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Sakharova T, Aringazina R, Lilyanov N, Monov D. Features of the clinical course of Autoimmune Encephalitis Associated with various antibodies. Neurol Sci 2024:10.1007/s10072-024-07604-7. [PMID: 38806881 DOI: 10.1007/s10072-024-07604-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 05/16/2024] [Indexed: 05/30/2024]
Abstract
Despite the increasing incidence of autoimmune encephalitis and the incomplete recovery observed in patients post-affliction, the issue of timely diagnosis remains unresolved. The primary objective of this study is identification the distinctive clinical presentation features evaluation the management strategies, and assess the outcomes of the disease in patients with various forms of autoimmune encephalitis. The research aims to contribute in a better understanding of the disease progression and facilitate the selection of optimal therapeutic interventions. A retrospective observational study enrolled 68 patients aged 18 years and older with verified autoimmune encephalitis who underwent treatment in state hospitals in Sofia, Bulgaria, from the beginning of 2014 to the end of 2022. The number of patients with pathology linked to antibodies against glycine receptors (Gly-R) was half as much, with 32 and 17 patients, respectively. The primary manifestations of autoimmune encephalitis included cognitive impairments observed in 51 patients, seizures occurring in 44 patients, and mood disorders observed in 22 patients. While the findings of imaging studies were nonspecific, hospitalizations for patients with this pathology, especially those with antibodies to CASPR2 and DPPX, were prolonged (114 and 232 days, respectively). In the vast majority of cases, incomplete recovery with residual symptoms was noted. Among the diverse forms of autoimmune encephalitis, the most prevalent is NMDA-R. Cognitive impairments predominate in the autoimmune encephalitis clinical presentation. Prolonged hospitalization periods and incomplete recovery of patients are characteristic features of autoimmune encephalitis, despite combined therapy involving intravenous administration of methylprednisolone and immunoglobulins.
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Affiliation(s)
- Tatyana Sakharova
- Department of Biology and General Genetics, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Raisa Aringazina
- Department of Internal Diseases № 1, Non-Commercial Joint-Stock Society «West Kazakhstan Marat Ospanov Medical University», Aktobe, Kazakhstan
| | - Nikolay Lilyanov
- Department of Anesthesiology and Intensive Care, Medical University of Sofia, Sofia, Bulgaria.
| | - Dimitar Monov
- Department of Anesthesiology and Intensive Care, Medical University of Sofia, Sofia, Bulgaria
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Labib A, Burke O, Nichols A, Maderal AD. Approach to diagnosis, evaluation, and treatment of generalized and nonlocal dysesthesia: A review. J Am Acad Dermatol 2023; 89:1192-1200. [PMID: 37517675 DOI: 10.1016/j.jaad.2023.06.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 08/01/2023]
Abstract
Dysesthesia is an abnormal sensation in the skin that occurs in the absence of any extraordinary stimulus or other primary cutaneous disorders, excluding any delusions or tactile hallucinations. Clinicians have characterized dysesthesias to include sensations such as burning, tingling, pruritus, allodynia, hyperesthesia, or anesthesia. The etiology and pathogenesis of various generalized dysesthesias is largely unknown, though many dysesthesias have been associated with systemic pathologies including malignancy, infection, autoimmune disorders, and neuropathies. Dermatologists are often the first-line clinicians for patients presenting with such cutaneous findings, thus it is crucial for these physicians to be able to methodically work-up generalized dysesthesias to build a working differential diagnosis, follow up with key labs and/or imaging, and offer patients evidence-based treatment to relieve their symptoms. This broad literature review is an attempt to centralize key studies, cases, and series to help guide dermatologists in their assessment and evaluation of complaints of abnormal cutaneous sensations.
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Affiliation(s)
- Angelina Labib
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Olivia Burke
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Anna Nichols
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Andrea D Maderal
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida.
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Braczkowski M, Soszyński D, Sierakowska A, Braczkowski R, Kufel K, Łabuz-Roszak B. Autoimmune Encephalitis with Antibodies: Anti-NMDAR, Anti-AMPAR, Anti-GQ1b, Anti-DPPX, Anti-CASPR2, Anti-LGI1, Anti-RI, Anti-Yo, Anti-Hu, Anti-CV2 and Anti-GABAAR, in the Course of Psychoses, Neoplastic Diseases, and Paraneoplastic Syndromes. Diagnostics (Basel) 2023; 13:2589. [PMID: 37568953 PMCID: PMC10417199 DOI: 10.3390/diagnostics13152589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/25/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023] Open
Abstract
Encephalitis is a condition with a variety of etiologies, clinical presentations, and degrees of severity. The causes of these disorders include both neuroinfections and autoimmune diseases in which host antibodies are pathologically directed against self-antigens. In autoimmune encephalitis, autoantibodies are expressed in the central nervous system. The incidence of this disease is approximately 4% of all reported cases of encephalitis. Autoimmune encephalitis can be induced by antibodies against neuronal surface antigens such as N-methyl-D-aspartate-activated glutamate receptors (NMDAR), α-amino-3-hydroxy-5-methyl-4-isoxazole propionate receptors (AMPAR) or gangliosides GQ1b, DPPX, CASPR2, LGI1, as well as by antibodies against neuronal intracellular antigens. The paper presents a number of both mental and neurological symptoms of autoimmune encephalitis. Moreover, the coexistence of psychoses, neoplastic diseases, and the methods of diagnosing autoimmune encephalitis are discussed. Attention was also drawn to the fact that early diagnosis, as well as early initiation of targeted treatment, increases the chance of a successful course of the therapeutic process. Strategy and Methodology: The articles on which the following paper was based were searched using search engines such as PubMed and Medline. Considering that anti-NMDAR antibodies were first described in 2007, the articles were from 2007 to 2023. The selection of papers was made by entering the phrases "autoimmune encephalitis and psychosis/paraneplastic syndromes or cancer". The total number of articles that could be searched was 747, of which 100 items were selected, the most recent reports illustrating the presented topic. Thirty-four of them were rejected in connection with case reports or papers that could not be accessed.
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Affiliation(s)
- Michał Braczkowski
- Department of Physiology, Institute of Medical Sciences, University of Opole, 45040 Opole, Poland
| | - Dariusz Soszyński
- Department of Physiology, Institute of Medical Sciences, University of Opole, 45040 Opole, Poland
- Department of Human Physiology, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, 87100 Torun, Poland
| | - Alicja Sierakowska
- Student Scientific Society of Physiology, Department of Physiology, Institute of Medical Sciences, University of Opole, 45040 Opole, Poland; (A.S.)
- Student Association of Neurology, Department of Neurology, Institute of Medical Sciences, University of Opole, 45040 Opole, Poland
| | | | - Klaudia Kufel
- Student Scientific Society of Physiology, Department of Physiology, Institute of Medical Sciences, University of Opole, 45040 Opole, Poland; (A.S.)
| | - Beata Łabuz-Roszak
- Department of Neurology, Institute of Medical Sciences, University of Opole, 45040 Opole, Poland
- Department of Neurology, ST Jadwiga Regional Specialized Hospital, 45040 Opole, Poland
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Liu Y, Gong Y, Wu XL, Hao XM, Liu JP, Li YY, Yang KZ, Gao XY, Zhang J, Zhang L, Zhang XD, Wang J, Liu QG. Fire acupuncture for anti-LGI1 antibody autoimmune encephalitis: a case report. Front Neurosci 2023; 17:1203915. [PMID: 37539383 PMCID: PMC10395828 DOI: 10.3389/fnins.2023.1203915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/19/2023] [Indexed: 08/05/2023] Open
Abstract
Autoimmune encephalitis, a class of encephalitis, is clinically characterized by multifocal or diffuse brain injury, including aberrant mental behavior, convulsions, and near-event memory impairment. In this article, we describe a female patient with autoimmune encephalitis who tested positive for leucine-rich glioma inactivated 1 (LGI1) antibodies and had hippocampal inflammatory edema in the lesion area. During the first 3 months of her illness, the patient primarily experienced memory loss, the onset of rigid twitching in her extremities that lasted for 1 min while in remission, and incontinence. After gamma globulin administration, methylprednisolone shock, and other symptomatic therapies during hospitalization, the patient's psychiatric symptoms and seizures improved considerably; however, she did not fully recover her memory. After receiving fire acupuncture for 6 months, the patient's understanding, orientation, and calculation skills improved considerably. Her memory and mental state were also improved at the follow-up visit. In this case, the use of fire acupuncture for the treatment of autoimmune encephalitis resulted in favorable outcomes with important benefits for conditions affecting the central nervous system; however, more convincing data are required to support the effectiveness of this treatment method.
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Affiliation(s)
- Yu Liu
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yu Gong
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Xiao-li Wu
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Xiao-min Hao
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Ji-peng Liu
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Yin-yin Li
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Ke-zhen Yang
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Xin-yu Gao
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Jing Zhang
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Lin Zhang
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Xu-dong Zhang
- Department of Chinese Medicine, Beijing Jishuitan Hospital, Beijing, China
| | - Jun Wang
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Qing-guo Liu
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
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Yang F, Ma J, Zhu D, Wang Z, Li Y, He X, Zhang G, Kang X. The Role of S100A6 in Human Diseases: Molecular Mechanisms and Therapeutic Potential. Biomolecules 2023; 13:1139. [PMID: 37509175 PMCID: PMC10377078 DOI: 10.3390/biom13071139] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/11/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
S100A6, also known as calcyclin, is a low-molecular-weight Ca2+-binding protein from the S100 family that contains two EF-hands. S100A6 is expressed in a variety of mammalian cells and tissues. It is also expressed in lung, colorectal, pancreatic, and liver cancers, as well as other cancers such as melanoma. S100A6 has many molecular functions related to cell proliferation, the cell cycle, cell differentiation, and the cytoskeleton. It is not only involved in tumor invasion, proliferation, and migration, but also the pathogenesis of other non-neoplastic diseases. In this review, we focus on the molecular mechanisms and potential therapeutic targets of S100A6 in tumors, nervous system diseases, leukemia, endometriosis, cardiovascular disease, osteoarthritis, and other related diseases.
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Affiliation(s)
- Fengguang Yang
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou 730030, China; (F.Y.); (X.H.); (G.Z.)
- The Second Clinical Medical College, Lanzhou University, Lanzhou 730030, China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Jinglin Ma
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou 730030, China; (F.Y.); (X.H.); (G.Z.)
- The Second Clinical Medical College, Lanzhou University, Lanzhou 730030, China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou 730030, China
- School of Petrochemical Engineering, Lanzhou University of Technology, Lanzhou 730050, China
| | - Daxue Zhu
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou 730030, China; (F.Y.); (X.H.); (G.Z.)
- The Second Clinical Medical College, Lanzhou University, Lanzhou 730030, China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Zhaoheng Wang
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou 730030, China; (F.Y.); (X.H.); (G.Z.)
- The Second Clinical Medical College, Lanzhou University, Lanzhou 730030, China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Yanhu Li
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou 730030, China; (F.Y.); (X.H.); (G.Z.)
- The Second Clinical Medical College, Lanzhou University, Lanzhou 730030, China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Xuegang He
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou 730030, China; (F.Y.); (X.H.); (G.Z.)
- The Second Clinical Medical College, Lanzhou University, Lanzhou 730030, China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Guangzhi Zhang
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou 730030, China; (F.Y.); (X.H.); (G.Z.)
- The Second Clinical Medical College, Lanzhou University, Lanzhou 730030, China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Xuewen Kang
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou 730030, China; (F.Y.); (X.H.); (G.Z.)
- The Second Clinical Medical College, Lanzhou University, Lanzhou 730030, China
- Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou 730030, China
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Safan AS, Al-Termanini M, Abdelhady M, Osman Y, Awad Elzouki ANY, Abdussalam AL. Claustrum sparing sign in seronegative limbic encephalitis. eNeurologicalSci 2023; 31:100465. [PMID: 37250109 PMCID: PMC10212785 DOI: 10.1016/j.ensci.2023.100465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/31/2023] Open
Abstract
Background Limbic encephalitis (LE) is a rare variant of autoimmune encephalitis. It often manifests with subacute neuropsychiatric symptoms of agitation, delusions, variable seizure semiology, and short-term memory loss. Seronegative limbic encephalitis can pose a diagnostic conundrum owing to its inadequately understood pathophysiology. Case presentation We report a rare case of a young male with subacute neuropsychiatric manifestations of delusions, agitations and seizures. He was diagnosed with seronegative limbic encephalitis (SNLE). Brain MRI demonstrated bilateral Claustrum sparing sign. An EEG showed continuous left-sided epileptiform discharges in periodic to predominantly left middle temporal. Patient condition gradually improved with pulsed methylprednisolone, intravenous immunoglobulins and anti-seizure medications. Conclusion Claustrum remains one of the least understood neuroanatomical structures. Claustrum sign has been reported in febrile infection-related epilepsy syndrome (FIRES), LE, and autoimmune refractory epilepsy. To the best of our knowledge, we report the first case in literature with Claustrum sparing sign in seronegative Limbic Encephalitis. Further experimental models and researches are warranted to better understand the unique function of the claustrum and unravel possible other attributable auto-antibodies, which could alter treatment and prognosis.
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Affiliation(s)
- Abeer Sabry Safan
- Department of Neurology, Neurosciences Institute, Hamad Medical Corporation, Doha, Qatar
| | | | - Mohamed Abdelhady
- Department of Neuroradiology, Neurosciences Institute, Hamad Medical Corporation, Doha, Qatar
| | - Yasir Osman
- Department of Neurology, Neurosciences Institute, Hamad Medical Corporation, Doha, Qatar
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Wcisło S, Bojkowska-Otrębska K, Łabuz-Roszak B. PSYCHIATRIC DISORDERS IN AUTOIMMUNE ENCEPHALITIS - LITERATURE REVIEW. POLSKI MERKURIUSZ LEKARSKI : ORGAN POLSKIEGO TOWARZYSTWA LEKARSKIEGO 2023; 51:563-568. [PMID: 38069859 DOI: 10.36740/merkur202305117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Autoimmune encephalitis (AE) is a non-infectious inflammatory disease caused by the presence of autoantibodies directed against neuronal surface or intracellular antigens. Its incidence in Western countries is about 0.8 per 100,000 people. AE requires differentiation primarily with psychiatric diseases, but it also requires oncological vigilance. On the other hand, in the case of an acute episode of psychosis, differentiation with AE should always be pursued. This paper discusses the most common psychiatric disorders that occur in autoimmune encephalitis.
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Affiliation(s)
- Sandra Wcisło
- STUDENT SCIENTIFIC ASSOCIATION AT THE DEPARTMENT OF NEUROLOGY, INSTITUTE OF MEDICAL SCIENCES, UNIVERSITY OF OPOLE, OPOLE, POLAND
| | | | - Beata Łabuz-Roszak
- DEPARTMENT OF NEUROLOGY, INSTITUTE OF MEDICAL SCIENCES, UNIVERSITY OF OPOLE, OPOLE, POLAND; DEPARTMENT OF NEUROLOGY, ST. JADWIGA REGIONAL SPECIALIZED HOSPITAL, OPOLE, POLAND
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Ackerman A, Igawa T, Singla A, Kosack A. A Perplexing Case of Confusion. Clin Pediatr (Phila) 2022:99228221145301. [PMID: 36539962 DOI: 10.1177/00099228221145301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Anouk Ackerman
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Teryn Igawa
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ankit Singla
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA, USA
| | - Amanda Kosack
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA, USA
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Clinical and MRI differential analysis of autoimmune encephalitis and viral encephalitis. J Taibah Univ Med Sci 2022; 18:271-278. [PMID: 36817222 PMCID: PMC9926194 DOI: 10.1016/j.jtumed.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 07/29/2022] [Accepted: 09/13/2022] [Indexed: 02/02/2023] Open
Abstract
Objectives The goal of this study was to analyze the clinical and magnetic resonance imaging (MRI) characteristics of autoimmune encephalitis (AE) and viral encephalitis (VE) at the initial stage of onset. Methods This study was a retrospective analysis of the clinical manifestations, laboratory tests, electroencephalogram examination, imaging examinations, and treatment outcomes of 24 VE patients and 20 AE patients. Results The onset age was significantly younger in the VE group than in the AE group, mainly occurring in adolescents (P < 0.05). The proportions of fever, headache, and vomiting were higher in the VE group than in the AE group (P < 0.05), and there were few manifestations of central hypoventilation. The incidence of abnormal myocardial enzymes was significantly higher in the VE group than in the AE group (P < 0.05). There was no significant difference in electroencephalogram test results between the VE and AE groups. Regarding magnetic resonance imaging (MRI), the proportion of single lesion involving a single lobe or multiple asymmetries involving the limbic system in the VE group was higher than that in the AE group (P < 0.05). The incidence of lesion enhancement in the VE group was higher than that in the AE group. Meanwhile, diffusion-weighted imaging sequence was more sensitive than T2 liquid-attenuated inversion recovery sequence in the detection, efficacy evaluation, and follow-up review of the AE and VE groups. Conclusion The onset age of VE is younger, and the clinical symptoms of AE and VE differ with statistical significance. MRI can objectively reflect the imaging characteristics of both groups. Combining early clinical manifestations with imaging manifestations can facilitate early diagnosis and treatment, and improve the prognosis.
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Raventhiranathan N, Hussien AR, Mirchia K, Swarnkar A, Mangla R. Striatal dominant lupus encephalitis–Is it vasculitis or an autoimmune process? Literature review & new case report with vessel wall imaging. Radiol Case Rep 2022; 17:1205-1210. [PMID: 35169429 PMCID: PMC8829497 DOI: 10.1016/j.radcr.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Neveada Raventhiranathan
- Department of Radiology, State University of New York Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210
- Corresponding author.
| | | | - Kavya Mirchia
- Department of Radiology, State University of New York Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210
| | - Amar Swarnkar
- Department of Radiology, State University of New York Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210
| | - Rajiv Mangla
- Department of Radiology, State University of New York Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210
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Ball C, Fisicaro R, Morris L, White A, Pacicco T, Raj K, Agarwal A, Lee WC, Yu FF. Brain on fire: an imaging-based review of autoimmune encephalitis. Clin Imaging 2022; 84:1-30. [DOI: 10.1016/j.clinimag.2021.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/28/2021] [Accepted: 12/16/2021] [Indexed: 12/28/2022]
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Xu L, Chen Z. Anti-NMDA Receptor Encephalitis Misdiagnosed As Generalized Anxiety Disorder: A Case Report. Cureus 2021; 13:e20529. [PMID: 34956805 PMCID: PMC8693539 DOI: 10.7759/cureus.20529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2021] [Indexed: 11/24/2022] Open
Abstract
The autoimmune encephalitis is a rare group of neurological disorders mediated by immune mechanisms. Neuropsychiatric symptoms often occur in the early stages of the disease, so many patients seek treatment in psychiatry for the first time. If psychiatrists lack understanding and vigilance of the disease, it is very easy to be misdiagnosed as various primary psychiatric diseases, thus delaying diagnosis and treatment. Here, we report an older woman with autoimmune encephalitis. In the early stage, the patient was misdiagnosed as having generalized anxiety disorder because of obvious psychiatric symptoms, and then caused the doctor’s vigilance due to rapidly declining cognitive function, autonomic nervous dysfunction, involuntary movement, and other warning symptoms. Autoimmune encephalitis was diagnosed by cerebrospinal fluid examination, and the patient was cured and discharged after a period of immunotherapy.
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Affiliation(s)
- Liang Xu
- Department of Geriatric Psychiatry, Huzhou Third People's Hospital, the Affiliated Hospital of Huzhou University, Huzhou, Zhejiang Province, China, Huzhou, CHN
| | - Zheli Chen
- Department of Geriatric Psychiatry, Huzhou Third People's Hospital, the Affiliated Hospital of Huzhou University, Huzhou, Zhejiang Province, China, Huzhou, CHN
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Kambadja B, Marion H, Cousyn L, Mezouar N, Navarro V, Herlin B, Sophie D. When should we test patients with epilepsy for autoimmune antibodies? Results from a French retrospective single center study. J Neurol 2021; 269:3109-3118. [PMID: 34816332 DOI: 10.1007/s00415-021-10894-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/05/2021] [Accepted: 11/06/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Seizures represent a core symptom of autoimmune encephalitides with specific therapeutic issues. To date, patients with new-onset seizures or established epilepsy are not systematically tested for autoimmune antibodies. We aimed to identify clinical and paraclinical criterion that could help to select patients requiring additional autoimmune antibodies serum and cerebrospinal fluid (CSF) detection. METHODS In this retrospective single center study from the French Salpêtrière Hospital, data from 286 adult patients with epilepsy who received an autoantibody assay for the first time were analyzed. All patients were evaluated at our institution between January 2007 and December 2018 for assessment of new-onset epilepsy (n = 90) or established epilepsy (n = 196). We only analyzed patients that were screened for autoimmune antibodies. Demographic, clinical and neuroimaging measures were compared between patients with and without autoimmune encephalitis using Fisher's exact test for categorical variables and Welch's t test for continuous variables. Our primary goal was to identify significant factors that differentiated patients with and without autoimmune encephalitis. RESULTS We identified 27 patients with autoimmune epilepsy (9.4% of the patients who had been tested for autoantibodies). The significant factors differentiating patients with and without autoimmune encephalitis were: (i) the existence of a new-onset focal epilepsy + (e.g., newly diagnosed epilepsy < 6 months associated with additional symptoms, mainly cognitive or psychiatric symptoms), (ii) the presence of faciobrachial dystonic seizures very suggestive of anti- Leucine-rich glioma inactivated 1 (LGI1) encephalitis, and (iii) the presence of magnetic resonance imaging (MRI) abnormalities suggestive of encephalitis. CONCLUSION New-onset focal seizures combined with cognitive or psychiatric symptoms support the test for autoimmune antibodies. Further clinical already known red flags for an autoimmune origin are the presence of faciobrachial dystonic seizures and MRI signal changes consistent with encephalitis. On the other hand, isolated new-onset seizures and chronic epilepsy, even with associated symptoms, seem rarely linked to autoimmune encephalitis and should not lead to systematic testing.
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Affiliation(s)
- Bondish Kambadja
- Rehabilitation Unit, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Houot Marion
- Clinical Investigation Centre, Institut du Cerveau, Pitié-Salpêtrière Hospital, Paris, France
- Department of Neurology, Institute of Memory and Alzheimer's Disease (IM2A), Pitié-Salpêtrière Hospital, AP-HP, Paris, France
- Centre of Excellence of Neurodegenerative Disease (CoEN), Pitié-Salpêtrière Hospital, Paris, France
| | - Louis Cousyn
- Centre de Recherche de l'Institut du Cerveau, UMPC-UMR 7225 CNRS-UMRS 975 Inserm, Paris, France
- Université Paris Sorbonne, Paris, France
| | - Nicolas Mezouar
- Epilepsy Unit, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Vincent Navarro
- Centre de Recherche de l'Institut du Cerveau, UMPC-UMR 7225 CNRS-UMRS 975 Inserm, Paris, France
- Université Paris Sorbonne, Paris, France
- Epilepsy Unit, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
- Neurophysiology Unit Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Bastien Herlin
- Rehabilitation Unit, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
- Epilepsy Unit, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Dupont Sophie
- Rehabilitation Unit, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.
- Centre de Recherche de l'Institut du Cerveau, UMPC-UMR 7225 CNRS-UMRS 975 Inserm, Paris, France.
- Université Paris Sorbonne, Paris, France.
- Epilepsy Unit, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.
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14
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Li J, Jiang J, Lv J, Zhang R, Chen W, Li S, Jin Q, Wang G. Anti-γ-Aminobutyric Acid Type β Receptor Antibody-Associated Encephalitis After 2 Cycles of Durvalumab Therapy in a Patient with Small Cell Lung Cancer: A Case Report. Onco Targets Ther 2021; 14:5227-5236. [PMID: 34764654 PMCID: PMC8573260 DOI: 10.2147/ott.s337331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/21/2021] [Indexed: 01/21/2023] Open
Abstract
Anti-γ-aminobutyric acid type β receptor (anti-GABABR) antibody-associated encephalitis is a type of autoimmune encephalitis. According to current literature, its pathogenesis is reported to be closely related to tumor factors. However, diagnosis can be difficult because of the rarity of cases, limited clinical understanding, and a lack of specificity in clinical manifestation and imaging presentation. Clinical trials have demonstrated that immunotherapy can prolong the survival of patients with small cell lung cancer; however, in some cases, immunotherapy may induce anti-GABABR antibody-associated encephalitis. Patients who develop this encephalitis during immunotherapy often delay treatment because the cause is not clearly identified. In this study, we report a case of a 61-year-old man with a confirmed diagnosis of small cell lung cancer who had acute onset of cognitive impairment and seizures after two cycles of durvalumab (AstraZeneca UK Limited) combination chemotherapy. This reaction was initially considered as an immune-related adverse event (irAE) caused by durvalumab treatment, and the patient was eventually considered to have a paraneoplastic neurological disorder caused by the primary tumor. This report raises awareness of the symptoms of cognitive impairment and seizures in patients with small cell lung cancer, and the possible adverse events associated with immunotherapy. This case also highlights the importance of detecting anti-GABABR antibodies in patients with small cell lung cancer.
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Affiliation(s)
- Jiamo Li
- Department of Medical Oncology, The Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, People's Republic of China
| | - Jianing Jiang
- Department of Medical Oncology, The Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, People's Republic of China.,The Key Laboratory of Biomarker, High-Throughput Screening and Target Translation of Breast and Gastrointestinal Cancer, Dalian, Liaoning Province, People's Republic of China
| | - Jinyan Lv
- Department of Medical Oncology, The Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, People's Republic of China
| | - Ru Zhang
- Department of Medical Oncology, The Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, People's Republic of China
| | - Wenting Chen
- Department of Medical Oncology, The Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, People's Republic of China.,The Key Laboratory of Biomarker, High-Throughput Screening and Target Translation of Breast and Gastrointestinal Cancer, Dalian, Liaoning Province, People's Republic of China
| | - Shiyi Li
- Department of Medical Oncology, The Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, People's Republic of China
| | - Qianchen Jin
- Department of Medical Oncology, The Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, People's Republic of China
| | - Gang Wang
- Department of Medical Oncology, The Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, People's Republic of China.,The Key Laboratory of Biomarker, High-Throughput Screening and Target Translation of Breast and Gastrointestinal Cancer, Dalian, Liaoning Province, People's Republic of China
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15
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Mori L, Campanella W, Vestito L, Marinelli L, Benedetti L, Cocito L, Trompetto C. I can't count, but I can beat you playing cards: a case report on autoimmune encephalitis. BMC Neurol 2021; 21:347. [PMID: 34507555 PMCID: PMC8431866 DOI: 10.1186/s12883-021-02370-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 08/27/2021] [Indexed: 11/24/2022] Open
Abstract
Background Autoimmune encephalitis (AE) is a rare inflammatory disorder characterized by important psychiatric and neurologic symptoms. The literature documents high rates of neuropsychological dysfunction in N-methyl D-aspartate-receptor (NMDAr) encephalitis but papers don’t consider specifically calculation disturbances between the long-term deficits, although deficits in executive control and episodic memory were less likely to resolve. Case report Here we present a severe case of NMDAr encephalitis in a young patient without a relevant past medical history. Upon first examination he presented psycho-motor slowdown, speech disorders, severe cognitive deficits in all areas: concentration, attention, memory, language, dual task functions, increased latency in responses, severe dyscalculia. Upon first evaluation, the young patient underwent a battery of neuropsychological tests and he showed a dysexecutive syndrome with performances significantly low for age and education. Our patient hence underwent 1 month of intensive cognitive rehabilitation. After the rehabilitation treatment, he presented an amelioration in all domains except calculations. Conclusions In our patient the calculation disorder has proved to be the most relevant problem and the most difficult to treat. Clinicians should consider a careful approach to determine the prognosis of this syndrome because of the wide range of deficits, the need of prolonged treatment and the rate of long-term sequelae.
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Affiliation(s)
- Laura Mori
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy. .,IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | - William Campanella
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Lucio Marinelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Leonardo Cocito
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Carlo Trompetto
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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16
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Yang R, Ge F, Jiang J, Wang Y, Wan M, Zhang W. Temporal rank of clinical characteristics and prognosis of anti-N-methyl-d-aspartate receptor encephalitis. Brain Behav 2021; 11:e2277. [PMID: 34232562 PMCID: PMC8413795 DOI: 10.1002/brb3.2277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 05/10/2021] [Accepted: 06/23/2021] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Early recognition and intervention of patients with the anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis are important to achieve a better prognosis. The study aims to summarize the real-world perspectives of anti-NMDAR encephalitis patients in China via electronic medical records (EMRs). METHODS Using EMRs of patients from 2013 to 2019 from West China Hospital in China, a retrospective research was conducted to demonstrate the temporary rank of clinical characteristics and disease prognosis of anti-NMDAR encephalitis. The modified Rankin Scale (mRS) scores were used to divide the anti-NMDAR-encephalitis into two groups (poor prognosis vs. good prognosis). Chi-square test and logistic regression were used to analyze factors associated with prognosis. RESULTS Here, 78 patients were included. The most common clinical characteristics are cognitive dysfunction (86.0%) and thought disorder (86.0%). Cognitive dysfunction, thought disorder, and seizures tended to appear soon after prodrome symptoms. Logistics analysis results showed that cognitive dysfunction (OR = 4.48, 95% CI = 1.09-18.47), the score of (GCS ≤ 8) (OR = 4.52, 95% CI = 1.18-17.32), positive antibodies in serum (OR = 4.89, 95% CI = 1.19-20.13) and delay immunotherapy (OR = 4.76, 95% CI = 1.79-12.60) were risk factors of poor clinical outcomes. CONCLUSIONS There are two peaks in the development of autoimmune encephalitis (AE). The first peak is cognitive dysfunction, and the second peak is autonomic dysfunction. Cognitive dysfunction and GCS score ≤8 at admission, antibodies positive in serum, and delay immunotherapy were risk factors for a poor prognosis at discharge.
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Affiliation(s)
- Runnan Yang
- Mental Health Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fenfen Ge
- Mental Health Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jingwen Jiang
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yue Wang
- Mental Health Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Mengtong Wan
- Wuyuzhuang Honors College, Sichuan University, Chengdu, Sichuan, China
| | - Wei Zhang
- Mental Health Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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17
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Seasonal variation in autoimmune encephalitis: A multi-center retrospective study. J Neuroimmunol 2021; 359:577673. [PMID: 34333343 DOI: 10.1016/j.jneuroim.2021.577673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 07/14/2021] [Accepted: 07/21/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The aim of this study was to examine the seasonal distribution in clinical onset of autoimmune encephalitis (AE) in a multi-center cohort in China. METHODS This retrospective study consecutively recruited patients with new-onset definite neuronal surface antibody-associated AE between January 2015 and December 2020 from 3 tertiary hospitals. Demographic and clinical characteristics of the participants were comprehensively collected. Statistical analyses were performed using R. RESULTS Of the 184 patients of AE in our database, 149 (81.0%) were included in the final analysis. The median age of onset was 40.0 years, and 66 (44.3%) patients were female. AE predominantly started in autumn (47, 31.5%) and summer (43, 28.9%) months. Summer-autumn predominance of the clinical onsets was also present in the anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis group (54, 60.0%) and anti-leucine-rich glioma inactivated 1 (LGI1) encephalitis group (20, 76.9%). No obvious seasonal variations were observed among gender, onset age, disease duration, prodromal symptoms, clinical type of initial symptoms, and disease severity by the time of admission. CONCLUSION This study suggested summer-autumn predominance of the clinical onsets in patients with AE, especially anti-NMDAR and anti-LGI1 encephalitis. Therefore, clinicians should have a high index of suspicion for AE in encephalopathy patients in summer and autumn period.
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18
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Efferth T, Oesch F. The immunosuppressive activity of artemisinin-type drugs towards inflammatory and autoimmune diseases. Med Res Rev 2021; 41:3023-3061. [PMID: 34288018 DOI: 10.1002/med.21842] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 04/09/2021] [Accepted: 06/15/2021] [Indexed: 12/26/2022]
Abstract
The sesquiterpene lactone artemisinin from Artemisia annua L. is well established for malaria therapy, but its bioactivity spectrum is much broader. In this review, we give a comprehensive and timely overview of the literature regarding the immunosuppressive activity of artemisinin-type compounds toward inflammatory and autoimmune diseases. Numerous receptor-coupled signaling pathways are inhibited by artemisinins, including the receptors for interleukin-1 (IL-1), tumor necrosis factor-α (TNF-α), β3-integrin, or RANKL, toll-like receptors and growth factor receptors. Among the receptor-coupled signal transducers are extracellular signal-regulated protein kinase (ERK), c-Jun N-terminal kinase (JNK), phosphatidylinositol-4,5-bisphosphate 3-kinase (PI3K), AKT serine/threonine kinase (AKT), mitogen-activated protein kinase (MAPK)/extracellular signal regulated kinase (ERK) kinase (MEK), phospholipase C γ1 (PLCγ), and others. All these receptors and signal transduction molecules are known to contribute to the inhibition of the transcription factor nuclear factor κ B (NF-κB). Artemisinins may inhibit NF-κB by silencing these upstream pathways and/or by direct binding to NF-κB. Numerous NF-κB-regulated downstream genes are downregulated by artemisinin and its derivatives, for example, cytokines, chemokines, and immune receptors, which regulate immune cell differentiation, apoptosis genes, proliferation-regulating genes, signal transducers, and genes involved in antioxidant stress response. In addition to the prominent role of NF-κB, other transcription factors are also inhibited by artemisinins (mammalian target of rapamycin [mTOR], activating protein 1 [AP1]/FBJ murine osteosarcoma viral oncogene homologue [FOS]/JUN oncogenic transcription factor [JUN]), hypoxia-induced factor 1α (HIF-1α), nuclear factor of activated T cells c1 (NF-ATC1), Signal transducers and activators of transcription (STAT), NF E2-related factor-2 (NRF-2), retinoic-acid-receptor-related orphan nuclear receptor γ (ROR-γt), and forkhead box P-3 (FOXP-3). Many in vivo experiments in disease-relevant animal models demonstrate therapeutic efficacy of artemisinin-type drugs against rheumatic diseases (rheumatoid arthritis, osteoarthritis, lupus erythematosus, arthrosis, and gout), lung diseases (asthma, acute lung injury, and pulmonary fibrosis), neurological diseases (autoimmune encephalitis, Alzheimer's disease, and myasthenia gravis), skin diseases (dermatitis, rosacea, and psoriasis), inflammatory bowel disease, and other inflammatory and autoimmune diseases. Randomized clinical trials should be conducted in the future to translate the plethora of preclinical results into clinical practice.
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Affiliation(s)
- Thomas Efferth
- Department of Pharmaceutical Biology, Institute of Pharmaceutical and Biomedical Sciences, Johannes Gutenberg University, Mainz, Germany
| | - Franz Oesch
- Oesch-Tox Toxicological Consulting and Expert Opinions, Ingelheim, Germany and Institute of Toxicology, Johannes Gutenberg University of Mainz, Mainz, Germany
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19
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Neurological manifestation of cancer – paraneoplastic syndromes. CURRENT ISSUES IN PHARMACY AND MEDICAL SCIENCES 2021. [DOI: 10.2478/cipms-2021-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Neurological paraneoplastic syndromes (NPS) belong to a heterogeneous group of disorders affecting the nervous system. NPS occur as a result of immunological reaction to the tumor. As a result, the isolated syndrome is formed and manifests itself in many different ways, for example: limbic encephalitis, ataxia, dominant cerebellar degeneration, psychiatric disturbances, myasthenia gravis or diffuse encephalomyelitis. Detection of NPS is solely based on the presence of specific anti-neural antibodies. Although NPS had been previously considered unresponsive to therapy, some research has shown that there are effective therapies, including cancer- and immunotherapy targeted therapies.
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20
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Ketheesan S, Bertram G, Adam R, Stark A, Scott JG. Muddying the waters? A false positive case of autoimmune psychosis. Australas Psychiatry 2021; 29:278-281. [PMID: 33070625 DOI: 10.1177/1039856220965041] [Citation(s) in RCA: 1] [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
OBJECTIVE To discuss challenges with the diagnosis of autoimmune psychosis (AP) in people with chronic psychotic disorders. METHOD We present a case of a 23-year-old man with an exacerbation of treatment-refractory psychosis after receiving intravenous immunoglobulin (IVIG) for suspected AP, diagnosed 4 years after the onset of psychosis. We highlight the diagnostic and management challenges in such cases. RESULTS The diagnosis of AP in people with long-standing illness relies on the interpretation of non-specific clinical and laboratory findings in individuals with psychosocial problems and challenges of acceptance and adherence to complex medical investigations and treatments. Equivocal results from investigations undertaken without logical clinical reasoning can lead to inappropriate interventions that are costly and can cause iatrogenic harm. CONCLUSION Psychiatrists should restrict screening for antineuronal antibodies in people with chronic psychosis to those with higher risk features such as persistent treatment refractory symptoms with concurrent neurological signs and symptoms. Further research informing the clinical circumstances for antineuronal antibody testing is needed.
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Affiliation(s)
- Sarangan Ketheesan
- Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,Metro North Mental Health Service, Herston, QLD, Australia.,Laboratory of Psychiatric Neuroscience, James Cook University, Douglas, QLD, Australia
| | - Georgia Bertram
- Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,Metro North Mental Health Service, Herston, QLD, Australia
| | - Robert Adam
- Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,University of Queensland Centre for Clinical Research, Herston, QLD, Australia.,QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Anne Stark
- Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,Metro North Mental Health Service, Herston, QLD, Australia
| | - James G Scott
- Metro North Mental Health Service, Herston, QLD, Australia.,QIMR Berghofer Medical Research Institute, Herston, QLD, Australia.,Queensland Centre for Mental Health Research, Wacol, QLD, Australia
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21
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Fuchs K, Rummler S, Ries W, Helmschrott M, Selbach J, Ernst F, Morath C, Gauly A, Atiye S, Stauss-Grabo M, Giefer M. Performance, clinical effectiveness, and safety of immunoadsorption in a wide range of indications. Ther Apher Dial 2021; 26:229-241. [PMID: 33914397 PMCID: PMC9291474 DOI: 10.1111/1744-9987.13663] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/22/2021] [Accepted: 04/25/2021] [Indexed: 12/14/2022]
Abstract
Immunoadsorption is well known to selectively remove immunoglobulins and immune complexes from plasma and is applied in a variety of autoimmune diseases and for desensitization before, or at acute rejection after organ transplantation. Performance, safety, and clinical effectiveness of immunoadsorption were the aim of this study. This prospective, noninterventional, multicentre cohort study included patients treated with immunoadsorption (Immunosorba or GLOBAFFIN adsorbers) for any indication. Clinical effectiveness was assessed after termination of the patient's individual treatment schedule. Eighty‐one patients were included, 69 were treated with Immunosorba, 11 with GLOBAFFIN, one patient with both adsorbers. A majority of patients was treated for neurological indications, dilated cardiomyopathy, and before or after kidney or heart transplantation. Mean IgG reduction from pre‐ to post‐treatment was 69.9% ± 11.5% for Immunosorba and 74.1% ± 5.0% for GLOBAFFIN, respectively. The overall IgG reduction over a complete treatment block was 68%–93% with Immunosorba and 62%–90% with GLOBAFFIN depending on the duration of the overall treatment. After termination of the immunoadsorption therapy, an improvement of clinical status was observed in 63.0%, stabilization of symptoms in 29.6%, and a deterioration in 4.9% of patients. Changes in fibrinogen, thrombocytes, and albumin were mostly classified as noncritical. Overall, the treatments were well tolerated. Immunoadsorption in routine clinical practice with both GLOBAFFIN and Immunosorba has been safely performed, was well tolerated by patients, and effective in lowering immunoglobulins with an improvement or maintenance of clinical status, thus represents an additional therapeutic option for therapy refractory immune disorders.
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Affiliation(s)
- Kornelius Fuchs
- Department of Neurology, University Hospital, Regensburg, Germany
| | - Silke Rummler
- Institute for Transfusion Medicine, University Hospital, Jena, Germany
| | - Wolfgang Ries
- Internal Medicine, Department of Nephrology, Diakonissenkrankenhaus, Flensburg, Germany
| | | | - Jochen Selbach
- Department of Nephrology, Caritas Hospital, Bad Mergentheim, Germany
| | | | - Christian Morath
- Department for Dialysis, Nierenzentrum Heidelberg, Heidelberg, Germany
| | - Adelheid Gauly
- Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany
| | - Saynab Atiye
- Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany
| | | | - Mareike Giefer
- Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany
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22
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Sun Y, Ren G, Ren J, Shan W, Han X, Lian Y, Wang T, Wang Q. A Validated Nomogram That Predicts Prognosis of Autoimmune Encephalitis: A Multicenter Study in China. Front Neurol 2021; 12:612569. [PMID: 33897585 PMCID: PMC8060553 DOI: 10.3389/fneur.2021.612569] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 03/08/2021] [Indexed: 12/03/2022] Open
Abstract
The aim of this retrospective study was to derive and validate a reliable nomogram for predicting prognosis of autoimmune encephalitis (AE). A multi-center retrospective study was conducted in four hospitals in China, using a random split-sample method to allocate 173 patients into either a training (n = 126) or validation (n = 47) dataset. Demographic, radiographic and therapeutic presentation, combined with clinical features were collected. A modified Rankin Scale (mRS) at discharge was the principal outcome variable. A backward-stepwise approach based on the Akaike information criterion was used to test predictors and construct the final, parsimonious model. Multivariable analysis was conducted using logistic regression to develop a prognosis model and validate a nomogram using an independent dataset. The performance of the model was assessed using receiver operating characteristic curves and a Hosmer-Lemeshow test. The final nomogram model considered age, viral prodrome, consciousness impairment, memory dysfunction and autonomic dysfunction as predictors. Model validations displayed a good level of discrimination in the validation set: area under the Receiver operator characteristic curve = 0.72 (95% Confidence Interval: 0.56–0.88), Hosmer–Lemeshow analysis suggesting good calibration (chi-square: 10.33; p = 0.41). The proposed nomogram demonstrated considerable potential for clinical utility in prediction of prognosis in autoimmune encephalitis.
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Affiliation(s)
- Yueqian Sun
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guoping Ren
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jiechuan Ren
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Wei Shan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Institute for Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Xiong Han
- Department of Neurology, Henan Provincial People's Hospital, Henan, China
| | - Yajun Lian
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Tiancheng Wang
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Institute for Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neuromodulation, Beijing, China
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23
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Raibagkar P, Ramineni A. Autoimmune Neurologic Emergencies. Neurol Clin 2021; 39:589-614. [PMID: 33896534 DOI: 10.1016/j.ncl.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Over the past decade, understanding of autoimmune neurologic disorders has exponentially increased. Many patients present as a neurologic emergency and require timely evaluation with rapid management and intensive care. However, the diagnosis is often either missed or delayed, which may lead to a significant burden of disabling morbidity and even mortality. A high level of suspicion in the at-risk population should be maintained to facilitate more rapid diagnosis and prompt treatment. At present, there is no all-encompassing algorithm specifically applicable to the management of fulminant autoimmune neurologic disorders. This article discusses manifestations and management of various autoimmune neurologic emergencies.
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Affiliation(s)
- Pooja Raibagkar
- Concord Hospital Neurology Associates, 246 Pleasant Street, Concord, NH 03301, USA.
| | - Anil Ramineni
- Lahey Hospital & Medical Center, Beth Israel Lahey Health, 41 Mall Road, Burlington, MA 01803, USA
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24
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Hayden Z, Bóné B, Orsi G, Szots M, Nagy F, Csépány T, Mezei Z, Rajda C, Simon D, Najbauer J, Illes Z, Berki T. Clinical Characteristics and Outcome of Neuronal Surface Antibody-Mediated Autoimmune Encephalitis Patients in a National Cohort. Front Neurol 2021; 12:611597. [PMID: 33767656 PMCID: PMC7985080 DOI: 10.3389/fneur.2021.611597] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 02/16/2021] [Indexed: 01/15/2023] Open
Abstract
Background: In our previous single-center study of autoimmune encephalitis (AE) related autoantibody test results we found positivity in 60 patients out of 1,034 with suspected AE from 2012 through 2018 as part of a Hungarian nationwide program. In our current multicenter retrospective study, we analyzed the clinical characteristics and outcome of AE patients with positive neuronal cell surface autoantibody test results. Methods: A standard online questionnaire was used to collect demographic and clinical characteristics, laboratory and imaging data, therapy and prognosis of 30 definitive AE patients in four major clinical centers of the region. Results: In our study, 19 patients were positive for anti-NMDAR (63%), 6 patients (20%) for anti-LGI1, 3 patients for anti-GABABR (10%) and 3 patients for anti-Caspr2 (10%) autoantibodies. Most common prodromal symptoms were fever or flu-like symptoms (10/30, 33%). Main clinical features included psychiatric symptoms (83%), epileptic seizures (73%) and memory loss (50%). 19 patients (63%) presented with signs of central nervous system (CNS) inflammation, which occurred more frequently in elder individuals (p = 0.024), although no significant differences were observed in sex, tumor association, time to diagnosis, prognosis and immunotherapy compared to AE patients without CNS inflammatory markers. Anti-NMDAR encephalitis patients were in more severe condition at the disease onset (p = 0.028), although no significant correlation between mRS score, age, sex and immunotherapy was found. 27% of patients (n = 8) with associated tumors had worse outcome (p = 0.045) than patients without tumor. In most cases, immunotherapy led to clinical improvement of AE patients (80%) who achieved a good outcome (mRS ≤ 2; median follow-up 33 months). Conclusion: Our study confirms previous publications describing characteristics of AE patients, however, differences were observed in anti-NMDAR encephalitis that showed no association with ovarian teratoma and occurred more frequently among young males. One-third of AE patients lacked signs of inflammation in both CSF and brain MRI, which emphasizes the importance of clinical symptoms and autoantibody testing in diagnostic workflow for early introduction of immunotherapy, which can lead to favorable outcome in AE patients.
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Affiliation(s)
- Zsófia Hayden
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
| | - Beáta Bóné
- Department of Neurology, University of Pécs, Pécs, Hungary
| | - Gergely Orsi
- MTA-PTE Clinical Neuroscience MR Research Group, Pécs, Hungary.,Department of Neurosurgery, Clinical Centre, University of Pécs Medical School, Pécs, Hungary
| | - Monika Szots
- Department of Neurology, Somogy County Kaposi Mór University Teaching Hospital, Kaposvár, Hungary
| | - Ferenc Nagy
- Department of Neurology, Somogy County Kaposi Mór University Teaching Hospital, Kaposvár, Hungary
| | - Tünde Csépány
- Department of Neurology, University of Debrecen, Debrecen, Hungary
| | - Zsolt Mezei
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Cecília Rajda
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Diána Simon
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
| | - József Najbauer
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
| | - Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, BRIDGE, University of Southern Denmark, Odense, Denmark
| | - Timea Berki
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
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25
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Paraneoplastic and autoimmune encephalitis: Alterations of mood and emotion. HANDBOOK OF CLINICAL NEUROLOGY 2021; 183:221-234. [PMID: 34389119 DOI: 10.1016/b978-0-12-822290-4.00010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Autoimmune encephalitis often produces signs and symptoms that appear to be at the interface between neurology and psychiatry. Since psychiatric symptoms are often prominent, patients are often first seen in a psychiatric setting. Therefore it is important that psychiatrists, as well as neurologists, be able to recognize autoimmune encephalitis, a task that is often difficult. Early diagnosis of autoimmune encephalitis is crucial as this will usually result in a better outcome for the patient. This chapter provides an introduction to various autoimmune encephalitides and describes their pathophysiology and the possible associated neuropsychiatric, neuropsychological (cognitive), and neurological (sensory-motor) signs and symptoms. This chapter also reviews the possible treatments of these associated signs and symptoms.
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26
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Lee S, Kim HD, Lee JS, Kang HC, Kim SH. Clinical Features and Treatment Outcomes of Seronegative Pediatric Autoimmune Encephalitis. J Clin Neurol 2021; 17:300-306. [PMID: 33835752 PMCID: PMC8053533 DOI: 10.3988/jcn.2021.17.2.300] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 01/28/2021] [Accepted: 01/28/2021] [Indexed: 12/12/2022] Open
Abstract
Background and Purpose New diagnostic criteria for pediatric autoimmune encephalitis (AIE) have been introduced recently. A substantial proportion of cases of pediatric AIE are diagnosed as seronegative based on these criteria, and so the clinical characteristics of this group remain to be investigated. Methods This study included 46 pediatric patients younger than 18 years with suspected AIE. Clinical features, laboratory or radiological findings, and treatment outcomes were compared between seronegative and seropositive patients. Results Nine (19.6%) of the 46 patients were diagnosed as seropositive AIE. All of the patients with seropositive AIE had anti-N-methyl-D-aspartate receptor antibodies. Commonly identified neuropsychiatric symptoms were altered mental status, cognitive dysfunction, seizure, speech dysfunction, and psychotic disorder in both the seronegative and seropositive groups. Immunotherapy produced favorable treatment outcomes in both the seropositive (n=7, 77.8%) and seronegative (n=35, 94.6%) AIE patients. Treatment outcomes for first-line immunotherapy were better in seronegative AIE than seropositive AIE patients (p=0.003), and hence a smaller proportion of seronegative patients required second-line treatment (p=0.015). Conclusions Pediatric seronegative AIE patients showed clinical presentations similar to those of seropositive AIE patients, with favorable treatment outcomes after immunotherapy.
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Affiliation(s)
- Sangbo Lee
- Division of Pediatric Neurology, Epilepsy Research Institute, Severance Children's Hospital, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Heung Dong Kim
- Division of Pediatric Neurology, Epilepsy Research Institute, Severance Children's Hospital, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Soo Lee
- Division of Pediatric Neurology, Epilepsy Research Institute, Severance Children's Hospital, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Hoon Chul Kang
- Division of Pediatric Neurology, Epilepsy Research Institute, Severance Children's Hospital, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea.
| | - Se Hee Kim
- Division of Pediatric Neurology, Epilepsy Research Institute, Severance Children's Hospital, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea.
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Hanxin K, Xiaomin W, Hao Y, Shuihong Z. Case Report: Refractory Hypotension of GABA B Receptor Autoimmune Encephalitis. Front Neurol 2020; 11:571382. [PMID: 33335508 PMCID: PMC7736632 DOI: 10.3389/fneur.2020.571382] [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: 06/10/2020] [Accepted: 11/10/2020] [Indexed: 11/22/2022] Open
Abstract
Introduction: With the development of antibody detection technology, Gamma-Aminobutyric Acid (GABA) B receptor encephalitis is a known autoimmune disease. This paper describes a patient with refractory hypotension who suffered GABA B receptor autoimmune encephalitis. Case Report: We describe a 63-year-old man with GABA B receptor autoimmune encephalitis who had hypotension on day 17 of the disease onset. Despite two rounds of immunoglobulin administration, high-dose intravenous steroid injections and immunosuppressive therapy on day 35 of hospitalization, psychiatric symptoms and seizures were significantly improved; however, the patient's blood pressure remained low. Conclusion: This case study and literature review investigated the impairment of autonomic nerve function and its subsequent management in patients with GABA B receptor autoimmune encephalitis.
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Affiliation(s)
| | | | - Ying Hao
- Yuhang First People's Hospital, Hangzhou, China
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28
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The contribution of thymic tolerance to central nervous system autoimmunity. Semin Immunopathol 2020; 43:135-157. [PMID: 33108502 PMCID: PMC7925481 DOI: 10.1007/s00281-020-00822-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/09/2020] [Indexed: 12/15/2022]
Abstract
Autoimmune diseases of the central nervous system (CNS) are associated with high levels of morbidity and economic cost. Research efforts have previously focused on the contribution of the peripheral adaptive and innate immune systems to CNS autoimmunity. However, a failure of thymic negative selection is a necessary step in CNS-reactive T cells escaping into the periphery. Even with defective thymic or peripheral tolerance, the development of CNS inflammation is rare. The reasons underlying this are currently poorly understood. In this review, we examine evidence implicating thymic selection in the pathogenesis of CNS autoimmunity. Animal models suggest that thymic negative selection is an important factor in determining susceptibility to and severity of CNS inflammation. There are indirect clinical data that suggest thymic function is also important in human CNS autoimmune diseases. Specifically, the association between thymoma and paraneoplastic encephalitis and changes in T cell receptor excision circles in multiple sclerosis implicate thymic tolerance in these diseases. We identify potential associations between CNS autoimmunity susceptibility factors and thymic tolerance. The therapeutic manipulation of thymopoiesis has the potential to open up new treatment modalities, but a better understanding of thymic tolerance in CNS autoimmunity is required before this can be realised.
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29
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Li A, Gong X, Guo K, Lin J, Zhou D, Hong Z. Direct economic burden of patients with autoimmune encephalitis in western China. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/6/e891. [PMID: 33008922 PMCID: PMC7577530 DOI: 10.1212/nxi.0000000000000891] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 08/19/2020] [Indexed: 01/17/2023]
Abstract
Objective To analyze the cost of autoimmune encephalitis (AE) in China for the first time. Methods Patients who were newly diagnosed with antibody-positive AE (anti-NMDA receptor [NMDAR], anti-γ aminobutyric acid type B receptor [GABABR], antileucine-rich glioma-inactivated 1 [LGI1], and anticontactin-associated protein-2 [CASPR2]) at West China Medical Center between June 2012 and December 2018 were enrolled, and a cost-of-illness study was performed retrospectively. Data on clinical characteristics, costs, and utilization of sources were collected from questionnaires and the hospital information system. Results Of the 208 patients reviewed, the mean direct cost per patient was renminbi (RMB) 94,129 (United States dollars [USD] 14,219), with an average direct medical cost of RMB 88,373 (USD 13,349). The average inpatient cost per patients with AE was RMB 86,810 (USD 13,113). The direct nonmedical cost was much lower than the direct medical cost, averaging RMB 5,756 (USD 869). The direct cost of anti-LGI1/CASPR2 encephalitis was significantly lower than that of anti-NMDAR encephalitis and anti-GABABR encephalitis. The length of stay in the hospital was significantly associated with the direct cost. Conclusions The financial burden of AE is heavy for Chinese patients, and there are significant differences between different types of AE.
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Affiliation(s)
- Aiqing Li
- From the Department of Neurology, West China Medical Center, Sichuan University, Chengdu.
| | - Xue Gong
- From the Department of Neurology, West China Medical Center, Sichuan University, Chengdu
| | - Kundian Guo
- From the Department of Neurology, West China Medical Center, Sichuan University, Chengdu
| | - Jingfang Lin
- From the Department of Neurology, West China Medical Center, Sichuan University, Chengdu
| | - Dong Zhou
- From the Department of Neurology, West China Medical Center, Sichuan University, Chengdu
| | - Zhen Hong
- From the Department of Neurology, West China Medical Center, Sichuan University, Chengdu.
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30
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Zhu F, Shan W, Lv R, Li Z, Wang Q. Clinical Characteristics of Anti-GABA-B Receptor Encephalitis. Front Neurol 2020; 11:403. [PMID: 32508739 PMCID: PMC7253677 DOI: 10.3389/fneur.2020.00403] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/17/2020] [Indexed: 01/06/2023] Open
Abstract
Objective: Anti-GABA-B (gamma aminobutyric acid-B) receptor encephalitis is an autoimmune disease mediated by GABA-B-related antibodies. To fully understand the disease, we collected clinical data from patients with GABA-B receptor encephalitis and conducted an analysis to draw conclusions. Methods: All patients with GABA-B receptor encephalitis from the Neurology Department of Beijing Tiantan Hospital, affiliated with Capital Medical University, from August 2015 to September 2019 were accepted as study subjects. The clinical data of the patients were analyzed retrospectively and included the general demographic characteristics, clinical manifestations, and auxiliary examinations, including laboratory results, electroencephalograms (EEGs), brain magnetic resonance imaging (MRI), and positron emission tomography (PET-CT) results, as well as treatments. Results: From August 2015 to September 2019, 14 cases of anti-GABA-B receptor encephalitis were diagnosed. Among these patients, middle-aged and elderly men were the main demographic, with an average age of 52 years; moreover, the onset of the disease was relatively sudden, and the time from onset to diagnosis was ~1 month. The main clinical symptoms were frequent epileptic seizures, cognitive dysfunction, and mental behavioral disorders. In seven (50%) patients, the leukocyte in cerebrospinal fluid (CSF) were increased. Five (36%) patients had elevated cerebrospinal fluid protein. In most patients, the oligoclonal bands (83%) of CSF were positive, and 24 h IgG levels (92%) were increased. Anti-Hu or anti-Yo antibodies were positive in two (14%) patients. Tumor markers in 10 (71%) patients indicated that neuron-specific enolase, gastrin-releasing precursor, non-small cell lung cancer-related antigen, or carcinoembryonic antigen levels were increased. EEG results often indicated slow waves, sharp waves, or spike waves in temporal areas. Brain MRI always showed high T2 signals in the medial temporal lobe, hippocampus, and amygdala and swelling in the medial temporal lobe and hippocampus. PET-CT scans almost showed abnormal metabolism in the hippocampus and temporal lobe. Three (21%) patients who underwent systemic PET-CT showed hypermetabolism in pulmonary parenchymal nodules and enlargement of mediastinal lymph nodes. All patients underwent high-dose hormone therapy or immunoglobulin immunotherapy. After treatment, the symptoms of epilepsy, cognitive disorders, and mental behavioral disorders improved to varying degrees. However, one patient died of lung cancer. Conclusion: Anti-GABA-B receptor encephalitis mainly occurred in middle-aged and elderly men, and the disease onset was relatively sudden. Before disease onset, some patients experienced fever and non-specific respiratory symptoms, which mainly manifested as frequent epileptic seizures, cognitive dysfunction, and abnormal mental behavior. MRI and PET-CT revealed abnormal signals and local metabolism, respectively, in the temporal lobe. Moreover, the disease has a close relationship with lung cancer, which requires long-term follow-up observation.
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Affiliation(s)
- Fei Zhu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Wei Shan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
| | - Ruijuan Lv
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhimei Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
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Jiang JX, Fewings N, Dervish S, Fois AF, Duma SR, Silsby M, Bandodkar S, Ramanathan S, Bleasel A, John B, Brown DA, Lin MW. Novel Surrogate Markers of CNS Inflammation in CSF in the Diagnosis of Autoimmune Encephalitis. Front Neurol 2020; 10:1390. [PMID: 32116981 PMCID: PMC7034172 DOI: 10.3389/fneur.2019.01390] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/17/2019] [Indexed: 11/29/2022] Open
Abstract
Background: Autoimmune encephalitis (AE) is an important cause of refractory epilepsy, rapidly progressive cognitive decline, and unexplained movement disorders in adults. Whilst there is identification of an increasing number of associated autoantibodies, patients remain with a high clinical probability of autoimmune encephalitis but no associated characterized autoantibody. These patients represent a diagnostic and treatment dilemma. Objective: To evaluate routine and novel diagnostic tests of cerebrospinal fluid (CSF) in patients with a high probability of AE to attempt to identify better biomarkers of neuroinflammation. Methods: Over 18 months (2016-2018), adult patients with a high clinical probability of AE were recruited for a pilot cross-sectional explorative study. We also included viral polymerase-chain-reaction (PCR) positive CSF samples and CSF from neurology patients with "non-inflammatory" (NI) diagnoses for comparison. CSF was examined with standard investigations for encephalitis and novel markers (CSF light chains, and cytokines). Results and Conclusions: Thirty-two AE patients were recruited over 18 months. Twenty-one viral controls, 10 NI controls, and five other autoimmune neurological disease controls (AOND) were also included in the analysis. Our study found that conventional markers: presence of CSF monocytosis, oligoclonal bands, anti-neuronal immunofluorescence, and magnetic resonance imaging (MRI) changes could be suggestive of AE, but these investigations were neither sensitive nor specific. Promising novel makers of autoimmune encephalitis were the CSF cytokines IL-21 and IP10 which may provide better delineation between viral infections and autoimmune encephalitis than conventional markers, potentially leading to more immediate diagnosis and management of these patients.
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Affiliation(s)
- Jocelyn X. Jiang
- Department of Immunopathology, New South Wales Health Pathology-ICPMR, Westmead Hospital, Westmead, NSW, Australia
- Department Clinical Immunology, Westmead Hospital, Westmead, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Nicole Fewings
- Centre for Immunology and Allergy Research, The Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - Suat Dervish
- Westmead Research Hub, Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - Alessandro F. Fois
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Department of Neurology, Westmead Hospital, Westmead, NSW, Australia
| | - Stephen R. Duma
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Department of Neurology, Westmead Hospital, Westmead, NSW, Australia
| | - Matthew Silsby
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Department of Neurology, Westmead Hospital, Westmead, NSW, Australia
| | - Sushil Bandodkar
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Sudarshini Ramanathan
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Department of Neurology, Westmead Hospital, Westmead, NSW, Australia
- Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Andrew Bleasel
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Department of Neurology, Westmead Hospital, Westmead, NSW, Australia
| | - Bryne John
- Department of Anaesthetics, Westmead Hospital, Westmead, NSW, Australia
| | - David A. Brown
- Department of Immunopathology, New South Wales Health Pathology-ICPMR, Westmead Hospital, Westmead, NSW, Australia
- Department Clinical Immunology, Westmead Hospital, Westmead, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Ming-Wei Lin
- Department of Immunopathology, New South Wales Health Pathology-ICPMR, Westmead Hospital, Westmead, NSW, Australia
- Department Clinical Immunology, Westmead Hospital, Westmead, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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32
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Hayden Z, Böröcz K, Csizmadia Z, Balogh P, Kellermayer Z, Bodó K, Najbauer J, Berki T. Single-center study of autoimmune encephalitis-related autoantibody testing in Hungary. Brain Behav 2019; 9:e01454. [PMID: 31650706 PMCID: PMC6908871 DOI: 10.1002/brb3.1454] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 09/06/2019] [Accepted: 10/05/2019] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE Autoantibody detection is crucial for the early diagnosis of autoimmune encephalitis (AIE) since prompt therapy can determine the disease outcome. Here, we report a single-center 6-year retrospective study of autoantibody testing in AIE in the Hungarian population. METHODS Serum and/or cerebrospinal fluid (CSF) autoantibody tests were performed using cell-based indirect immunofluorescence assay for AIE diagnosis. Samples were provided by neurology clinics as part of a nationwide program. Test results were analyzed for samples received during the period from 2012 to 2018. RESULTS We tested 1,247 samples from 1,034 patients with suspected AIE. Autoantibodies were present in 60 patients (5.8% of total). The distribution of patients with different autoantibodies by age and sex was as follows: NMDAR (70%), mostly in young females, LGI1 (15%) in middle-aged males, GABAB R (12%) in elderly males, and Caspr2 (7%) in males. Long-term follow-up was conducted in 30 patients with repeated test requests, of which 17 remained positive, and 13 switched to negative. CONCLUSION We report the most comprehensive clinical laboratory study of autoantibody testing in AIE in the Hungarian population. Our results show that the frequency of different autoantibody types in AIE corresponds to the data described in the literature.
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Affiliation(s)
- Zsófia Hayden
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
| | - Katalin Böröcz
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
| | - Zsuzsanna Csizmadia
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
| | - Péter Balogh
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
| | - Zoltán Kellermayer
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
| | - Kornélia Bodó
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
| | - József Najbauer
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
| | - Tímea Berki
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
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33
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Tsai MH, Lin CH, Tsai KW, Lin MH, Ho CJ, Lu YT, Weng KP, Lin Y, Lin PH, Li SC. S100A6 Promotes B Lymphocyte Penetration Through the Blood-Brain Barrier in Autoimmune Encephalitis. Front Genet 2019; 10:1188. [PMID: 31850060 PMCID: PMC6901080 DOI: 10.3389/fgene.2019.01188] [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] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 10/28/2019] [Indexed: 12/12/2022] Open
Abstract
Autoimmune encephalitis (AE) is a severe neurological disease. The brain of the AE patient is attacked by a dysregulated immune system, which is caused by the excessive production of autoantibodies against neuronal receptors and synaptic proteins. AE is also characterized by the uncontrolled B lymphocyte infiltration through the blood–brain barrier (BBB) layer, and the investigation of the underlying mechanism involved in this infiltration may facilitate the discovery of novel therapies for AE. However, few AE-related studies have focused on this issue. In this study, we aimed to identify the factors involved in B lymphocyte infiltration in AE. For this purpose, we first enrolled four healthy control and five AE subjects, collecting their serum and/or total white blood cell samples. The white blood cell samples were further used for collecting RNA and DNA. Then, we simulated the in vivo B lymphocyte infiltration with an in vitro leukocyte transendothelial migration model. It turned out that AE serum treatment significantly and specifically promoted B cells to penetrate the BBB endothelial layer without affecting neutrophils. Next, through genome-wide DNA methylation assays on bisulfite-conversion DNA samples, we identified S100A6 and S100A11 as potential hypo-methylated disease genes in the AE samples. Further qPCR assays demonstrated their upregulation in AE samples, reflecting the negative correlations between gene expression and DNA methylation. Finally, recombinant S100A6 protein treatment significantly increased B lymphocyte infiltration through the BBB endothelial layer, which partially recapitulated the effect of AE serum. In summary, by using an in vitro leukocyte transendothelial migration model, we confirmed that S100A6 promoted B lymphocyte to penetrate the BBB endothelial layer, which is similar to the in vivo clinical manifestations of AE. Therefore, further studies on how the S100A6 protein facilitates B lymphocyte infiltration and on whether other factors in serum also contribute to this phenomenon are likely to improve our understanding of AE and hopefully to reveal novel therapeutic targets for this emerging treatable neurological disorder.
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Affiliation(s)
- Meng-Han Tsai
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Hsiang Lin
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kuo-Wang Tsai
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ming-Hong Lin
- Department of Microbiology and Immunology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Research Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chen-Jui Ho
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yan-Ting Lu
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ken-Pen Weng
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Department of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Nursing, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan
| | - Yuyu Lin
- Genomics and Proteomics Core Laboratory, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Pei-Hsien Lin
- Genomics and Proteomics Core Laboratory, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Sung-Chou Li
- Genomics and Proteomics Core Laboratory, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Dubot-Pérès A, Mayxay M, Phetsouvanh R, Lee SJ, Rattanavong S, Vongsouvath M, Davong V, Chansamouth V, Phommasone K, Moore C, Dittrich S, Lattana O, Sirisouk J, Phoumin P, Panyanivong P, Sengduangphachanh A, Sibounheuang B, Chanthongthip A, Simmalavong M, Sengdatka D, Seubsanith A, Keoluangkot V, Phimmasone P, Sisout K, Detleuxay K, Luangxay K, Phouangsouvanh I, Craig SB, Tulsiani SM, Burns MA, Dance DAB, Blacksell SD, de Lamballerie X, Newton PN. Management of Central Nervous System Infections, Vientiane, Laos, 2003-2011. Emerg Infect Dis 2019; 25:898-910. [PMID: 31002063 PMCID: PMC6478220 DOI: 10.3201/eid2505.180914] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
During 2003–2011, we recruited 1,065 patients of all ages admitted to Mahosot Hospital (Vientiane, Laos) with suspected central nervous system (CNS) infection. Etiologies were laboratory confirmed for 42.3% of patients, who mostly had infections with emerging pathogens: viruses in 16.2% (mainly Japanese encephalitis virus [8.8%]); bacteria in 16.4% (including Orientia tsutsugamushi [2.9%], Leptospira spp. [2.3%], and Rickettsia spp. [2.3%]); and Cryptococcus spp. fungi in 6.6%. We observed no significant differences in distribution of clinical encephalitis and meningitis by bacterial or viral etiology. However, patients with bacterial CNS infection were more likely to have a history of diabetes than others. Death (26.3%) was associated with low Glasgow Coma Scale score, and the mortality rate was higher for patients with bacterial than viral infections. No clinical or laboratory variables could guide antibiotic selection. We conclude that high-dependency units and first-line treatment with ceftriaxone and doxycycline for suspected CNS infections could improve patient survival in Laos.
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35
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Kerik-Rotenberg N, Diaz-Meneses I, Hernandez-Ramirez R, Muñoz-Casillas R, Reynoso-Mejia CA, Flores-Rivera J, Espinola-Nadurille M, Ramirez-Bermudez J, Aguilar-Palomeque C. A Metabolic Brain Pattern Associated With Anti-N-Methyl-D-Aspartate Receptor Encephalitis. PSYCHOSOMATICS 2019; 61:39-48. [PMID: 31611047 DOI: 10.1016/j.psym.2019.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis causes substantial neurological disability. Autoantibodies causing encephalitis directed against the neuronal cell surface or synapse are of diagnostic importance giving the possibility of successful immunotherapy. OBJECTIVE In this study, we aim to provide supporting evidence that brain 18F-FDG-PET may be helpful in identifying likely patterns of regional brain glucose metabolism. METHODS Thirty-three patients (18 men and 15 women; age range of 17-55 y) with positive NMDA receptor antibody encephalitis that underwent an 18F-FDG-PET imaging examination were prospectively selected and compared with a reference group of 14 brain 18F-FDG-PET scans from healthy volunteers using voxel-based statistical analysis. Clusters of hyper- and hypo-metabolism were reported for the whole sample of patients (FWE-corrected P < 0.05), and uncorrected at P < 0.005 for a group of relapsed patients. RESULTS Mixed metabolic patterns (focal/bilateral hypermetabolism in the temporal lobe, insula, and cerebellum; associated with severe bilateral hypometabolism in the occipital and parietal lobes) were found. CONCLUSIONS Our findings suggest that 18F-FDG-PET should be included as an imaging tool when assessing affected patients in the clinical workup to rule out anti-NMDA encephalitis and help determine the most effective treatment.
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Affiliation(s)
- Nora Kerik-Rotenberg
- PET/CT Molecular Imaging Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico.
| | - Ivan Diaz-Meneses
- PET/CT Molecular Imaging Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Rodrigo Hernandez-Ramirez
- PET/CT Molecular Imaging Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Rodrigo Muñoz-Casillas
- PET/CT Molecular Imaging Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Carlos A Reynoso-Mejia
- PET/CT Molecular Imaging Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Jose Flores-Rivera
- Department of Neurology, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Mariana Espinola-Nadurille
- Department of Neuropsychiatry, Neuropsychiatry Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Jesus Ramirez-Bermudez
- Department of Neuropsychiatry, Neuropsychiatry Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Carlos Aguilar-Palomeque
- PET/CT Molecular Imaging Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
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Knudtzen FC, Nilsson AC, Skarphedinsson S, Blaabjerg M. False-positive anti-NMDA receptor antibodies in severe case of Lyme neuroborreliosis. Neurol Sci 2019; 41:197-199. [PMID: 31273488 PMCID: PMC7223168 DOI: 10.1007/s10072-019-04004-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 07/01/2019] [Indexed: 11/03/2022]
Affiliation(s)
- Fredrikke Christie Knudtzen
- Clinical Center of Emerging and Vectorborne Infections, Department of Infectious Diseases, Odense University Hospital, JB Winsloews vej 4, entrance 18-20, 5000, Odense C, Denmark.
| | | | - Sigurdur Skarphedinsson
- Clinical Center of Emerging and Vectorborne Infections, Department of Infectious Diseases, Odense University Hospital, JB Winsloews vej 4, entrance 18-20, 5000, Odense C, Denmark
| | - Morten Blaabjerg
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Dong X, Zheng D, Nao J. Clinical characteristics and factors associated with short-term prognosis in adult patients with autoimmune encephalitis of non-neoplastic etiology. Neurol Sci 2019; 40:1567-1575. [PMID: 30955116 DOI: 10.1007/s10072-019-03883-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 04/02/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Reports that autoimmune encephalitis (AE) is associated with antibodies have increased; however, little is known about the distribution of clinical symptoms, imaging changes, and prognostic factors in patients with AE of non-neoplastic etiology. Accordingly, we evaluated the clinical characteristics and factors associated with short-term prognosis. METHODS From January 2016 to June 2018, 31 adult patients were diagnosed with AE of non-neoplastic etiology at Shengjing Hospital of China Medical University and their demographic and clinical characteristics were abstracted. Factors affecting disease severity and predictors of prognosis were analyzed. RESULTS Among 31 patients, 19 had anti-NMDAR, 5 had anti-GABABR, and 7 had anti-LGI1 antibody encephalitis. Status epilepticus, ataxia, and cognitive dysfunction were the most common neurological symptoms. Deep white matter (DWM) abnormalities were the most common changes observed on MRI. Logistic regression analysis indicated that conscious disturbance (odds ratio = 11.67, 95%, confidence interval 2.13-64.04; p = 0.005) is an independent factor associated with poor prognosis in AE. CONCLUSION The clinical manifestations of AE are diverse; status epilepticus, ataxia, and cognitive dysfunction are most common. The DWM of the brain, rather than the limbic lobe system, was most prone to MR signal abnormalities. Conscious disturbance may be an important predictor of poor short-term prognosis in patients with AE of non-neoplastic etiology.
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Affiliation(s)
- Xiaoyu Dong
- Department of Neurology, Shengjing Hospital, China Medical University, 36 Sanhao Street, Heping District, Shenyang, Liaoning, 110004, People's Republic of China
| | - Dongming Zheng
- Department of Neurology, Shengjing Hospital, China Medical University, 36 Sanhao Street, Heping District, Shenyang, Liaoning, 110004, People's Republic of China
| | - Jianfei Nao
- Department of Neurology, Shengjing Hospital, China Medical University, 36 Sanhao Street, Heping District, Shenyang, Liaoning, 110004, People's Republic of China.
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Abstract
Patients with prolonged seizures that do not respond to intravenous benzodiazepines and a second-line anticonvulsant suffer from refractory status epilepticus and those with seizures that do not respond to continuous intravenous anesthetic anticonvulsants suffer from super-refractory status epilepticus. Both conditions are associated with significant morbidity and mortality. A strict pharmacological treatment regimen is urgently required, but the level of evidence for the available drugs is very low. Refractory complex focal status epilepticus generally does not require anesthetics, but all intravenous non-anesthetizing anticonvulsants may be used. Most descriptive data are available for levetiracetam, phenytoin and valproate. Refractory generalized convulsive status epilepticus is a life-threatening emergency, and long-term clinical consequences are eminent. Administration of intravenous anesthetics is mandatory, and drugs acting at the inhibitory gamma-aminobutyric acid (GABA)A receptor such as midazolam, propofol and thiopental/pentobarbital are recommended without preference for one of those. One in five patients with anesthetic treatment does not respond and has super-refractory status epilepticus. With sustained seizure activity, excitatory N-methyl-d-aspartate (NMDA) receptors are increasingly expressed post-synaptically. Ketamine is an antagonist at this receptor and may prove efficient in some patients at later stages. Neurosteroids such as allopregnanolone increase sensitivity at GABAA receptors; a Phase 1/2 trial demonstrated safety and tolerability, but randomized controlled data failed to demonstrate efficacy. Adjunct ketogenic diet may contribute to termination of difficult-to-treat status epilepticus. Randomized controlled trials are needed to increase evidence for treatment of refractory and super-refractory status epilepticus, but there are multiple obstacles for realization. Hitherto, prospective multicenter registries for pharmacological treatment may help to improve our knowledge.
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Affiliation(s)
- Martin Holtkamp
- Epilepsy-Center Berlin-Brandenburg, Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
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Lin YT, Yang X, Lv JW, Liu XW, Wang SJ. CXCL13 Is A Biomarker Of Anti-Leucine-Rich Glioma-Inactivated Protein 1 Encephalitis Patients. Neuropsychiatr Dis Treat 2019; 15:2909-2915. [PMID: 31632040 PMCID: PMC6792990 DOI: 10.2147/ndt.s222258] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 09/17/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Although antibody-mediated immune responses are considered pathogenic and responsible for neural injury in anti-leucine-rich glioma-inactivated protein 1 (anti-LGI1) encephalitis, previous studies have indicated that cytokines and chemokines might play roles in the pathogenic process by serving as B cell enhancers. In this study, we detected the profiles of cytokines and chemokines in the cerebral fluid (CSF) and serum of patients with anti-LGI1 encephalitis to identify potential biomarkers. METHODS Sixteen patients diagnosed with anti-LGI1 encephalitis and nine patients diagnosed with noninflammatory neurologic disorders were included in the study. Cytokines and chemokines including IL-6, IL-10, IL-17, CXCL12, CXCL13, BAFF and HMGB1 in serum and CSF were measured. RESULTS The serum and CSF levels of CXCL13 were significantly higher in patients with anti-LGI1 encephalitis (36.32±34.71 pg/mL and 2.23±2.41 pg/mL, respectively) than in controls (10.84±5.02 pg/mL and 0.34±0.21 pg/mL, respectively). There was no significant difference in serum or CSF levels of IL-6, IL-10, IL-17, CXCL12, BAFF and HMGB1 between the two groups. CONCLUSION CXCL13 is a potential biomarker of active inflammation in anti-LGI1 encephalitis. The distinctive response of cytokines and chemokines might be closely linked to the mechanisms underlying this condition.
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Affiliation(s)
- You-Ting Lin
- Department of Neurology, Shandong Provincial Hospital, Shandong University, Ji'nan, People's Republic of China
| | - Xue Yang
- Department of Neurology, Qilu Hospital, Shandong University, Ji'nan, People's Republic of China
| | - Jing-Wei Lv
- Department of Neurology, Qilu Hospital, Shandong University, Ji'nan, People's Republic of China
| | - Xue-Wu Liu
- Department of Neurology, Qilu Hospital, Shandong University, Ji'nan, People's Republic of China
| | - Sheng-Jun Wang
- Department of Neurology, Qilu Hospital, Shandong University, Ji'nan, People's Republic of China
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Hermetter C, Fazekas F, Hochmeister S. Systematic Review: Syndromes, Early Diagnosis, and Treatment in Autoimmune Encephalitis. Front Neurol 2018; 9:706. [PMID: 30233481 PMCID: PMC6135049 DOI: 10.3389/fneur.2018.00706] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 08/03/2018] [Indexed: 12/15/2022] Open
Abstract
In recent years, new antibodies have been discovered which mediate autoimmune encephalitis. This immunological response can be triggered by an infection or a tumor. Classical onconeuronal antibodies are directed against intracellular neuronal agents but recently, a novel group of antibodies to neuronal cell-surface and synaptic antigens associated with different CNS-syndromes, has been discovered. Interestingly, the syndromes in this group can be successfully treated with immunotherapy and frequently do not have underlying tumors. The aim of this review is to describe the current state of knowledge about autoimmune encephalitis, in order to provide clinicians with a concise, up-to-date overview. Thus, a comprehensive literature search was performed in medical databases. The literature was carefully studied and new findings focusing on the symptoms, diagnosis and treatment were summarized and interpreted. Even though it might be challenging in some cases, the awareness of certain symptom constellations and demographic information, in combination with laboratory- and MRI-results, allows clinicians to make the diagnosis of probable autoimmune encephalitis at an early stage. Treatment can therefore be initiated faster, which significantly improves the outcome. Further investigations could define the underlying pathogenic mechanisms. Randomized controlled trials, paired with increasing clinical experience, will be necessary to improve the identification of affected patients, treatment strategies, and outcomes in the years to come.
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Affiliation(s)
| | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
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Abstract
Typical and atypical antipsychotics are the first-line treatments for schizophrenia, but these classes of drugs are not universally effective, and they can have serious side effects that impact compliance. Antipsychotic drugs generally target the dopamine pathways with some variation. As research of schizophrenia pathophysiology has shifted away from a strictly dopamine-centric focus, the development of new pharmacotherapies has waned. A field of inquiry with centuries-old roots is gaining traction in psychiatric research circles and may represent a new frontier for drug discovery in schizophrenia. At the forefront of this investigative effort is the immune system and its many components, pathways and phenotypes, which are now known to actively engage the brain. Studies in schizophrenia reveal an intricate association of environmentally-driven immune activation in concert with a disrupted genetic template. A consistent conduit through this gene-environmental milieu is the gut-brain axis, which when dysregulated can generate pathological autoimmunity. In this review, we present epidemiological and biochemical evidence in support of an autoimmune component in schizophrenia and depict gut processes and a dysbiotic microbiome as a source and perpetuator of autoimmune dysfunction in the brain. Within this framework, we review the role of infectious agents, inflammation, gut dysbioses and autoantibody propagation on CNS pathologies such as neurotransmitter receptor hypofunction and complement pathway-mediated synaptic pruning. We then review the new pharmacotherapeutic horizon and novel agents directed to impact these pathological conditions. At the core of this discourse is the understanding that schizophrenia is etiologically and pathophysiologically heterogeneous and thus its treatment requires individualized attention with disease state variants diagnosed with objective biomarkers.
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Affiliation(s)
| | | | - Robert H Yolken
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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An unusual case of anti-MOG CNS demyelination with concomitant mild anti-NMDAR encephalitis. J Neuroimmunol 2018; 320:107-110. [DOI: 10.1016/j.jneuroim.2018.03.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/26/2018] [Accepted: 03/26/2018] [Indexed: 11/27/2022]
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Wagner JN, Kalev O, Sonnberger M, Krehan I, von Oertzen TJ. Evaluation of Clinical and Paraclinical Findings for the Differential Diagnosis of Autoimmune and Infectious Encephalitis. Front Neurol 2018; 9:434. [PMID: 29951031 PMCID: PMC6008545 DOI: 10.3389/fneur.2018.00434] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 05/23/2018] [Indexed: 12/30/2022] Open
Abstract
Background: The differential diagnosis of autoimmune and infectious encephalitis is notoriously difficult. For this study, we compare the presenting clinical symptoms and paraclinical test results of autoimmune and infectious encephalitis patients. A clinical algorithm for the diagnosis of autoimmune encephalitis has recently been published. We test these Graus criteria on our cohort for diagnostic sensitivity and specificity within the first week of presentation. Methods: We included all patients seen at our department within a 10-year-period who were diagnosed with encephalitis. The discharge diagnoses served as the reference standard for testing the clinical algorithm for two conditions: use of all the clinical information available on a patient during the first week of hospital admission assuming undefined autoantibody status and microbiological test results (C1) vs. consideration of all the information available on a patient, including the results of serological and microbiological testing (C2). Results: Eighty-four patients (33 autoimmune, 51 infectious encephalitis) were included in the study. Fifty-one (17 autoimmune, 34 infectious) had a definite clinical diagnosis. The two groups differed significantly for the presence of headache, fever, epileptic seizures, and CSF cell-count at presentation. Application of the clinical algorithm resulted in a low sensitivity (58%) and very low specificity (8%) for the diagnosis of possible autoimmune encephalitis. The latter increased considerably in the subgroups of probable and definite autoimmune encephalitis. Whereas the sensitivity of the individual diagnostic categories was clearly time-dependent, the specificity rested foremost on the knowledge of the results of microbiological testing. Anti-CASPR2- and -LGI1-associated autoimmune encephalitis and tick-borne virus encephalitis presented particular diagnostic pitfalls. Conclusions: We define clinical symptoms and paraclinical test results which prove valuable for the differentiation between infectious and autoimmune encephalitis. Sensitivity and specificity of the clinical algorithm clearly depended on the amount of time passed after hospital admission and knowledge of microbiological test results. Accepting this limitation for the acute setting, the algorithm remains a valuable diagnostic aid for antibody-negative autoimmune encephalitis or in resource-poor settings. The initiation of immune therapy however should not be delayed if an autoimmune etiology is considered likely, even if the diagnostic criteria of the algorithm are not (yet) fulfilled.
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Affiliation(s)
- Judith N Wagner
- Department of Neurology 1, Kepler University Hospital, Linz, Austria
| | - Ognian Kalev
- Department of Neuropathology, Kepler University Hospital, Linz, Austria
| | | | - Ingomar Krehan
- Department of Neurology 2, Kepler University Hospital, Linz, Austria
| | - Tim J von Oertzen
- Department of Neurology 1, Kepler University Hospital, Linz, Austria
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Scott JG, Gillis D, Ryan AE, Hargovan H, Gundarpi N, McKeon G, Hatherill S, Newman MP, Parry P, Prain K, Patterson S, Wong RCW, Wilson RJ, Blum S. The prevalence and treatment outcomes of antineuronal antibody-positive patients admitted with first episode of psychosis. BJPsych Open 2018; 4:69-74. [PMID: 29971149 PMCID: PMC6020277 DOI: 10.1192/bjo.2018.8] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 12/05/2017] [Accepted: 01/21/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Antineuronal antibodies are associated with psychosis, although their clinical significance in first episode of psychosis (FEP) is undetermined. AIMS To examine all patients admitted for treatment of FEP for antineuronal antibodies and describe clinical presentations and treatment outcomes in those who were antibody positive. METHOD Individuals admitted for FEP to six mental health units in Queensland, Australia, were prospectively tested for serum antineuronal antibodies. Antibody-positive patients were referred for neurological and immunological assessment and therapy. RESULTS Of 113 consenting participants, six had antineuronal antibodies (anti-N-methyl-D-aspartate receptor antibodies [n = 4], voltage-gated potassium channel antibodies [n = 1] and antibodies against uncharacterised antigen [n = 1]). Five received immunotherapy, which prompted resolution of psychosis in four. CONCLUSIONS A small subgroup of patients admitted to hospital with FEP have antineuronal antibodies detectable in serum and are responsive to immunotherapy. Early diagnosis and treatment is critical to optimise recovery. DECLARATION OF INTEREST None.
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Affiliation(s)
- James G. Scott
- Centre for Clinical Research, The University of Queensland
(UQCCR), Metro North Mental Health, Royal Brisbane and Women's
Hospital (RBWH), and the Queensland Centre for Mental Health Research (QCMHR),
Australia
| | - David Gillis
- Division of Immunology, Pathology Queensland
Central Laboratory, RBWH, Australia
| | | | | | | | | | - Sean Hatherill
- Metro South Addiction and Mental Health Service,
Child and Youth Academic Clinical Unit,
Queensland, Australia
| | - Martin P. Newman
- Division of Immunology, Pathology Queensland
Central Laboratory, RBWH, and Faculty of Medicine,
University of Queensland, Australia
| | - Peter Parry
- Child and Youth Mental Health Service,
Children's Health Queensland, Australia
| | - Kerri Prain
- Division of Immunology, Pathology Queensland
Central Laboratory, RBWH, Australia
| | - Sue Patterson
- Metro North Mental Health, RBWH,
and Department of Applied Psychology, Griffith
University, Queensland, Australia
| | - Richard C. W. Wong
- Division of Immunology, Pathology Queensland
Central Laboratory, RBWH, and Department of Immunology,
Princess Alexandra Hospital, Queensland,
Australia
| | - Robert J. Wilson
- Division of Immunology, Pathology Queensland
Central Laboratory, RBWH, and Department of Immunology,
Princess Alexandra Hospital, Queensland,
Australia
| | - Stefan Blum
- Faculty of Medicine, University of
Queensland and Department of Neurology,
Princess Alexandra Hospital, Queensland,
Australia
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Bauer J, Becker AJ, Elyaman W, Peltola J, Rüegg S, Titulaer MJ, Varley JA, Beghi E. Innate and adaptive immunity in human epilepsies. Epilepsia 2017; 58 Suppl 3:57-68. [PMID: 28675562 PMCID: PMC5535008 DOI: 10.1111/epi.13784] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2017] [Indexed: 01/10/2023]
Abstract
Inflammatory mechanisms have been increasingly implicated in the origin of seizures and epilepsy. These mechanisms are involved in the genesis of encephalitides in which seizures are a common complaint. Experimental and clinical evidence suggests different inflammatory responses in the brains of patients with epilepsy depending on the etiology. In general, activation of both innate and adaptive immunity plays a role in refractory forms of epilepsy. Epilepsies in which seizures develop after infiltration of cells of the adaptive immune system in the central nervous system (CNS) include a broad range of epileptic disorders with different (known or unknown) etiologies. Infiltration of lymphocytes is observed in autoimmune epilepsies, especially the classical paraneoplastic encephalitides with antibodies against intracellular tumor antigens. The presence of lymphocytes in the CNS also has been found in focal cerebral dysplasia type 2 and in cortical tubers. Various autoantibodies have been shown to be associated with temporal lobe epilepsy (TLE) and hippocampal sclerosis of unknown etiology, which may be due to the presence of viral DNA. During the last decade, an increasing number of antineuronal autoantibodies directed against membranous epitopes have been discovered and are associated with various neurologic syndromes, including limbic encephalitis. A major challenge in epilepsy is to define biomarkers, which would allow the recognition of patient populations who might benefit from immune-modulatory therapies. Some peripheral inflammatory markers appear to be differentially expressed in patients with medically controlled and medically refractory and, as such, could be used for diagnostic, prognostic, or therapeutic purposes. Establishing an autoimmune basis in patients with drug-resistant epilepsy allows for efficacious and targeted immunotherapy. Although current immunotherapies can give great benefit to the correctly identified patient, there are limitations to their efficacy and they may have considerable side effects. Thus the identification of new immunomodulatory compounds remains of utmost importance.
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Affiliation(s)
- Jan Bauer
- Department of Neuroimmunology, Center for Brain Research Medical University of Vienna, Vienna, Austria
| | - Albert J Becker
- Section for Translational Epilepsy Research, Department of Neuropathology, University of Bonn - Medical Center, Bonn, Germany
| | - Wassim Elyaman
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, U.S.A.,The Broad Institute, Cambridge, Massachusetts, U.S.A
| | - Jukka Peltola
- Department Neurology, Tampere University Hospital, Tampere, Finland
| | - Stephan Rüegg
- Department Neurology, University Hospital Basel, Basel, Switzerland
| | - Maarten J Titulaer
- Department Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - James A Varley
- Nuffield Department Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom
| | - Ettore Beghi
- IRCCS-Mario Negri Institute for Pharmacological Research, Milano, Italy
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Delirious Mania Associated with Autoimmune Gastrothyroidal Syndrome of a Mid-Life Female: The Role of Hashimoto Encephalopathy and a 3-Year Follow-Up including Serum Autoantibody Levels. Case Rep Psychiatry 2016; 2016:4168050. [PMID: 27688922 PMCID: PMC5023828 DOI: 10.1155/2016/4168050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 08/05/2016] [Accepted: 08/09/2016] [Indexed: 11/30/2022] Open
Abstract
We report the case study of a 57-year-old Caucasian female with steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT), commonly termed Hashimoto encephalopathy (HE). This presentation includes one of the longest lasting follow-up studies of HE considering the neuropsychiatric symptoms (here delirium, mania, and EEG-slowing) and their relation to serum autoantibody levels. Antithyroid-peroxidase autoantibodies, the hallmark of autoimmune thyroiditis, were found in the serum and also in the cerebrospinal fluid. Diagnostic analyses found no evidence of limbic encephalopathies characterized by serum antibodies against intracellular, synaptic, or further cell surface antigenic targets, neoplasm, and connective tissue or vasculitis diseases. A potential contribution of bipolar disorder and metabolic encephalopathies due to severe hypothyroidism, glucocorticoid treatment, accelerated thyroid hormone replacement therapy, or vitamin B deficiency is critically discussed. Another special feature of this case report is the linkage of HE to an autoimmune polyendocrine syndrome (type 3B) affecting the gastroduodenum in addition to the thyroid gland.
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[Cell depletion and myoablation for neuroimmunological diseases]. DER NERVENARZT 2016; 87:814-20. [PMID: 27389598 DOI: 10.1007/s00115-016-0156-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The treatment of autoimmune disorders of the nervous system is based on interventions for the underlying immune phenomena. OBJECTIVE To summarize concepts of cell depletion and myeloablation studied in the context of neuroimmunological disorders. METHOD Evaluation of the available literature on multiple sclerosis as the most widely studied neuroimmunological entity. RESULTS Three concepts have been introduced: classical immunosuppressants, such as azathioprine, mitoxantrone and cyclophosphamide exert general lymphopenic effects and thereby moderately decrease disease activity. Myeloablative regimens combined with autologous hematopoietic stem cell transplantation have a profound and in most cases long-lasting impact on autoimmunity at the cost of potentially life-threatening side effects. Alemtuzumab (anti-CD52), rituximab and ocrelizumab (both anti-CD20) are depleting antibodies directed against certain lymphocyte subsets and substantially ameliorate disease activity in relapsing-remitting multiple sclerosis. Ocrelizumab also shows efficacy in the primary progressive form of multiple sclerosis. CONCLUSIONS Most of the presented cell-depleting and myeloablative therapies are highly effective treatment options but are also accompanied by significant risks. In the context of the increasing number of alternative immunomodulatory options the indications for use should be cautiously considered.
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