervous system diseases that appear to benefit from immunotherapy. The associated autoantibodies are directed against the extracellular domains of cell-surface-expressed neuronal or glial proteins such as LGI1, N-methyl-D-aspartate receptor, and aquaporin-4. The original descriptions of the associated clinical syndromes were phenotypically well circumscribed. However, as availability of antibody testing has increased, the range of associated patient phenotypes and demographics has expanded. This in turn has led to the recognition of more immunotherapy-responsive syndromes in patients presenting with cognitive and behavioral problems, seizures, movement disorders, psychiatric features, and demyelinating disease. Although antibody detection remains diagnostically important, clinical recognition of these distinctive syndromes should ensure early and appropriate immunotherapy administration. We review the emerging paradigm of cell-surface-directed antibody-mediated neurological diseases, describe how the associated disease spectrums have broadened since the original descriptions, discuss some of the methodological issues regarding techniques for antibody detection and emphasize considerations surrounding immunotherapy administration. As these disorders continue to reach mainstream neurology and even psychiatry, more cell-surface-directed antibodies will be discovered, and their possible relevance to other more common disease presentations should become more clearly defined.
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Affiliation(s)
- Sarosh R Irani
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom; Multiple Sclerosis and Neuroinflammation Center, Department of Neurology, University of California, San Francisco, San Francisco, CA
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