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Shelly S, Dubey D, Mills JR, Klein CJ. Paraneoplastic neuropathies and peripheral nerve hyperexcitability disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:239-273. [PMID: 38494281 DOI: 10.1016/b978-0-12-823912-4.00020-7] [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: 03/19/2024]
Abstract
Peripheral neuropathy is a common referral for patients to the neurologic clinics. Paraneoplastic neuropathies account for a small but high morbidity and mortality subgroup. Symptoms include weakness, sensory loss, sweating irregularity, blood pressure instability, severe constipation, and neuropathic pain. Neuropathy is the first presenting symptom of malignancy among many patients. The molecular and cellular oncogenic immune targets reside within cell bodies, axons, cytoplasms, or surface membranes of neural tissues. A more favorable immune treatment outcome occurs in those where the targets reside on the cell surface. Patients with antibodies binding cell surface antigens commonly have neural hyperexcitability with pain, cramps, fasciculations, and hyperhidrotic attacks (CASPR2, LGI1, and others). The antigenic targets are also commonly expressed in the central nervous system, with presenting symptoms being myelopathy, encephalopathy, and seizures with neuropathy, often masked. Pain and autonomic components typically relate to small nerve fiber involvement (nociceptive, adrenergic, enteric, and sudomotor), sometimes without nerve fiber loss but rather hyperexcitability. The specific antibodies discovered help direct cancer investigations. Among the primary axonal paraneoplastic neuropathies, pathognomonic clinical features do not exist, and testing for multiple antibodies simultaneously provides the best sensitivity in testing (AGNA1-SOX1; amphiphysin; ANNA-1-HU; ANNA-3-DACH1; CASPR2; CRMP5; LGI1; PCA2-MAP1B, and others). Performing confirmatory antibody testing using adjunct methods improves specificity. Antibody-mediated demyelinating paraneoplastic neuropathies are limited to MAG-IgM (IgM-MGUS, Waldenström's, and myeloma), with the others associated with cytokine elevations (VEGF, IL6) caused by osteosclerotic myeloma, plasmacytoma (POEMS), and rarely angiofollicular lymphoma (Castleman's). Paraneoplastic disorders have clinical overlap with other idiopathic antibody disorders, including IgG4 demyelinating nodopathies (NF155 and Contactin-1). This review summarizes the paraneoplastic neuropathies, including those with peripheral nerve hyperexcitability.
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Affiliation(s)
- Shahar Shelly
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Neurology, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Christopher J Klein
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
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Chekanova E, Simaniv T, Evdokimenko A, Zakharova M. Anti-Ma2 paraneoplastic autoimmune encephalitis. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:89-95. [DOI: 10.17116/jnevro202212207289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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3
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El-Abassi RN, Soliman M, Levy MH, England JD. Treatment and Management of Autoimmune Neuropathies. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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4
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Albarrán V, Pozas J, Rodríguez F, Carrasco Á, Corral E, Lage Y, Álvarez-Ballesteros P, Soria A, Garrido P. Acute anti-Ma2 paraneoplastic encephalitis associated to pembrolizumab: a case report and review of literature. Transl Lung Cancer Res 2021; 10:3303-3311. [PMID: 34430366 PMCID: PMC8350103 DOI: 10.21037/tlcr-21-222] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 06/02/2021] [Indexed: 12/02/2022]
Abstract
Anti-Ma2 encephalitis is a rare neurological disorder with a predominant involvement of brainstem, limbic and diencephalic structures. Although an unspecific encephalopathy is the usual form of presentation, acute-onset neurologic symptoms and other atypical manifestations have been described and account for the challenging diagnosis of this entity. Despite being usually detected as a paraneoplastic syndrome in patients with early-stage tumors or without a previous history of malignancy, a growing concern has arisen from several cases reported in metastatic patients under treatment with immune checkpoint inhibitors. We report what to our knowledge is the first known case of anti-Ma2 encephalitis associated to pembrolizumab and presenting as an acute-onset focal neurological syndrome, consisting on acute global aphasia, right upper limb paresia, hypoacusia, sleep disorder, decreased conscious level and a motor focal status that was refractory to anticonvulsant therapy. A brain MRI scan showed a focal alteration of the cortical-subcortical signal on the left parietal lobe. CSF study found a significant hyperproteinorrhachia and electroencephalography showed lateralized periodic discharges (LPDs), suggestive of a diffuse encephalopathy. A positive result for anti-Ma2 antibodies was obtained both in blood and CSF samples through indirect immune-fluorescence (IFI) and later confirmed by western-blot technique. Our patient obtained a mild response to steroid therapy and a significant improvement after the administration of intravenous immunoglobulins. The hypothesis that checkpoint inhibitors may trigger the expression of previously subclinical paraneoplastic events, through the strengthening of cytotoxic T cells-mediated immune response, is supported by our finding of preexisting anti-Ma2 antibodies in preserved blood samples obtained before the initiation of pembrolizumab in our patient. Further research is needed to reveal if the detection of onconeural antibodies prior to a treatment with checkpoint inhibitors may be used as a predictive biomarker of neurologic immune-related high-grade toxicity.
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Affiliation(s)
- Víctor Albarrán
- Medical Oncology Department, Ramón y Cajal University Hospital, Madrid, Spain
| | - Javier Pozas
- Medical Oncology Department, Ramón y Cajal University Hospital, Madrid, Spain
| | | | - Ángela Carrasco
- Immunology Department, Ramón y Cajal University Hospital, Madrid, Spain
| | - Elena Corral
- Medical Oncology Department, Ramón y Cajal University Hospital, Madrid, Spain
| | - Yolanda Lage
- Medical Oncology Department, Ramón y Cajal University Hospital, Madrid, Spain
| | | | - Ainara Soria
- Medical Oncology Department, Ramón y Cajal University Hospital, Madrid, Spain
| | - Pilar Garrido
- Medical Oncology Department, Ramón y Cajal University Hospital, Madrid, Spain
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Sleep and neurological autoimmune diseases. Neuropsychopharmacology 2020; 45:129-140. [PMID: 31302665 PMCID: PMC6879573 DOI: 10.1038/s41386-019-0463-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 06/17/2019] [Accepted: 07/02/2019] [Indexed: 12/17/2022]
Abstract
Neurological autoimmune diseases are characterized by an inappropriate immune response that by mistake targets the nervous system. As a result, patients experiment a number of neurological manifestations that may include insomnia, excessive daytime sleepiness, cataplexy, central hypoventilation, and REM sleep behavior disorder. Polysomnographic evaluation may reveal disorganized sleep architecture involving both NREM and REM sleep, and REM sleep intrusions into wakefulness. The study of sleep disorders in the setting of autoimmune diseases (e.g., narcolepsy, anti-IgLON5 disease, paraneoplastic neurological syndromes) shows that an abnormal immune-mediated (humoral or cellular) response target the neuronal structures (e.g., brainstem, hypothalamus) and neurotransmitters systems (e.g., hypocretin) that regulate sleep resulting in sleep impairment. It is a window to examine the link between the autoimmune system and the sleep regulation at the molecular, cellular, and anatomic level.
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Review of paraneoplastic syndromes in children. Pediatr Radiol 2019; 49:534-550. [PMID: 30877339 DOI: 10.1007/s00247-019-04371-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 01/24/2019] [Accepted: 02/21/2019] [Indexed: 12/27/2022]
Abstract
Paraneoplastic syndromes are defined as clinical syndromes that are not related to direct tumor invasion or compression but are secondary to tumor secretion of functional peptides/hormones or related to immune cross-reactivity with normal host tissue. Paraneoplastic syndromes have a wide range of presentations and can present before the primary malignancy or tumor recurrence is diagnosed. They can mimic non-neoplastic processes, making detection, diagnosis and treatment difficult. However, they can also provide clues to the presence of an underlying malignancy. In this paper, we reviewed a range of paraneoplastic syndromes that can occur in children including: (1) neurologic (opsoclonus-myoclonus, limbic, anti-N-methyl-d-aspartate [NMDA] and anti-Ma2 encephalitis and myasthenia gravis); (2) endocrine (neuroendocrine tumors, hypercalcemia, SIADH [syndrome of inappropriate antidiuretic hormone secretion], osteomalacia/rickets and ROHHAD [rapid onset of obesity, hypoventilation, hypothalamic dysfunction and autonomic dysregulation]); and (3) dermatologic/rheumatologic syndromes (hypertrophic osteoarthropathy and paraneoplastic pemphigus). Familiarity with these syndromes can aid in early diagnosis, treatment and imaging optimization.
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Vogrig A, Joubert B, Maureille A, Thomas L, Bernard E, Streichenberger N, Cotton F, Ducray F, Honnorat J. Motor neuron involvement in anti-Ma2-associated paraneoplastic neurological syndrome. J Neurol 2018; 266:398-410. [DOI: 10.1007/s00415-018-9143-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/12/2018] [Accepted: 11/26/2018] [Indexed: 12/11/2022]
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Macher S, Zimprich F, De Simoni D, Höftberger R, Rommer PS. Management of Autoimmune Encephalitis: An Observational Monocentric Study of 38 Patients. Front Immunol 2018; 9:2708. [PMID: 30524441 PMCID: PMC6262885 DOI: 10.3389/fimmu.2018.02708] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 11/01/2018] [Indexed: 12/30/2022] Open
Abstract
Over the last years the clinical picture of autoimmune encephalitis has gained importance in neurology. The broad field of symptoms and syndromes poses a great challenge in diagnosis for clinicians. Early diagnosis and the initiation of the appropriate treatment is the most relevant step in the management of the patients. Over the last years advances in neuroimmunology have elucidated pathophysiological basis and improved treatment concepts. In this monocentric study we compare demographics, diagnostics, treatment options and outcomes with knowledge from literature. We present 38 patients suffering from autoimmune encephalitis. Antibodies were detected against NMDAR and LGI1 in seven patients, against GAD in 6 patients) one patient had coexisting antibodies against GABAA and GABAB), against CASPR2, IGLON5, YO, Glycine in 3 patients, against Ma-2 in 2 patients, against CV2 and AMPAR in 1 patient; two patients were diagnosed with hashimoto encephalitis with antibodies against TPO/TG. First, we compare baseline data of patients who were consecutively diagnosed with autoimmune encephalitis from a retrospective view. Further, we discuss when to stop immunosuppressive therapy since how long treatment should be performed after clinical stabilization or an acute relapse is still a matter of debate. Our experiences are comparable with data from literature. However, in contrary to other experts in the field we stop treatment and monitor patients very closely after tumor removal and after rehabilitation from first attack.
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Affiliation(s)
- Stefan Macher
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Desiree De Simoni
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paulus S Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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Naides SJ. The role of the laboratory in the expanding field of neuroimmunology: Autoantibodies to neural targets. J Immunol Methods 2018; 463:1-20. [PMID: 30300607 DOI: 10.1016/j.jim.2018.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 04/12/2018] [Indexed: 12/15/2022]
Abstract
Accelerated identification of autoantibodies associated with previously idiopathic neurological disease has provided insights into disease mechanisms, enhanced understanding of neurological function, and opportunities for improved therapeutic interventions. The role of the laboratory in the expanding field of neuroimmunology is critical as specific autoantibody identification provides guidance to clinicians in diagnosis, prognosis, tumor search strategies, and therapeutic interventions. The number of specific autoantibodies identified continues to increase and newer testing strategies increase efficiencies in the laboratory and availability to clinicians. The need for broadly targeted efficient testing is underscored by the variability in clinical presentation and tumor associations attributable to a specific autoantibody, and conversely the various autoantibody specificities that can be the cause of a given clinical presentation. While many of the antineural antibodies were first recognized in the setting of neoplastic disease, idiopathic autoimmune neurological disease in the absence of underlying tumor is increasingly recognized. Appropriation of therapeutic modalities used to treat autoimmune disease to treat these autoantibody mediated neurological diseases has improved patient outcomes. Interaction between clinicians and laboratorians is critical to our understanding of these diseases and optimization of the clinical benefits of our increasing knowledge in neuroimmunology.
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Affiliation(s)
- Stanley J Naides
- Immunology R&D, Quest Diagnostics Nichols Institute, 33608 Ortega Highway, San Juan Capistrano, CA 92675, USA.
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Mélé N, Berzero G, Maisonobe T, Salachas F, Nicolas G, Weiss N, Beaudonnet G, Ducray F, Psimaras D, Lenglet T. Motor neuron disease of paraneoplastic origin: a rare but treatable condition. J Neurol 2018; 265:1590-1599. [DOI: 10.1007/s00415-018-8881-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 04/14/2018] [Accepted: 04/16/2018] [Indexed: 02/07/2023]
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11
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Progressive Muscular Atrophy. Neuromuscul Disord 2018. [DOI: 10.1007/978-981-10-5361-0_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ju W, Qi B, Wang X, Yang Y. Anti-Ma2-associated limbic encephalitis with coexisting chronic inflammatory demyelinating polyneuropathy in a patient with non-Hodgkin lymphoma: A case report. Medicine (Baltimore) 2017; 96:e8228. [PMID: 28984777 PMCID: PMC5738013 DOI: 10.1097/md.0000000000008228] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
RATIONALE We report the rare case of a 74-year-old man with anti-Ma2-associated paraneoplastic neurologic syndrome (PNS), and review and analyze the clinical manifestations, diagnosis, and treatment of the disease. PATIENT CONCERNS The patient presented with a 5-month history of muscle weakness, progressive body aches, and weakness and numbness in both lower extremities. Before his hospitalization, he had experienced cognitive function decline; ptosis, inward gaze, and vertical gaze palsy in the right eye; and occasional visual hallucinations. Brain and spinal cord magnetic resonance imaging (MRI) yielded normal results. Anti-Ma2 antibodies were detected in both serum and cerebrospinal fluid. A 4-hour electroencephalogram showed irregular sharp slow waves and δ waves in the temporal region. Electromyography showed peripheral nerve demyelination. Positron-emission tomography/computed tomography (PET-CT) examination revealed hypermetabolism in the lymph nodes of the whole body. Biopsy of the lymph nodes showed non-Hodgkin lymphoma. DIAGNOSIS A clinical diagnosis of lymphoma and PNS was made. INTERVENTIONS The patient was treated with intravenous dexamethasone (15 mg/day) for 3 days. LESSONS We have presented a rare case of a PNS involving both the central and peripheral nervous systems. The clinical features of this case indicated anti-Ma2-associated encephalitis and chronic inflammatory demyelinating polyneuropathy. PET-CT played a critical role in enabling early diagnosis and prompt treatment in this case.
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Affiliation(s)
| | - Baochang Qi
- Department of Orthopedic Trauma, the First Hospital of Jilin University, Changchun, Jilin, China
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14
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Amygdalar and hippocampal connections with brainstem and spinal cord: A diffusion MRI study in human brain. Neuroscience 2017; 343:346-354. [DOI: 10.1016/j.neuroscience.2016.12.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 12/05/2016] [Accepted: 12/09/2016] [Indexed: 11/23/2022]
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Shiraishi W, Iwanaga Y, Yamamoto A. [A case of an anti-Ma2 antibody-positive patient presenting with variable CNS symptoms mimicking multiple system atrophy with a partial response to immunotherapy]. Rinsho Shinkeigaku 2016; 55:96-100. [PMID: 25746072 DOI: 10.5692/clinicalneurol.55.96] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 70-year-old man with a 5-month history of progressive bradykinesia of the bilateral lower extremities was admitted to our hospital. At the age of 64, he underwent proximal gastrectomy for gastric cancer. He also had a history of subacute combined degeneration of the spinal cord since the age of 67, which was successfully treated with vitamin B12 therapy. Four weeks before admission to our hospital, he admitted himself to his former hospital complaining of walking difficulty. Two weeks later, however, his symptoms progressed rapidly; he was immobilized for two weeks and did not respond to the vitamin therapy. On admission to our hospital, he showed moderate paralysis of the lower extremities, cog-wheel rigidity of the four extremities, and dystonic posture of his left hand. He also showed orthostatic hypotension and vesicorectal disorders. Blood examination and cerebrospinal fluid analysis revealed no remarkable abnormalities. Electroencephalography showed frontal dominant, high voltage, sharp waves. His brain and spinal MRI revealed no notable abnormalities. We suspected autoimmune disease and commenced one course of intravenous methylprednisolone therapy, resulting in improvement of the parkinsonism and orthostatic hypotension. Based on these results, we investigated possible neural antigens and detected anti-Ma2 antibody. In addition to limbic encephalitis, anti-Ma2 antibody-positive neural disorders are characterized by rapid eye movement sleep behavior disorders or parkinsonism. Here, we report an anti-Ma2 antibody positive patient presenting variable CNS symptoms mimicking multiple system atrophy, who responded to immunotherapy.
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Nishioka K, Hoshino Y, Kanai K, Ueno S, Nakazato T, Takanashi M, Tanaka R, Yokoyama K, Arimura K, Kuwabara S, Hattori N. Case of Morvan syndrome with anti-Ma2/Ta antibodies. ACTA ACUST UNITED AC 2016. [DOI: 10.1111/cen3.12325] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Kenya Nishioka
- Department of Neurology; Juntendo University School of Medicine; Tokyo Japan
| | - Yasunobu Hoshino
- Department of Neurology; Juntendo University School of Medicine; Tokyo Japan
| | - Kauzuaki Kanai
- Department of Neurology; Juntendo University School of Medicine; Tokyo Japan
| | - Shinichi Ueno
- Department of Neurology; Juntendo University School of Medicine; Tokyo Japan
| | - Tomoko Nakazato
- Department of Neurology; Juntendo University School of Medicine; Tokyo Japan
| | - Masashi Takanashi
- Department of Neurology; Juntendo University School of Medicine; Tokyo Japan
| | - Ryota Tanaka
- Department of Neurology; Juntendo University School of Medicine; Tokyo Japan
| | - Kazumasa Yokoyama
- Department of Neurology; Juntendo University School of Medicine; Tokyo Japan
| | | | - Satoshi Kuwabara
- Department of Neurology; Graduate School of Medicine; Chiba University; Chiba Japan
| | - Nobutaka Hattori
- Department of Neurology; Juntendo University School of Medicine; Tokyo Japan
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Ghasemi M. Amyotrophic lateral sclerosis mimic syndromes. IRANIAN JOURNAL OF NEUROLOGY 2016; 15:85-91. [PMID: 27326363 PMCID: PMC4912674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) misdiagnosis has many broad implications for the patient and the neurologist. Potentially curative treatments exist for certain ALS mimic syndromes, but delay in starting these therapies may have an unfavorable effect on outcome. Hence, it is important to exclude similar conditions. In this review, we discuss some of the important mimics of ALS.
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Affiliation(s)
- Majid Ghasemi
- 1 Neuroscience Research Center AND Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Mrabet S, Ben Achour N, Kraoua I, Benrhouma H, Klaa H, Rouissi A, Ben Ahmed M, Ben Youssef Turki I. Anti-Ma2-encephalitis in a 2 year-old child: A newly diagnosed case and literature review. Eur J Paediatr Neurol 2015; 19:737-42. [PMID: 26190012 DOI: 10.1016/j.ejpn.2015.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 05/25/2015] [Accepted: 06/29/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Anti-Ma2-associated encephalitis is a rare paraneoplastic neurological syndrome characterized by isolated or combined limbic, diencephalic, or brainstem dysfunction. It is rarely reported in children. CASE STUDY We describe the clinical data of a 2-year-old girl referred to our department for refractory focal seizures associated with fever, followed by behavioural changes, speech disturbances and confusional episodes. Brain magnetic resonance imaging (MRI) showed left temporoparietal brain involvement. Haematological, biochemical and infectious evaluations were unremarkable. Autoimmune encephalitis was suspected. Paraneoplastic antibodies tests showed positive results for anti-Ma2 antibodies. Screening for underlying tumour was negative. Immunomodulatory treatment was administrated. The patient showed improvement of vigilance and behaviour. However, she kept refractory epilepsy. CONCLUSION Although poor response to immunotherapy, early diagnosis and appropriate treatment of this disorder may prevent irreversible sequelae.
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Affiliation(s)
- Saloua Mrabet
- Research Unit UR12 SP24 and Department of Child and Adolescent Neurology, National Institute Mongi Ben Hmida of Neurology, Tunis, Tunisia
| | - Nedia Ben Achour
- Research Unit UR12 SP24 and Department of Child and Adolescent Neurology, National Institute Mongi Ben Hmida of Neurology, Tunis, Tunisia.
| | - Ichraf Kraoua
- Research Unit UR12 SP24 and Department of Child and Adolescent Neurology, National Institute Mongi Ben Hmida of Neurology, Tunis, Tunisia
| | - Hanène Benrhouma
- Research Unit UR12 SP24 and Department of Child and Adolescent Neurology, National Institute Mongi Ben Hmida of Neurology, Tunis, Tunisia
| | - Hedia Klaa
- Research Unit UR12 SP24 and Department of Child and Adolescent Neurology, National Institute Mongi Ben Hmida of Neurology, Tunis, Tunisia
| | - Aida Rouissi
- Research Unit UR12 SP24 and Department of Child and Adolescent Neurology, National Institute Mongi Ben Hmida of Neurology, Tunis, Tunisia
| | - Malika Ben Ahmed
- Department of Clinical Immunology, Pasteur Institute, Tunis, Tunisia
| | - Ilhem Ben Youssef Turki
- Research Unit UR12 SP24 and Department of Child and Adolescent Neurology, National Institute Mongi Ben Hmida of Neurology, Tunis, Tunisia
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Peripheral neuropathies associated with antibodies directed to intracellular neural antigens. Rev Neurol (Paris) 2014; 170:570-6. [DOI: 10.1016/j.neurol.2014.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 07/31/2014] [Indexed: 11/22/2022]
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20
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Didelot A, Honnorat J. Paraneoplastic disorders of the central and peripheral nervous systems. HANDBOOK OF CLINICAL NEUROLOGY 2014; 121:1159-1179. [PMID: 24365410 DOI: 10.1016/b978-0-7020-4088-7.00078-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Paraneoplatic neurologic syndromes (PNS) have been seminally defined as acute or subacute neurological syndromes resulting from nervous system dysfunction that is remote from the site of a malignant neoplasm or its metastases. However, in respect to our current understanding of their pathogenesis we may redefine these disorders as cancer-related dysimmune neurologic syndromes. We first deal with the epidemiology and the pathogenesis of PNS, then the different classic PNS are reviewed with clinical features according to the associated onconeuronal antibodies. Finally, therapeutic approaches are discussed.
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Affiliation(s)
- Adrien Didelot
- Centre de Référence, de Diagnostic et de Traitement des Syndromes Neurologiques Paranéoplasiques and INSERM U842, UMR-S842, Lyon, France.
| | - Jérôme Honnorat
- Centre de Référence, de Diagnostic et de Traitement des Syndromes Neurologiques Paranéoplasiques and INSERM U842, UMR-S842, Lyon, France
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Antoine JC, Camdessanché JP. Paraneoplastic disorders of the peripheral nervous system. Presse Med 2013; 42:e235-44. [DOI: 10.1016/j.lpm.2013.01.059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 12/16/2012] [Accepted: 01/07/2013] [Indexed: 11/28/2022] Open
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Microscopic Dysgerminoma Associated With Anti-Ma2 Paraneoplastic Encephalitis in a Patient With Gonadal Dysgenesis. Int J Gynecol Pathol 2013; 32:277-82. [DOI: 10.1097/pgp.0b013e31825f7c25] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Abstract
The identification of autoantibodies associated with dysimmune neuropathies was a major contribution to the characterization of peripheral nerve disorders, the understanding of their pathophysiology, and the clinical diagnosis of neuropathies. Antibodies directed to GM1, GQ1b, and disyalilated gangliosides, and anti-MAG antibodies are very useful in the diagnosis of acute or chronic motor or sensory-motor neuropathies with or without monoclonal IgM. Anti-onconeural anti-Hu and anti-CV2/CRMP antibodies allow when they are detected the diagnosis of paraneoplastic neuropathies. This chapter focuses on the description of these antibodies as diagnostic markers and on their immunopathogenesis. We give a background overview on the origin of these antibodies, their detection, and review those studies, which clearly show that these antibodies are capable of binding to the target tissues in peripheral nerve and thereby can exert a variety of pathophysiological effects. The corresponding electrophysiological and histological changes observed both in human and animal models are exemplified in order to get a better understanding of the immune mechanisms of these antibody-mediated neuropathies.
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Affiliation(s)
- Andreas Steck
- Department of Neurology, University Hospital Basel, Basel, Switzerland.
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Kubota A, Tajima T, Narukawa S, Yamazato M, Fukaura H, Takahashi Y, Tanaka K, Shimizu J, Nomura K. [Anti-Ma2, anti-NMDA-receptor and anti-GluRε2 limbic encephalitis with testicular seminoma: short-term memory disturbance]. Rinsho Shinkeigaku 2012; 52:666-71. [PMID: 22989902 DOI: 10.5692/clinicalneurol.52.666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 36-year-old man presented with cognitive impairment and disturbance of short-term memory functions with character change. Cerebrospinal fluid analysis revealed no abnormalities; however, brain MRI revealed high-signal intensity from bilateral hippocampus lesions on fluid attenuated inversion recovery (FLAIR) images and T(2) weighted images. The 18F-fluorodeoxyglucose PET demonstrated high glucose uptake in the bilateral hippocampus lesions. He was diagnosed as limbic encephalitis, and was administered high-dose intravenous methylprednisolone and immune adsorption plasma therapy followed by intravenous immunoglobulin therapy. MRI abnormalities improved after treatment but recent memory disturbance remained. Ma2 antibody, NMDA-receptor antibody, and GluRε2 antibody were positive. Eleven months atter the onset of disease, the tumor was identified in left testicle by ultrasound and removed the tumor. The pathological findings were seminoma. We experienced a case of paraneoplastic limbic encephalitis associated with seminoma with short-term memory disturbance. The occurrence of paraneoplastic limbic encephalitis with antibodies against cell membrane (NMDA-receptor antibody and GluRε2 antibody) and intracellular (Ma2 antibody) is rare even in the literature.
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Affiliation(s)
- Akihiro Kubota
- Department of Neurology, Saitama Medical Center, Saitama Medical University
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Murphy SM, Khan U, Alifrangis C, Hazell S, Hrouda D, Blake J, Ball J, Gabriel C, Markarian P, Rees J, Karim A, Seckl MJ, Lunn MP, Reilly MM. Anti Ma2-associated myeloradiculopathy: expanding the phenotype of anti-Ma2 associated paraneoplastic syndromes. J Neurol Neurosurg Psychiatry 2012; 83:232-3. [PMID: 21205983 PMCID: PMC3719382 DOI: 10.1136/jnnp.2010.223271] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Anti-Ma2 associated paraneoplastic syndrome usually presents as limbic encephalitis in association with testicular tumours., Only four patients have been reported with involvement outside the CNS, two of whom also had limbic or brainstem encephalitis., We report a man with anti- Ma2 associated myeloradiculopathy and previous testicular cancer whose neurological syndrome stabilised and anti-Ma2 titres fell following orchidectomy of a microscopically normal testis.
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Piccolo G, Tavazzi E, Jarius S, Alfonsi E, Cavagna L, Piccolo L, Zardini E, Voltz R, Franciotta D. Anti-Ma2/Ta antibodies in a woman with primary lateral sclerosis-like phenotype and Sjögren syndrome. Neurol Sci 2011; 32:915-7. [DOI: 10.1007/s10072-011-0510-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Accepted: 02/18/2011] [Indexed: 01/09/2023]
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Abstract
PURPOSE OF REVIEW To describe specificities and new advances in treatment of paraneoplastic neurological syndromes (PNS). RECENT FINDINGS PNS are defined as neurological syndromes of unknown cause that often antedate the diagnosis of an underlying cancer that is usually not clinically evident. The clinical signs of PNS are accurately described and 'classical' PNS have been established. Within the context of these syndromes, the concept of limbic encephalitis has evolved dramatically in the last 2 years due to the description of new auto-antibodies. The diagnosis and treatment of the associated cancer remains the key goal of the clinical management of PNS. However, the specific treatment of the neurological symptoms primarily depends on the immunological findings. SUMMARY There is increasing recognition of an extensive array of PNS and of several paraneoplastic antibodies as biological markers of these disorders. Basic immunological studies support the pathogenic role of some of these antibodies. Others are only markers of the disease.
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Mononeuropathie multiple et anticorps anti-Ma2. Rev Neurol (Paris) 2008; 164:608-11. [DOI: 10.1016/j.neurol.2008.03.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2007] [Revised: 02/12/2008] [Accepted: 03/11/2008] [Indexed: 11/21/2022]
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Pathways and genes differentially expressed in the motor cortex of patients with sporadic amyotrophic lateral sclerosis. BMC Genomics 2007; 8:26. [PMID: 17244347 PMCID: PMC1796866 DOI: 10.1186/1471-2164-8-26] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2006] [Accepted: 01/23/2007] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a fatal disorder caused by the progressive degeneration of motoneurons in brain and spinal cord. Despite identification of disease-linked mutations, the diversity of processes involved and the ambiguity of their relative importance in ALS pathogenesis still represent a major impediment to disease models as a basis for effective therapies. Moreover, the human motor cortex, although critical to ALS pathology and physiologically altered in most forms of the disease, has not been screened systematically for therapeutic targets. RESULTS By whole-genome expression profiling and stringent significance tests we identify genes and gene groups de-regulated in the motor cortex of patients with sporadic ALS, and interpret the role of individual candidate genes in a framework of differentially expressed pathways. Our findings emphasize the importance of defense responses and cytoskeletal, mitochondrial and proteasomal dysfunction, reflect reduced neuronal maintenance and vesicle trafficking, and implicate impaired ion homeostasis and glycolysis in ALS pathogenesis. Additionally, we compared our dataset with publicly available data for the SALS spinal cord, and show a high correlation of changes linked to the diseased state in the SALS motor cortex. In an analogous comparison with data for the Alzheimer's disease hippocampus we demonstrate a low correlation of global changes and a moderate correlation for changes specifically linked to the SALS diseased state. CONCLUSION Gene and sample numbers investigated allow pathway- and gene-based analyses by established error-correction methods, drawing a molecular portrait of the ALS motor cortex that faithfully represents many known disease features and uncovers several novel aspects of ALS pathology. Contrary to expectations for a tissue under oxidative stress, nuclear-encoded mitochondrial genes are uniformly down-regulated. Moreover, the down-regulation of mitochondrial and glycolytic genes implies a combined reduction of mitochondrial and cytoplasmic energy supply, with a possible role in the death of ALS motoneurons. Identifying candidate genes exclusively expressed in non-neuronal cells, we also highlight the importance of these cells in disease development in the motor cortex. Notably, some pathways and candidate genes identified by this study are direct or indirect targets of medication already applied to unrelated illnesses and point the way towards the rapid development of effective symptomatic ALS therapies.
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Abstract
Involvement of the peripheral nervous system (PNS) is common in patients with cancer and any part, including motor neurons, sensory ganglia, nerve roots, plexuses, cranial and peripheral nerves, and neuromuscular junctions, can be affected. Different mechanisms can initiate damage associated with cancer-related PNS disorders. These include tumour infiltration, toxicity of treatments, metabolic and nutritional perturbations, cachexia, virus infections, and paraneoplastic neurological syndromes. The type of cancer, lymphoma, or solid tumour is a further determinant of a PNS disorder. In this Review we discuss the different causes and mechanisms of disorders of the PNS in patients with cancer and we will focus on their assessment and diagnosis.
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Mathew RM, Vandenberghe R, Garcia-Merino A, Yamamoto T, Landolfi JC, Rosenfeld MR, Rossi JE, Thiessen B, Dropcho EJ, Dalmau J. Orchiectomy for suspected microscopic tumor in patients with anti-Ma2-associated encephalitis. Neurology 2006; 68:900-5. [PMID: 17151337 PMCID: PMC1909749 DOI: 10.1212/01.wnl.0000252379.81933.80] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To report the presence of microscopic neoplasms of the testis in men with anti-Ma2-associated encephalitis (Ma2-encephalitis) and to discuss the clinical implications. METHODS Orchiectomy specimens were examined using immunohistochemistry with Ma2 and Oct4 antibodies. RESULTS Among 25 patients with Ma2-encephalitis younger than 50 years, 19 had germ-cell tumors, and 6 had no evidence of cancer. These 6 patients underwent orchiectomy because they fulfilled five criteria: 1) demonstration of anti-Ma2 antibodies in association with MRI or clinical features compatible with Ma2-encephalitis, 2) life-threatening or progressive neurologic deficits, 3) age < 50 years, 4) absence of other tumors, and 5) new testicular enlargement or risk factors for germ-cell tumors, mainly cryptorchidism or ultrasound evidence of testicular microcalcifications. All orchiectomy specimens showed intratubular-germ cell neoplasms unclassified type (IGCNU) and other abnormalities including microcalcifications, atrophy, fibrosis, inflammatory infiltrates, or hypospermatogenesis. Ma2 was expressed by neoplastic cells in three of three patients examined. Even though most patients had severe neurologic deficits at the time of orchiectomy (median progression of symptoms, 10 months), 4 had partial improvement and prolonged stabilization (8 to 84 months, median 22.5 months) and two did not improve after the procedure. CONCLUSIONS In young men with Ma2-encephalitis, 1) the disorder should be attributed to a germ-cell neoplasm of the testis unless another Ma2-expressing tumor is found, 2) negative tumor markers, ultrasound, body CT, or PET do not exclude an intratubular germ-cell neoplasm of the testis, and 3) if no tumor is found, the presence of the five indicated criteria should prompt consideration of orchiectomy.
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Affiliation(s)
- R M Mathew
- Department of Neurology, Division Neuro-oncology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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