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Alobaidy A, Alsulaimi M, Alajmi A. Spectrum of neurological manifestations, existence of diabetes mellitus, and 5-year mortality and cancer association outcomes in a cohort of Omani patients with positive anti- GAD autoimmunity. Expert Rev Clin Immunol 2024. [PMID: 39167450 DOI: 10.1080/1744666x.2024.2395853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 07/08/2024] [Accepted: 08/01/2024] [Indexed: 08/23/2024]
Abstract
OBJECTIVES There is scarce data in the literature concerning the anti-GAD65 antibodies (GAD-Abs) autoimmunity in the Omani population. METHODS Retrospective cohort study included GAD-Abs positive patients (n = 444) presented to a tertiary referral center in Oman from January 2005 until January 2018, with a five-year follow-up to study the cancer association and mortality outcomes. RESULTS Out of 444 patients, 27 patients (6.1%) showed GAD-Abs related neurological disorders. Adult age group was significantly associated with more GAD-Abs related neurological manifestations compared to pediatric and adolescents age group (P = 0.045). There was no association between the presence or absence of neurological manifestations with diabetes mellitus nor the titer level of GAD-Abs. Refractory status epilepticus and stiff person syndrome were the main causes of death in patients with neurological manifestations over five years and none of them found to have associated cancer. CONCLUSION The GAD-Abs autoimmunity represents a spectrum of neurological manifestations with variable severity and outcome among Omanis with positive GAD-Abs testing. The results of this study will serve as a platform for future studies to address the impact of GAD-Abs autoimmunity on the morbidity, mortality and treatment efficacy in the Omani population.
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Affiliation(s)
- Ammar Alobaidy
- Sultan Qaboos University Hospital, Department of Medicine- Neurology Unit, Muscat, Oman
| | - Mulham Alsulaimi
- Sultan Qaboos University, College of Medicine and Health Sciences, Muscat, Oman
| | - Ameer Alajmi
- Sultan Qaboos University, College of Medicine and Health Sciences, Muscat, Oman
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Anusha M, Ramesh R, Shanmugam S, Hazeena P, Avadhani D, Ranganathan LN, Paramanandam V, Kailash KK. Camptocormia in a young man with anti-GAD-seropositive stiff-person syndrome. BMJ Case Rep 2024; 17:e262122. [PMID: 39122374 DOI: 10.1136/bcr-2024-262122] [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: 08/12/2024] Open
Abstract
Stiff-person syndrome (SPS) usually manifests as an autoimmune neuromuscular disorder characterised by pronounced and advancing rigidity, primarily affecting the trunk and proximal muscles. There are various clinical subtypes like classic SPS (truncal stiffness, generalised rigidity and muscle spasms), partial SPS (stiff-limb syndrome) and uncommon forms including progressive encephalomyelitis with rigidity and myoclonus. Camptocormia, defined as forward flexion of the spine in the upright position that disappears in the supine position, without fixed deformity, has been described only in two cases as an initial presentation of Anti glutamic acid decarboxylase (GAD) autoimmunity. We encountered a young male presenting with a progressive forward-leaning posture and involuntary rhythmic movements in the lower limb. Diagnostic workup included MRI, blood routines, autoimmune screening, genetic testing, lumbar puncture and electromyography. Elevated serum anti-GAD antibody levels, inflammatory CSF and certain other clinical features supported the diagnosis of SPS. Treatment involved benzodiazepines, muscle relaxants and immunotherapy with intravenous immunoglobulin. This case underscores the importance of considering immune-mediated causes, such as SPS, in patients presenting with camptocormia.
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Affiliation(s)
- Mekala Anusha
- Neurology, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai, Tamil Nadu, India
| | - Rithvik Ramesh
- Neurology, Sri Ramachandra Medical College and Research Institute, Chennai, India
| | - Sundar Shanmugam
- Neurology, Sri Ramachandra Medical College and Research Institute, Chennai, India
| | - Philo Hazeena
- Neurology, Sri Ramachandra Medical College and Research Institute, Chennai, India
| | - Deepa Avadhani
- Neurology, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai, Tamil Nadu, India
| | - Lakshmi Narasimhan Ranganathan
- Neurology, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai, Tamil Nadu, India
| | - Vijayashankar Paramanandam
- Neurology, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai, Tamil Nadu, India
| | - Kannan Karthik Kailash
- Neurology, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai, Tamil Nadu, India
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Dalakas MC. Stiff Person Syndrome and GAD Antibody-Spectrum Disorders. Continuum (Minneap Minn) 2024; 30:1110-1135. [PMID: 39088290 DOI: 10.1212/con.0000000000001457] [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: 08/03/2024]
Abstract
OBJECTIVE Antibodies against glutamic acid decarboxylase (GAD), originally associated with stiff person syndrome (SPS), define the GAD antibody-spectrum disorders that also include cerebellar ataxia, autoimmune epilepsy, limbic encephalitis, progressive encephalomyelitis with rigidity and myoclonus (PERM), and eye movement disorders, all of which are characterized by autoimmune neuronal excitability. This article elaborates on the diagnostic criteria for SPS and SPS spectrum disorders, highlights disease mimics and misdiagnoses, describes the electrophysiologic mechanisms and underlying autoimmunity of stiffness and spasms, and provides a step-by-step therapeutic scheme. LATEST DEVELOPMENTS Very-high serum GAD antibody titers are diagnostic for GAD antibody-spectrum disorders and also predict the presence of GAD antibodies in the CSF, increased intrathecal synthesis, and reduced CSF γ-aminobutyric acid (GABA) levels. Low serum GAD antibody titers or the absence of antibodies generates diagnostic challenges that require careful distinction in patients with a variety of painful spasms and stiffness, including functional neurologic disorders. Antibodies against glycine receptors, first found in patients with PERM, are seen in 13% to 15% of patients with SPS, whereas amphiphysin and gephyrin antibodies, seen in 5% of patients with SPS spectrum disorders, predict a paraneoplastic association. GAD-IgG from different SPS spectrum disorders recognizes the same dominant GAD intracellular epitope and, although the pathogenicity is unclear, is an excellent diagnostic marker. The biological basis of muscle stiffness and spasms is related to autoimmune neuronal hyperexcitability caused by impaired reciprocal γ-aminobutyric acid-mediated (GABA-ergic) inhibition, which explains the therapeutic response to GABA-enhancing agents and immunotherapies. ESSENTIAL POINTS It is essential to distinguish SPS spectrum disorders from disease mimics to avoid both overdiagnoses and misdiagnoses, considering that SPS is treatable if managed correctly from the outset to prevent disease progression. A step-by-step, combination therapy of GABA-enhancing medications along with immunotherapies ensures prolonged clinical benefits.
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Rezigh A, Rezigh A, Sherman S. Lessons in clinical reasoning - pitfalls, myths, and pearls: a woman brought to a halt. Diagnosis (Berl) 2024; 11:205-211. [PMID: 38329454 DOI: 10.1515/dx-2023-0162] [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: 11/10/2023] [Accepted: 01/19/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVES Limitations in human cognition commonly result in clinical reasoning failures that can lead to diagnostic errors. A metacognitive structured reflection on what clinical findings fit and/or do not fit with a diagnosis, as well as how discordance of data can help advance the reasoning process, may reduce such errors. CASE PRESENTATION A 60-year-old woman with Hashimoto thyroiditis, diabetes, and generalized anxiety disorder presented with diffuse arthralgias and myalgias. She had been evaluated by physicians of various specialties and undergone multiple modalities of imaging, as well as a electromyography/nerve conduction study (EMG/NCS), leading to diagnoses of fibromyalgia, osteoarthritis, and lumbosacral plexopathy. Despite treatment for these conditions, she experienced persistent functional decline. The only definitive alleviation of her symptoms identified was in the few days following intra-articular steroid injections for osteoarthritis. On presentation to our institution, she appeared fit with a normal BMI. She was a long-time athlete and had been training consistently until her symptoms began. Prediabetes had been diagnosed the year prior and her A1c progressed despite lifestyle modifications and 10 pounds of intentional weight loss. She reported fatigue, intermittent nausea without emesis, and reduced appetite. Examination revealed intact strength and range of motion in both the shoulders and hips, though testing elicited pain. She had symmetric hyperreflexia as well as a slowed, rigid gait. Autoantibody testing revealed strongly positive serum GAD-65 antibodies which were confirmed in the CSF. A diagnosis of stiff-person syndrome was made. She had an incomplete response to first-line therapy with high-dose benzodiazepines. IVIg was initiated with excellent response and symptom resolution. CONCLUSIONS Through integrated commentary on the diagnostic reasoning process from clinical reasoning experts, this case underscores the importance of frequent assessment of fit along with explicit explanation of dissonant features in order to avoid misdiagnosis and halt diagnostic inertia. A fishbone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic error. The case discussant demonstrates the power of iterative reasoning, case progression without commitment to a single diagnosis, and the dangers of both explicit and implicit bias. Finally, this case provides clinical teaching points in addition to a pitfall, myth, and pearl specific to overcoming diagnostic inertia.
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Affiliation(s)
- Austin Rezigh
- Department of Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Alec Rezigh
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Stephanie Sherman
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Wang Y, Hu C, Aljarallah S, Reyes Mantilla M, Mukharesh L, Simpson A, Roy S, Harrison K, Shoemaker T, Comisac M, Balshi A, Obando D, Maldonado DAP, Koshorek J, Snoops S, Fitzgerald KC, Newsome SD. Expanding clinical profiles and prognostic markers in stiff person syndrome spectrum disorders. J Neurol 2024; 271:1861-1872. [PMID: 38078976 PMCID: PMC10973082 DOI: 10.1007/s00415-023-12123-0] [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: 09/08/2023] [Revised: 11/15/2023] [Accepted: 11/19/2023] [Indexed: 03/28/2024]
Abstract
OBJECTIVE To describe the clinical features of a cohort of individuals with stiff person syndrome spectrum disorders (SPSD) and identify potential early predictors of future disability. BACKGROUND There is a need to better understand the full spectrum of clinical and paraclinical features and long-term impact of SPSD. DESIGN/METHODS Observational study from 1997 to 2022 at Johns Hopkins. Clinical phenotypes included classic SPS, partial SPS (limb or trunk limited), SPS-plus (classic features plus cerebellar/brainstem involvement), and progressive encephalomyelitis with rigidity and myoclonus (PERM). Outcome measures were modified Rankin scale (mRS) and use of assistive device for ambulation. Multivariate logistic regression was used to assess significant predictors of outcomes. RESULTS Cohort included 227 individuals with SPSD with mean follow-up of 10 years; 154 classic, 48 SPS-plus, 16 PERM, and 9 partial. Mean age at symptom onset was 42.9 ± 14.1 years, majority were white (69.2%) and female (75.8%). Median time to diagnosis was 36.2 months (longest for SPS-plus and PERM) and 61.2% were initially misdiagnosed. Most had systemic co-morbidities and required assistive devices for ambulation. Female sex (OR 2.08; CI 1.06-4.11) and initial brainstem/cerebellar involvement (OR 4.41; CI 1.63-14.33) predicted worse outcome by mRS. Older age at symptom onset (OR 1.04; CI 1.01-1.06), female sex (OR 1.99; CI 1.01-4.01), Black race (OR 4.14; CI 1.79-10.63), and initial brainstem/cerebellar involvement (OR 2.44; CI 1.04-7.19) predicted worse outcome by use of assistive device. Early implementation of immunotherapy was associated with better outcomes by either mRS (OR 0.45; CI 0.22-0.92) or use of assistive device (OR 0.79; CI 0.66-0.94). CONCLUSIONS We present the expanding phenotypic variability of this rare spectrum of disorders and highlight potential predictors of future disability.
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Affiliation(s)
- Yujie Wang
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Chen Hu
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Salman Aljarallah
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Maria Reyes Mantilla
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Loulwah Mukharesh
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Alexandra Simpson
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Shuvro Roy
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Kimystian Harrison
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Thomas Shoemaker
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Michael Comisac
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Alexandra Balshi
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Danielle Obando
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Daniela A Pimentel Maldonado
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Jacqueline Koshorek
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Sarah Snoops
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Kathryn C Fitzgerald
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Scott D Newsome
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA.
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Lennartz M, Benjamin Dünnebier N, Höflmayer D, Dwertmann Rico S, Kind S, Reiswich V, Viehweger F, Lutz F, Fraune C, Gorbokon N, Luebke AM, Hube-Magg C, Büscheck F, Menz A, Uhlig R, Krech T, Hinsch A, Burandt E, Sauter G, Simon R, Kluth M, Steurer S, Marx AH, Lebok P, Dum D, Minner S, Jacobsen F, Clauditz TS, Bernreuther C. GAD2 Is a Highly Specific Marker for Neuroendocrine Neoplasms of the Pancreas. Am J Surg Pathol 2024; 48:377-386. [PMID: 38271200 PMCID: PMC10930383 DOI: 10.1097/pas.0000000000002186] [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: 01/27/2024]
Abstract
Glutamate decarboxylase 2 (GAD2) is the most important inhibitory neurotransmitter and plays a role in insulin-producing β cells of pancreatic islets. The limitation of GAD2 expression to a few normal cell types makes GAD2 a potential immunohistochemical diagnostic marker. To evaluate the diagnostic utility of GAD2 immunohistochemistry, a tissue microarray containing 19,202 samples from 152 different tumor entities and 608 samples of 76 different normal tissue types was analyzed. In normal tissues, GAD2 staining was restricted to brain and pancreatic islet cells. GAD2 staining was seen in 20 (13.2%) of 152 tumor categories, including 5 (3.3%) tumor categories containing at least 1 strongly positive case. GAD2 immunostaining was most commonly seen in neuroendocrine carcinomas (58.3%) and neuroendocrine tumors (63.2%) of the pancreas, followed by granular cell tumors (37.0%) and neuroendocrine tumors of the lung (11.1%). GAD2 was only occasionally (<10% of cases) seen in 16 other tumor entities including paraganglioma, medullary thyroid carcinoma, and small cell neuroendocrine carcinoma of the urinary bladder. Data on GAD2 and progesterone receptor (PR) expression (from a previous study) were available for 95 pancreatic and 380 extrapancreatic neuroendocrine neoplasms. For determining a pancreatic origin of a neuroendocrine neoplasm, the sensitivity of GAD2 was 64.2% and specificity 96.3%, while the sensitivity of PR was 56.8% and specificity 92.6%. The combination of PR and GAD2 increased both sensitivity and specificity. GAD2 immunohistochemistry is a highly useful diagnostic tool for the identification of pancreatic origin in case of neuroendocrine neoplasms with unknown site of origin.
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Affiliation(s)
- Maximilian Lennartz
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | | | - Doris Höflmayer
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | | | - Simon Kind
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Viktor Reiswich
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Florian Viehweger
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Florian Lutz
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Christoph Fraune
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Natalia Gorbokon
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Andreas M. Luebke
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Claudia Hube-Magg
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Franziska Büscheck
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Anne Menz
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Ria Uhlig
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Till Krech
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
- Institute of Pathology, Clinical Center Osnabrueck, Osnabrueck
| | - Andrea Hinsch
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Eike Burandt
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Guido Sauter
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Ronald Simon
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Martina Kluth
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Stefan Steurer
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Andreas H. Marx
- Department of Pathology, Academic Hospital Fuerth, Fuerth Germany
| | - Patrick Lebok
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
- Institute of Pathology, Clinical Center Osnabrueck, Osnabrueck
| | - David Dum
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Sarah Minner
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Frank Jacobsen
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Till S. Clauditz
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg
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Navarro-Ledesma S, Hamed-Hamed D, Pruimboom L. A new perspective of frozen shoulder pathology; the interplay between the brain and the immune system. Front Physiol 2024; 15:1248612. [PMID: 38617059 PMCID: PMC11009429 DOI: 10.3389/fphys.2024.1248612] [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: 06/27/2023] [Accepted: 03/18/2024] [Indexed: 04/16/2024] Open
Abstract
Frozen shoulder (FS), also known as adhesive capsulitis of the shoulder (FS), is a fibrotic inflammatory process of unknown etiology whose main symptoms are pain, stiffness and the loss of joint mobility. These symptoms may be associated with pathologies such as diabetes, Dupuytren's syndrome and the prevalence of today's sedentary lifestyle. This literature review provides an overview of the epidemiology and pathogenesis of this pathology, as well as the mechanisms of lowgrade chronic inflammation and infection, insulin resistance, and omics-science associated with it. We also propose a new hypothesis related to the possibility that the GABAergic system could play a decisive role in the development of frozen shoulder and that therefore diabetes type 1, endocrinological autoimmune disorders and frozen shoulder are connected by the same pathophysiological mechanisms. If that is true, the combined presence of psycho-emotional stress factors and pathogenic immune challenges could be the main causes of frozen shoulder syndrome. Finally, we propose a series of possible intervention strategies based on a multifactorial etiological and mechanistic concept.
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Affiliation(s)
- Santiago Navarro-Ledesma
- Department of Physical Therapy, Faculty of Health Sciences, Campus of Melilla, University of Granada, Melilla, Spain
- University Chair in Clinical Psychoneuroimmunology, University of Granada and PNI Europe, Melilla, Spain
| | - Dina Hamed-Hamed
- Clinical Medicine and Public Health PhD Program, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Leo Pruimboom
- University Chair in Clinical Psychoneuroimmunology, University of Granada and PNI Europe, Melilla, Spain
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8
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Rajmohan R, Baveja S, Nguyen D, Shah E, Sy M, Attaripour S, Swope D. Case report: Approaches to treatment-refractory and super-refractory glutamic acid decarboxylase antibody-spectrum disorders. Front Immunol 2024; 14:1297340. [PMID: 38259445 PMCID: PMC10800536 DOI: 10.3389/fimmu.2023.1297340] [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: 09/19/2023] [Accepted: 12/12/2023] [Indexed: 01/24/2024] Open
Abstract
Background Glutamic acid decarboxylase antibody-spectrum disorders (GAD-SDs) include a group of autoimmune neurological diseases associated with neuronal excitability, most noticeably stiff person syndrome. Immune modulators are the mainstay of treatment, but a significant number of patients remain refractory. Methods We present our single-center experience of eight cases of GAD-SD, two of which were refractory to immune modulatory treatments. Results Of the two cases that were refractory to immunomodulation, one showed significant improvement with bilateral globus pallidus interna deep brain stimulation (GPi DBS) placement, and the other showed significant improvement with autologous hematopoietic stem cell transplant (aHSCT). Discussion To our knowledge, this is the first instance of GPi DBS placement being noted to improve GAD-SD movements.
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Affiliation(s)
- Ravi Rajmohan
- Department of Neurology, University of California, Irvine, CA, United States
| | - Shivali Baveja
- School of Medicine, University of California, Irvine, CA, United States
| | - Dai Nguyen
- Department of Internal Medicine, University of California, Davis, CA, United States
| | - Eshita Shah
- Department of Neurology, University of California, Irvine, CA, United States
| | - Michael Sy
- Department of Neurology, University of California, Irvine, CA, United States
| | - Sanaz Attaripour
- Department of Neurology, University of California, Irvine, CA, United States
| | - David Swope
- Department of Neurology, University of California, Irvine, CA, United States
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9
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Di Stefano V, Alonge P, Rini N, Militello M, Lupica A, Torrente A, Brighina F. Efgartigimod beyond myasthenia gravis: the role of FcRn-targeting therapies in stiff-person syndrome. J Neurol 2024; 271:254-262. [PMID: 37682316 PMCID: PMC10769952 DOI: 10.1007/s00415-023-11970-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/21/2023] [Accepted: 08/24/2023] [Indexed: 09/09/2023]
Abstract
Stiff-person syndrome (SPS) is a rare autoimmune neurological disorder characterized by high titers of antibodies against glutamic acid decarboxylase (GAD) causing impaired GABAergic inhibitory neurotransmission. To date, there is not a defined therapy for such condition, but immunomodulating therapies, such as plasma exchange, intravenous immunoglobulins, and rituximab, have been widely used in clinical practice. However, the efficacy and tolerability of these treatments is not well established. Efgartigimod, a new neonatal Fc receptor (FcRn) blocker, is a human IgG1 antibody Fc fragment engineered with increased affinity for FcRn binding, leading to a reduction in IgGs levels, including pathogenic IgG autoantibody showing promising results in neurological autoimmune disorders and has been approved for the treatment of AChR-seropositive generalized myasthenia gravis (MG). In this study, we report and describe the first data on treatment with efgartigimod in three patients affected by both AChR-seropositive generalized MG and anti-GAD-seropositive SPS. Patients were followed since the start of efgartigimod and for the whole treatment period (12 weeks). MG symptoms were assessed with the "MG activity of daily living score" and the Quantitative Myasthenia Gravis score, while SPS ones were assessed with the "SPS activity of daily living score"; muscle strength was assessed with the Medical Research Council Sum score; the overall disability from MG and SPS was assessed by the modified Rankin Scale. All patients showed an improvement in symptoms of both SPS and MG after 2 cycles of treatment. Our data suggest that efgartigimod may be considered as a candidate drug for SPS and other autoantibody-mediated neurological disorders.
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Affiliation(s)
- Vincenzo Di Stefano
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Via del Vespro, 143 90127, Palermo, Italy.
| | - Paolo Alonge
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Via del Vespro, 143 90127, Palermo, Italy
| | - Nicasio Rini
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Via del Vespro, 143 90127, Palermo, Italy
| | - Massimiliano Militello
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Via del Vespro, 143 90127, Palermo, Italy
| | - Antonino Lupica
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Via del Vespro, 143 90127, Palermo, Italy
| | - Angelo Torrente
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Via del Vespro, 143 90127, Palermo, Italy
| | - Filippo Brighina
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Via del Vespro, 143 90127, Palermo, Italy
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Masciocchi S, Businaro P, Scaranzin S, Morandi C, Franciotta D, Gastaldi M. General features, pathogenesis, and laboratory diagnostics of autoimmune encephalitis. Crit Rev Clin Lab Sci 2024; 61:45-69. [PMID: 37777038 DOI: 10.1080/10408363.2023.2247482] [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: 03/23/2023] [Accepted: 08/09/2023] [Indexed: 10/02/2023]
Abstract
Autoimmune encephalitis (AE) is a group of inflammatory conditions that can associate with the presence of antibodies directed to neuronal intracellular, or cell surface antigens. These disorders are increasingly recognized as an important differential diagnosis of infectious encephalitis and of other common neuropsychiatric conditions. Autoantibody diagnostics plays a pivotal role for accurate diagnosis of AE, which is of utmost importance for the prompt recognition and early treatment. Several AE subgroups can be identified, either according to the prominent clinical phenotype, presence of a concomitant tumor, or type of neuronal autoantibody, and recent diagnostic criteria have provided important insights into AE classification. Antibodies to neuronal intracellular antigens typically associate with paraneoplastic neurological syndromes and poor prognosis, whereas antibodies to synaptic/neuronal cell surface antigens characterize many AE subtypes that associate with tumors less frequently, and that are often immunotherapy-responsive. In addition to the general features of AE, we review current knowledge on the pathogenic mechanisms underlying these disorders, focusing mainly on the potential role of neuronal antibodies in the most frequent conditions, and highlight current theories and controversies. Then, we dissect the crucial aspects of the laboratory diagnostics of neuronal antibodies, which represents an actual challenge for both pathologists and neurologists. Indeed, this diagnostics entails technical difficulties, along with particularly interesting novel features and pitfalls. The novelties especially apply to the wide range of assays used, including specific tissue-based and cell-based assays. These assays can be developed in-house, usually in specialized laboratories, or are commercially available. They are widely used in clinical immunology and in clinical chemistry laboratories, with relevant differences in analytic performance. Indeed, several data indicate that in-house assays could perform better than commercial kits, notwithstanding that the former are based on non-standardized protocols. Moreover, they need expertise and laboratory facilities usually unavailable in clinical chemistry laboratories. Together with the data of the literature, we critically evaluate the analytical performance of the in-house vs commercial kit-based approach. Finally, we propose an algorithm aimed at integrating the present strategies of the laboratory diagnostics in AE for the best clinical management of patients with these disorders.
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Affiliation(s)
- Stefano Masciocchi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, Università degli Studi di Pavia, Pavia, Italy
| | - Pietro Businaro
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, Università degli Studi di Pavia, Pavia, Italy
| | - Silvia Scaranzin
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Chiara Morandi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Diego Franciotta
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Matteo Gastaldi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
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Zaharova VV, Ruina EA, Antipenko EA. [Stiff-person syndrome]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:139-144. [PMID: 39072580 DOI: 10.17116/jnevro2024124061139] [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: 07/30/2024]
Abstract
Stiff-person syndrome is a rare autoimmune disorder manifested by stiffness in the trunk and proximal limb muscles and painful muscle spasms in them. The disease is associated with the production of glutamate decarboxylase autoantibodies, an enzyme converting glutamate into gamma-aminobutyric acid. An increase of anti-GAD antibody serum levels above 10.000 IU/mL is specific for stiff-person syndrome. Our own clinical observation of a patient diagnosed with stiff-person syndrome is presented.
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Affiliation(s)
- V V Zaharova
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - E A Ruina
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - E A Antipenko
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
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Li EC, Lai QL, Cai MT, Fang GL, Shen CH, Ding MP, Zhang YX. Anti-adenylate kinase 5 encephalitis: Clinical characteristics, diagnosis, and management of this rare entity. J Transl Autoimmun 2023; 7:100218. [PMID: 37859804 PMCID: PMC10582738 DOI: 10.1016/j.jtauto.2023.100218] [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: 06/06/2023] [Revised: 09/08/2023] [Accepted: 10/06/2023] [Indexed: 10/21/2023] Open
Abstract
The spectrum and understanding of antibody-positive autoimmune encephalitis (AE) have expanded over the past few decades. In 2007, a rare subtype of AE known as anti-adenylate kinase 5 (AK5) encephalitis, was first reported. This disease is more common in elderly males, with limbic encephalitis as the core phenotype (characterized by subacute anterograde amnesia, sometimes with psychiatric symptoms, and rarely with seizures). Brain magnetic resonance imaging typically demonstrated initial temporal lobe T2/fluid-attenuated inversion recovery hyperintensities, and subsequent atrophy. No concomitant tumors have been found yet. AK5 antibody, targeting the intracellular antigen, is a biomarker for a non-paraneoplastic T-cell autoimmunity response, and can be detected in serum and cerebrospinal fluid using tissue-based and cell-based assays. Cytotoxic T-cell-mediating neuronal injury and loss play a pivotal role in the immunopathogenesis of anti-AK5 encephalitis. Patients mostly show poor response to immunotherapy and thus a poor prognosis in the long run. Herein, we review the literature and provide updated knowledge of this less-known entity, focusing on clinical characteristics, paraclinical findings, diagnosis process, and therapeutic approaches.
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Affiliation(s)
- Er-Chuang Li
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
- Department of Neurology, Taikang Ningbo Hospital, Ningbo, 315042, China
| | - Qi-Lun Lai
- Department of Neurology, Zhejiang Hospital, Hangzhou, 310013, China
| | - Meng-Ting Cai
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Gao-Li Fang
- Department of Neurology, Zhejiang Chinese Medicine and Western Medicine Integrated Hospital, Hangzhou, 310003, China
| | - Chun-Hong Shen
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Mei-Ping Ding
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Yin-Xi Zhang
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
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Klein da Costa B, de Oliveira Pinto P, Staub L, Hansel G, Vanik Pinto G, Porcello Schilling L, Rodrigues Dos Passos G, Alves Martins W, Becker J, Machado Castilhos R, Palmini A, Sato DK. Neurological syndromes and potential triggers associated with antibodies to neuronal surface antigens. Mult Scler Relat Disord 2023; 80:105022. [PMID: 37864878 DOI: 10.1016/j.msard.2023.105022] [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: 06/18/2023] [Revised: 09/05/2023] [Accepted: 09/23/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Autoantibodies against surface neuronal antigens have been associated with specific neurological presentations including autoimmune encephalitis (AE), with variable association with neoplasia and infections. METHODS We described the phenotype and environmental associations of patients with neurological syndromes associated with antibodies against neuronal surface antigens who were referred to a tertiary center in the South of Brazil. All patients were tested for neuronal autoantibodies using cell-based assays. Clinical, radiological, and laboratory findings were retrospectively reviewed. RESULTS We identified 16 patients, 15 had subacute, and one had a progressive disease course. Among patients with subacute onset, 11 (73 %) were N-Methyl-d-Aspartate receptor (NMDAr-IgG)+, 3 (20 %) were Leucine-rich Glioma-Inactivated-1 (LGI1-IgG)+, and 1 (6 %) was positive for Glycine receptor-IgG. The patient with a progressive disease course had antibodies against IgLON5. Most patients had disease onset in spring and summer suggesting environmental factors for the development of AE. Also, we observed a different pattern of brain lesions when NMDAr-IgG encephalitis followed herpes encephalitis and a previously unreported association with Rosai-Dorfman-Destombe disease. All patients with encephalopathy met criteria for possible AE and all proven NMDAr-IgG+ met criteria for NMDAr-IgG encephalitis. However, only one LGI1-IgG+ patient fulfilled clinical criteria for limbic encephalitis. All but one received high-dose intravenous methylprednisolone, 11 also had intravenous human immunoglobulin, and 4 plasma exchange. Furthermore, all patients received second-line immunotherapy. Importantly, most patients improved with immunotherapy, even when initiated later in the disease course. CONCLUSION We identified seasonal variability associated with neuronal surface antibodies suggesting environmental triggers. Also, we described the coexistence of NMDAr-IgG encephalitis with histiocytosis. In our series, most patients received second-line immunotherapy. We observed neurologic improvement after treatment even in cases of delayed diagnosis. Increasing the recognition and availability of tests and treatments for these conditions is of paramount importance in low- and middle-income countries.
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Affiliation(s)
- Bruna Klein da Costa
- Hospital São Lucas/ Brain Institute of Rio Grande do Sul, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.
| | - Paula de Oliveira Pinto
- Hospital São Lucas/ Brain Institute of Rio Grande do Sul, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Lia Staub
- School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Gisele Hansel
- Hospital São Lucas/ Brain Institute of Rio Grande do Sul, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Guilherme Vanik Pinto
- Hospital São Lucas/ Brain Institute of Rio Grande do Sul, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Lucas Porcello Schilling
- Hospital São Lucas/ Brain Institute of Rio Grande do Sul, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Giordani Rodrigues Dos Passos
- Hospital São Lucas/ Brain Institute of Rio Grande do Sul, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - William Alves Martins
- Hospital São Lucas/ Brain Institute of Rio Grande do Sul, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Jefferson Becker
- Hospital São Lucas/ Brain Institute of Rio Grande do Sul, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Raphael Machado Castilhos
- Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - André Palmini
- Hospital São Lucas/ Brain Institute of Rio Grande do Sul, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Douglas Kazutoshi Sato
- Hospital São Lucas/ Brain Institute of Rio Grande do Sul, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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Matsui N, Tanaka K, Ishida M, Yamamoto Y, Matsubara Y, Saika R, Iizuka T, Nakamura K, Kuriyama N, Matsui M, Arisawa K, Nakamura Y, Kaji R, Kuwabara S, Izumi Y. Prevalence, Clinical Profiles, and Prognosis of Stiff-Person Syndrome in a Japanese Nationwide Survey. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200165. [PMID: 37739810 PMCID: PMC10519438 DOI: 10.1212/nxi.0000000000200165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/17/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND AND OBJECTIVES To elucidate current epidemiologic, clinical, and immunologic profiles and treatments of stiff-person syndrome (SPS) in Japan. METHODS A nationwide mail survey was conducted using an established method. Data processing sheets were sent to randomly selected departments of internal medicine, neurology, pediatrics, psychiatry, and neurosurgery in hospitals and clinics throughout Japan to identify patients with SPS who were seen between January 2015 and December 2017. RESULTS Thirty cases were identified as glutamic acid decarboxylase 65 (GAD65)-positive SPS cases on the basis of detailed clinical data of 55 cases. Four patients had α1 subunit of glycine receptor (GlyR) antibodies, and 1 patient had both GAD65 and GlyR antibodies. The total estimated number of patients with GAD65-positive SPS was 140, and the estimated prevalence was 0.11 per 100,000 population. The median age at onset was 51 years (range, 26-83 years), and 23 (76%) were female. Of these, 70% had classic SPS, and 30% had stiff-limb syndrome. The median time from symptom onset to diagnosis was significantly longer in the high-titer GAD65 antibody group than in the low-titer group (13 months vs 2.5 months, p = 0.01). The median modified Rankin Scale (mRS) at baseline was 4, and the median mRS at the last follow-up was 2. Among the 29 GAD65-positive patients with ≥1 year follow-up, 7 received only symptomatic treatment, 9 underwent immunotherapy without long-term immunotherapy, and 13 received long-term immunotherapy such as oral prednisolone. The coexistence of type 1 diabetes mellitus and the lack of long-term immunotherapy were independent risk factors for poor outcome (mRS ≥3) in the GAD65-positive patients (odds ratio, 15.0; 95% CI 2.6-131.6; p = 0.001; odds ratio, 19.8; 95% CI 3.2-191.5; p = 0.001, respectively). DISCUSSION This study provides the current epidemiologic and clinical status of SPS in Japan. The symptom onset to the diagnosis of SPS was longer in patients with high-titer GAD65 antibodies than in those with low-titer GAD65 antibodies. The outcome of patients with SPS was generally favorable, but more aggressive immunotherapies are necessary for GAD65-positive patients with SPS.
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Affiliation(s)
- Naoko Matsui
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Keiko Tanaka
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Mitsuyo Ishida
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Yohei Yamamoto
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Yuri Matsubara
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Reiko Saika
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Takahiro Iizuka
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Koshi Nakamura
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Nagato Kuriyama
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Makoto Matsui
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Kokichi Arisawa
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Yosikazu Nakamura
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Ryuji Kaji
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Satoshi Kuwabara
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
| | - Yuishin Izumi
- From the Department of Neurology (N.M., M.I., Y.I.), Tokushima University Graduate School of Biomedical Sciences; Department of Animal Model Development (K.T.), Brain Research Institute, Niigata University; Department of Multiple Sclerosis Therapeutics (K.T.), Fukushima Medical University, School of Medicine; Department of Neurology (Y.Y.), Tokushima University Hospital; Department of Public Health (Y.M., Y.N.), Jichi Medical University, Shimotsuke; Department of Neurology (R.S.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara; Department of Public Health and Hygiene (K.N.), Graduate School of Medicine, University of the Ryukyus, Okinawa; Department of Epidemiology for Community Health and Medicine (N.K.), Kyoto Prefectural University of Medicine; Department of Social Health Medicine (N.K.), Shizuoka Graduate University of Public Health; Department of Neurology (M.M.), Kanazawa Medical University, Ishikawa; Department of Preventive Medicine (K.A.), Tokushima University Graduate School of Biomedical Sciences; National Hospital Organization Utano Hospital (R.K.), Kyoto; and Department of Neurology (S.K.), Graduate School of Medicine, Chiba University, Japan
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15
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Disserol CCD, Kowacs DP, Nabhan SK, Teive HAG, Kowacs PA. Case report: Successful autologous hematopoietic stem cell transplantation in a patient with GAD antibody-spectrum disorder with rapidly progressive dementia. Front Neurol 2023; 14:1254981. [PMID: 37928135 PMCID: PMC10622657 DOI: 10.3389/fneur.2023.1254981] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/20/2023] [Indexed: 11/07/2023] Open
Abstract
The prevalence of neurological syndromes associated with antibodies to glutamic acid decarboxylase is increasing. While cognitive impairment is a common feature of this condition, it seldom emerges as the primary symptom. In this study, we discuss a case of refractory dementia associated with the glutamic acid decarboxylase spectrum disorder. Interestingly, this case showed a favorable outcome following autologous hematopoietic stem cell transplantation. We also provide an in-depth review of the current literature on the use of this therapeutic approach for the treatment of this disease.
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Affiliation(s)
- Caio César Diniz Disserol
- Department of Neurology, Instituto de Neurologia de Curitiba, Curitiba, Brazil
- Department of Neurology, Complexo do Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Brazil
| | - Dora Pedroso Kowacs
- Department of Neurology, Instituto de Neurologia de Curitiba, Curitiba, Brazil
| | - Samir Kanaan Nabhan
- Blood and Marrow Transplantation Program, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil
| | - Hélio Afonso Ghizoni Teive
- Department of Neurology, Complexo do Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Brazil
| | - Pedro André Kowacs
- Department of Neurology, Instituto de Neurologia de Curitiba, Curitiba, Brazil
- Department of Neurology, Complexo do Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Brazil
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16
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Musso G, Zoccarato M, Gallo N, Padoan A, Cosma C, Zuliani L, De Gaspari P, Pegoraro E, Plebani M, Basso D. Analytical evaluation of a GAD65 antibodies chemiluminescence immunoassay for CSF in neurological syndromes. Clin Chem Lab Med 2023; 61:1802-1807. [PMID: 37114858 DOI: 10.1515/cclm-2023-0072] [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: 01/18/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVES Antibodies against glutamic acid decarboxylase isoform 65 (GAD-Ab) have been found in different severe neurological conditions associated with altered synthesis of γ-aminobutyric acid (GABA). Serum GAD-Ab can be found in up to 90 % of patients with type 1 diabetes mellitus (T1DM), mostly at relatively low concentrations, while high concentrations of GAD-ab are thought to be more frequently associate to a neurological condition, with levels 100-folds higher than those found in T1DM. Although CSF testing is recommended when suspecting a GAD-associated neurological syndrome, no commercial immunoassay is validated for this use and no cut-off is internationally recognized to support the diagnosis. METHODS In this study we validated CSF testing of GAD-Ab on an automated chemiluminescence (CLIA) immunoassay that had previously shown good agreement with ELISA on serum. RESULTS We tested 43 CSF from patients with typical GAD-associated neurological disorders and patients with other neurological conditions, identifying a clinical cut-off of 18 kIU/L that discriminated GAD-disease with an area under the curve (AUC) of 0.921. CLIA showed good analytical performances on repeatability and recovery tests in CSF and confirmed an excellent agreement with ELISA. CONCLUSIONS GAD-Ab associated neurological disorders are rare but CSF testing for GAD-Ab is a common request for neurologists when suspecting an insidious autoimmune central nervous system disease. CLIA platforms are expected to be increasingly adopted in clinical laboratories due to their flexibility and reliability, therefore studies on decisional levels should be implemented for improving the interpretation and utilization of laboratory data.
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Affiliation(s)
- Giulia Musso
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy
- Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Marco Zoccarato
- Neurology Unit, Ospedale Sant'Antonio, University-Hospital of Padova, Padova, Italy
| | - Nicoletta Gallo
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy
| | - Andrea Padoan
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy
- Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Chiara Cosma
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy
- QI.LAB.MED, Spin-off of the University of Padova, Padova, Italy
| | - Luigi Zuliani
- Department of Neurology, Ospedale San Bortolo, Vicenza, Italy
| | - Piera De Gaspari
- Neuroimmunology Group, Pediatric Research Institute "Città della Speranza", Padova, Italy
| | - Elena Pegoraro
- Department of Neurosciences DNS, University of Padova, Padova, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy
- Department of Medicine-DIMED, University of Padova, Padova, Italy
- QI.LAB.MED, Spin-off of the University of Padova, Padova, Italy
| | - Daniela Basso
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy
- Department of Medicine-DIMED, University of Padova, Padova, Italy
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17
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Papadopoulos VE, Papadimas GK, Androudi S, Anagnostouli M, Evangelopoulos ME. Stiff-Leg Syndrome Associated with Autoimmune Retinopathy and Its Treatment with IVIg-A Case Report and Review of the Literature. Brain Sci 2023; 13:1361. [PMID: 37891730 PMCID: PMC10605544 DOI: 10.3390/brainsci13101361] [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: 07/31/2023] [Revised: 09/17/2023] [Accepted: 09/20/2023] [Indexed: 10/29/2023] Open
Abstract
Antibodies to glutamic acid decarboxylase (GAD) have been predominantly associated with stiff-person syndrome (SPS), which is often accompanied by organ-specific autoimmune diseases, such as late-onset type 1 diabetes. Autoimmune retinal pathology in SPS has recently been suggested to coexist in patients suffering from this disease; however, evidence reporting potential treatment options for the neurological and visual symptoms these patients experience remains scarce. We provide a review of the relevant literature, presenting a rare case of a middle-aged woman with autoimmune retinopathy (AIR) followed by stiff-leg syndrome who responded to intravenous immune globulin treatment (IVIg). Our report adds to previously reported data supporting the efficacy of IVIg in SPS spectrum disorders while also proposing the potential effect of IVIg in treating SPS spectrum patients with coexisting AIR.
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Affiliation(s)
- Vassilis E Papadopoulos
- First Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - George K Papadimas
- First Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Sofia Androudi
- Department of Ophthalmology, University of Thessaly, 41110 Larissa, Greece
| | - Maria Anagnostouli
- First Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Maria-Eleftheria Evangelopoulos
- First Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
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18
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Vlad B, Wang Y, Newsome SD, Balint B. Stiff Person Spectrum Disorders-An Update and Outlook on Clinical, Pathophysiological and Treatment Perspectives. Biomedicines 2023; 11:2500. [PMID: 37760941 PMCID: PMC10525659 DOI: 10.3390/biomedicines11092500] [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: 08/01/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Stiff person spectrum disorders (SPSD) are paradigm autoimmune movement disorders characterized by stiffness, spasms and hyperekplexia. Though rare, SPSD represent a not-to-miss diagnosis because of the associated disease burden and treatment implications. After decades as an enigmatic orphan disease, major advances in our understanding of the evolving spectrum of diseases have been made along with the identification of multiple associated autoantibodies. However, the most important recent developments relate to the recognition of a wider affection, beyond the classic core motor symptoms, and to further insights into immunomodulatory and symptomatic therapies. In this review, we summarize the recent literature on the clinical and paraclinical spectrum, current pathophysiological understanding, as well as current and possibly future therapeutic strategies.
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Affiliation(s)
- Benjamin Vlad
- Department of Neurology, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Yujie Wang
- Department of Neurology, University of Washington, Seattle, WA 98195, USA
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Scott D. Newsome
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Bettina Balint
- Department of Neurology, University Hospital Zurich, 8091 Zurich, Switzerland;
- Faculty of Medicine, University of Zurich, 8091 Zurich, Switzerland
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19
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Thevarkalam M, Kannoth S, Nambiar V, Gopinath S, Mathai A, Anandakuttan A, Krishnan S, Bhaskaran R. Neurological Manifestations of Glutamic Acid Decarboxylase Autoimmunity in Indian Patients. Ann Indian Acad Neurol 2023; 26:663-671. [PMID: 38022450 PMCID: PMC10666894 DOI: 10.4103/aian.aian_392_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/05/2023] [Accepted: 06/23/2023] [Indexed: 12/01/2023] Open
Abstract
Objective To study the neurological manifestations of glutamic acid decarboxylase (GAD 65) autoimmunity in Indian patients. Methods Retrospective study conducted in a tertiary care referral hospital in South India. Patients who tested positive for GAD 65 antibodies from February 2013 to July 2019 were included. Results We identified 922 patients who underwent GAD 65 testing, of which 81 tested positive (8.78%) [mean age 55.42 years (SD 17.39, range 9-86 years, median age 57 years)]. Males (n = 47) outnumbered the females (n = 34). All the GAD values measured were <5000 IU/ml. There were 34 cases (42%) of atypical parkinsonism (16/34, 47% fulfilled the diagnostic criteria for autoimmune atypical parkinsonism) in our series forming the most common group with GAD 65 positivity, followed by autoimmune encephalitis (8 cases, 9.88%). Men were more affected with atypical parkinsonism (22/34; 64.70%), stiff person syndrome (2/3; 66.66%), and neuropathy (4/7; 57.1%) while women were more with autoimmune encephalitis (6/8; 75%). Eighteen (22.6%) had underlying autoimmunity (three had type 1 diabetes mellitus). Six (7.4%) had underlying neoplasm. Thirty-three out of 43 patients responded to immunotherapy (76.74%). Five had spontaneous improvement. Conclusion Glutamic acid decarboxylase65 antibody values were much lower in our study population. Male-dominant autoimmunity was seen unlike that in Western literature. The most striking was the high preponderance of atypical parkinsonism in GAD 65-positive patients. We also found that GAD 65 positivity is a useful marker for a positive response to immunotherapy in suspected autoimmune neurological syndromes irrespective of their titers.
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Affiliation(s)
- Meena Thevarkalam
- Department of Biochemistry, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Sudheeran Kannoth
- Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
- Department of Neuroimmunology Laboratory, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Vivek Nambiar
- Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Siby Gopinath
- Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Annamma Mathai
- Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
- Department of Neuroimmunology Laboratory, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Anandkumar Anandakuttan
- Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Sajitha Krishnan
- Department of Biochemistry, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Renjitha Bhaskaran
- Department of Biostatistics, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
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20
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Zong S, Vinke AM, Du P, Hoffmann C, Mané-Damas M, Molenaar PC, Damoiseaux JGMC, Losen M, Rouhl RPW, Martinez-Martinez P. Anti-GAD65 autoantibody levels measured by ELISA and alternative types of immunoassays in relation to neuropsychiatric diseases versus diabetes mellitus type 1. Front Neurol 2023; 14:1111063. [PMID: 37305746 PMCID: PMC10248002 DOI: 10.3389/fneur.2023.1111063] [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: 11/29/2022] [Accepted: 05/10/2023] [Indexed: 06/13/2023] Open
Abstract
Background Anti-GAD65 autoantibodies (GAD65-Abs) may occur in patients with epilepsy and other neurological disorders, but the clinical significance is not clear-cut. Whereas high levels of GAD65-Abs are considered pathogenic in neuropsychiatric disorders, low or moderate levels are only considered as mere bystanders in, e.g., diabetes mellitus type 1 (DM1). The value of cell-based assays (CBA) and immunohistochemistry (IHC) for GAD65-Abs detection has not been clearly evaluated in this context. Objective To re-evaluate the assumption that high levels of GAD65-Abs are related to neuropsychiatric disorders and lower levels only to DM1 and to compare ELISA results with CBA and IHC to determine the additional value of these tests. Methods 111 sera previously assessed for GAD65-Abs by ELISA in routine clinical practice were studied. Clinical indications for testing were, e.g., suspected autoimmune encephalitis or epilepsy (neuropsychiatric cohort; n = 71, 7 cases were initially tested positive for GAD65-Abs by ELISA), and DM1 or latent autoimmune diabetes in adults (DM1/LADA cohort (n = 40, all were initially tested positive)). Sera were re-tested for GAD65-Abs by ELISA, CBA, and IHC. Also, we examined the possible presence of GAD67-Abs by CBA and of other neuronal autoantibodies by IHC. Samples that showed IHC patterns different from GAD65 were further tested by selected CBAs. Results ELISA retested GAD65-Abs level in patients with neuropsychiatric diseases was higher than in patients with DM1/LADA (only retested positive samples were compared; 6 vs. 38; median 47,092 U/mL vs. 581 U/mL; p = 0.02). GAD-Abs showed positive both by CBA and IHC only if antibody levels were above 10,000 U/mL, without a difference in prevalence between the studied cohorts. We found other neuronal antibodies in one patient with epilepsy (mGluR1-Abs, GAD-Abs negative), and in a patient with encephalitis, and two patients with LADA. Conclusion GAD65-Abs levels are significantly higher in patients with neuropsychiatric disease than in patients with DM1/LADA, however, positivity in CBA and IHC only correlates with high levels of GAD65-Abs, and not with the underlying diseases.
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Affiliation(s)
- Shenghua Zong
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
| | - Anita M. Vinke
- Department of Neurology, Maastricht University Medical Center (MUMC +), Maastricht, Netherlands
| | - Peng Du
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
| | - Carolin Hoffmann
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
- Algarve Biomedical Center, Algarve Biomedical Center Research Institute, Faro, Portugal
| | - Marina Mané-Damas
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
| | - Peter C. Molenaar
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
| | | | - Mario Losen
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
| | - Rob P. W. Rouhl
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
- Department of Neurology, Maastricht University Medical Center (MUMC +), Maastricht, Netherlands
- Academic Centre for Epileptology Kempenhaeghe/MUMC+, Maastricht, Netherlands
| | - Pilar Martinez-Martinez
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
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21
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Tröscher AR, Mair KM, Verdú de Juan L, Köck U, Steinmaurer A, Baier H, Becker A, Blümcke I, Finzel M, Geis C, Höftberger R, Mawrin C, von Oertzen TJ, Pitsch J, Surges R, Voges B, Weis S, Winklehner M, Woermann F, Bauer J, Bien CG. Temporal lobe epilepsy with GAD antibodies: neurons killed by T cells not by complement membrane attack complex. Brain 2023; 146:1436-1452. [PMID: 36314080 PMCID: PMC10115353 DOI: 10.1093/brain/awac404] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/22/2022] [Accepted: 10/03/2022] [Indexed: 11/14/2022] Open
Abstract
Temporal lobe epilepsy (TLE) is one of the syndromes linked to antibodies against glutamic acid decarboxylase (GAD). It has been questioned whether 'limbic encephalitis with GAD antibodies' is a meaningful diagnostic entity. The immunopathogenesis of GAD-TLE has remained enigmatic. Improvement of immunological treatability is an urgent clinical concern. We retrospectively assessed the clinical, MRI and CSF course as well as brain tissue of 15 adult patients with GAD-TLE who underwent temporal lobe surgery. Brain tissue was studied by means of immunohistochemistry, multiplex fluorescent microscopy and transcriptomic analysis for inflammatory mediators and neuronal degeneration. In 10 patients, there was a period of mediotemporal swelling and T2 signal increase; in nine cases this occurred within the first 6 years after symptom onset. This resulted in unilateral or bilateral hippocampal sclerosis; three cases developed hippocampal sclerosis within the first 2 years. All CSF studies done within the first year (n = 6) revealed intrathecal synthesis of immunoglobulin G. Temporal lobe surgeries were done after a median disease duration of 9 years (range 3 weeks to 60 years). Only two patients became seizure-free. Brain parenchyma collected during surgery in the first 6 years revealed high numbers of plasma cells but no signs of antibody-mediated tissue damage. Even more dense was the infiltration by CD8+ cytotoxic T lymphocytes (CTLs) that were seen to locally proliferate. Further, a portion of these cells revealed an antigen-specific resident memory T cell phenotype. Finally, CTLs with cytotoxic granzyme B+ granules were also seen in microglial nodules and attached to neurons, suggesting a CTL-mediated destruction of these cells. With longer disease duration, the density of all lymphocytes decreased. Whole transcriptome analysis in early/active cases (but not in late/inactive stages) revealed 'T cell immunity' and 'Regulation of immune processes' as the largest overrepresented clusters. To a lesser extent, pathways associated with B cells and neuronal degeneration also showed increased representation. Surgically treated patients with GAD-TLE go through an early active inflammatory, 'encephalitic' stage (≤6 years) with CTL-mediated, antigen-driven neuronal loss and antibody-producing plasma cells but without signs of complement-mediated cell death. Subsequently, patients enter an apparently immunologically inactive or low-active stage with ongoing seizures, probably caused by the structural damage to the temporal lobe. 'Limbic encephalitis' with GAD antibodies should be subsumed under GAD-TLE. The early tissue damage explains why immunotherapy does not usually lead to freedom from seizures.
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Affiliation(s)
- Anna R Tröscher
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
- Department of Neurology I, Neuromed Campus, Kepler University Hospital, Linz, Austria
| | - Katharina M Mair
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Laia Verdú de Juan
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Ulrike Köck
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Anja Steinmaurer
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
| | | | - Albert Becker
- Section for Translational Epilepsy Research Department of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Ingmar Blümcke
- Department of Neuropathology, Universitätsklinikum Erlangen, Erlangen, Germany
| | | | - Christian Geis
- Section Translational Neuroimmunology, Department of Neurology, University Hospital Jena, Jena, Germany
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Christian Mawrin
- Department of Neuropathology, University Hospital Magdeburg, Magdeburg, Germany
| | - Tim J von Oertzen
- Department of Neurology I, Neuromed Campus, Kepler University Hospital, Linz, Austria
| | - Julika Pitsch
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Berthold Voges
- Hamburg Epilepsy Centre, Protestant Hospital Alsterdorf, Department of Neurology and Epileptology, Hamburg, Germany
| | - Serge Weis
- Division of Neuropathology, Department of Pathology and Molecular Pathology, Neuromed Campus, Kepler University Hospital Linz, Linz, Austria
| | - Michael Winklehner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Friedrich Woermann
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
- Epilepsy Centre Bodensee, Ravensburg, Germany
| | - Jan Bauer
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Christian G Bien
- Department of Epileptology (Krankenhaus Mara), Medical School, Campus Bielefeld-Bethel, Bielefeld University, Bielefeld, Germany
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22
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Warren N, Freier K, Siskind D, O'Gorman C, Blum S, Gillis D, Scott JG. Anti-glutamic acid decarboxylase antibody screening in first-episode psychosis. Aust N Z J Psychiatry 2023; 57:603-612. [PMID: 35362325 DOI: 10.1177/00048674221089560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The Royal Australian and New Zealand College of Psychiatrists recommends screening for a range of antibodies in first-episode psychosis, including anti-glutamic acid decarboxylase antibodies. Glutamic acid decarboxylase antibody-associated encephalitis occurs with high antibody titres and may cause cognitive dysfunction, seizures and psychiatric symptoms. However, glutamic acid decarboxylase antibodies are more frequently found in lower titre in association with other autoimmune disorders (such as diabetes mellitus type 1) and in healthy individuals. The utility of testing unselected populations of consumers with psychosis is unclear. The psychiatric manifestations of this disorder are also poorly described. METHODS First, systematic review of cohort and case-control studies that tested for IgG glutamic acid decarboxylase antibodies in psychiatric populations was conducted. Random-effects meta-analysis of odds ratio for antibody positivity in cases with psychosis and controls assessed prevalence. Second, literature review of all published cases and case series of glutamic acid decarboxylase antibody-associated limbic encephalitis was assessed for frequency and description of psychotic symptoms. RESULTS There were 17 studies, in which 2754 individuals with psychotic disorders were tested for glutamic acid decarboxylase IgG antibodies. Thirty-one consumers with psychosis (0.7%) had positive glutamic acid decarboxylase antibodies compared to 24 controls (1.0%), all at low titre and not fulfilling diagnostic criteria for autoimmune encephalitis. Meta-analysis found no significant difference in rates of glutamic acid decarboxylase antibody positivity (odds ratio = 1.8, 95% confidence interval: [0.90, 3.63]). Literature review found 321 cases of glutamic acid decarboxylase antibody-associated limbic encephalitis, with psychosis in 15 (4.3%) cases. Clinical screening would have identified all cases that presented to psychiatric services. CONCLUSION Glutamic acid decarboxylase antibodies were uncommon in consumers with psychosis, with no significant difference in prevalence from controls and no cases of encephalitis identified. In cases with established glutamic acid decarboxylase antibody-associated limbic encephalitis, psychotic symptoms were uncommon and identifiable by clinical assessment. Targeted antibody testing guidelines should be further considered.
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Affiliation(s)
- Nicola Warren
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Karen Freier
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Dan Siskind
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Cullen O'Gorman
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Neurology, The Princess Alexandra Hospital, Brisbane, QLD, Australia
- Mater Centre for Clinical Neurosciences, Mater Hospital, Brisbane, QLD, Australia
| | - Stefan Blum
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Neurology, The Princess Alexandra Hospital, Brisbane, QLD, Australia
- Mater Centre for Clinical Neurosciences, Mater Hospital, Brisbane, QLD, Australia
| | - David Gillis
- Pathology Queensland Central Laboratory, Division of Immunology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - James G Scott
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
- Metro North Mental Health Service, Brisbane, QLD, Australia
- Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
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23
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Pidoplichko VI, Figueiredo TH, Braga MFM, Pan H, Marini AM. Alpha-linolenic acid enhances the facilitation of GABAergic neurotransmission in the BLA and CA1. Exp Biol Med (Maywood) 2023; 248:596-604. [PMID: 37208920 PMCID: PMC10350796 DOI: 10.1177/15353702231165010] [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: 01/31/2023] [Accepted: 03/02/2023] [Indexed: 05/21/2023] Open
Abstract
Hyperexcitability is a major mechanism implicated in several neuropsychiatric disorders, such as organophosphate-induced status epilepticus (SE), primary epilepsy, stroke, spinal cord injury, traumatic brain injury, schizophrenia, and autism spectrum disorders. Underlying mechanisms are diverse, but a functional impairment and loss of GABAergic inhibitory neurons are common features in many of these disorders. While novel therapies abound to correct for the loss of GABAergic inhibitory neurons, it has been difficult at best to improve the activities of daily living for the majority of patients. Alpha-linolenic acid (ALA) is an essential omega-3 polyunsaturated fatty acid found in plants. ALA exerts pleiotropic effects in the brain that attenuate injury in chronic and acute brain disease models. However, the effect of ALA on GABAergic neurotransmission in hyperexcitable brain regions involved in neuropsychiatric disorders, such as the basolateral amygdala (BLA) and CA1 subfield of the hippocampus, is unknown. Administration of a single dose of ALA (1500 nmol/kg) subcutaneously increased the charge transfer of inhibitory postsynaptic potential currents mediated by GABAA receptors in pyramidal neurons by 52% in the BLA and by 92% in the CA1 compared to vehicle animals a day later. Similar results were obtained in pyramidal neurons from the BLA and CA1 when ALA was bath-applied in slices from naïve animals. Importantly, pretreatment with the high-affinity, selective TrkB inhibitor, k252, completely abolished the ALA-induced increase in GABAergic neurotransmission in the BLA and CA1, suggesting a brain-derived neurotrophic factor (BDNF)-mediated mechanism. Addition of mature BDNF (20 ng/mL) significantly increased GABAA receptor inhibitory activity in the BLA and CA1 pyramidal neurons similar to the results obtained with ALA. ALA may be an effective treatment for neuropsychiatric disorders where hyperexcitability is a major feature.
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Affiliation(s)
- Volodymir I Pidoplichko
- Department of Anatomy, Physiology and Genetics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Taiza H Figueiredo
- Department of Anatomy, Physiology and Genetics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Maria FM Braga
- Department of Anatomy, Physiology and Genetics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Hongna Pan
- Department of Neurology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Ann M Marini
- Department of Neurology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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24
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Hou JY, Liu HU, Kuo CY, Liu YH, Lin JJ, Hsieh MY, Hung PC, Cheng YT, Su IC, Wang HS, Chou IJ, Lin KL. The clinical relevance of anti-glutamic acid decarboxylase antibodies in children with encephalitis/encephalopathy. Front Neurosci 2023; 16:1081580. [PMID: 36817097 PMCID: PMC9932768 DOI: 10.3389/fnins.2022.1081580] [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: 10/27/2022] [Accepted: 12/31/2022] [Indexed: 02/05/2023] Open
Abstract
Anti-glutamic acid decarboxylase (anti-GAD) antibodies are associated with different types of syndromes. However, few studies have investigated the correlation between anti-GAD antibody titers with clinical severity and outcomes in children with encephalitis/encephalopathy. In this single-center retrospective cohort study, we consecutively enrolled hospitalized children who had encephalitis and/or encephalopathy with positive anti-GAD antibodies in serum and/or cerebrospinal fluid (CSF) from February 2010 to October 2021. Thirty-seven patients were included and divided into high-titer and low-titer groups. The patients with high anti-GAD antibody titers were associated with initial symptoms of language difficulty and ataxia. The level of titers was not associated with severity or outcomes. Anti-GAD antibody titers decreased after immunotherapy, however, the clinical response to immunotherapy was variable. A transient elevation in anti-GAD antibody titers during immunotherapy was noted. Further studies are warranted to investigate the role of anti-GAD antibodies in the pathogenesis and immune mechanisms of encephalitis/encephalopathy.
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Affiliation(s)
- Ju-Yin Hou
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Hsin-Uei Liu
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Cheng-Yen Kuo
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Yi-Hsuan Liu
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Jainn-Jim Lin
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan,Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Meng-Ying Hsieh
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Po-Cheng Hung
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Yi-Ting Cheng
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - I-Chen Su
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Huei-Shyong Wang
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - I-Jun Chou
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan,College of Medicine, Chang Gung University, Taoyuan City, Taiwan,I-Jun Chou,
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan,College of Medicine, Chang Gung University, Taoyuan City, Taiwan,*Correspondence: Kuang-Lin Lin,
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25
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Muacevic A, Adler JR, McFarlane SI. Autoimmune Encephalitis With Autoimmune Diabetes: A Case of Horror Autotoxicus. Cureus 2023; 15:e34268. [PMID: 36855486 PMCID: PMC9968443 DOI: 10.7759/cureus.34268] [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] [Accepted: 01/27/2023] [Indexed: 01/28/2023] Open
Abstract
Diagnosing autoimmune encephalitis relies on clinical, radiological, and serological studies. Several autoantibodies have been implicated and recognized, with dozens of potential targets identified in the past 20 years. Despite that progress, some patients with encephalitis present a diagnostic dilemma with a seronegative status. The presence of other autoimmune diseases in a patient with encephalitis should provide a clue to the autoimmune nature of a developing neurological syndrome (cognitive, psychiatric, behavioral, and catatonia). In this report, we describe the case of a young man with type 1 diabetes mellitus who was diagnosed with seronegative autoimmune encephalitis after presenting with catatonia. We describe the lengthy clinical course, the various therapeutic trials, and his clinical outcome and response to B-cell depleting agent. This study also discusses the potential pathophysiologic pathways, providing a rationale for the diagnostic workup and therapeutic options for autoimmune encephalopathy in this case presentation.
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26
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Elsherbini N, Weingartshofer A, Backman SB. Postoperative hypotonia in a patient with stiff person syndrome: a case report and literature review. Can J Anaesth 2022; 69:1419-1425. [PMID: 35986141 DOI: 10.1007/s12630-022-02306-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Stiff person syndrome (SPS), an autoimmune disease that manifests with episodic muscle rigidity and spasms, has anesthetic considerations because postoperative hypotonia may occur. This hypotonia has been linked to muscle relaxants and volatile anesthetics and may persist in spite of neostigmine administration and train-of-four (TOF) monitoring suggesting full reversal. We present a patient with SPS who experienced hypotonia following total intravenous anesthesia (TIVA), which was promptly reversed with sugammadex. These observations are considered in light of the relevant medical literature. CLINICAL FEATURES A 46-yr-old female patient with SPS underwent breast lumpectomy and sentinel node biopsy. Anesthesia consisted of TIVA (propofol/remifentanil) with adjunctive administration of rocuronium 20 mg to obtain adequate intubating conditions. Despite return of the TOF ratio to 100% within 30 min, hypotonia was clinically evident at conclusion of surgery two hours later. Sugammadex 250 mg reversed residual muscle relaxation permitting uneventful extubation. A literature review identified six instances of postoperative hypotonia (TIVA, n = 3; volatile anesthetics, n = 3) in spite of neostigmine administration (n = 2) and TOF monitoring suggesting full reversal (n = 4). CONCLUSIONS Patients with SPS may show hypotonia regardless of general anesthetic technique (TIVA vs inhalational anesthesia), which can persist despite recovery of the TOF ratio and may be more effectively reversed by a chelating agent than with an anticholinesterase. If general anesthesia is required, we suggest a cautious approach to administering muscle relaxants including using the smallest dose necessary, considering the importance of clinical assessment of muscle strength recovery in addition to TOF monitoring, and discussing postoperative ventilation risk with the patient prior to surgery.
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Affiliation(s)
- Noha Elsherbini
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | | | - Steven B Backman
- MUHC Department of Anesthesia, Royal Victoria Hospital, 1001 Boulevard Décarie, Rm C05.2653, Montreal, QC, H4A 3J1, Canada.
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27
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Kelch-like protein 11 antibody-associated paraneoplastic neurological syndrome: A state-of-the-art review. Clin Immunol 2022; 241:109074. [PMID: 35809856 DOI: 10.1016/j.clim.2022.109074] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 07/01/2022] [Accepted: 07/04/2022] [Indexed: 11/22/2022]
Abstract
The Kelch-like protein 11 antibody-associated paraneoplastic neurological syndrome (KLHL 11-PNS) was first identified in 2019. This novel antibody, targeting the intracellular KLHL 11 antigen, can be detected in serum and cerebrospinal fluid using tissue-based and cell-based assays. It is thought to be a biomarker for a T-cell autoimmunity response. The most likely immunopathogenesis of KLHL 11-PNS appears to be linked to cytotoxic T-cell-mediated neuronal injury and loss. Patients have adult-male predilection, rhombencephalitis (brainstem and / or cerebellar involvement), and a robust oncological correlation with testicular germ cell tumors (predominately seminoma). Brain magnetic resonance imaging demonstrated T2 / fluid-attenuated inversion recovery hyperintensities and atrophy of the temporal lobe, cerebellum, and brainstem. Most patients responded poorly to immunotherapy and oncotherapy and thus had a poor long-term prognosis. We review the literature and provide an update of current knowledge regarding KLHL 11-PNS, including epidemiology, underlying mechanism, clinical presentations, paraclinical and oncological findings, diagnostic workup, and treatment approaches.
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Aung NL, Vakani V, Wassel M. A Case of Hyperglycemic Ketoacidosis in a Patient Without Diabetes. Cureus 2022; 14:e24560. [PMID: 35664400 PMCID: PMC9148192 DOI: 10.7759/cureus.24560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 11/09/2022] Open
Abstract
We present the case of a 70-year-old Caucasian female who presented to the emergency department with acute pancreatitis and ketoacidosis. An extensive workup for ketoacidosis showed that the patient had hyperglycemic ketoacidosis with findings similar to diabetic ketoacidosis (DKA). However, the patient did not have a history of diabetes, and no diagnosis of diabetes could be made on the current admission as well. Ketoacidosis was determined to be induced by acute hyperglycemia secondary to pancreatitis, which suppresses insulin secretion transiently. It is important to note that DKA can be seen in patients with different types of diabetes and is not just limited to type 1 diabetes.
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29
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Dalakas MC. Stiff-person Syndrome and GAD Antibody-spectrum Disorders: GABAergic Neuronal Excitability, Immunopathogenesis and Update on Antibody Therapies. Neurotherapeutics 2022; 19:832-847. [PMID: 35084720 PMCID: PMC9294130 DOI: 10.1007/s13311-022-01188-w] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2022] [Indexed: 01/10/2023] Open
Abstract
Although antibodies against Glutamic Acid Decarboxylase (GAD) were originally associated with Stiff Person Syndrome (SPS), they now denote the "GAD antibody-spectrum disorders (GAD-SD)" that include Cerebellar Ataxia, Autoimmune Epilepsy, Limbic Encephalitis, PERM and eye movement disorder. In spite of the unique clinical phenotype that each of these disorders has, there is significant overlapping symptomatology characterized by autoimmune neuronal excitability. In addition to GAD, three other autoantibodies, against glycine receptors, amphiphysin and gephyrin, are less frequently or rarely associated with SPS-SD. Very high serum anti-GAD antibody titers are a key diagnostic feature for all GAD-SD, commonly associated with the presence of GAD antibodies in the CSF, a reduced CSF GABA level and increased anti-GAD-specific IgG intrathecal synthesis denoting stimulation of B-cell clones in the CNS. Because anti-GAD antibodies from the various hyperexcitability syndromes recognize the same dominant GAD epitope, the clinical heterogeneity among GAD-SD patients remains unexplained. The paper highlights the biologic basis of autoimmune hyperexcitability connected with the phenomenon of reciprocal inhibition as the fundamental mechanism of the patients' muscle stiffness and spasms; addresses the importance of high-GAD antibody titers in diagnosis, pinpointing the diagnostic challenges in patients with low-GAD titers or their distinction from functional disorders; and discusses whether high GAD-antibodies are disease markers or pathogenic in the context of their association with reduced GABA level in the brain and CSF. Finally, it focuses on therapies providing details on symptomatic GABA-enhancing drugs and the currently available immunotherapies in a step-by-step approach. The prospects of future immunotherapeutic options with antibody therapies are also summarized.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit National and Kapodistrian University of Athens Medical School, Athens, Greece.
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30
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Anti-GAD antibodies associated autoimmunity presenting as isolated dementia: an expansion of GAD antibody-spectrum disorders. Acta Neurol Belg 2022; 123:657-659. [PMID: 35347639 DOI: 10.1007/s13760-022-01937-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/20/2022] [Indexed: 11/01/2022]
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31
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Dimova P, Minkin K. Case Report: Multisystem Autoimmune and Overlapping GAD65-Antibody-Associated Neurological Disorders With Beneficial Effect of Epilepsy Surgery and Rituximab Treatment. Front Neurol 2022; 12:756668. [PMID: 35126284 PMCID: PMC8810502 DOI: 10.3389/fneur.2021.756668] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 12/13/2021] [Indexed: 12/18/2022] Open
Abstract
Glutamic acid decarboxylase (GAD) antibodies are associated with disabling conditions such as stiff person syndrome, temporal lobe epilepsy (TLE), limbic encephalitis, cerebellar ataxia (CA), and ocular movement disorders, which are usually chronic and difficult to treat. GAD-related TLE has poor response to anti-seizure medications and immune therapies, and epilepsy surgery is rarely successful. We report on a 47-year-old female with history of migraine, autoimmune thyroid disease, ankylosing spondylitis, and drug-resistant TLE. A video electroencephalography recorded frequent seizures with temporo-insular semiology, correlating to left temporal epileptiform activity and left mesiotemporal hyperintensity on magnetic resonance imaging. GAD autoimmunity was confirmed by very high GAD antibody titers in serum and cerebrospinal fluid. Steroids, immunoglobulins, and cyclophosphamide had no effect, and selective left amygdalectomy was performed based on very restricted hypermetabolism on positron-emission tomography. After transient seizure freedom, significant epilepsy improvement was observed in spite of memory decline. Transient worsening was noted 1 year later during diabetes mellitus manifestation and 5 years later during presentation of progressive CA, which stabilized on rituximab treatment. We believe this case illustrates the diversity and the frequent overlap of GAD-associated disorders, the need of early and aggressive immunotherapy in severe patients, as well as the possible benefit from epilepsy surgery in some GAD-TLE.
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Affiliation(s)
- Petia Dimova
- Epileptology Unit at Epilepsy Surgery Center, Department of Neurosurgery, St. Ivan Rilski University Hospital, Sofia, Bulgaria
- *Correspondence: Petia Dimova
| | - Krassimir Minkin
- Functional and Epilepsy Surgery Center, Department of Neurosurgery, St. Ivan Rilski University Hospital, Sofia, Bulgaria
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32
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One in a Million: A Case Report of Stiff Person Syndrome. Case Rep Rheumatol 2022; 2022:7741545. [PMID: 35070465 PMCID: PMC8776484 DOI: 10.1155/2022/7741545] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 12/23/2021] [Indexed: 11/18/2022] Open
Abstract
Stiff person syndrome (SPS) is a rare autoimmune disease caused by lack of inhibition to excitatory neurotransmitters in the central nervous system (CNS) leading to inappropriate motor unit firing. The pathophysiology is incompletely understood; however, high titers of antiglutamic acid decarboxylase antibody (anti-GAD Ab) are strongly associated with this disease. We present a 50-year-old woman with a history of ongoing gait and balance issues for 5 years with multiple negative workups. She recently had an acute exacerbation which left her bedbound, unable to move her legs or turn from side to side. After a negative workup at an outside hospital, the patient was discharged to a subacute rehabilitation facility. She then presented to our institution due to worsening of her condition and was ultimately diagnosed with SPS which was successfully treated. We review the case presentation and treatment options in the context of a severe disabling disease presentation.
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Winter WE, Pittman DL, Jialal I. Practical Clinical Applications of Islet Autoantibody Testing in Type 1 Diabetes. J Appl Lab Med 2022; 7:197-205. [PMID: 34996067 DOI: 10.1093/jalm/jfab113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/09/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND The distinction between type 1 diabetes (T1D) and type 2 diabetes (T2D) is extremely important for the choice of therapy, body weight and dietary management, screening for coexistent autoimmune diseases and comorbidities, anticipated prognosis, and risk assessment in relatives. Not uncommonly, the presentation of the patient may not allow an unambiguous discrimination between T1D and T2D. To help resolve this challenge, the detection of islet autoantibodies can support the diagnosis of T1D. CONTENT The presence of islet autoantibodies in a person with diabetes indicates an autoimmune etiology therefore establishing the diagnosis of T1D. Presently 5 islet autoantibodies are available for routine clinical use: islet cell cytoplasmic autoantibodies (ICA), insulin autoantibodies (IAA), glutamic acid decarboxylase autoantibodies (GADA), insulinoma associated-2 autoantibodies (IA-2A), and zinc transporter-8 autoantibodies (ZnT8A). There are caveats to the selection of which islet autoantibodies should be measured. Islet autoantibodies can also predict the development of T1D. Therefore, once safe and effective therapies are available to prevent T1D, islet autoantibody testing is expected to become a routine part of medical practice. A very rare cause of autoimmune diabetes is the type B insulin resistance syndrome resulting from antagonistic autoantibodies to the insulin receptor. Rarely hypoglycemia can result from agonistic insulin receptor autoantibodies, or high-titer IAA causing the autoimmune insulin syndrome (i.e., Hirata disease). SUMMARY In summary, autoimmune causes of dysglycemia are increasing in clinical importance requiring the scrutiny of laboratorians. The determination of islet autoantibodies can greatly aid in the diagnosis and the prediction of T1D.
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Affiliation(s)
- William E Winter
- Departments of Pathology and Pediatrics, University of Florida, Gainesville, FL, USA
| | - David L Pittman
- Department of Pathology, University of Florida, Gainesville, FL, USA
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Thaler FS, Zimmermann L, Kammermeier S, Strippel C, Ringelstein M, Kraft A, Sühs KW, Wickel J, Geis C, Markewitz R, Urbanek C, Sommer C, Doppler K, Penner L, Lewerenz J, Rößling R, Finke C, Prüss H, Melzer N, Wandinger KP, Leypoldt F, Kümpfel T. Rituximab Treatment and Long-term Outcome of Patients With Autoimmune Encephalitis: Real-world Evidence From the GENERATE Registry. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:e1088. [PMID: 34599001 PMCID: PMC8488759 DOI: 10.1212/nxi.0000000000001088] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 08/23/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND OBJECTIVES To determine the real-world use of rituximab in autoimmune encephalitis (AE) and to correlate rituximab treatment with the long-term outcome. METHODS Patients with NMDA receptor (NMDAR)-AE, leucine-rich glioma-inactivated-1 (LGI1)- AE, contactin-associated protein-like-2 (CASPR2)-AE, or glutamic acid decarboxylase 65 (GAD65) disease from the GErman Network for Research on AuToimmune Encephalitis who had received at least 1 rituximab dose and a control cohort of non-rituximab-treated patients were analyzed retrospectively. RESULTS Of the 358 patients, 163 (46%) received rituximab (NMDAR-AE: 57%, CASPR2-AE: 44%, LGI1-AE: 43%, and GAD65 disease: 37%). Rituximab treatment was initiated significantly earlier in NMDAR- and LGI1-AE (median: 54 and 155 days from disease onset) compared with CASPR2-AE or GAD65 disease (median: 632 and 1,209 days). Modified Rankin Scale (mRS) scores improved significantly in patients with NMDAR-AE, both with and without rituximab treatment. Although being more severely affected at baseline, rituximab-treated patients with NMDAR-AE more frequently reached independent living (mRS score ≤2) (94% vs 88%). In LGI1-AE, rituximab-treated and nontreated patients improved, whereas in CASPR2-AE, only rituximab-treated patients improved significantly. No improvement was observed in patients with GAD65 disease. A significant reduction of the relapse rate was observed in rituximab-treated patients (5% vs 13%). Detection of NMDAR antibodies was significantly associated with mRS score improvement. A favorable outcome was also observed with early treatment initiation. DISCUSSION We provide real-world data on immunosuppressive treatments with a focus on rituximab treatment for patients with AE in Germany. We suggest that early and short-term rituximab therapy might be an effective and safe treatment option in most patients with NMDAR-, LGI1-, and CASPR2-AE. CLASS OF EVIDENCE This study provides Class IV evidence that rituximab is an effective treatment for some types of AE.
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Affiliation(s)
- Franziska S. Thaler
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Luise Zimmermann
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Stefan Kammermeier
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Christine Strippel
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Marius Ringelstein
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Andrea Kraft
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Kurt-Wolfram Sühs
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Jonathan Wickel
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Christian Geis
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Robert Markewitz
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Christian Urbanek
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Claudia Sommer
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Kathrin Doppler
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Loana Penner
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Jan Lewerenz
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Rosa Rößling
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Carsten Finke
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Harald Prüss
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Nico Melzer
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Klaus-Peter Wandinger
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Frank Leypoldt
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - Tania Kümpfel
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
| | - on behalf of the German Network for Research on Autoimmune Encephalitis (GENERATE)
- From the Institute of Clinical Neuroimmunology (F.S.T., T.K.), University Hospital and Biomedical Center, Ludwig-Maximilians-Universität, Munich; Section of Translational Neuroimmunology (L.Z., J.W., C.G.), Department of Neurology, Jena University Hospital, Jena; Department of Neurology (S.K.), University Hospital, Ludwig-Maximilians-University, Munich; Department of Neurology with Institute of Translational Neurology (Christine Strippel, N.M.), University of Muenster; Department of Neurology (M.R., N.M.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology Martha-Maria Hospital (A.K.), Halle/Saale, Academic Hospital of University Halle-Wittenberg; Department of Neurology (K.-W.S.), Hannover Medical School; Department of Neurology (R.M., K.-P.W.), University Hospital Schleswig-Holstein, Lübeck; Department of Neurology (C.U.), Klinikum der Stadt Ludwigshafen a. Rh. gGmbH, Ludwigshafen; Department of Neurology (C. Sommer, K.D.), University Hospital Würzburg; Department of Neurology (L.P., J.L.), Ulm University; Department of Neurology and Experimental Neurology (R.R., C.F., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin (R.R., H.P.); Neuroimmunology Section (K.-P.W., F.L.), Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel, Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-Universität Kiel, Germany
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Dalakas MC. Update on Intravenous Immunoglobulin in Neurology: Modulating Neuro-autoimmunity, Evolving Factors on Efficacy and Dosing and Challenges on Stopping Chronic IVIg Therapy. Neurotherapeutics 2021; 18:2397-2418. [PMID: 34766257 PMCID: PMC8585501 DOI: 10.1007/s13311-021-01108-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 02/07/2023] Open
Abstract
In the last 25 years, intravenous immunoglobulin (IVIg) has had a major impact in the successful treatment of previously untreatable or poorly controlled autoimmune neurological disorders. Derived from thousands of healthy donors, IVIg contains IgG1 isotypes of idiotypic antibodies that have the potential to bind pathogenic autoantibodies or cross-react with various antigenic peptides, including proteins conserved among the "common cold"-pre-pandemic coronaviruses; as a result, after IVIg infusions, some of the patients' sera may transiently become positive for various neuronal antibodies, even for anti-SARS-CoV-2, necessitating caution in separating antibodies derived from the infused IVIg or acquired humoral immunity. IVIg exerts multiple effects on the immunoregulatory network by variably affecting autoantibodies, complement activation, FcRn saturation, FcγRIIb receptors, cytokines, and inflammatory mediators. Based on randomized controlled trials, IVIg is approved for the treatment of GBS, CIDP, MMN and dermatomyositis; has been effective in, myasthenia gravis exacerbations, and stiff-person syndrome; and exhibits convincing efficacy in autoimmune epilepsy, neuromyelitis, and autoimmune encephalitis. Recent evidence suggests that polymorphisms in the genes encoding FcRn and FcγRIIB may influence the catabolism of infused IgG or its anti-inflammatory effects, impacting on individualized dosing or efficacy. For chronic maintenance therapy, IVIg and subcutaneous IgG are effective in controlled studies only in CIDP and MMN preventing relapses and axonal loss up to 48 weeks; in practice, however, IVIg is continuously used for years in all the aforementioned neurological conditions, like is a "forever necessary therapy" for maintaining stability, generating challenges on when and how to stop it. Because about 35-40% of patients on chronic therapy do not exhibit objective neurological signs of worsening after stopping IVIg but express subjective symptoms of fatigue, pains, spasms, or a feeling of generalized weakness, a conditioning effect combined with fear that discontinuing chronic therapy may destabilize a multi-year stability status is likely. The dilemmas of continuing chronic therapy, the importance of adjusting dosing and scheduling or periodically stopping IVIg to objectively assess necessity, and concerns in accurately interpreting IVIg-dependency are discussed. Finally, the merit of subcutaneous IgG, the ineffectiveness of IVIg in IgG4-neurological autoimmunities, and genetic factors affecting IVIg dosing and efficacy are addressed.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit, Dept. of Pathophysiology, National and Kapodistrian University of Athens Medical School, Athens, Greece.
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Abstract
Autoimmune neurogenic dysphagia refers to manifestation of dysphagia due to autoimmune diseases affecting muscle, neuromuscular junction, nerves, roots, brainstem, or cortex. Dysphagia is either part of the evolving clinical symptomatology of an underlying neurological autoimmunity or occurs as a sole manifestation, acutely or insidiously. This opinion article reviews the autoimmune neurological causes of dysphagia, highlights clinical clues and laboratory testing that facilitate early diagnosis, especially when dysphagia is the presenting symptom, and outlines the most effective immunotherapeutic approaches. Dysphagia is common in inflammatory myopathies, most prominently in inclusion body myositis, and is frequent in myasthenia gravis, occurring early in bulbar-onset disease or during the course of progressive, generalized disease. Acute-onset dysphagia is often seen in Guillain–Barre syndrome variants and slowly progressive dysphagia in paraneoplastic neuropathies highlighted by the presence of specific autoantibodies. The most common causes of CNS autoimmune dysphagia are demyelinating and inflammatory lesions in the brainstem, occurring in patients with multiple sclerosis and neuromyelitis optica spectrum disorders. Less common, but often overlooked, is dysphagia in stiff-person syndrome especially in conjunction with cerebellar ataxia and high anti-GAD autoantibodies, and in gastrointestinal dysmotility syndromes associated with autoantibodies against the ganglionic acetyl-choline receptor. In the setting of many neurological autoimmunities, acute-onset or progressive dysphagia is a potentially treatable condition, requiring increased awareness for prompt diagnosis and early immunotherapy initiation.
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