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Ohashi N, Kamijima S, Watanabe R, Tazawa KI. [Peripheral neuropathy associated with severe glial fibrillary acidic protein (GFAP) astrocytopathy: a case report]. Rinsho Shinkeigaku 2024; 64:403-407. [PMID: 38797687 DOI: 10.5692/clinicalneurol.cn-001940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
A 44-year-old man was admitted due to a fever. He developed unconsciousness and respiratory failure, necessitating mechanical ventilation. After the administration of methylprednisolone and intravenous immunoglobulin for suspected autoimmune encephalitis, his consciousness and respiratory state improved. However, he exhibited pronounced tetraparalysis and impaired sensation below the neck. A spinal MRI revealed swelling of the entire spinal cord, indicating myelitis. Deep tendon reflexes were diminished in all extremities, and a nerve conduction study confirmed motor-dominant axonal polyneuropathy. Subsequently, he developed a fever and headache. Brain MRI demonstrated FLAIR hyperintensities in the basal ganglia and brain stem. CSF analysis for anti-glial fibrillary acidic protein (GFAP) antibody turned out positive, leading to the diagnosis of GFAP astrocytopathy. Although the steroid re-administration improved muscle strength in his upper limbs and reduced the range of diminished sensation, severe hemiparalysis remained. Severe GFAP astrocytopathy can be involved with polyneuropathy. Early detection and therapeutic intervention for this condition may lead to a better prognosis.
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Affiliation(s)
| | | | - Rie Watanabe
- Department of Neurology, Nagano Red Cross Hospital
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2
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Oka H, Nakamura T, Sugawara T, Ishizawa K, Amari M, Kawarabayashi T, Okamoto K, Takatama M, Nakata S, Yoshimoto Y, Yamazaki A, Yokoo H, Kimura A, Shimohata T, Ikeda Y, Shoji M. A case of chronic progressive autoimmune GFAP astrocytopathy with extensive meningoencephalomyelitis and contrast enhancement on MRI. eNeurologicalSci 2024; 35:100507. [PMID: 38911509 PMCID: PMC11192973 DOI: 10.1016/j.ensci.2024.100507] [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: 08/26/2023] [Revised: 05/20/2024] [Accepted: 05/31/2024] [Indexed: 06/25/2024] Open
Abstract
•We herein present a case of chronic progressive autoimmune GFAP astrocytopathy.•Symmetrical high-intensity signals on FLAIR were observed in the white matter of the temporal and occipital lobes, lateral cerebral ventricle walls, hippocampus, amygdala, and occipital cortex, with extensive Gd enhancement in radial perivascular lesions and the ependyma in the choroid plexus.•Improvements were achieved by 4 courses of IVMP and one of IVIg.
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Affiliation(s)
- Hironori Oka
- Department of Neurology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-0034, Japan
- Geriatrics Research Institute and Hospital, 3-26-8 Otomo-machi, Maebashi 371-0847, Japan
| | - Takumi Nakamura
- Department of Neurology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-0034, Japan
| | - Takashi Sugawara
- Geriatrics Research Institute and Hospital, 3-26-8 Otomo-machi, Maebashi 371-0847, Japan
| | - Kunihiko Ishizawa
- Geriatrics Research Institute and Hospital, 3-26-8 Otomo-machi, Maebashi 371-0847, Japan
| | - Masakuni Amari
- Geriatrics Research Institute and Hospital, 3-26-8 Otomo-machi, Maebashi 371-0847, Japan
| | - Takeshi Kawarabayashi
- Geriatrics Research Institute and Hospital, 3-26-8 Otomo-machi, Maebashi 371-0847, Japan
| | - Koichi Okamoto
- Geriatrics Research Institute and Hospital, 3-26-8 Otomo-machi, Maebashi 371-0847, Japan
| | - Masamitsu Takatama
- Geriatrics Research Institute and Hospital, 3-26-8 Otomo-machi, Maebashi 371-0847, Japan
| | - Satoshi Nakata
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Japan
| | - Yuhei Yoshimoto
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Japan
| | - Ayako Yamazaki
- Department of Human Pathology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Japan
| | - Hideaki Yokoo
- Department of Human Pathology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Japan
| | - Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagito-machi, Gifu 501-1112, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagito-machi, Gifu 501-1112, Japan
| | - Yoshio Ikeda
- Department of Neurology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-0034, Japan
| | - Mikio Shoji
- Geriatrics Research Institute and Hospital, 3-26-8 Otomo-machi, Maebashi 371-0847, Japan
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Segal Y, Zekeridou A. Interest of rare autoantibodies in autoimmune encephalitis and paraneoplastic neurological syndromes: the utility (or futility) of rare antibody discovery. Curr Opin Neurol 2024; 37:295-304. [PMID: 38533672 DOI: 10.1097/wco.0000000000001261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
PURPOSE OF REVIEW The increasing recognition and diagnosis of autoimmune encephalitis (AE) and paraneoplastic neurological syndromes (PNS) is partly due to neural autoantibody testing and discovery. The past two decades witnessed an exponential growth in the number of identified neural antibodies. This review aims to summarize recent rare antibody discoveries in the context of central nervous system (CNS) autoimmunity and evaluate the ongoing debate about their utility. RECENT FINDINGS In the last 5 years alone 15 novel neural autoantibody specificities were identified. These include rare neural antibody biomarkers of autoimmune encephalitis, cerebellar ataxia or other movement disorders, including multifocal presentations. SUMMARY Although the clinical applications of these rare antibody discoveries may be limited by the low number of positive cases, they still provide important diagnostic, prognostic, and therapeutic insights.
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Affiliation(s)
- Yahel Segal
- Department of Laboratory Medicine and Pathology
| | - Anastasia Zekeridou
- Department of Laboratory Medicine and Pathology
- Department of Neurology
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
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Chen Y, Luo C, Zhou G, Wang H, Dai K, Wu W, Wang S, Su Z, Peng F, Jiang Y. The discrimination between autoimmune glial fibrillary acidic protein astrocytopathy and tuberculous meningitis. Mult Scler Relat Disord 2024; 85:105527. [PMID: 38432014 DOI: 10.1016/j.msard.2024.105527] [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: 11/16/2023] [Revised: 02/25/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE The differential diagnosis between autoimmune glial fibrillary acidic protein astrocytopathy (AGFAPA) mimicking tuberculous meningitis and tuberculous meningitis (TBM) remains challenging in clinical practice. This study aims to identify the clinical, laboratory parameters, and clinical score systems that may be helpful in differentiating AGFAPA from TBM. METHOD Overall 22 AGFAPA patients who were initially misdiagnosed as TBM (AGFAPA-TBM) and 30 confirmed TBM patients were included. The clinical, laboratory, imaging parameters, Thwaites systems, and Lancet consensus scoring systems (LCSS) of all patients were reviewed. Logistic regression was employed to establish a diagnostic formula to differentiate AGFAPA-TBM from TBM. The receiver operating characteristic (ROC) curve was applied to determine the best diagnostic critical point of the formula. RESULTS Urinary retention was more frequent in AGFAPA-TBM patients (72.7% vs 33.3%, p = 0.012). A significantly lower ratio of T-SPOT. TB was noted in AGFAPA-TBM patients (9.1% vs 82.1%, p < 0.001). We found the LCSS was able to differentiate AGFAPA-TBM from TBM (AUC value 0.918, 95% CI=0.897-0.924). Furthermore, we set up a new scoring system with three variables: urinary retention, T-SPOT. TB, and cerebral imaging criteria in LCSS. The proposed diagnostic score ranges from -8 to 2, and a score of ≥ 0 was suggestive of AGFAPA-TBM (AUC value 0.938, 95% CI=0.878-0.951). CONCLUSIONS This study is the first to evaluate the Thwaites system and LCSS in AGFAPA-TBM and TBM. We provide an alternative diagnostic formula to differentiate AGFAPA-TBM from TBM and suggest testing for GFAP antibodies to avoid misdiagnosis when this scoring system meets AGFAPA-TBM.
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Affiliation(s)
- Yanxiang Chen
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China; Department of Neurology, Xiaolan People's Hospital of Zhongshan, 65#, Middle Section of Jucheng Avenue, Xiaolan, Zhongshan, Guangdong Province 528400, China
| | - Chongliang Luo
- Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St Louis, MO 63110, USA
| | - Guonan Zhou
- Department of Encephalopathy, Zhongshan Chenxinghai Hospital of Integrated Traditional Chinese and Western Medicine, 18# Zhuyuan Road, Zhongshan, Guangdong Province 528400, China
| | - Hui Wang
- Department of Neurology, Xiaolan People's Hospital of Zhongshan, 65#, Middle Section of Jucheng Avenue, Xiaolan, Zhongshan, Guangdong Province 528400, China
| | - Kai Dai
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China
| | - Weijuan Wu
- Department of Neurology, Sanshui District People's Hospital, Sanshui, Foshan, Guangdong Province 528100, China
| | - Siguang Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China
| | - Zhihui Su
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China
| | - Fuhua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China.
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China.
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Shosha E, Connolly C, Budhram A. Case report: Headache as the sole neurological symptom in autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy. Front Neurol 2024; 15:1366263. [PMID: 38699059 PMCID: PMC11063300 DOI: 10.3389/fneur.2024.1366263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/14/2024] [Indexed: 05/05/2024] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a recently emerging autoimmune disease of the central nervous system (CNS); GFAP astrocytopathy is characterized by optic neuritis and meningoencephalomyelitis. We report the case of a 55-year-old man, otherwise healthy, who presented with isolated headaches for three months, without other features of meningoencephalitis or myelitis. His neurological examination and fundoscopy were unremarkable. Gadolinium-enhanced brain MRI demonstrated increased T2 hyperintensity within the right sub-lenticular basal ganglia, with additional leptomeningeal enhancement along the bilateral perisylvian regions and mesial temporal lobes. Cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis, elevated protein, matching oligoclonal bands, and a negative infectious and cytological workup. Cell-based assays for anti-aquaporin-4, anti-myelin oligodendrocyte glycoprotein, autoimmune encephalitis panel, and vasculitis workup were all negative, except for CSF positivity for GFAP α antibody. Oncological screening, including CT of the chest, abdomen, pelvis, and scrotal US, was unremarkable. Immunotherapy with high-dose intravenous steroids for five days and subsequent single four-weekly doses resulted in the resolution of both clinical and radiographic features, with a maintained status 24 months after onset. This case highlights isolated headache and basal ganglia, mesial temporal lobe involvement as a rare presentation of autoimmune GFAP astrocytopathy.
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Affiliation(s)
- Eslam Shosha
- Neurology Division, Department of Medicine, McMaster University, Hamilton Health Science Center, Hamilton, ON, Canada
| | - Colleen Connolly
- Neurology Division, Department of Medicine, McMaster University, Hamilton Health Science Center, Hamilton, ON, Canada
| | - Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Science Center, London, ON, Canada
- Department of Pathology and Laboratory Medicine, Western University, London Health Science Center, London, ON, Canada
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6
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Morishima Y, Hata T, Nakajima S, Shindo K, Tsuchiya M, Watanabe T, Tahara I, Kondo T, Kimura A, Shimohata T, Ueno Y. Case report: Atypical case of autoimmune glial fibrillary acidic protein astrocytopathy following COVID-19 vaccination refractory to immunosuppressive treatments. Front Immunol 2024; 15:1361685. [PMID: 38665914 PMCID: PMC11043467 DOI: 10.3389/fimmu.2024.1361685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
A 54-year-old Japanese man presented with headache and fever the day after SARS-CoV-2 vaccination. He became deeply unconscious within a week. Brain MRI showed periventricular linear enhancements and a few spotty lesions in the cerebral white matter. Cerebrospinal fluid (CSF) testing showed mild pleocytosis. He was treated with intravenous methylprednisolone and plasma exchange. However, the white matter lesions enlarged to involve the brainstem and cerebellum, and long cord spinal lesions appeared. Anti-glial fibrillary acidic protein (GFAP) antibody was positive in the CSF and serum, and he was therefore diagnosed as autoimmune GFAP-astrocytopathy (GFAP-A). In addition, high-dose immunoglobulin therapy was administered twice, but his symptoms did not improve; the white matter lesions enlarged further, and modified Rankin Scale score increased to 5. A brain biopsy specimen showed infiltration of macrophages and CD4 + lymphocytes together with neuron and oligodendrocytic injuries and glial scar. Although GFAP-A generally responds well to steroids, the present case developed GFAP-A following SARS-CoV-2 vaccination, with refractory to intensive immunosuppressive therapy and atypical pathologic findings of infiltration of CD4 + lymphocytes and demyelination.
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Affiliation(s)
- Yuto Morishima
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | - Takanori Hata
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | - Sho Nakajima
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | - Kazumasa Shindo
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | - Mai Tsuchiya
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | | | - Ippei Tahara
- Department of Pathology, University of Yamanashi, Chuo, Japan
| | - Tetsuo Kondo
- Department of Pathology, University of Yamanashi, Chuo, Japan
| | - Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yuji Ueno
- Department of Neurology, University of Yamanashi, Chuo, Japan
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7
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Kimura A. [Clinical features and pathogenesis of Glial fibrillary acidic protein (GFAP) antibody-associated disorders]. Rinsho Shinkeigaku 2024; 64:75-84. [PMID: 38281748 DOI: 10.5692/clinicalneurol.cn-001925] [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: 01/30/2024]
Abstract
Glial fibrillary acidic protein (GFAP) antibody-associated disorders (AD) were recently proposed to be immune-mediated neurological disorders. The pathogenesis of GFAP antibody-AD is poorly understood. Pathologically, there is a marked infiltration of large numbers of lymphocytes, including CD8+ and CD4+ T cells, into the meningeal and brain parenchyma, especially around the perivascular areas. GFAP-specific cytotoxic T cells are considered to be the effector cells of GFAP antibody-AD. The common phenotype of GFAP antibody-AD includes meningoencephalitis with or without myelitis. During the clinical disease course, patients present with consciousness disturbances, urinary dysfunction, movement disorders, meningeal irritation, and cognitive dysfunction. The detection of GFAP antibodies in the cerebrospinal fluid (CSF) by cell-based assay is essential for a diagnosis of GFAP antibody-AD. The CSF can be examined for lymphocyte-predominant pleocytosis and elevated protein levels. Brain linear perivascular radial enhancement patterns are observed in about half of GFAP antibody-AD patients. Spinal cord magnetic resonance imaging is used to detect longitudinal extensive spinal cord lesions. Although corticosteroid therapy is generally effective, some patients have a poor prognosis and relapse.
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Affiliation(s)
- Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine
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8
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Guo Y, Endmayr V, Zekeridou A, McKeon A, Leypoldt F, Hess K, Kalinowska-Lyszczarz A, Klang A, Pakozdy A, Höftberger E, Hametner S, Haider C, De Simoni D, Peters S, Gelpi E, Röcken C, Oberndorfer S, Lassmann H, Lucchinetti CF, Höftberger R. New insights into neuropathology and pathogenesis of autoimmune glial fibrillary acidic protein meningoencephalomyelitis. Acta Neuropathol 2024; 147:31. [PMID: 38310187 PMCID: PMC10838242 DOI: 10.1007/s00401-023-02678-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/06/2023] [Accepted: 12/24/2023] [Indexed: 02/05/2024]
Abstract
Anti-glial fibrillary acidic protein (GFAP) meningoencephalomyelitis (autoimmune GFAP astrocytopathy) is a new autoimmune central nervous system (CNS) disease diagnosable by the presence of anti-GFAP autoantibodies in the cerebrospinal fluid and presents as meningoencephalomyelitis in the majority of patients. Only few neuropathological reports are available and little is known about the pathogenic mechanisms. We performed a histopathological study of two autopsies and nine CNS biopsies of patients with anti-GFAP autoantibodies and found predominantly a lymphocytic and in one autopsy case a granulomatous inflammatory phenotype. Inflammatory infiltrates were composed of B and T cells, including tissue-resident memory T cells. Although obvious astrocytic damage was absent in the GFAP-staining, we found cytotoxic T cell-mediated reactions reflected by the presence of CD8+/perforin+/granzyme A/B+ cells, polarized towards astrocytes. MHC-class-I was upregulated in reactive astrocytes of all biopsies and two autopsies but not in healthy controls. Importantly, we observed a prominent immunoreactivity of astrocytes with the complement factor C4d. Finally, we provided insight into an early phase of GFAP autoimmunity in an autopsy of a pug dog encephalitis that was characterized by marked meningoencephalitis with selective astrocytic damage with loss of GFAP and AQP4 in the lesions.Our histopathological findings indicate that a cytotoxic T cell-mediated immune reaction is present in GFAP autoimmunity. Complement C4d deposition on astrocytes could either represent the cause or consequence of astrocytic reactivity. Selective astrocytic damage is prominent in the early phase of GFAP autoimmunity in a canine autopsy case, but mild or absent in subacute and chronic stages in human disease, probably due to the high regeneration potential of astrocytes. The lymphocytic and granulomatous phenotypes might reflect different stages of lesion development or patient-specific modifications of the immune response. Future studies will be necessary to investigate possible implications of pathological subtypes for clinical disease course and therapeutic strategies.
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Affiliation(s)
- Yong Guo
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Verena Endmayr
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
- Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
- Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Frank Leypoldt
- Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein Kiel, Lübeck, Germany
- Department of Neurology, University Medical Center Schleswig-Holstein and Kiel University, Kiel, Germany
| | - Katharina Hess
- Institute of Neuropathology, University Hospital Muenster, Muenster, North Rhine Westphalia, Germany
- Department of Pathology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Alicja Kalinowska-Lyszczarz
- Department of Neurology, Division of Neurochemistry and Neuropathology, Poznan University of Medical Sciences, Poznań, Poland
| | - Andrea Klang
- Institute of Pathology, University of Veterinary Medicine, Vienna, Austria
| | - Akos Pakozdy
- Internal Medicine, University Clinic for Small Animals, University of Veterinary Medicine, Vienna, Austria
| | - Elisabeth Höftberger
- Internal Medicine, University Clinic for Small Animals, University of Veterinary Medicine, Vienna, Austria
| | - Simon Hametner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Carmen Haider
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Désirée De Simoni
- Division of Neurology, Karl Landsteiner University of Health Sciences, University Hospital, St. Pölten, Austria
| | - Sönke Peters
- Clinic for Radiology and Neuroradiology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Ellen Gelpi
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christoph Röcken
- Department of Pathology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Stefan Oberndorfer
- Division of Neurology, Karl Landsteiner University of Health Sciences, University Hospital, St. Pölten, Austria
| | - Hans Lassmann
- Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | | | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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9
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Kvam KA, Stahl JP, Chow FC, Soldatos A, Tattevin P, Sejvar J, Mailles A. Outcome and Sequelae of Autoimmune Encephalitis. J Clin Neurol 2024; 20:3-22. [PMID: 38179628 PMCID: PMC10782092 DOI: 10.3988/jcn.2023.0242] [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: 07/04/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 01/06/2024] Open
Abstract
Autoimmune etiologies are a common cause for encephalitis. The clinical syndromes consistent with autoimmune encephalitis are both distinct and increasingly recognized, but less is known about persisting sequelae or outcomes. We searched PubMed for reports on outcomes after autoimmune encephalitis. Studies assessing validated, quantitative outcomes were included. We performed a narrative review of the published literature of outcomes after autoimmune encephalitis. We found 146 studies that produced outcomes data. The mortality rates were 6%-19% and the relapse risks were 10%-62%. Most patients achieved a good outcome based on a score on the modified Rankin Scale (mRS) of ≤2. Forty-nine studies evaluated outcomes beyond mRS; these studies investigated cognitive outcome, psychiatric sequelae, neurological deficits, global function, and quality-of-life/patient-reported outcomes using various tools at varying time points after the index hospital discharge. These more-detailed assessments revealed that most patients had persistent impairments, with frequent deficits in cognitive function, especially memory and attention. Depression and anxiety were also common. Many of these sequelae continued to improve over months or even years after the acute illness. While we found that lasting impairments were common among survivors of autoimmune encephalitis, additional research is needed to better understand the nature and impact of these sequelae. Standardized evaluation protocols are needed to improve the ability to compare outcomes across studies, guide rehabilitation strategies, and inform outcomes of interest in treatment trials as the field advances.
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Affiliation(s)
- Kathryn A Kvam
- Department of Neurology & Neurological Sciences, Center for Academic Medicine, Stanford University, Stanford, CA, USA.
| | | | - Felicia C Chow
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, CA, USA
| | - Ariane Soldatos
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - James Sejvar
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alexandra Mailles
- Department of Infectious Diseases, Santé publique France, Saint-Maurice, France
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10
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Bien CG, Büttner T, Reichen IC, Thomas A, Vlad B, Woermann F, Bien CI, Jelcic I. Glial Fibrillary Acidic Protein Autoimmunity After Aseptic Meningitis: A Report of 2 Cases. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200180. [PMID: 37949666 PMCID: PMC10691222 DOI: 10.1212/nxi.0000000000200180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/21/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVES We describe 2 patients with glial fibrillary acidic protein (GFAP) autoimmunity secondary to aseptic viral meningitis or meningoencephalomyelitis. METHODS This study involved a retrospective chart review. RESULTS Two female patients, 45 and 55 years of age, developed aseptic meningoencephalomyelitis or meningitis; in one patient, it was likely caused by herpes simplex virus 2. The patients were recovering from the infectious condition when they, 51 and 5 days after onset, had new symptoms with detection of GFAP antibodies in the CSF; CSF and serum samples from the initial lumbar punctures had been negative for GFAP antibodies. Both patients recovered with steroid treatment (in one case, plus rituximab; in the other, plus azathioprine) including resolution of MRI and CSF abnormalities. DISCUSSION These 2 patients had GFAP autoimmunity secondary to viral meningoencephalomyelitis or meningitis. This suggests that GFAP astrocytopathy might not always be a primary disease entity; it may follow another brain injury that triggers this autoimmune response.
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Affiliation(s)
- Christian G Bien
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany.
| | - Thomas Büttner
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Ina C Reichen
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Annette Thomas
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Benjamin Vlad
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Friedrich Woermann
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
| | - Corinna I Bien
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany.
| | - Ilijas Jelcic
- From the Bielefeld University (C.G.B.); Klinikum Emden (T.B., A.T.), Germany; University Hospital Zurich and University of Zurich (I.C.R., B.V., I.J.), Switzerland; Laboratory Krone (C.I.B.), Bad Salzuflen; Krankenhaus Mara (F.W.), Bielefeld, Germany
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11
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Tang M, Huang S, Guo W, Zhou J, Huang Z, Li W, Sun Q, Wang Z. Case report: Excessive daytime sleepiness as a presenting manifestation of autoimmune glial fibrillary acidic protein astrocytopathy. Front Immunol 2023; 14:1302514. [PMID: 38173730 PMCID: PMC10761546 DOI: 10.3389/fimmu.2023.1302514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
Autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A) is a recently discovered autoimmune inflammatory disease of the central nervous system. It presents with a variety of clinical symptoms, including fever, seizures, psychiatric symptoms, limber weakness, and sensory symptoms. However, the symptoms of sleep disorders have not been sufficiently addressed. Here, we report a case of GFAP-A in which the patient complained of excessive daytime sleepiness and an excessive need for sleep. Our patient was a 58-year-old male who experienced excessive daytime sleepiness for 50 days following SARS-CoV-2 infection. He was diagnosed with coronavirus disease 2019 on June 1st. On the 7th of June, he experienced excessive daytime sleepiness, nausea, reduced food intake, lower limb weakness, and dysuria. Subsequently, his sleepiness significantly deteriorated on July 21st. Five months prior, the patient underwent laparoscopic partial right nephrectomy for clear-cell renal cell carcinoma. Brain MRI revealed abnormal hyperintense lesions in the pontine brain and around the mesencephalic aqueduct on T2 and T2-fluid attenuated inversion recovery (T2-FLAIR) sequences However, these lesions did not exhibit any pathological enhancement. Spinal cord MRI revealed lesions in the C6-C7 and T2-T3 segments on the T2 sequence. His Epworth Sleepiness Scale (ESS) score was 16 (reference range, <10), and 24-hour polysomnography supported the diagnosis of rapid-eye-movement sleep disorder and severe sleep apnea-hypopnea syndrome. Glial fibrillary acidic protein IgG antibodies were detected in the cerebrospinal fluid (1:32, cell-based assay) but not in the serum. The level of hypocretin in the cerebrospinal fluid was 29.92 pg/mL (reference range ≥110 pg/mL), suggesting narcolepsy type 1. After treatment with corticosteroids for approximately 1 month, the patient showed considerable clinical and radiological improvement, as well as an increase in hypocretin levels. Although repeated polysomnography and multiple sleep latency tests suggested narcolepsy, his ESS score decreased to 8. Our findings broaden the range of clinical manifestations associated with GFAP-A, thereby enhancing diagnostic and therapeutic strategies for this disease. Additionally, our results indicate a potential common autoimmune mechanism involving GFAP-A and orexin system dysregulation, warranting further investigation.
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Affiliation(s)
| | | | | | | | | | | | | | - Zan Wang
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin, China
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12
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Oprea E, Elosegi JA. Autoimmune GFAP-IgG astrocytopathy manifesting with acute cerebellitis and severe gastrointestinal symptoms. Rev Neurol (Paris) 2023; 179:1147-1151. [PMID: 37858434 DOI: 10.1016/j.neurol.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/31/2023] [Accepted: 08/04/2023] [Indexed: 10/21/2023]
Affiliation(s)
- E Oprea
- Neurology department, Cliniques Universitaires Saint Luc, Bruxelles, Belgique.
| | - J A Elosegi
- Neurology department, CHU Ambroise-Paré, Mons, Belgique
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13
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Weidauer S, Hattingen E, Arendt CT. Cervical myelitis: a practical approach to its differential diagnosis on MR imaging. ROFO-FORTSCHR RONTG 2023; 195:1081-1096. [PMID: 37479218 DOI: 10.1055/a-2114-1350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
BACKGROUND Differential diagnosis of non-compressive cervical myelopathy encompasses a broad spectrum of inflammatory, infectious, vascular, neoplastic, neurodegenerative, and metabolic etiologies. Although the speed of symptom onset and clinical course seem to be specific for certain neurological diseases, lesion pattern on MR imaging is a key player to confirm diagnostic considerations. METHODS The differentiation between acute complete transverse myelitis and acute partial transverse myelitis makes it possible to distinguish between certain entities, with the latter often being the onset of multiple sclerosis. Typical medullary MRI lesion patterns include a) longitudinal extensive transverse myelitis, b) short-range ovoid and peripheral lesions, c) polio-like appearance with involvement of the anterior horns, and d) granulomatous nodular enhancement prototypes. RESULTS AND CONCLUSION Cerebrospinal fluid analysis, blood culture tests, and autoimmune antibody testing are crucial for the correct interpretation of imaging findings. The combination of neuroradiological features and neurological and laboratory findings including cerebrospinal fluid analysis improves diagnostic accuracy. KEY POINTS · The differentiation of medullary lesion patterns, i. e., longitudinal extensive transverse, short ovoid and peripheral, polio-like, and granulomatous nodular, facilitates the diagnosis of myelitis.. · Discrimination of acute complete and acute partial transverse myelitis makes it possible to categorize different entities, with the latter frequently being the overture of multiple sclerosis (MS).. · Neuromyelitis optica spectrum disorders (NMOSD) may start as short transverse myelitis and should not be mistaken for MS.. · The combination of imaging features and neurological and laboratory findings including cerebrospinal fluid analysis improves diagnostic accuracy.. · Additional brain imaging is mandatory in suspected demyelinating, systemic autoimmune, infectious, paraneoplastic, and metabolic diseases..
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Affiliation(s)
- Stefan Weidauer
- Institute for Neuroradiology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Elke Hattingen
- Institute for Neuroradiology, Goethe University Frankfurt, Frankfurt am Main, Germany
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14
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Uppal P, Smith J, Castillo-Pinto C, Wells EM, Jayakar A, Harrar D. Glial Fibrillary Acidic Protein (GFAP) Astrocytopathy: An Emerging Cause of Meningoencephalomyelitis in Children and Adolescents. J Child Neurol 2023; 38:659-664. [PMID: 37981797 DOI: 10.1177/08830738231214301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
Introduction: We describe 5 children with GFAP astrocytopathy with the goal of further characterizing this rare form of meningoencephalomyelitis. Methods: Retrospective chart review of patients diagnosed with GFAP astrocytopathy between 2019 and 2021. Results: Patients were 8-17 years old, and all were male. Fever, headache, and vomiting were common presenting symptoms, and weakness, tremor, and ataxia were common initial examination findings. Initial magnetic resonance imaging (MRI) showed spinal cord abnormalities in 2 patients and leptomeningeal enhancement in 1. Most patients had cerebral spinal fluid pleocytosis, and all screened negative for malignancy. Three patients progressed to coma, and all were treated with immunosuppressant therapy. By discharge, all patients had improved over their clinical nadir, although none had returned to baseline. Discussion: GFAP astrocytopathy is a recently recognized cause of meningoencephalomyelitis in children. Here, we expand our understanding of this entity with the goal of aiding those treating children with GFAP astrocytopathy.
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Affiliation(s)
- Prayerna Uppal
- The School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | - Jacklyn Smith
- Department of Neurology, Nicklaus Children's Hospital, Miami, FL, USA
| | | | - Elizabeth M Wells
- Division of Neurology, Children's National Hospital, Washington, DC, USA
| | - Anuj Jayakar
- Department of Neurology, Nicklaus Children's Hospital, Miami, FL, USA
| | - Dana Harrar
- Division of Neurology, Children's National Hospital, Washington, DC, USA
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15
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Meira AT, de Moraes MPM, Ferreira MG, Franklin GL, Rezende Filho FM, Teive HAG, Barsottini OGP, Pedroso JL. Immune-mediated ataxias: Guide to clinicians. Parkinsonism Relat Disord 2023; 117:105861. [PMID: 37748994 DOI: 10.1016/j.parkreldis.2023.105861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/13/2023] [Accepted: 09/17/2023] [Indexed: 09/27/2023]
Abstract
Immune-mediated cerebellar ataxias were initially described as a clinical entity in the 1980s, and since then, an expanding body of evidence has contributed to our understanding of this topic. These ataxias encompass various etiologies, including postinfectious cerebellar ataxia, gluten ataxia, paraneoplastic cerebellar degeneration, opsoclonus-myoclonus-ataxia syndrome and primary autoimmune cerebellar ataxia. The increased permeability of the brain-blood barrier could potentially explain the vulnerability of the cerebellum to autoimmune processes. In this manuscript, our objective is to provide a comprehensive review of the most prevalent diseases within this group, emphasizing clinical indicators, pathogenesis, and current treatment approaches.
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Affiliation(s)
- Alex T Meira
- Universidade Federal da Paraíba, Departamento de Medicina Interna, Serviço de Neurologia, João Pessoa, PB, Brazil.
| | | | - Matheus G Ferreira
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Serviço de Neurologia, Curitiba, PR, Brazil
| | - Gustavo L Franklin
- Pontifícia Universidade Católica, Departamento de Medicina Interna, Serviço de Neurologia, Curitiba, PR, Brazil
| | | | - Hélio A G Teive
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Serviço de Neurologia, Curitiba, PR, Brazil
| | | | - José Luiz Pedroso
- Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo, SP, Brazil
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16
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Li X, Wang J, Li L, Yang C, Zhao X, Yang B, Zhang P, Liu B, Li Y, Zhang Z, Duan R. Epstein-Barr virus: To be a trigger of autoimmune glial fibrillary acidic protein astrocytopathy? CNS Neurosci Ther 2023; 29:4139-4146. [PMID: 37458208 PMCID: PMC10651959 DOI: 10.1111/cns.14336] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 05/30/2023] [Accepted: 06/18/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a novel autoimmune disease of central nervous system (CNS). It is unclear whether Epstein-Barr virus (EBV) is related to autoimmune GFAP astrocytopathy. OBJECTIVE To describe the clinical, laboratory, and imaging characteristics of patients with autoimmune GFAP astrocytopathy. METHODS The clinical, laboratory, and imaging findings of patients are presented. The levels of GFAP in CSF were detected by ELISA. T and B cell subsets in CSF were detected by flow cytometry. GFAP-IgG in serum and cerebrospinal fluid (CSF) were tested by cell-based assay (CBA) and tissue-based assay (TBA). RESULTS All three patients had fever, cognitive dysfunction, limb weakness, and positive GFAP-IgG with EBV infection in CSF. Enteric glia cells may involve in this disease. Typical imaging findings include the gadolinium enhancement of linear perivascular radial perpendicular to the ventricle, meningeal enhancement (especially in midbrain interpeduncal fossa), longitudinally extensive lesions involving spindle cords, and more T2/Flair-hyperintense lesions in the periventricular white matter at late stage. The patients had poor response to antiviral treatment and strong response to steroid pulse therapy. CONCLUSION EBV could induce CNS autoimmune response in autoimmune GFAP astrocytopathy. The detection of GFAP-IgG and EBV may facilitate the early diagnosis in these patients.
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Affiliation(s)
- Xiao‐Li Li
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Department of Neurology, Shandong Provincial Qianfoshan HospitalCheeloo College of Medicine, Shandong UniversityJinanChina
- Shandong Institute of NeuroimmunologyJinanChina
| | - Jun‐Yan Wang
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
| | - Liang‐Kang Li
- Department of Neurology, Shandong Provincial Qianfoshan HospitalCheeloo College of Medicine, Shandong UniversityJinanChina
| | - Chun‐Lin Yang
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Department of Neurology, Shandong Provincial Qianfoshan HospitalCheeloo College of Medicine, Shandong UniversityJinanChina
- Shandong Institute of NeuroimmunologyJinanChina
| | - Xue‐Lu Zhao
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
| | - Bing Yang
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Department of Neurology, Shandong Provincial Qianfoshan HospitalCheeloo College of Medicine, Shandong UniversityJinanChina
- Shandong Institute of NeuroimmunologyJinanChina
| | - Peng Zhang
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Department of Neurology, Shandong Provincial Qianfoshan HospitalCheeloo College of Medicine, Shandong UniversityJinanChina
- Shandong Institute of NeuroimmunologyJinanChina
| | - Bin Liu
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Department of Neurology, Shandong Provincial Qianfoshan HospitalCheeloo College of Medicine, Shandong UniversityJinanChina
- Shandong Institute of NeuroimmunologyJinanChina
| | - Yan‐Bin Li
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Department of Neurology, Shandong Provincial Qianfoshan HospitalCheeloo College of Medicine, Shandong UniversityJinanChina
- Shandong Institute of NeuroimmunologyJinanChina
| | - Zhao‐Xu Zhang
- Department of NeurologyPeking University People's HospitalBeijingChina
| | - Rui‐Sheng Duan
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Department of Neurology, Shandong Provincial Qianfoshan HospitalCheeloo College of Medicine, Shandong UniversityJinanChina
- Shandong Institute of NeuroimmunologyJinanChina
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17
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Quack L, Glatter S, Wegener-Panzer A, Cleaveland R, Bertolini A, Endmayr V, Seidl R, Breu M, Wendel E, Schimmel M, Baumann M, Rauchenzauner M, Pritsch M, Boy N, Muralter T, Kluger G, Makoswski C, Kraus V, Leiz S, Loehr-Nilles C, Kreth JH, Braig S, Schilling S, Kern J, Blank C, Tro Baumann B, Vieth S, Wallot M, Reindl M, Ringl H, Wandinger KP, Leypoldt F, Höftberger R, Rostásy K. Autoantibody status, neuroradiological and clinical findings in children with acute cerebellitis. Eur J Paediatr Neurol 2023; 47:118-130. [PMID: 38284996 DOI: 10.1016/j.ejpn.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 10/10/2023] [Accepted: 10/13/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Acute cerebellitis (AC) in children and adolescents is an inflammatory disease of the cerebellum due to viral or bacterial infections but also autoimmune-mediated processes. OBJECTIVE To investigate the frequency of autoantibodies in serum and CSF as well as the neuroradiological features in children with AC. MATERIAL AND METHODS Children presenting with symptoms suggestive of AC defined as acute/subacute onset of cerebellar symptoms and MRI evidence of cerebellar inflammation or additional CSF pleocytosis, positive oligoclonal bands (OCBs), and/or presence of autoantibodies in case of negative cerebellar MRI. Children fulfilling the above-mentioned criteria and a complete data set including clinical presentation, CSF studies, testing for neuronal/cerebellar and MOG antibodies as well as MRI scans performed at disease onset were eligible for this retrospective multicenter study. RESULTS 36 patients fulfilled the inclusion criteria for AC (f:m = 14:22, median age 5.5 years). Ataxia was the most common cerebellar symptom present in 30/36 (83 %) in addition to dysmetria (15/36) or dysarthria (13/36). A substantial number of children (21/36) also had signs of encephalitis such as somnolence or seizures. In 10/36 (28 %) children the following autoantibodies (abs) were found: MOG-abs (n = 5) in serum, GFAPα-abs (n = 1) in CSF, GlyR-abs (n = 1) in CSF, mGluR1-abs (n = 1) in CSF and serum. In two further children, antibodies were detected only in serum (GlyR-abs, n = 1; GFAPα-abs, n = 1). MRI signal alterations in cerebellum were found in 30/36 children (83 %). Additional supra- and/or infratentorial lesions were present in 12/36 children, including all five children with MOG-abs. Outcome after a median follow-up of 3 months (range: 1 a 75) was favorable with an mRS ≤2 in 24/36 (67 %) after therapy. Antibody (ab)-positive children were significantly more likely to have a better outcome than ab-negative children (p = .022). CONCLUSION In nearly 30 % of children in our study with AC, a range of abs was found, underscoring that autoantibody testing in serum and CSF should be included in the work-up of a child with suspected AC. The detection of MOG-abs in AC does expand the MOGAD spectrum.
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Affiliation(s)
- L Quack
- Department of Pediatric Neurology, Childreńs Hospital Datteln, University Witten/Herdecke, Datteln, Germany
| | - S Glatter
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Austria; Comprehensive Center for Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - A Wegener-Panzer
- Department of Pediatric Radiology, Childreńs Hospital Datteln, University Witten/Herdecke, Datteln, Germany
| | - R Cleaveland
- Department of Pediatric Radiology, Childreńs Hospital Datteln, University Witten/Herdecke, Datteln, Germany
| | - A Bertolini
- Department of Pediatric Neurology, Childreńs Hospital Datteln, University Witten/Herdecke, Datteln, Germany
| | - V Endmayr
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Austria
| | - R Seidl
- Department of Pediatrics, Bethanien Hospital, Moers, Germany
| | - M Breu
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - E Wendel
- Division of Pediatric Neurology, Department of Pediatrics, Olgahospital, Stuttgart, Germany
| | - M Schimmel
- Division of Pediatric Neurology, Clinic of Pediatrics, Augsburg University Hospital, University of Augsburg, Augsburg, Germany
| | - M Baumann
- Department of Pediatric I, Pediatric Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - M Rauchenzauner
- Department of Pediatric I, Pediatric Neurology, Medical University of Innsbruck, Innsbruck, Austria; Centre of Epilepsy for Children and Adolescents, Schoen Klinik Vogtareuth, Hospital for Neuropediatrics and Neurological Rehabilitation, Vogtareuth, Germany
| | - M Pritsch
- Department of Neuropediatrics, Children's Hospital DRK Siegen, Siegen, Germany
| | - N Boy
- Centre for Child and Adolescent Medicine, Department of General Pediatrics, Division of Neuropediatrics and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - T Muralter
- Centre of Epilepsy for Children and Adolescents, Schoen Klinik Vogtareuth, Hospital for Neuropediatrics and Neurological Rehabilitation, Vogtareuth, Germany
| | - G Kluger
- Centre of Epilepsy for Children and Adolescents, Schoen Klinik Vogtareuth, Hospital for Neuropediatrics and Neurological Rehabilitation, Vogtareuth, Germany; Research Institute for Rehabilitation, Transition, and Palliation, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - C Makoswski
- Pediatric Neurology, Department of Pediatrics, Kinderklinik München Schwabing, School of Medicine, Technical University of Munich, Germany
| | - V Kraus
- Pediatric Neurology, Department of Pediatrics, Kinderklinik München Schwabing, School of Medicine, Technical University of Munich, Germany; Social Pediatrics, Department of Pediatrics, Technical University of Munich, Munich, Germany
| | - S Leiz
- Department of Pediatrics and Adolescent Medicine, Hospital Dritter Orden, Munich, Germany
| | - C Loehr-Nilles
- Department of Neuropediatrics, Klinikum Mutterhaus der Borromäerinnen, Trier, Germany
| | - J H Kreth
- Department of Neuropediatrics, Social Pediatric Center, Klinikum Leverkusen, Leverkusen, Germany
| | - S Braig
- Department of Pediatrics, Klinikum Bayreuth, Bayreuth, Germany
| | - S Schilling
- Department of Neuropediatrics, Clinic of Pediatrics, Barmherzige Brüder St. Hedwig Hospital, Regensburg, Germany
| | - J Kern
- Department of Pediatric Neurology and Developmental Medicine, University Children's Hospital Tübingen, Germany
| | - C Blank
- Department of Pediatric Neurology, Children's Hospital St. Marien, Landshut, Germany
| | - B Tro Baumann
- Department of Neuropediatrics, Children's Hospital DRK Siegen, Siegen, Germany
| | - S Vieth
- Department of Pediatrics, University Medical Center Schleswig Holstein, Kiel, Germany
| | - M Wallot
- Department of Pediatrics, Bethanien Hospital, Moers, Germany
| | - M Reindl
- Clinical Department of Neurology, Medical University of Innsbruck, Austria
| | - H Ringl
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria; Department of Radiology, Klinik Donaustadt, Vienna, Austria
| | - K P Wandinger
- Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Kiel/Lübeck, Germany
| | - F Leypoldt
- Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Kiel/Lübeck, Germany; Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - R Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria.
| | - K Rostásy
- Department of Pediatric Neurology, Childreńs Hospital Datteln, University Witten/Herdecke, Datteln, Germany.
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18
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Theuriet J, Cluse F, Gravier-Dumonceau A, Picard G, Closs S, Rogemond V, Timestit N, Bouhour F, Petiot P, Davy V, Chanson E, Arzalluz-Luque J, Marignier R, Honnorat J, Pegat A. Peripheral nervous system involvement accompanies central nervous system involvement in anti-glial fibrillary acidic protein (GFAP) antibody-related disease. J Neurol 2023; 270:5545-5560. [PMID: 37540278 PMCID: PMC10576672 DOI: 10.1007/s00415-023-11908-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Glial fibrillary acidic protein (GFAP) is expressed by astrocytes in the central nervous system (CNS), but also by immature and regenerative Schwann cells in the peripheral nervous system (PNS). GFAP antibodies (GFAP-Abs) in cerebrospinal fluid (CSF) have been mainly described in patients with meningoencephalomyelitis. We aimed to study PNS symptoms in patients with CSF GFAP-Abs. METHODS We retrospectively included all patients tested positive for GFAP-Abs in the CSF by immunohistochemistry and confirmed by cell-based assay expressing human GFAPα since 2017, from two French reference centers. RESULTS In a cohort of 103 CSF GFAP-Abs patients, 25 (24%) presented with PNS involvement. Among them, the median age at onset was 48 years and 14/25 (56%) were female. Abnormal electroneuromyography was observed in 11/25 patients (44%), including eight isolated radiculopathies, one radiculopathy associated with polyneuropathy, one radiculopathy associated with sensory neuronopathy, and one demyelinating polyradiculoneuropathy. Cranial nerve involvement was observed in 18/25 patients (72%). All patients except one had an associated CNS involvement. The first manifestation of the disease concerned the PNS in three patients. First-line immunotherapy was administered to 18/24 patients (75%). The last follow-up modified Rankin Scale was ≤ 2 in 19/23 patients (83%). Patients with PNS involvement had significantly more bladder dysfunction than patients with isolated CNS involvement (68 vs 40.3%, p = 0.031). CONCLUSIONS PNS involvement in GFAP-Abs autoimmunity is heterogeneous but not rare and is mostly represented by acute or subacute cranial nerve injury and/or lower limb radiculopathy. Rarely, PNS involvement can be the first manifestation revealing the disease.
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Affiliation(s)
- Julian Theuriet
- Service d'electroneuromyographie et de pathologies neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, 59 boulevard Pinel, Bron, France
| | - Florent Cluse
- Service d'electroneuromyographie et de pathologies neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, 59 boulevard Pinel, Bron, France
- Service de Neurologie C, troubles du mouvement et pathologies neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, Bron, France
| | - Alice Gravier-Dumonceau
- Service de Neurologie C, troubles du mouvement et pathologies neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, Bron, France
| | - Géraldine Picard
- French Reference Centre on Paraneoplastic Neurological Syndrome, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
| | - Sterenn Closs
- French Reference Centre on Paraneoplastic Neurological Syndrome, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
| | - Véronique Rogemond
- French Reference Centre on Paraneoplastic Neurological Syndrome, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
| | - Noémie Timestit
- Service de biostatistique, Hospices Civils de Lyon, Lyon, France
| | - Françoise Bouhour
- Service d'electroneuromyographie et de pathologies neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, 59 boulevard Pinel, Bron, France
| | - Philippe Petiot
- Service d'electroneuromyographie et de pathologies neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, 59 boulevard Pinel, Bron, France
| | - Vincent Davy
- Service de neurologie, Hôpital Pitié Salpétrière, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Eve Chanson
- Service de neurologie, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Joaquín Arzalluz-Luque
- Service de Neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, Hôpital Neurologique Pierre-Wertheimer, Hospices Civils de Lyon, Bron, France
| | - Romain Marignier
- Service de Neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, Hôpital Neurologique Pierre-Wertheimer, Hospices Civils de Lyon, Bron, France
- Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre-Wertheimer, Hospices Civils de Lyon, Bron, France
| | - Jerome Honnorat
- French Reference Centre on Paraneoplastic Neurological Syndrome, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
- MeLiS-UCBL-CNRS UMR 5284-INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Antoine Pegat
- Service d'electroneuromyographie et de pathologies neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, 59 boulevard Pinel, Bron, France.
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Qin M, Chen J, Guo X, Xiang X, Nie L, Wang Y, Mao L. Movement disorders in autoimmune encephalitis: an update. J Neurol 2023; 270:5288-5302. [PMID: 37523063 DOI: 10.1007/s00415-023-11881-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/13/2023] [Accepted: 07/13/2023] [Indexed: 08/01/2023]
Abstract
Autoimmune encephalitis (AE) is a form of encephalitis resulting from an immune response targeting central nervous system antigens, which is characterized by cognitive impairment, neuropsychiatric symptoms, seizures, movement disorders (MDs), and other encephalopathy symptoms. MDs frequently manifest throughout the progression of the disease, with recurrent involuntary movements leading to discomfort and, in some cases, necessitating admission to the intensive care unit. Prompt identification and management of MDs can aid in the diagnosis and prognosis of AE. This review synthesizes current knowledge on the characteristics, underlying mechanisms, and treatment options for MDs in the context of AE.
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Affiliation(s)
- Mengting Qin
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiaojiao Chen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoqing Guo
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuying Xiang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lei Nie
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yong Wang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Ling Mao
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Liu Q, Yang X, Zhang Bao J, Ma B, Niu X, Wang X, Zhang Q, Quan C. Clinical characteristics of patient with GFAP-IgG: a review of 31 patients from two tertiary referral centers in China. Int J Neurosci 2023:1-12. [PMID: 37897492 DOI: 10.1080/00207454.2023.2277664] [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: 07/26/2023] [Accepted: 10/26/2023] [Indexed: 10/30/2023]
Abstract
OBJECTIVE This study presents a comprehensive analysis of the clinical characteristics of 31 patients exhibiting cerebrospinal fluid (CSF) and/or serum positivity for GFAP-IgG, with a specific emphasis on 24 cases demonstrating only GFAP-IgG positivity. The investigation thoroughly evaluates their clinical, radiological, and laboratory features, as well as treatment responses, with the objective of offering clinicians potential diagnostic and therapeutic approaches. METHODS A total of 31 patients with GFAP-IgG in the CSF and/or serum were registered between August 2016 and August 2021 at the General Hospital of Ningxia Medical University and Huashan Hospital of Fudan University. We retrospectively reviewed their clinical records. RESULTS Overall, the patients were positive with GFAP-IgG in their CSF (15/31), in serum (6/31), and both CSF and serum (10/31). Among them, two were eventually diagnosed with astroglioma and primary central nervous system lymphoma, respectively; one patient had typical multiple sclerosis; three exhibited overlapping GFAP-IgG and aquaporin-4-IgG (AQP4-IgG); and one patient was coexisting N-methyl-D-aspartate receptor IgG. The remaining 24 patients were only GFAP-IgG positive. In total, 22 out of the 24 patients had abnormal MRI outcomes, involving the brain, meninges, and spinal cord. Besides, seven of the 24 patients developed optic neuritis. The CSF protein levels positively correlated with the Expanded Disability Status Scale score (EDSSs). Significantly decreased EDSSs, modified Rankin Scale score, GFAP-IgG titer, CSF protein level, and CSF white blood cell counts were observed after immunomodulatory therapy. CONCLUSION The clinical manifestations of GFAP-IgG exhibit a wide range of phenotypes that lack specificity. These findings emphasize the significance of not exclusively relying on the presence of antibodies to diagnose GFAP-A, but rather integrating them with the clinical phenotypes. GFAP-IgG testing enables the diagnosis of autoimmune GFAP astrocytopathy, a treatable autoimmune disease affecting the central nervous system. This condition provides opportunities for investigating innovative mechanisms of CNS autoimmunity and inflammation.
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Affiliation(s)
- Qiang Liu
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, Ningxia Province, China
| | - Xiao Yang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, Ningxia Province, China
| | - Jingzi Zhang Bao
- Department of Neurology and Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
| | - Boya Ma
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, Ningxia Province, China
| | - Xiaoyan Niu
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, Ningxia Province, China
| | - Xu Wang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, Ningxia Province, China
| | - Qing Zhang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, Ningxia Province, China
| | - Chao Quan
- Department of Neurology and Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
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Sun M, Liu H, Zhu B, Liu Y, Li A, Wang L. Comparison of glial fibrillary acidic protein-immunoglobulin G-associated myelitis with myelin oligodendrocyte glycoprotein-immunoglobulin G-associated myelitis. Front Neurol 2023; 14:1266067. [PMID: 38020648 PMCID: PMC10645061 DOI: 10.3389/fneur.2023.1266067] [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: 07/24/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Objective Glial fibrillary acidic protein-immunoglobulin G (GFAP-IgG)-associated myelitis and myelin oligodendrocyte glycoprotein-IgG (MOG-IgG)-associated myelitis have rarely been compared. Therefore, this study aimed to explore the clinical, laboratory, and imaging features of them to identify the differences. Methods Overall, 14 and 24 patients with GFAP-IgG-and MOG-IgG-associated myelitis, respectively, were retrospectively screened and included in the study. Results Among the 14 patients with GFAP-IgG-associated myelitis, the condition was more common in males (71.4%), with a median age of onset of 36.5 years, and more common in adults than in children (35.7%). In contrast, among the 24 patients with MOG-IgG-associated myelitis, the condition was equally divided between males and females, with a median age of onset of 9.5 years and more in children (66.7%) than in adults. The median age of onset of GFAP-IgG-associated myelitis was later than that of the MOG-IgG group. Isolated myelitis was rare in both groups. Elevated cerebrospinal fluid (CSF) protein levels were more prevalent in patients with GFAP-IgG-associated myelitis (64.3%) than in those with MOG-IgG-associated myelitis (16.7%) (p < 0.05), whereas patchy gadolinium enhancement of the cerebral lesion site was less common in patients with GFAP-IgG-associated myelitis than in those with MOG-IgG associated myelitis (p < 0.05). Six patients had a combination of other neurological autoantibodies, the specific mechanism of the overlapping antibodies remains unclear. Conclusion Cerebrospinal fluid analysis and gadolinium enhanced MRI examination may help to distinguish the two kinds of myelitis.
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Affiliation(s)
- Mengyang Sun
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hao Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Bingqing Zhu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yang Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Aijia Li
- Zhengzhou University Medical College, Zhengzhou, China
| | - Limei Wang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Yue J, Lin P, Lian C, Yao H, Jiang L, Liao S, Xu L, Zhang J, Tan J, Chen Z, Yang J, Gao C, Huang L, Yang X, Long Y. Brain radial enhancement pattern in patients with negative glial fibrillary acidic protein-IgG: A cases series study. J Neurol Sci 2023; 453:120782. [PMID: 37683309 DOI: 10.1016/j.jns.2023.120782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/27/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Brain radial enhancement pattern on magnetic resonance imaging (MRI) has been identified as typical lesions in autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A). However, the authors encountered several patients without GFAP-IgG showing that such specific imaging. In the present study, we reported the clinical pictures of 5 GFAP-IgG-negative patients with GFAP-A specific imaging pattern. METHODS Data was retrospectively obtained from June 2013 through April 2023, and five GFAP-IgG-negative patients with valid data were recruited. Clinical information was either obtained by the investigators or retrieved from the referring clinicians and included prodromal symptoms, neurologic manifestations, comorbidities, results of ancillary studies. RESULTS Altogether five GFAP-IgG-negative patients with "meningoencephalitis/encephalitis" manifestations and brain radial perivascular enhancement were confirmed. One patient had peripheral lymphoma. Four patients had other autoimmune antibody in serum and/or cerebrospinal fluid, of which one patient had positive aquaporin IgG. Clinical features of the five patients included headache, fever, epilepsy and abnormal behavioral symptoms. MRI of patients revealed radial perivascular gadolinium enhancement extending from the lateral ventricles to the white matter suggestive of autoimmune GFAP-A. CONCLUSION GFAP-A-like disorders with radial perivascular enhancement could be found in GFAP-IgG-negative patients with or without neoplasm, which could provide new insight into the differential diagnosis of GFAP-A.
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Affiliation(s)
- Jiajia Yue
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Peihao Lin
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Chun Lian
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Haiyan Yao
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Lihong Jiang
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Sha Liao
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Lufen Xu
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Jiayuan Zhang
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Jie Tan
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Zixuan Chen
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Jie Yang
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Cong Gao
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Li Huang
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Xinguang Yang
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Sun Yat-sen Memorial Hospital, the Second Affiliated Hospital of Sun Yat-sen University, 107#Yan Jiang West Road, Guangzhou, China
| | - Youming Long
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China.
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Du J, Cao S, Xia L, Li Q, Tian Y. Plasma exchange for two patients with autoimmune GFAP astrocytopathy with rapid progression to respiratory failure: a case report. Front Immunol 2023; 14:1265609. [PMID: 37869007 PMCID: PMC10585171 DOI: 10.3389/fimmu.2023.1265609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 09/13/2023] [Indexed: 10/24/2023] Open
Abstract
Background Patients with autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy can present with early neurological deterioration, but rapidly progressive respiratory failure is rarely reported. We present the cases of two patients with autoimmune GFAP astrocytopathy who experienced rapid progression to respiratory failure and were effectively treated using plasma exchange therapy. Case report Two patients were diagnosed with autoimmune GFAP astrocytopathy. Their initial symptoms were consistent with those of previously observed cases of autoimmune GFAP astrocytopathy. However, they experienced rapid progression to respiratory failure due to their lesion location. Specifically, case 1 had lesions in the medulla oblongata, and case 2 had lesions in the high cervical spinal cord, which are both common sites of lesions causing respiratory failure. The patients did not respond well to intravenous methylprednisolone and intravenous immunoglobulin initially and could not be withdrawn from ventilator support. Fortunately, subsequent plasma exchange therapy led to significant clinical improvements and successful withdrawal from ventilator support. Discussion Patients with autoimmune GFAP astrocytopathy can present with rapidly progressive respiratory failure. Early treatment with plasma exchange can be beneficial in withdrawing patients from ventilator support.
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Affiliation(s)
- Jing Du
- Department of Neurology, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Shugang Cao
- Department of Neurology, Second Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of Neurology, The Second People’s Hospital of Hefei, Affiliated Hefei Hospital of Anhui Medical University, Hefei, China
| | - Lan Xia
- Department of Neurology, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Qi Li
- Department of Neurology, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yanghua Tian
- Department of Neurology, Second Affiliated Hospital of Anhui Medical University, Hefei, China
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Kaga M, Ueda T, Yoshikawa S. A rare case of glial fibrillary acidic protein astrocytopathy that resolved spontaneously within a self-limited course. Heliyon 2023; 9:e20912. [PMID: 37867900 PMCID: PMC10589841 DOI: 10.1016/j.heliyon.2023.e20912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 10/06/2023] [Accepted: 10/11/2023] [Indexed: 10/24/2023] Open
Abstract
Glial fibrillary acidic protein astrocytopathy is a form of autoimmune meningoencephalomyelitis. The presence of antibodies in spinal fluid against glial fibrillary acidic protein is necessary to diagnose the disease. There is no standard treatment and few cases of glial fibrillary acidic protein astrocytopathy have been reported. A 31-year-old healthy Japanese man presented to our emergency department with a 7-day history of fever and headache. He was in good general condition, without abnormalities on physical examination, and a general hematological examination revealed hyponatremia (130 mEq/L). Five days later, he was followed up and new subjective symptoms were noted: tremor in the right hand, constipation, sweating, and lightheadedness. Cerebrospinal fluid examination revealed a cell count of 57/μL (96 % mononuclear cells, 4 % multinuclear cells), elevated protein level (103 mg/dL), elevated adenosine deaminase level (15.0 U/L), negative polymerase chain reaction test results for herpes simplex virus and Mycobacterium tuberculosis, negative cerebrospinal fluid culture, and negative cerebrospinal fluid anti-acid bacteria culture, indicating aseptic meningitis. T1-weighted contrast-enhanced magnetic resonance imaging of the head showed a linear contrast effect perpendicular to the lateral ventricular wall and along the perivascular vessels spreading radially. Based on the presence of hyponatremia, history of movement disorder and autonomic symptoms, high adenosine deaminase level in cerebrospinal fluid, and findings on contrast-enhanced magnetic resonance imaging of the head, we suspected glial fibrillary acidic protein astrocytopathy and assessed anti-glial fibrillary acidic proteinαantibody in cerebrospinal fluid, which was positive, and diagnosed glial fibrillary acidic protein astrocytopathy. After careful follow-up with symptomatic treatment without immunosuppressive therapy, the fever, headache, tremor, and autonomic symptoms were improved over time. Contrast-enhanced magnetic resonance imaging of the head and findings of cerebrospinal fluid also showed improvement. glial fibrillary acidic protein astrocytopathy should be a differential diagnosis in patients with aseptic meningitis with movement disorders or autonomic symptoms and elevated cerebrospinal fluid adenosine deaminase. Careful follow-up without immunosuppressive treatment should be considered for patients with minimal neurologic symptoms as glial fibrillary acidic protein astrocytopathy may have a self-limiting course and resolve.
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Affiliation(s)
- Mihiro Kaga
- Emergency and General Internal Medicine, Rakuwakai Marutamachi Hospital, Kyoto, Japan
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takeshi Ueda
- Emergency and General Internal Medicine, Rakuwakai Marutamachi Hospital, Kyoto, Japan
| | - Satoshi Yoshikawa
- Emergency and General Internal Medicine, Rakuwakai Marutamachi Hospital, Kyoto, Japan
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Liang Y, Wang G, Li B, Li G, Zeng H. Autoimmune glial fibrillary acidic protein astrocytosis mimicking tuberculous meningitis: a retrospective study. J Neurol 2023; 270:4860-4867. [PMID: 37338614 PMCID: PMC10511357 DOI: 10.1007/s00415-023-11818-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND This study aimed to summarize the clinical features of Autoimmune Glial Fibrillary Acidic Protein Astrocytosis mimicking tuberculosis meningitis to improve clinicians' understanding of this disease. METHODS We retrospectively analyzed the clinical manifestations, cerebrospinal fluid results, and imaging data of five patients with Autoimmune Glial Fibrillary Acidic Protein Astrocytosis mimicking tuberculous meningitis who were admitted to Xiangya Hospital Central South University between October 2021 and July 2022. RESULTS Five patients were aged 31-59 years, with a male-to-female ratio of 4:1. Among the cases reviewed, four had a history of prodromal infections manifesting as fever and headache. One patient developed limb weakness and numbness with clinical manifestations of meningitis, meningoencephalitis, encephalomyelitis, or meningomyelitis. Cerebrospinal fluid analysis revealed an increased cell count in five cases, with a lymphocyte majority. All five cases had a CSF protein level > 1.0 g/L, CSF/blood glucose ratio < 0.5, and two patients had CSF glucose < 2.2 mmol/L. Decreased CSF chloride was observed in three cases, while increased ADA was observed in one case. Both serum and cerebrospinal fluid were positive for anti-GFAP antibodies in three cases, while in two cases, only CSF was positive for anti-GFAP antibodies. Additionally, hyponatremia and hypochloremia were observed in three cases. No tumors were detected in any of the five patients during tumor screening, and all five cases had a good prognosis following immunotherapy. CONCLUSION Anti-GFAP antibody testing should be routinely performed in patients with suspected tuberculosis meningitis to avoid misdiagnosis.
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Affiliation(s)
- Yingfang Liang
- Department of Comprehensive Internal Medicine, The Affiliated Tumor Hospital of Guangxi Medical University, 71#Hedi Rd, Nanning, GuangXi, China
| | - Gangqi Wang
- Department of Neurology, Xiangya Hospital, Central South University, 87#Xiangya Rd, Changsha, Hunan, China
| | - Bixun Li
- Department of Comprehensive Internal Medicine, The Affiliated Tumor Hospital of Guangxi Medical University, 71#Hedi Rd, Nanning, GuangXi, China
| | - Guoliang Li
- Department of Neurology, Xiangya Hospital, Central South University, 87#Xiangya Rd, Changsha, Hunan, China.
| | - Hao Zeng
- Department of Spine and Osteopathy Surgery, The First Affiliated Hospital of Guangxi Medical University, 6#Shuangyong Rd, Nanning, GuangXi, China.
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Kraker JA, Chen JJ. An update on optic neuritis. J Neurol 2023; 270:5113-5126. [PMID: 37542657 DOI: 10.1007/s00415-023-11920-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 07/27/2023] [Accepted: 07/30/2023] [Indexed: 08/07/2023]
Abstract
Optic neuritis (ON) is the most common cause of subacute optic neuropathy in young adults. Although most cases of optic neuritis (ON) are classified as typical, meaning idiopathic or associated with multiple sclerosis, there is a growing understanding of atypical forms of optic neuritis such as antibody mediated aquaporin-4 (AQP4)-IgG neuromyelitis optica spectrum disorder (NMOSD) and the recently described entity, myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD). Differentiating typical ON from atypical ON is important because they have different prognoses and treatments. Findings of atypical ON, including severe vision loss with poor recovery with steroids or steroid dependence, prominent optic disc edema, bilateral vision loss, and childhood or late adult onset, should prompt serologic testing for AQP4-IgG and MOG-IgG. Although the traditional division of typical and atypical ON can be helpful, it should be noted that there can be severe presentations of otherwise typical ON and mild presentations of atypical ON that blur these traditional lines. Rare causes of autoimmune optic neuropathies, such as glial fibrillary acidic protein (GFAP) and collapsin response-mediator protein 5 (CRMP5) autoimmunity also should be considered in patients with bilateral painless optic neuropathy associated with optic disc edema, especially if there are other accompanying suggestive neurologic symptoms/signs. Typical ON usually recovers well without treatment, though recovery may be expedited by steroids. Atypical ON is usually treated with intravenous steroids, and some forms, such as NMOSD, often require plasma exchange for acute attacks and long-term immunosuppressive therapy to prevent relapses. Since treatment is tailored to the cause of the ON, elucidating the etiology of the ON is of the utmost importance.
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Affiliation(s)
- Jessica A Kraker
- Department of Ophthalmology, Mayo Clinic Hospital, Rochester, MN, USA
| | - John J Chen
- Department of Ophthalmology, Mayo Clinic Hospital, Rochester, MN, USA.
- Department of Neurology, Mayo Clinic Hospital, Rochester, MN, USA.
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Li T, Li X, Hong S, Jiang L, Ma J. Clinical characteristics of autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy in children: A case series of 16 patients. J Neuroimmunol 2023; 382:578176. [PMID: 37572437 DOI: 10.1016/j.jneuroim.2023.578176] [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: 03/04/2023] [Revised: 06/14/2023] [Accepted: 08/06/2023] [Indexed: 08/14/2023]
Abstract
PURPOSE To investigate the clinical characteristics of autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy in children. METHODS We reviewed the medical records of Children's Hospital of Chongqing Medical University from January 2020 to September 2021 and retrospectively analysed the clinical features, magnetic resonance imaging (MRI) findings, laboratory findings, treatment and outcome of children with autoimmune GFAP astrocytopathy. RESULTS Sixteen patients were included: 6 and 10 tested positive for GFAP-IgG in cerebrospinal fluid (CSF) and both CSF and serum, respectively. The median patient age was 115 months (range: 36-180 months), and 7 patients (43.8%) were male. All patients had the clinical syndrome of encephalitis/meningoencephalitis with or without myelitis: encephalitis (8), meningoencephalitis (3), encephalomyelitis (1) and meningoencephalomyelitis (4). The most common clinical symptoms were fever (11), altered consciousness (11), headache (10) and seizure (9). Four patients developed central respiratory failure for which mechanical ventilation was needed. All patients showed hyperintense T2-weighted lesions on brain MRI in the cerebral white matter (13), brainstem (11), basal ganglia (11), thalamus (9), and cerebellum (3). Nine patients (56%) had abnormal hyperintense lesions in the bilateral basal ganglia and thalamus. Six of 12 patients who underwent gadolinium-enhanced brain MRI showed abnormal enhancement images, and five of them showed linear perivascular radial enhancement. The modified Rankin scale (mRS) score decreased significantly in most patients after immunotherapy. Two patients with coexisting neural autoantibodies relapsed; however, 15 patients who were followed up successfully had favorable outcomes at the last follow-up. CONCLUSION Children with autoimmune GFAP astrocytopathy usually have a clinical syndrome of encephalitis/meningoencephalitis with or without myelitis. Except for the linear perivascular radial gadolinium enhancement pattern, hyperintense lesions in the bilateral basal ganglia and thalamus might be another characteristic brain MRI finding of autoimmune GFAP astrocytopathy in children. Although a few patients with coexisting neural autoantibodies might relapse, children with autoimmune GFAP astrocytopathy usually have favorable outcomes after immunotherapy.
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Affiliation(s)
- Tianyi Li
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xiujuan Li
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Siqi Hong
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Li Jiang
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jiannan Ma
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China.
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Zhang JR, Zhuang S, Xu XD, Song WL, Li KR, Jiang Y, Cheng XY, Shi JJ, Hu WD, Liu CF, Zhang YL. Overlapping Epstein-Barr virus encephalitis and autoimmune glial fibrillary acidic protein astrocytopathy. J Neuroimmunol 2023; 382:578174. [PMID: 37573633 DOI: 10.1016/j.jneuroim.2023.578174] [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: 03/27/2023] [Revised: 05/30/2023] [Accepted: 08/06/2023] [Indexed: 08/15/2023]
Abstract
We describe three cases of overlapping Epstein-Barr virus (EBV) Encephalitis and Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy (GFAP-A). The three cases all presented with initial symptoms of fever, headache, coma, and posture tremor of the upper limbs, then followed by limb weakness and dysuria. All of the three cases were on ventilators. Case 1 and 2 improved dramatically after intravenous methylprednisoloneand immunoglobulin treatment. However, case 3 presented dyspneic, and died from gastrointestinal hemorrhage. The GFAP-A triggered by EBV intracranial infection could initially masquerade as EBV encephalitis only, and the detection of GFAP antibody is essential for differentiation.
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Affiliation(s)
- Jin-Ru Zhang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Sheng Zhuang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiao-Dong Xu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Wen-Li Song
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Ke-Ru Li
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yu Jiang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiao-Yu Cheng
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Ji-Jun Shi
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Wei-Dong Hu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China.
| | - Chun-Feng Liu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China; Jiangsu Key Laboratory of Neuropsychiatric Diseases and Institute of Neuroscience, Soochow University, Suzhou, China.
| | - Yan-Lin Zhang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China.
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Greco G, Masciocchi S, Diamanti L, Bini P, Vegezzi E, Marchioni E, Colombo E, Rigoni E, Businaro P, Ferraro OE, Bianchi Marzoli S, Bergamaschi R, Franciotta D, Gastaldi M. Visual System Involvement in Glial Fibrillary Acidic Protein Astrocytopathy: Two Case Reports and a Systematic Literature Review. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200146. [PMID: 37582612 PMCID: PMC10427126 DOI: 10.1212/nxi.0000000000200146] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/27/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND AND OBJECTIVES Glial fibrillary acidic protein (GFAP) antibodies can associate with an astrocytopathy often presenting as a meningoencephalitis. Visual involvement has been reported but scarcely defined. We describe 2 cases of GFAP astrocytopathy with predominant visual symptoms and present a systematic review of the literature. METHODS We describe 2 patients with GFAP astrocytopathy from our neurology department. We performed a systematic review of the literature according to PRISMA guidelines, including all patients with this disease and available clinical data, focusing on visual involvement. RESULTS Patient 1 presented with bilateral optic disc edema and severe sudden bilateral loss of vision poorly responsive to therapy. Patient 2 showed bilateral optic disc edema, headache, and mild visual loss with complete recovery after steroids. We screened 275 records and included 84 articles (62 case reports and 22 case series) for a total of 592 patients. Visual involvement was reported in 149/592 (25%), with either clinical symptoms or paraclinical test-restricted abnormalities. Bilateral optic disc edema was found in 80/159 (50%) of patients investigated with fundoscopy, among which 49/80 (61%) were asymptomatic. One hundred (100/592, 17%) reported visual symptoms, often described as blurred vision or transient visual obscurations. Optic neuritis was rare and diagnosed in only 6% of all patients with GFAP astrocytopathy, often without consistent clinical and paraclinical evidence to support the diagnosis. Four patients (including patient 1) manifested a severe, bilateral optic neuritis with poor treatment response. In patients with follow-up information, a relapsing disease course was more frequently observed in those with vs without visual involvement (35% vs 11%, p = 0.0035, OR 3.6 [CI 1.44-8.88]). DISCUSSION Visual system involvement in GFAP astrocytopathy is common and heterogeneous, ranging from asymptomatic bilateral optic disc edema to severe bilateral loss of vision, but optic neuritis is rare. GFAP CSF antibody testing should be considered in patients with encephalitis/meningoencephalitis or myelitis and bilateral optic disc edema, even without visual symptoms, and in patients with severe bilateral optic neuritis, especially when AQP4 antibodies are negative. Visual symptoms might associate with a higher relapse risk and help to identify patients who may require chronic immunosuppression.
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Affiliation(s)
- Giacomo Greco
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Stefano Masciocchi
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Luca Diamanti
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Paola Bini
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Elisa Vegezzi
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Enrico Marchioni
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Elena Colombo
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Eleonora Rigoni
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Pietro Businaro
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Ottavia E Ferraro
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Stefania Bianchi Marzoli
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Roberto Bergamaschi
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Diego Franciotta
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Matteo Gastaldi
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy.
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Liu D, Lin PH, Li HL, Yang J, You Y, Yang X, Jiang LH, Ma CY, Xu LF, Zhang QX, Liao S, Chen H, Yue JJ, Lu YY, Lian C, Liu Y, Wang ZH, Ye JL, Qiu W, Shu YQ, Wang HY, Liu HL, Wang Y, Duan CM, Yang H, Wu XL, Zhang L, Feng HY, Chen H, Zhou HS, Xu QH, Zhao GX, Ou TF, Wang JL, Lu YH, Mao ZF, Gao C, Guo J, Zhang HY, Chen S, Li J, Long YM. Early autoimmunity and outcome in virus encephalitis: a retrospective study based on tissue-based assay. J Neurol Neurosurg Psychiatry 2023; 94:605-613. [PMID: 37225405 PMCID: PMC10359542 DOI: 10.1136/jnnp-2022-330626] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 02/28/2023] [Indexed: 05/26/2023]
Abstract
To explore the autoimmune response and outcome in the central nervous system (CNS) at the onset of viral infection and correlation between autoantibodies and viruses. METHODS A retrospective observational study was conducted in 121 patients (2016-2021) with a CNS viral infection confirmed via cerebrospinal fluid (CSF) next-generation sequencing (cohort A). Their clinical information was analysed and CSF samples were screened for autoantibodies against monkey cerebellum by tissue-based assay. In situ hybridisation was used to detect Epstein-Barr virus (EBV) in brain tissue of 8 patients with glial fibrillar acidic protein (GFAP)-IgG and nasopharyngeal carcinoma tissue of 2 patients with GFAP-IgG as control (cohort B). RESULTS Among cohort A (male:female=79:42; median age: 42 (14-78) years old), 61 (50.4%) participants had detectable autoantibodies in CSF. Compared with other viruses, EBV increased the odds of having GFAP-IgG (OR 18.22, 95% CI 6.54 to 50.77, p<0.001). In cohort B, EBV was found in the brain tissue from two of eight (25.0%) patients with GFAP-IgG. Autoantibody-positive patients had a higher CSF protein level (median: 1126.00 (281.00-5352.00) vs 700.00 (76.70-2899.00), p<0.001), lower CSF chloride level (mean: 119.80±6.24 vs 122.84±5.26, p=0.005), lower ratios of CSF-glucose/serum-glucose (median: 0.50[0.13-0.94] vs 0.60[0.26-1.23], p=0.003), more meningitis (26/61 (42.6%) vs 12/60 (20.0%), p=0.007) and higher follow-up modified Rankin Scale scores (1 (0-6) vs 0 (0-3), p=0.037) compared with antibody-negative patients. A Kaplan-Meier analysis revealed that autoantibody-positive patients experienced significantly worse outcomes (p=0.031). CONCLUSIONS Autoimmune responses are found at the onset of viral encephalitis. EBV in the CNS increases the risk for autoimmunity to GFAP.
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Affiliation(s)
- Ding Liu
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Pei-Hao Lin
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Hui-Lu Li
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jie Yang
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yong You
- Department of Neurology, The Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan, China
| | - Xiao Yang
- Department of Neurology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Li-Hong Jiang
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Cai-Yu Ma
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Lu-Fen Xu
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Qing-Xia Zhang
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Sha Liao
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Han Chen
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jia-Jia Yue
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yu-Ying Lu
- Key Laboratory of Microbial Molecular Biology of Hunan Province, Hunan Provincial Center for Disease Control and Prevention, Changsha, Hunan, China
| | - Chun Lian
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yin Liu
- Department of Radiology, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Zhan-Hang Wang
- Department of Neurology, Guangdong 999 Brain Hospital, Guangzhou, Guangdong, China
| | - Jin-Long Ye
- Department of Neurology, Guangdong 999 Brain Hospital, Guangzhou, Guangdong, China
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Ya-Qing Shu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Hai-Yang Wang
- Department of Neurology, Jining No. 1 People's Hospital, Jining, China
| | - Hong-Li Liu
- Department of Neurology, First Hospital of Qinhuangdao, Qinhuangdao, Hebei, China
| | - Yue Wang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Chun-Mei Duan
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Xiu-Ling Wu
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, Hebei, China
| | - Lu Zhang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Hui-Yu Feng
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Huan Chen
- Department of Neurology, Shantou Central Hospital, Shantou, Guangdong, China
| | - Hou-Shi Zhou
- Department of Neurology, Shantou Central Hospital, Shantou, Guangdong, China
| | - Qian-Hui Xu
- Department of Neurology, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Gui-Xian Zhao
- Department of Neurology, Huashan Hospital of Fudan University, Shanghai, China
| | - Teng-Fei Ou
- Department of Neurology, The Second People's Hospital of Foshan, Foshan, Guangdong, China
| | - Jin-Liang Wang
- Department of Neurology, The Second People's Hospital of Foshan, Foshan, Guangdong, China
| | - Yu-Hua Lu
- Department of Neurology, People's Hospital of Chongqing Banan District, Chongqing, China
| | - Zhi-Feng Mao
- Neurimmunology Group, Institution of Kingmed, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Cong Gao
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jun Guo
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Hong-Ya Zhang
- Department of Neurology, Shenzhen University General Hospital, Shenzhen, Guangdong, China
| | - Sheng Chen
- Department of Neurology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jing Li
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - You-Ming Long
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
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Cheng W, He L, Luo H, Jiang Y, Tan C, Fan X. Magnetic Resonance Imaging Characteristics of Autoimmune Glial Fibrillary Acidic Protein (GFAP) Astrocytopathy: A Pediatric Series in Southwest China. Neuropsychiatr Dis Treat 2023; 19:1685-1693. [PMID: 37538100 PMCID: PMC10395509 DOI: 10.2147/ndt.s417492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 07/24/2023] [Indexed: 08/05/2023] Open
Abstract
Objective To investigate and summarize the magnetic resonance imaging (MRI) manifestations of autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy in children. Methods We retrospectively analyzed data from 17 pediatric patients with autoimmune GFAP astrocytopathy confirmed by the detection of GFAP autoantibodies in cerebrospinal fluid in our single-center. Furthermore, we reviewed current literature and summarized previous findings on the MRI characteristics of this disease in children. Results In these 17 patients, the clinical manifestations and results of CSF analysis were suggestive of autoimmune disorder, with a good improvement. The lesions on MRI were most commonly located in the bilateral basal ganglia (70.6%), thalamus (64.7%), cerebral white matter (29.4%). 93.3% of the cerebral lesions were relatively scattered and small, 80% of the spinal lesions presented as longitudinally extensive ones. Both periventricular radial linear (PVRL) (53.8%) and punctate or linear enhancement in basal ganglia and thalamus (53.8%) were commonly observed, followed by the leptomeningeal enhancement (46.2% in the brain and 62.5% in the spinal cord). We then included 55 pediatric patients with MRI data from current literature in our analysis (n = 72, 44 males). Our results revealed similar MRI findings but the enhancement pattern between our series and previously published cases, that is, leptomeningeal enhancement in the brain 46.2% vs 31.4%, in spinal cord 62.5% vs 18.4%, and PVRL enhancement 53.8% vs 11.2%. There were no detailed reports on punctate or linear enhancement. Conclusion The MRI characteristics of autoimmune GFAP astrocytopathy in children could be suggestive. Scattered and small lesions (especially punctate or linear) in the bilateral thalamus, basal ganglia, and white matter, as well as longitudinally extensive spinal cord lesions (if present), with punctate, PVRL and leptomeningeal enhancement might be a distinct indication for the early diagnosis of this disorder.
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Affiliation(s)
- Weiqin Cheng
- Department of Radiology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People’s Republic of China
| | - Ling He
- Department of Radiology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People’s Republic of China
| | - Hechuan Luo
- Department of Radiology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People’s Republic of China
| | - Yan Jiang
- Department of Neurology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People’s Republic of China
| | - Chengbing Tan
- Department of Neurology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People’s Republic of China
| | - Xiao Fan
- Department of Radiology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People’s Republic of China
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Schulz P, Lütt A, Stöcker W, Teegen B, Holtkamp M, Prüss H. High frequency of cerebrospinal fluid autoantibodies in patients with seizures or epilepsies of unknown etiology. Front Neurol 2023; 14:1211812. [PMID: 37475738 PMCID: PMC10356105 DOI: 10.3389/fneur.2023.1211812] [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: 04/25/2023] [Accepted: 06/09/2023] [Indexed: 07/22/2023] Open
Abstract
Introduction The increasing identification of specific autoantibodies against brain structures allows further refinement of the group of autoimmune-associated epilepsies and affects diagnostic and therapeutic algorithms. The early etiological allocation of a first seizure is particularly challenging, and the contribution of cerebrospinal fluid (CSF) analysis is not fully understood. Methods In this retrospective study with a mean of 7.8 years follow-up involving 39 well-characterized patients with the initial diagnosis of new-onset seizure or epilepsy of unknown etiology and 24 controls, we determined the frequency of autoantibodies to brain proteins in CSF/serum pairs using cell-based assays and unbiased immunofluorescence staining of unfixed murine brain sections. Results Autoantibodies were detected in the CSF of 30.8% of patients. Underlying antigens involved glial fibrillary acidic protein (GFAP) and N-methyl-D-aspartate (NMDA) receptors, but also a range of yet undetermined epitopes on neurons, glial and vascular cells. While antibody-positive patients had higher frequencies of cancer, they did not differ from antibody-negative patients with respect to seizure type, electroencephalography (EEG) and cranial magnetic resonance imaging (cMRI) findings, neuropsychiatric comorbidities or pre-existing autoimmune diseases. In 5.1% of patients with seizures or epilepsy of initially presumed unknown etiology, mostly CSF findings resulted in etiological reallocation as autoimmune-associated epilepy. Discussion These findings strengthen the potential role for routine CSF analysis. Further studies are needed to understand the autoantibody contribution to etiologically unclear epilepsies, including determining the antigenic targets of underlying autoantibodies.
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Affiliation(s)
- Paulina Schulz
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
| | - Alva Lütt
- Psychiatric University Hospital Charité at St. Hedwig Hospital, Berlin, Germany
- Department of Psychiatry and Neurosciences, CCM, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Berlin, Germany
| | | | - Bianca Teegen
- Institute for Experimental Immunology, Lübeck, Germany
| | - Martin Holtkamp
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
- Epilepsy-Center Berlin-Brandenburg, Institute for Diagnostics of Epilepsy, Berlin, Germany
| | - Harald Prüss
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, Berlin, Germany
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Zhang W, Xie Y, Wang Y, Liu F, Wang L, Lian Y, Liu H, Wang C, Xie N. Clinical characteristics and prognostic factors for short-term outcomes of autoimmune glial fibrillary acidic protein astrocytopathy: a retrospective analysis of 33 patients. Front Immunol 2023; 14:1136955. [PMID: 37350972 PMCID: PMC10282742 DOI: 10.3389/fimmu.2023.1136955] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/23/2023] [Indexed: 06/24/2023] Open
Abstract
Background Autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A) is a recently discovered inflammatory central nervous system (CNS) disease, whose clinical characteristics and prognostic factors for short-term outcomes have not been defined yet. We aimed to assess the symptoms, laboratory tests, imaging findings, treatment, and short-term prognosis of GFAP-A. Methods A double-center retrospective cohort study was performed between May 2018 and July 2022. The clinical characteristics and prognostic factors for short-term outcomes were determined. Results We enrolled 33 patients with a median age of 28 years (range: 2-68 years), 15 of whom were children (<18 years). The clinical spectrum is dominated by meningoencephalomyelitis. Besides, we also found nausea, vomiting, poor appetite, and neuropathic pain in some GFAP-A patients, which were not mentioned in previous reports. And adults were more prone to limb numbness than children. Magnetic resonance imaging revealed lesions involving the brain parenchyma, meninges, and spinal cord, exhibiting patchy, linear, punctate, and strip T2 hyperintensities. First-line immunotherapy, including corticosteroid and gamma globulin, was effective in most patients in the acute phase (P = 0.02). However, patients with overlapping AQP4 antibodies did not respond well to first-line immunotherapy and coexisting neural autoantibodies were more common in women. Additionally, the short-term prognosis was significantly better in children than in adults (P = 0.04). Positive non-neural autoantibodies and proven viral infection were independent factors associated with poor outcomes (P = 0.03, 0.02, respectively). Conclusion We expanded the spectrum of clinical symptoms of autoimmune GFAP-A. The clinical symptoms and short-term prognosis differed between children and adults. Positive non-neural autoantibodies and proven viral infection at admission suggest a poor short-term prognosis.
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Affiliation(s)
- Wanwan Zhang
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yinyin Xie
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yali Wang
- Department of Neurology, Henan Children’s Hospital, Zhengzhou, China
| | - Fengxia Liu
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Li Wang
- Department of Neurology, Henan Children’s Hospital, Zhengzhou, China
| | - Yajun Lian
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongbo Liu
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Cui Wang
- Department of Clinical Laboratory, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Nanchang Xie
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Lin J, Dong L, Yu L, Huang J. Autoimmune glial fibrillary acidic protein astrocytopathy coexistent with reversible splenial lesion syndrome: A case report and literature review. Front Neurol 2023; 14:1192118. [PMID: 37305765 PMCID: PMC10249068 DOI: 10.3389/fneur.2023.1192118] [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: 03/23/2023] [Accepted: 05/03/2023] [Indexed: 06/13/2023] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a rare autoimmune disorder. Reversible splenial lesion syndrome (RESLES) is a transient clinical-imaging syndrome characterized by specific magnetic resonance imaging (MRI) pattern. A 58-year-old man was admitted with a fever, headache, and confusion for 1 week. Brain MRI showed abnormal leptomeningeal enhancement in the brainstem and high signal intensity on diffusion-weighted MRI of the corpus callosum. Anti-GFAP antibody was positive in the serum and cerebrospinal fluid analysis. This patient significantly improved and had no relapse after glucocorticoid and immune suppressant therapy. A repeated brain MRI revealed the lesion in the corpus callosum and abnormal leptomeningeal enhancement in the brainstem disappeared. Linear perivascular radial enhancement is the characteristic pattern of autoimmune GFAP astrocytopathy which is rarely coexistent with RESLES.
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Yaguchi T, Kimura A, Takekoshi A, Matsuo M, Tomita H, Shimohata T. Autoimmune glial fibrillary acidic protein astrocytopathy associated with breast cancer: a case report. BMC Neurol 2023; 23:145. [PMID: 37016352 PMCID: PMC10071775 DOI: 10.1186/s12883-023-03194-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 03/30/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy (GFAP-A) is an autoimmune inflammatory central nervous system disorder characterized by the detection of autoantibodies that recognize GFAP in CSF. The pathogenesis of GFAP-A is poorly understood. Some patients had a neoplasm detected and GFAP expressed by neoplasms is plausible as immunogen triggering paraneoplastic neurological autoimmunity. CASE PRESENTATION We report a case of 76-year-old female patient with GFAP-A complicated with breast cancer. She presented with altered consciousness, nuchal rigidity, speech disturbances, and weakness. Her clinical symptoms were improved by immunotherapy and cancer treatments. Immunohistochemical analysis showed that the restricted tumor expressed GFAP. The infiltration of CD3 + T cells were observed in the peritumoral and intratumoral areas. The most common infiltrating lymphocytes were CD8 + T cells. CD4 + T cells and CD20 + B cells were also observed in the predominant peritumoral area. CONCLUSIONS These results suggest that GFAP-A may occur in a paraneoplastic neurological syndrome associated with breast cancer.
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Affiliation(s)
- Tomonori Yaguchi
- Department of Neurology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Akira Takekoshi
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Mikiko Matsuo
- Department of Tumor Pathology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hiroyuki Tomita
- Department of Tumor Pathology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan.
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Ali SB, Cecchin A, Burfoot R, Field D, Ravindran J, Pucar PA, Banovic T. Glial fibrillary acidic protein antibodies: a spectacular neuronal immunofluorescence pattern with important clinical implications. Pathology 2023; 55:405-407. [PMID: 36041890 DOI: 10.1016/j.pathol.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/25/2022] [Accepted: 06/01/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Syed Basharat Ali
- Department of Immunopathology, SA Pathology, Adelaide, SA, Australia; Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Amelia Cecchin
- Department of Immunopathology, SA Pathology, Adelaide, SA, Australia
| | - Rebecca Burfoot
- Department of Immunopathology, SA Pathology, Adelaide, SA, Australia
| | - Deborah Field
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Janakan Ravindran
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Phillippa A Pucar
- Department of Immunopathology, SA Pathology, Adelaide, SA, Australia; Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Tatjana Banovic
- Department of Immunopathology, SA Pathology, Adelaide, SA, Australia; Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, SA, Australia; Department of Immunology, Flinders University, Bedford Park, SA, Australia.
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Qin N, Wu X, Wang J, Wang W, Wang X, Ma Y, Wang L. Case report: Autoimmune glial fibrillary acidic protein astrocytopathy misdiagnosed as tuberculous meningitis. Front Neurol 2023; 14:1123603. [PMID: 36970528 PMCID: PMC10034075 DOI: 10.3389/fneur.2023.1123603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/13/2023] [Indexed: 03/11/2023] Open
Abstract
IntroductionAutoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a new form of autoimmunity-mediated central nervous system disease. It is especially easy to misdiagnose when clinical symptoms and cerebrospinal fluid (CSF) indicators are similar to those observed in patients with tuberculous meningitis (TBM).MethodsWe retrospectively analyzed five cases of autoimmune GFAP astrocytopathy that were initially misdiagnosed as TBM.ResultsIn the five reported cases, all but one patient had meningoencephalitis in the clinic, and all patients exhibited increased pressure, lymphocytosis, increased protein levels, and decreased glucose levels in their CSF results and did not have typical imaging findings of autoimmune GFAP astrocytopathy. TBM was the initial diagnosis in all five patients. However, we found no direct evidence of tuberculosis infection, and anti-tuberculosis treatment had inconclusive effects. Following a GFAP antibody test, the diagnosis of autoimmune GFAP astrocytopathy was made.ConclusionWhen there is a suspected diagnosis of TBM but TB-related tests are negative, the possibility of autoimmune GFAP astrocytopathy should be considered.
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Salari M, Etemadifar M, Soleymani R, Murgai AA, Rashedi R. A case of glial fibrillary acidotic protein (GFAP) meningoencephalitis with rheumatoid arthritis. Clin Case Rep 2023; 11:e7038. [PMID: 36879678 PMCID: PMC9984675 DOI: 10.1002/ccr3.7038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/12/2022] [Accepted: 02/12/2023] [Indexed: 03/06/2023] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is an inflammatory disease of the central nervous system (CNS), which affects various regions in the CNS, presenting by variable clinical manifestations. Meningoencephalitis is the most common clinical presentation and association with autoimmune disorders has been reported in about 20% of these patients. Diagnosis is confirmed by the presence of CSF or serum immunoglobulin-G (IgG) against GFAP. The reported case is a 53-year-old woman with the history of long-standing rheumatoid arthritis who first presented with acute-onset dizziness and gait disturbance, periventricular linear and radial enhancement pattern on MRI, and normal CSF analysis, successfully treated with an increase in the dose of oral steroids. After a year she had a subacute-onset, moderate to severe holocephalic headache, normal neurologic examination and CSF analysis, and bilateral diffuse, pachymeningeal, and leptomeningeal enhancement on MRI. According to her Brain MRI imaging with relapsing remitting course steroid responsive ataxia and aseptic meningitis, her serum was tested for GFAP IgG antibodies which was positive. The reported patient is the first in the literature reported pachymeningitis in GFAP astrocytopathy. This case highlights the co-occurrence of rheumatoid arthritis with GFAP-associated astrocytopathy, and expands on the previously reported cases with similar association. This might also suggest a common immune pathogenesis.
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Affiliation(s)
- Mehri Salari
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellence Shahid Beheshti University of medical Sciences Tehran Iran
| | - Masoud Etemadifar
- Department of Functional Neurosurgery, Medical School Isfahan University of Medical Sciences Isfahan Iran
| | - Reyhaneh Soleymani
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellence Shahid Beheshti University of medical Sciences Tehran Iran
| | | | - Ronak Rashedi
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellence Shahid Beheshti University of medical Sciences Tehran Iran
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Liang X, Shen Y. Area postrema syndrome with linear enhancement along the surface of the brainstem and fourth ventricle in autoimmune GFAP astrocytopathy. BMC Neurol 2023; 23:78. [PMID: 36805663 PMCID: PMC9940409 DOI: 10.1186/s12883-023-03126-5] [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: 05/21/2022] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Glial fibrillary acidic protein (GFAP) astrocytopathy, a novel autoimmune disease of the nervous system, was first defined in 2016. To our knowledge, area postrema syndrome (APS) with linear enhancement along the surface of the brainstem and fourth ventricle is extremely rare in this disorder. CASE PRESENTATION A Chinese woman presented with intractable nausea and vomiting after onset of flu-like symptoms. Brain magnetic resonance imaging (MRI) disclosed abnormal signal intensities in the dorsal medulla oblongata including area postrema. Besides, linear enhancement surrounding the surface of the brainstem and fourth ventricle was visualized after gadolinium injection. Cerebrospinal fluid (CSF) analysis showed increased cell count and protein. A cell-based assay was positive for anti-GFAP IgG in CSF. She was diagnosed with autoimmune GFAP astrocytopathy and treated with high-dose glucocorticoid. The patient received a quick recovery with entire resolution of the initial abnormalities. CONCLUSIONS Isolated APS can be the initial manifestation of autoimmune GFAP astrocytopathy. Linear enhancement surrounding the surface of the brainstem and fourth ventricle is another neuroradiological hallmark.
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Affiliation(s)
- Xinming Liang
- Department of Neurology, Nanyang Central Hospital, Nanyang, Henan Province China
| | - Yaoyao Shen
- Department of Neurology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, No. 92 Aiguo Road, Donghu District, Nanchang, 330006, Jiangxi Province, China.
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Etemadifar M, Fereidan-Esfahani M, Sedaghat N, Kargaran PK, Mansouri AR, Abhari AP, Aghababaei A, Jannesari A, Salari M, Ganjalikhani-Hakemi M, Nouri H. Non-infectious meningitis and CNS demyelinating diseases: A conceptual review. Rev Neurol (Paris) 2023:S0035-3787(23)00756-7. [PMID: 36781321 DOI: 10.1016/j.neurol.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 09/11/2022] [Accepted: 10/17/2022] [Indexed: 02/13/2023]
Abstract
Many cases of aseptic meningitis or meningoencephalitis, unresponsive to antimicrobial treatments, have been reported recently in patients with established/new-onset central nervous system (CNS) inflammatory demyelinating diseases (CNSIDDs). Given the higher probability of infectious etiologies, CNSIDDs are rarely considered among the differentials in meningitis or meningoencephalitis cases. We gathered and tabulated cases of non-infectious, steroid-responsive meningitis or meningoencephalitis associated with neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein-associated disease (MOGAD). This conceptual review highlights the need to bolster routine infectious workups with immunological workups in cases of meningoencephalitis or meningitis where potential autoimmune etiologies can be suspected. Although differentiating CNSIDDs with meningeal involvement from infectious meningitis may not substantially affect acute treatment strategies, long-term management and follow-up of the two are entirely different. We also discuss future research directions and hypotheses on how CNSIDDs may be associated with meningitis-like presentations, e.g. overlapping glial fibrillary acidic protein astrocytopathy or autoimmune encephalitis, alterations in regulatory T-helper cells function, and undetected viral agents.
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Affiliation(s)
- M Etemadifar
- Department of Neurosurgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - M Fereidan-Esfahani
- Department of Neurology, Mayo Clinic Rochester, Rochester, MN, USA; Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic Rochester, Rochester, MN, USA
| | - N Sedaghat
- Alzahra Research Institute, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran; Network of Immunity in Infection, Malignancy, and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Isfahan, Iran
| | - P K Kargaran
- Department of Cardiovascular Medicine, Center for Regenerative Medicine, Mayo Clinic, Rochester, Rochester, MN, USA
| | - A R Mansouri
- Alzahra Research Institute, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - A P Abhari
- Alzahra Research Institute, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran; Network of Immunity in Infection, Malignancy, and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Isfahan, Iran
| | - A Aghababaei
- Alzahra Research Institute, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - A Jannesari
- Alzahra Research Institute, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - M Salari
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M Ganjalikhani-Hakemi
- Department of Immunology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - H Nouri
- Alzahra Research Institute, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran; Network of Immunity in Infection, Malignancy, and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Isfahan, Iran.
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Datyner E, Adeseye V, Porter K, Dryden I, Sarma A, Vu N, Patrick AE, Paueksakon P. Small vessel childhood primary angiitis of the central nervous system with positive anti-glial fibrillary acidic protein antibodies: a case report and review of literature. BMC Neurol 2023; 23:57. [PMID: 36737749 PMCID: PMC9895965 DOI: 10.1186/s12883-023-03093-x] [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: 11/10/2021] [Accepted: 01/25/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Small vessel childhood primary angiitis of the central nervous system (SV-cPACNS) is a rare disease characterized by inflammation within small vessels such as arterioles or capillaries. CASE PRESENTATION We report a case of SV-cPACNS in an 8-year-old boy confirmed by brain biopsy. This patient was also incidentally found to have anti-glial fibrillary acidic protein (GFAP) antibodies in the cerebrospinal fluid (CSF) but had no evidence of antibody-mediated disease on brain biopsy. A literature review highlighted the rarity of SV-cPACNS and found no prior reports of CSF GFAP-associated SV-cPACNS in the pediatric age group. CONCLUSION We present the first case of biopsy proven SV-cPACNS vasculitis associated with an incidental finding of CSF GFAP antibodies. The GFAP antibodies are likely a clinically insignificant bystander in this case and possibly in other diseases with CNS inflammation. Further research is needed to determine the clinical significance of newer CSF autoantibodies such as anti-GFAP before they are used for medical decision-making in pediatrics.
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Affiliation(s)
- E Datyner
- grid.412807.80000 0004 1936 9916Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN USA
| | - V Adeseye
- grid.412807.80000 0004 1936 9916Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN USA
| | - K Porter
- grid.152326.10000 0001 2264 7217Vanderbilt University, Nashville, TN USA
| | - I Dryden
- grid.412807.80000 0004 1936 9916Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 1161 21St Avenue South, Nashville, TN MCN C2318B37232-2561 USA
| | - A Sarma
- grid.412807.80000 0004 1936 9916Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN USA
| | - N Vu
- grid.412807.80000 0004 1936 9916Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN USA
| | - AE Patrick
- grid.412807.80000 0004 1936 9916Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN USA
| | - P Paueksakon
- grid.412807.80000 0004 1936 9916Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 1161 21St Avenue South, Nashville, TN MCN C2318B37232-2561 USA
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Wen PY, Wang GQ, Dou LW, Chen Q, Chen XW, Gong L. A case report of autoimmune GFAP astrocytopathy presenting with abnormal heart rate variability and blood pressure variability. BMC Neurol 2023; 23:24. [PMID: 36647033 PMCID: PMC9843977 DOI: 10.1186/s12883-023-03070-4] [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: 05/03/2022] [Accepted: 01/10/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Autonomic dysfunctions including bladder dysfunction, gastrointestinal dysfunction and orthostasis are common symptoms of autoimmune glial fibrillary acidic protein astrocytopathy (A-GFAP-A); however, cardiac autonomic dysfunction and abnormal circadian rhythm of blood pressure, which can lead to poor prognosis and even sudden cardiac death, has never been reported in A-GFAP-A patient. CASE PRESENTATION A 68-year-old male Chinese patient presented to our hospital with headache, fever, progressive disturbance of consciousness, dysuria, and limb weakness. Abnormal heart rate variability and non-dipper circadian rhythm of blood pressure gradually developed during hospitalization, which is rare in A-GFAP-A. He had positive GFAP IgG in cerebrospinal fluid (CSF). Enhanced brian MRI showed uneven enhancement and T2 hyperintense lesions of medulla oblongata; Cervical spine MRI showed T2 hyperintense lesions in medulla oblongata and upper margin of the T2 vertebral body. A contrast-enhanced thoracic spine MRI showed uneven enhancement and T2 hyperintense lesions of T1 to T6 vertebral segments. After treatment with intravenous immunoglobulin and corticosteroids, the patient's symptoms, including autonomic dysfunction, alleviated dramatically. Finally, his heart rate variability and blood pressure variability became normal. CONCLUSIONS Our case broadens the spectrum of expected symptoms in A-GFAP- A syndromes as it presented with heart rate variability and blood pressure variability.
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Affiliation(s)
- Pu-yuan Wen
- grid.412679.f0000 0004 1771 3402Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China ,grid.440323.20000 0004 1757 3171Department of Neurology, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong China
| | - Guang-qiang Wang
- grid.440323.20000 0004 1757 3171Department of Cardiology, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong China
| | - Lian-wei Dou
- grid.440323.20000 0004 1757 3171Department of Neurology, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong China
| | - Qi Chen
- grid.440323.20000 0004 1757 3171Department of Neurology, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong China
| | - Xian-wen Chen
- grid.412679.f0000 0004 1771 3402Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Li Gong
- grid.440323.20000 0004 1757 3171Department of Neurology, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong China
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[Clinical features of autoimmune glial fibrillary acidic protein astrocytopathy in children: an analysis of 34 cases]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:67-72. [PMID: 36655666 PMCID: PMC9893831 DOI: 10.7499/j.issn.1008-8830.2208105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To study the clinical features of children with autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A). METHODS A retrospective analysis was performed on the medical data of 34 children with GFAP-A who attended the Department of Neurology, Children's Hospital of Chongqing Medical University, from January 2020 to February 2022. The medical data included clinical manifestations, cerebrospinal fluid features, imaging examination results, treatment, and prognosis. RESULTS The median age of onset was 8.4 (range 1.9-14.9) years for the 34 children with GFAP-A. The main clinical manifestations included headache (50%, 17/34), fever (47%, 16/34), visual impairment (47%, 16/34), and disturbance of consciousness (44%, 15/34). Abnormal cerebrospinal fluid results were observed in 19 children (56%, 19/34), among whom 8 children had positive autoantibody. The children with overlap syndrome had significantly higher recurrence rate and rate of use of immunosuppressant than those without overlap syndrome (P<0.05). About 77% (24/31) of the children had good response to immunotherapy, and only 1 child had poor prognosis. CONCLUSIONS Children with GFAP-A often have non-specific clinical symptoms and show good response to immunotherapy. Children with overlap syndrome have a high recurrence rate, and early application of immunosuppressants may help to prevent recurrence and alleviate symptoms.
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Liang C, Chu E, Kuoy E, Soun JE. Autoimmune-mediated encephalitis and mimics: A neuroimaging review. J Neuroimaging 2023; 33:19-34. [PMID: 36217010 DOI: 10.1111/jon.13060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/10/2022] [Accepted: 09/20/2022] [Indexed: 02/01/2023] Open
Abstract
Autoimmune encephalitis is a category of autoantibody-mediated neurological disorders that often presents a diagnostic challenge due to its variable clinical and imaging findings. The purpose of this image-based review is to provide an overview of the major subtypes of autoimmune encephalitis and their associated autoantibodies, discuss their characteristic clinical and imaging features, and highlight several disease processes that may mimic imaging findings of autoimmune encephalitis. A literature search on autoimmune encephalitis was performed and publications from neuroradiology, neurology, and nuclear medicine literature were included. Cases from our institutional database that best exemplify major imaging features were presented.
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Affiliation(s)
- Conan Liang
- Department of Radiological Sciences, University of California, Irvine Medical Center, Orange, California, USA
| | - Eleanor Chu
- Department of Radiological Sciences, University of California, Irvine Medical Center, Orange, California, USA
| | - Edward Kuoy
- Department of Radiological Sciences, University of California, Irvine Medical Center, Orange, California, USA
| | - Jennifer E Soun
- Department of Radiological Sciences, University of California, Irvine Medical Center, Orange, California, USA
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Fortunato F, Giugno A, Sammarra I, Labate A, Gambardella A. Epilepsy, Immunity and Neuropsychiatric Disorders. Curr Neuropharmacol 2023; 21:1714-1735. [PMID: 35794773 PMCID: PMC10514543 DOI: 10.2174/1570159x20666220706094651] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/03/2022] [Accepted: 06/13/2022] [Indexed: 11/22/2022] Open
Abstract
Several studies have focused on the emerging role of immunity and inflammation in a wide range of neurological disorders. Autoimmune diseases involving central nervous system share well defined clinical features including epileptic seizures and additional neuropsychiatric symptoms, like cognitive and psychiatric disturbances. The growing evidence about the role of immunity in the pathophysiologic mechanisms underlying these conditions lead to the concept of autoimmune epilepsy. This relatively-new term has been introduced to highlight the etiological and prognostic implications of immunity in epileptogenesis. In this review, we aim to discuss the role of autoimmunity in epileptogenesis and its clinical, neurophysiological, neuroimaging and therapeutic implications. Moreover, we wish to address the close relationship between immunity and additional symptoms, particularly cognitive and psychiatric features, which deeply impact clinical outcomes in these patients. To assess these aspects, we first analyzed Rasmussen's encephalitis. Subsequently, we have covered autoimmune encephalitis, particularly those associated with autoantibodies against surface neuronal antigens, as these autoantibodies express a direct immune-mediated mechanism, different from those against intracellular antigens. Then, we discussed the connection between systemic immune disorders and neurological manifestations. This review aims to highlight the need to expand knowledge about the role of inflammation and autoimmunity in the pathophysiology of neurological disorders and the importance to early recognize these clinical entities. Indeed, early identification may result in faster recovery and a better prognosis.
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Affiliation(s)
- Francesco Fortunato
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
| | - Alessia Giugno
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
| | - Ilaria Sammarra
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
| | - Angelo Labate
- BIOMORF Department, Neurology Unit, University of Messina, Messina, Italy
| | - Antonio Gambardella
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
- Institute of Molecular Bioimaging and Physiology, National Research Council, I-88100 Catanzaro, Italy
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Gaig C, Graus F. Motor symptoms in nonparaneoplastic CNS disorders associated with neural antibodies. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:277-294. [PMID: 37620074 DOI: 10.1016/b978-0-323-98817-9.00004-1] [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: 08/26/2023]
Abstract
Motor symptoms are common, and sometimes predominant, in almost all nonparaneoplastic CNS disorders associated with neural antibodies. These CNS disorders can be classified into five groups: (1) Autoimmune encephalitis with antibodies against synaptic receptors, (2) cerebellar ataxias associated with neuronal antibodies that mostly target intracellular antigens. (3) Stiff-person syndrome and progressive encephalomyelitis with rigidity and myoclonus which have antibodies against glutamic acid decarboxylase and glycine receptor, respectively. Both diseases have in common the presence of predominant muscle stiffness and rigidity. (4) Three diseases associated with glial antibodies. Two present motor symptoms mainly due to the involvement of the spinal cord: neuromyelitis optica spectrum disorders with aquaporin-4 antibodies and myelin oligodendrocyte glycoprotein antibody-associated disease. The third disorder is the meningoencephalitis associated with glial fibrillar acidic protein antibodies which frequently also presents a myelopathy. (5) Two antibody-related diseases which are characterized by prominent sleep dysfunction: anti-IgLON5 disease, a disorder that frequently presents a variety of movement disorders, and Morvan syndrome associated with contactin-associated protein-like 2 antibodies and clinical manifestations of peripheral nerve hyperexcitability. In this chapter, we describe the main clinical features of these five groups with particular emphasis on the presence, frequency, and types of motor symptoms.
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Affiliation(s)
- Carles Gaig
- Neurology Service, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Francesc Graus
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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Novoa C, Salazar P, Cisternas P, Gherardelli C, Vera-Salazar R, Zolezzi JM, Inestrosa NC. Inflammation context in Alzheimer's disease, a relationship intricate to define. Biol Res 2022; 55:39. [PMID: 36550479 PMCID: PMC9784299 DOI: 10.1186/s40659-022-00404-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 11/15/2022] [Indexed: 12/24/2022] Open
Abstract
Alzheimer's disease (AD), the most common form of dementia, is characterized by the accumulation of amyloid β (Aβ) and hyperphosphorylated tau protein aggregates. Importantly, Aβ and tau species are able to activate astrocytes and microglia, which release several proinflammatory cytokines, such as tumor necrosis factor α (TNF-α) and interleukin 1β (IL-1β), together with reactive oxygen (ROS) and nitrogen species (RNS), triggering neuroinflammation. However, this inflammatory response has a dual function: it can play a protective role by increasing Aβ degradation and clearance, but it can also contribute to Aβ and tau overproduction and induce neurodegeneration and synaptic loss. Due to the significant role of inflammation in the pathogenesis of AD, several inflammatory mediators have been proposed as AD markers, such as TNF-α, IL-1β, Iba-1, GFAP, NF-κB, TLR2, and MHCII. Importantly, the use of anti-inflammatory drugs such as NSAIDs has emerged as a potential treatment against AD. Moreover, diseases related to systemic or local inflammation, including infections, cerebrovascular accidents, and obesity, have been proposed as risk factors for the development of AD. In the following review, we focus on key inflammatory processes associated with AD pathogenesis.
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Affiliation(s)
- Catalina Novoa
- grid.7870.80000 0001 2157 0406Centro de Envejecimiento y Regeneración (CARE-UC), Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Alameda Bernardo O’Higgins 340, P.O. Box 114-D, Santiago, Chile
| | - Paulina Salazar
- grid.7870.80000 0001 2157 0406Centro de Envejecimiento y Regeneración (CARE-UC), Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Alameda Bernardo O’Higgins 340, P.O. Box 114-D, Santiago, Chile
| | - Pedro Cisternas
- grid.499370.00000 0004 6481 8274Instituto de Ciencias de la Salud, Universidad de O’Higgins, Rancagua, Chile
| | - Camila Gherardelli
- grid.7870.80000 0001 2157 0406Centro de Envejecimiento y Regeneración (CARE-UC), Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Alameda Bernardo O’Higgins 340, P.O. Box 114-D, Santiago, Chile
| | - Roberto Vera-Salazar
- grid.412179.80000 0001 2191 5013Facultad de Ciencias Médicas, Escuela de Kinesiología, Universidad de Santiago de Chile, Santiago, Chile
| | - Juan M. Zolezzi
- grid.442242.60000 0001 2287 1761Centro de Excelencia en Biomedicina de Magallanes (CEBIMA), Escuela de Medicina, Universidad de Magallanes, Punta Arenas, Chile
| | - Nibaldo C. Inestrosa
- grid.7870.80000 0001 2157 0406Centro de Envejecimiento y Regeneración (CARE-UC), Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Alameda Bernardo O’Higgins 340, P.O. Box 114-D, Santiago, Chile ,grid.442242.60000 0001 2287 1761Centro de Excelencia en Biomedicina de Magallanes (CEBIMA), Escuela de Medicina, Universidad de Magallanes, Punta Arenas, Chile
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Liu L, Fang B, Qiao Z, Di X, Ma Q, Zhang J, Wang J. Clinical Manifestation, Auxiliary Examination Features, and Prognosis of GFAP Autoimmunity: A Chinese Cohort Study. Brain Sci 2022; 12:brainsci12121662. [PMID: 36552122 PMCID: PMC9775969 DOI: 10.3390/brainsci12121662] [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: 09/04/2022] [Revised: 11/16/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE This paper reports the clinical manifestation and auxiliary examination features of 15 Chinese patients with glial fibrillary acidic protein (GFAP) autoimmunity. METHODS From June 2016 to December 2019, patients suspected to have neurological autoimmune disease after having their serum and cerebrospinal fluid (CSF) tested for conventional neural antibodies were scanned for additional autoantibodies by immunohistochemistry. Samples that showed a characteristic immunoreactive pattern reminiscent of the GFAP of astrocytes were selected and confirmed by cell-based assay using cells-expressing human GFAPα. RESULTS A total of 15 patients (eight male and seven female) with a median age at onset of 53 years (range 28-72) were identified as GFAP-IgG-positive. Fourteen cases had GFAP-IgG detected in the CSF, while serum GFAP-IgG was detected in 11 cases. Eleven of the fifteen patients (73.3%) presented with an acute monophasic course, of which 10 (90.9%) had antecedent flu-like symptoms. The predominant phenotype was meningoencephalitis (46.7%), followed by meningoencephalomyelitis in 40% of the cases. The most common clinical features included long tract signs, brainstem symptoms, tremors, headaches, and psychiatric symptoms. Magnetic resonance imaging (MRI) revealed the enhancement of the meninges, the surface of the brainstem, the cerebellum, and the spinal cord as predominant. Inflammatory CSF showed mild lymphocyte-predominant pleocytosis with a median of 51/μL and elevated protein with a median of 87.5 mg/dL. Five patients had coexisting antibodies, including NMDAR-IgG in three patients and Yo and MOG-IgG in one patient each. One patient underwent a stereotactic brain biopsy, and the neuropathology diagnosis was diffuse large B-cell lymphoma. One patient had ovarian teratoma. Eleven of the fifteen (73.3%) patients received both intravenous immunoglobulin and steroids. Among them, three patients also received immunosuppressive agents later. During a two-year follow-up, 9 of the 15 (60%) patients achieved complete clinical remission. CONCLUSIONS The clinical presentation of GFAP astrocytopathy is heterogeneous. It can be characterized by an acute monophasic course and a chronic relapsing course. Tremors are a prominent clinical manifestation in patients with an acute monophasic course with GFAP-IgG antibodies only. Most patients responded well to immunotherapy. In patients with GFAP autoimmunity, presenting with a chronic relapsing course, one should actively search for immunogenic factors and the culprit antibodies. In the case of primary central nervous system lymphoma, GFAP autoimmunity does not always equate to autoimmune GFAP astrocytopathy.
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Affiliation(s)
- Lei Liu
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100176, China
| | - Boyan Fang
- Neurological Rehabilitation Center, Beijing Rehabilitation Hospital, Capital Medical University, Beijing 100144, China
- Correspondence: (B.F.); (J.W.); Tel.: +86-010-56981223 (B.F.); +86-010-58266168 (J.W.)
| | - Zhixin Qiao
- Medical Research Center, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Xiaomeng Di
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100176, China
| | - Qiuying Ma
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100176, China
| | - Jingxiao Zhang
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100176, China
| | - Jiawei Wang
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100176, China
- Correspondence: (B.F.); (J.W.); Tel.: +86-010-56981223 (B.F.); +86-010-58266168 (J.W.)
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Someko H, Shiojiri T. Autoimmune glial fibrillar acidic protein astrocytopathy mimicking tuberculous meningitis. BMJ Case Rep 2022; 15:e252518. [PMID: 36400717 PMCID: PMC9677027 DOI: 10.1136/bcr-2022-252518] [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: 11/20/2022] Open
Abstract
Autoimmune glial fibrillar acidic protein (GFAP) astrocytopathy typically presents as acute or subacute meningoencephalitis with or without myelitis. We describe a case of autoimmune GFAP astrocytopathy that mimicked tuberculous meningitis. A man in his 70s was referred to our hospital with lethargy persistent for 2 months, appetite loss for 1 month and fever with headache for 10 days. The cerebrospinal fluid test revealed lymphocytic pleocytosis with elevated adenosine deaminase (ADA). Laboratory investigations ruled out microbial and neoplastic causes. Empirical therapy for tuberculous meningitis combined with corticosteroid improved the patient's condition. Culture for Mycobacterium tuberculosis failed to show microbial growth despite 1 month of incubation. The cerebrospinal fluid was examined for GFAP antibody and returned positive result. Antituberculous agents were discontinued, and corticosteroid was administered until patient's symptoms resolved completely. Thus, clinicians should consider autoimmune GFAP astrocytopathy as one of the differential diagnoses of lymphocytic meningitis with elevated ADA.
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Affiliation(s)
- Hidehiro Someko
- General Internal Medicine, Asahi General Hospital, Asahi, Chiba, Japan
| | - Toshiaki Shiojiri
- General Internal Medicine, Asahi General Hospital, Asahi, Chiba, Japan
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Zhang J, Gan J, Wang J. A case of GFAP-IgG positivity followed by anti-NMDAR encephalitis. BMC Pediatr 2022; 22:600. [PMID: 36253739 PMCID: PMC9575200 DOI: 10.1186/s12887-022-03650-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 09/30/2022] [Indexed: 12/02/2022] Open
Abstract
Background In recent years, there have been an increasing number of reports on overlapping antibodies in autoimmune encephalitis (AE). There are various types of overlapping antibodies, but the clinical significance of each type is not yet clear. Glial antibodies, such as MOG, AQP4, and especially NMDAR, can be detected in patients with AE. However, little is known about the overlapping antibodies of anti-glial fibrillary acidic protein (GFAP), and only a few case reports have described this overlap. Case presentation The patient was a 7-year-old girl with recurrent intermittent fever and seizures, and viral encephalitis was diagnosed at the beginning of the disease. She was discharged after treatment with acyclovir, high-dose immunoglobulins, and valproic acid as an antiseizure medication. Subsequently, the patient still had occasional seizures and abnormal behavior, and the anti-NMDAR antibody test was positive (1:3.2). She was treated with high-dose methylprednisolone and antiseizure therapy. Approximately half a year later, the patient experienced fever and seizures again, serum GFAP IgG was 1:100, and a head MRI indicated new lesions. Improvement was achieved after repeated high-dose methylprednisolone and continuous prednisone anti-inflammatory therapy. Conclusions Anti-NMDAR encephalitis combined with GFAP-IgG is uncommon, and repeated tests for AE-associated antibodies may be required in patients with recurrent encephalitis. Compared with cerebrospinal fluid antibody-positive children, serum GFAP IgG-positive children should be comprehensively diagnosed according to their clinical manifestations. It is worth considering whether overlapping antibody syndrome can still be an issue for patients with AE who recover and have negative antibodies after a few months if disease recurrence and new antibodies are detected.
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Affiliation(s)
- Jia Zhang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, 610041, China.,Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Development and Maternal and Child Diseases of Sichuan Province, Chengdu, Sichuan, China
| | - Jing Gan
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, 610041, China.,Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Development and Maternal and Child Diseases of Sichuan Province, Chengdu, Sichuan, China
| | - Jianjun Wang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, 610041, China. .,Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, Sichuan, China. .,Key Laboratory of Development and Maternal and Child Diseases of Sichuan Province, Chengdu, Sichuan, China.
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