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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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Wang HY, Yang XY, Han J, Liu H, Yan ZR, Liang Z. Clinical characteristics of anti-N-methyl-D-aspartate receptor encephalitis in patients with a long-term history of mental disorders. Eur J Med Res 2022; 27:38. [PMID: 35272706 PMCID: PMC8908639 DOI: 10.1186/s40001-022-00664-5] [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: 09/14/2021] [Accepted: 02/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is an autoimmune disorder characterized by complex neuropsychiatric syndromes during disease onset. Although this disease has been well documented in the last decade, clinical characteristics of anti-NMDA receptor encephalitis in patients with long-term diagnostic history of mental disorders remain unclear. METHODS Here, we reviewed and analyzed series of anti-NMDA receptor encephalitis patients with a long-term medical history of psychiatric disorders through a review of literature using PubMed, web of science and Embase database. In addition, we described a patient of anti-NMDA receptor encephalitis with a long-term history of major depressive disorder. RESULTS A total of 14 patients with anti-NMDA receptor encephalitis and a long-term history of mental disorders were included in our study. We found that most patients were adult (92.9%) and female (78.6%). These patients often first visited a psychiatric department (71.43%). The mean disease course of psychiatric disorders was more than 9 years. Speech impairment (71.4%), abnormal behaviors (64.3%), and catatonia (64.3%) were the most common clinical symptoms. Most patients (85.7%) had a satisfactory prognosis after immunotherapy. CONCLUSION Anti-NMDA receptor encephalitis in individuals with mental disorders is an underestimated condition, yet it presents complex clinical symptoms. Mental and behavioral impairments are more frequently observed in newly diagnosed anti-NMDA receptor encephalitis patients with a long-term history of mental disorders than those without mental illness. A diagnosis of anti-NMDA receptor encephalitis should be considered when patients with mental illness show sudden fluctuations in psychiatric symptoms.
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Affiliation(s)
- Hai-Yang Wang
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian, 116011, Liaoning, China.,Department of Neurology, Jining No. 1 People's Hospital, Jining, 272000, China
| | - Xiao-Yu Yang
- Department of Psychiatry, School of Mental Health, Jining Medical University, Jining, 272000, China
| | - Jinming Han
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Huakun Liu
- Department of Neurology, Jining No. 1 People's Hospital, Jining, 272000, China
| | - Zhong-Rui Yan
- Department of Neurology, Jining No. 1 People's Hospital, Jining, 272000, China
| | - Zhanhua Liang
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian, 116011, Liaoning, China.
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Stoyanov A, McDougall A, Urriola N. Musical hallucinations: a rare and atypical presentation of anti-IgLON5 disease responsive to immunosuppressive therapy. BMJ Case Rep 2021; 14:14/2/e236963. [PMID: 33602757 PMCID: PMC7896582 DOI: 10.1136/bcr-2020-236963] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
IgLON5 antibodies are typically associated with the insidious onset of sleep disorder, parasomnia, gait disturbance and abnormal movements, with variable response to immunosuppressive therapy. We describe a case of a 50-year-old man who presented with acute speech difficulties, headache and focal seizures followed by well-formed visual hallucinations, and later, musical hallucinations of mainstream popular music. MRI of the brain demonstrated right temporal lobe changes with corresponding epileptiform activity seen on electroencephalogram. Subsequently, IgLON5 antibodies were detected in the serum. The patient was treated with anticonvulsants, as well as azathioprine with a tapering oral prednisone course with a complete resolution of the symptoms. Our case demonstrates an unusual presentation of the rare but increasingly described anti-IgLON5 disease, with musical hallucinations. The case highlights the variable and evolving clinical phenotypes that can be seen in autoimmune central nervous system disorders.
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Affiliation(s)
- Alex Stoyanov
- Department of Clinical Immunology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Alan McDougall
- Neurology Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Nicolas Urriola
- Department of Clinical Immunology, Liverpool Hospital, Liverpool, New South Wales, Australia
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Abstract
Anti-N-methyl-D-aspartate receptor (NMDAr) encephalitis is a relatively recent autoimmune entity, as it was first described in 2007. Given that it is a condition with neuropsychiatric symptoms, its initial symptom is frequently psychiatric in nature. Hence, psychiatrists are often the first physicians to assess these patients and, as so, must recognize this type of encephalitis as a possible cause. Catatonia may be inaugural or develop throughout the course of the disease. Management of patients with anti-NMDAr encephalitis is based on etiologic treatment with immunotherapy and removal of the associated tumor, if any. However, these catatonic patients may have variable responses to etiologic treatment, sometimes with refractory catatonic symptoms, which attests to the necessary urgency to know how to manage these patients. In the clinical setting, physicians appear to be using guidelines originally created to the management of catatonia due to primary psychiatric conditions. In this literature review, catatonia was historically contextualized and anti-NMDAr encephalitis overall described. Finally, catatonia secondary to this type of encephalitis was discussed.
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Gurrera RJ. Frequency and temporal sequence of clinical features in adults with anti-NMDA receptor encephalitis presenting with psychiatric symptoms. Psychol Med 2019; 49:2709-2716. [PMID: 30560745 DOI: 10.1017/s0033291718003665] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Anti-NMDA receptor (NMDAr) encephalitis is the most common autoimmune encephalitis in adults. It mimics psychiatric disorders so often that most patients are initially referred to a psychiatrist, and many are misdiagnosed. Without prompt and effective treatment, patients are likely to suffer a protracted course with significant residual disability, or death. This study focuses on the frequency and chronology of salient clinical features in adults with anti-NMDAr encephalitis who are likely to be first evaluated by a psychiatrist because their presentation suggests a primary psychiatric disorder. METHODS A systematic search of PubMed and EMBASE databases identified published reports of anti-NMDAr encephalitis associated with prominent behavioral or psychiatric symptoms. After eliminating redundancies, the frequencies and relative timing of clinical features were tabulated. Signs and symptoms were assigned temporal ranks based on the timing of their first appearance relative to the first appearance of other signs and symptoms in each patient; median ranks were used to compare temporal sequencing of both individual features and major symptom domains. RESULTS Two hundred thirty unique cases (185 female) met study inclusion criteria. The most common features were seizures (60.4%), disorientation/confusion (42.6%), orofacial dyskinesias (39.1%), and mutism/staring (37.4%). Seizures, fever, and cognitive dysfunction were often the earliest features to emerge, but psychiatric features predominated and sequencing varied greatly between individuals. CONCLUSIONS Clinicians should consider anti-NMDAr encephalitis when new psychiatric symptoms are accompanied by a recent viral prodrome, seizures or unexplained fever, or when the quality of the psychiatric symptoms is unusual (e.g. non-verbal auditory hallucinations).
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Affiliation(s)
- Ronald J Gurrera
- VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Scott JG, Gillis D, Ryan AE, Hargovan H, Gundarpi N, McKeon G, Hatherill S, Newman MP, Parry P, Prain K, Patterson S, Wong RCW, Wilson RJ, Blum S. The prevalence and treatment outcomes of antineuronal antibody-positive patients admitted with first episode of psychosis. BJPsych Open 2018; 4:69-74. [PMID: 29971149 PMCID: PMC6020277 DOI: 10.1192/bjo.2018.8] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 12/05/2017] [Accepted: 01/21/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Antineuronal antibodies are associated with psychosis, although their clinical significance in first episode of psychosis (FEP) is undetermined. AIMS To examine all patients admitted for treatment of FEP for antineuronal antibodies and describe clinical presentations and treatment outcomes in those who were antibody positive. METHOD Individuals admitted for FEP to six mental health units in Queensland, Australia, were prospectively tested for serum antineuronal antibodies. Antibody-positive patients were referred for neurological and immunological assessment and therapy. RESULTS Of 113 consenting participants, six had antineuronal antibodies (anti-N-methyl-D-aspartate receptor antibodies [n = 4], voltage-gated potassium channel antibodies [n = 1] and antibodies against uncharacterised antigen [n = 1]). Five received immunotherapy, which prompted resolution of psychosis in four. CONCLUSIONS A small subgroup of patients admitted to hospital with FEP have antineuronal antibodies detectable in serum and are responsive to immunotherapy. Early diagnosis and treatment is critical to optimise recovery. DECLARATION OF INTEREST None.
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Affiliation(s)
- James G. Scott
- Centre for Clinical Research, The University of Queensland
(UQCCR), Metro North Mental Health, Royal Brisbane and Women's
Hospital (RBWH), and the Queensland Centre for Mental Health Research (QCMHR),
Australia
| | - David Gillis
- Division of Immunology, Pathology Queensland
Central Laboratory, RBWH, Australia
| | | | | | | | | | - Sean Hatherill
- Metro South Addiction and Mental Health Service,
Child and Youth Academic Clinical Unit,
Queensland, Australia
| | - Martin P. Newman
- Division of Immunology, Pathology Queensland
Central Laboratory, RBWH, and Faculty of Medicine,
University of Queensland, Australia
| | - Peter Parry
- Child and Youth Mental Health Service,
Children's Health Queensland, Australia
| | - Kerri Prain
- Division of Immunology, Pathology Queensland
Central Laboratory, RBWH, Australia
| | - Sue Patterson
- Metro North Mental Health, RBWH,
and Department of Applied Psychology, Griffith
University, Queensland, Australia
| | - Richard C. W. Wong
- Division of Immunology, Pathology Queensland
Central Laboratory, RBWH, and Department of Immunology,
Princess Alexandra Hospital, Queensland,
Australia
| | - Robert J. Wilson
- Division of Immunology, Pathology Queensland
Central Laboratory, RBWH, and Department of Immunology,
Princess Alexandra Hospital, Queensland,
Australia
| | - Stefan Blum
- Faculty of Medicine, University of
Queensland and Department of Neurology,
Princess Alexandra Hospital, Queensland,
Australia
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Hemiataxia: A Novel Presentation of Anti-NMDA Receptor Antibody Mediated Encephalitis in an Adolescent. Case Rep Psychiatry 2017; 2017:1310465. [PMID: 29333310 PMCID: PMC5733199 DOI: 10.1155/2017/1310465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 08/21/2017] [Accepted: 08/30/2017] [Indexed: 12/17/2022] Open
Abstract
Anti-NMDA receptor antibody associated encephalitis as a cause of new-onset neuropsychiatric manifestations in children and adults can represent a significant diagnostic challenge for clinicians. Clinical signs often include encephalopathy, new-onset psychosis, and movement phenomenon. Although orofacial dyskinesias were initially identified as a characteristic movement phenomenon in this type of encephalitis, an expanded range of abnormalities has recently been reported, including isolated ataxia. We report a case of isolated hemiataxia in a young adult with mild initial psychiatric manifestations. A personal and family history of preceding neuropsychiatric symptoms produced diagnostic confusion and resulted in a significant diagnostic and therapeutic delay. Our case confirms the unilateral movement manifestations that have been emphasized in recent reports. Additionally, it confirms the need for involvement of neurologic as well as psychiatric services in the evaluation of such cases and emphasizes the importance of the neurologic examination in presentations with an initial psychiatric predominance.
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Dalmau J, Geis C, Graus F. Autoantibodies to Synaptic Receptors and Neuronal Cell Surface Proteins in Autoimmune Diseases of the Central Nervous System. Physiol Rev 2017; 97:839-887. [PMID: 28298428 PMCID: PMC5539405 DOI: 10.1152/physrev.00010.2016] [Citation(s) in RCA: 340] [Impact Index Per Article: 48.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Investigations in the last 10 years have revealed a new category of neurological diseases mediated by antibodies against cell surface and synaptic proteins. There are currently 16 such diseases all characterized by autoantibodies against neuronal proteins involved in synaptic signaling and plasticity. In clinical practice these findings have changed the diagnostic and treatment approach to potentially lethal, but now treatable, neurological and psychiatric syndromes previously considered idiopathic or not even suspected to be immune-mediated. Studies show that patients' antibodies can impair the surface dynamics of the target receptors eliminating them from synapses (e.g., NMDA receptor), block the function of the antigens without changing their synaptic density (e.g., GABAb receptor), interfere with synaptic protein-protein interactions (LGI1, Caspr2), alter synapse formation (e.g., neurexin-3α), or by unclear mechanisms associate to a new form of tauopathy (IgLON5). Here we first trace the process of discovery of these diseases, describing the triggers and symptoms related to each autoantigen, and then review in detail the structural and functional alterations caused by the autoantibodies with special emphasis in those (NMDA receptor, amphiphysin) that have been modeled in animals.
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Affiliation(s)
- Josep Dalmau
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania; Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain; Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany; Servei de Neurologia, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Christian Geis
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania; Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain; Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany; Servei de Neurologia, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Francesc Graus
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania; Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain; Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany; Servei de Neurologia, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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