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Shelly S, Dubey D, Mills JR, Klein CJ. Paraneoplastic neuropathies and peripheral nerve hyperexcitability disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:239-273. [PMID: 38494281 DOI: 10.1016/b978-0-12-823912-4.00020-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Peripheral neuropathy is a common referral for patients to the neurologic clinics. Paraneoplastic neuropathies account for a small but high morbidity and mortality subgroup. Symptoms include weakness, sensory loss, sweating irregularity, blood pressure instability, severe constipation, and neuropathic pain. Neuropathy is the first presenting symptom of malignancy among many patients. The molecular and cellular oncogenic immune targets reside within cell bodies, axons, cytoplasms, or surface membranes of neural tissues. A more favorable immune treatment outcome occurs in those where the targets reside on the cell surface. Patients with antibodies binding cell surface antigens commonly have neural hyperexcitability with pain, cramps, fasciculations, and hyperhidrotic attacks (CASPR2, LGI1, and others). The antigenic targets are also commonly expressed in the central nervous system, with presenting symptoms being myelopathy, encephalopathy, and seizures with neuropathy, often masked. Pain and autonomic components typically relate to small nerve fiber involvement (nociceptive, adrenergic, enteric, and sudomotor), sometimes without nerve fiber loss but rather hyperexcitability. The specific antibodies discovered help direct cancer investigations. Among the primary axonal paraneoplastic neuropathies, pathognomonic clinical features do not exist, and testing for multiple antibodies simultaneously provides the best sensitivity in testing (AGNA1-SOX1; amphiphysin; ANNA-1-HU; ANNA-3-DACH1; CASPR2; CRMP5; LGI1; PCA2-MAP1B, and others). Performing confirmatory antibody testing using adjunct methods improves specificity. Antibody-mediated demyelinating paraneoplastic neuropathies are limited to MAG-IgM (IgM-MGUS, Waldenström's, and myeloma), with the others associated with cytokine elevations (VEGF, IL6) caused by osteosclerotic myeloma, plasmacytoma (POEMS), and rarely angiofollicular lymphoma (Castleman's). Paraneoplastic disorders have clinical overlap with other idiopathic antibody disorders, including IgG4 demyelinating nodopathies (NF155 and Contactin-1). This review summarizes the paraneoplastic neuropathies, including those with peripheral nerve hyperexcitability.
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Affiliation(s)
- Shahar Shelly
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Neurology, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Christopher J Klein
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
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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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Villagrán-García M, Farina A, Muñiz-Castrillo S, Wucher V, Dhairi M, Timestit N, Ciano-Petersen NL, Vogrig A, Picard G, Benaiteau M, Psimaras D, Petrova AV, Alberto T, Aupy J, Giry M, Rogemond V, Desestret V, Joubert B, Honnorat J. Revisiting anti-Hu paraneoplastic autoimmunity: phenotypic characterization and cancer diagnosis. Brain Commun 2023; 5:fcad247. [PMID: 37794924 PMCID: PMC10546956 DOI: 10.1093/braincomms/fcad247] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/26/2023] [Accepted: 09/21/2023] [Indexed: 10/06/2023] Open
Abstract
Anti-Hu are the most frequent antibodies in paraneoplastic neurological syndromes, mainly associated with an often limited stage small cell lung cancer. The clinical presentation is pleomorphic, frequently multifocal. Although the predominant phenotypes are well characterized, how different neurological syndromes associate is unclear. Likewise, no specific study assessed the performance of new-generation CT and PET scanners for cancer screening in these patients. Herein, we aimed to describe the clinical pattern and cancer screening in a retrospective cohort of 466 patients with anti-Hu autoimmunity from the French Reference Centre on Paraneoplastic Neurological Syndromes registry. Clinical presentation, cancer screening and diagnosis were analysed. Among the 466 patients, 220 (54%) had multifocal neurological involvement. A hierarchical cluster analysis grouped the patients into (i) mainly limbic encephalitis, (ii) predominantly peripheral neuropathy and (iii) broad involvement of the nervous system (mixed group). Compared with limbic encephalitis and mixed groups, patients in the neuropathy group more frequently had a chronic onset of symptoms (29 versus 13 and 17%), elevated CSF proteins (83 versus 47 and 67%) and died from cancer progression (67 versus 15 and 28%; all P < 0.05). No significant difference in overall survival was observed between groups. Dysautonomia and brainstem signs were associated with a higher risk of death from the neurological cause; cancer diagnosis was the main predictor of all-cause death, especially when diagnosed within 2 years from clinical onset (all P < 0.05). Three hundred and forty-nine (75%) patients had cancer: in 295 (84%) neurological symptoms preceded tumour diagnosis, being lung cancer in 262 (89%), thereof small cell lung cancer in 227 (87%). First CT scan revealed lung cancer in 205/241 (85%), and PET scan shortened the interval to diagnosis when the initial CT scan was negative [7 months (1-66) in 27 patients versus 14 months (2-45) in 6; P < 0.001]. Although cancer diagnosis mostly occurred within 2 years from clinical onset, 13/295 (4%) patients exceeded that threshold. Conversely, 33 patients (7%) were 'cancer-free' after 2 years of follow-up. However, 13/33 (39%) had initial suspicious imaging findings that spontaneously regressed. In conclusion, although anti-Hu autoimmunity clinical presentation is mostly multifocal, we observed patients with a predominant limbic syndrome or isolated sensory neuropathy. Early implementation of PET scan shortens the interval to cancer diagnosis, which was the strongest predictor of death, especially if diagnosed ≤2 years from clinical onset. As cancer was diagnosed >2 years after clinical onset in few patients, screening should be extended up to 5 years. In addition, tumour regression was suspected in a substantial proportion of 'cancer-free' patients.
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Affiliation(s)
- Macarena Villagrán-García
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron 69677, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, University Claude Bernard Lyon 1, Lyon 69008, France
| | - Antonio Farina
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron 69677, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, University Claude Bernard Lyon 1, Lyon 69008, France
- Department of Neuroscience, Psychology, Pharmacology and Child Health, University of Florence, Florence 50139, Italy
| | - Sergio Muñiz-Castrillo
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron 69677, France
- Center for Sleep Sciences and Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Valentin Wucher
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron 69677, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, University Claude Bernard Lyon 1, Lyon 69008, France
| | - Maroua Dhairi
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron 69677, France
| | - Noémie Timestit
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron 69677, France
- Department of Biostatistics, Hospices Civils de Lyon, Lyon 69424, France
| | - Nicolás Lundahl Ciano-Petersen
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron 69677, France
- Biomedical Research Institute of Málaga (IBIMA) and Platform of Nanomedicine (BIONAND), Málaga 29590, Spain
| | - Alberto Vogrig
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron 69677, France
- Clinical Neurology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine 33100, Italy
- Department of Medicine (DAME), University of Udine Medical School, Udine 33100, Italy
| | - Géraldine Picard
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron 69677, France
| | - Marie Benaiteau
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron 69677, France
| | - Dimitri Psimaras
- AP-HP, Hospital Group Pitié-Salpêtrière, Neurology 2 Department Mazarin, Paris 75013, France
- Inserm, CNRS, Paris Brain Institute, Institut du Cerveau et de la Moelle épinière (ICM), Paris 75013, France
| | | | - Tifanie Alberto
- Department of Neurology, CRC SEP, Centre Hospitalier of Lille, Lille 59000, France
| | - Jérôme Aupy
- Department of Clinical Neurosciences, Centre Hospitalier of Bordeaux, Bordeaux 33000, France
- CNRS, IMN, UMR 5293, University of Bordeaux, Bordeaux 33076, France
| | - Marine Giry
- AP-HP, Hospital Group Pitié-Salpêtrière, Neurology 2 Department Mazarin, Paris 75013, France
- Inserm, CNRS, Paris Brain Institute, Institut du Cerveau et de la Moelle épinière (ICM), Paris 75013, France
| | - Véronique Rogemond
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron 69677, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, University Claude Bernard Lyon 1, Lyon 69008, France
| | - Virginie Desestret
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron 69677, France
| | - Bastien Joubert
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron 69677, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, University Claude Bernard Lyon 1, Lyon 69008, France
| | - Jérôme Honnorat
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron 69677, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, University Claude Bernard Lyon 1, Lyon 69008, France
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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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Hsieh PC, Wu YR. Diagnosis and Clinical Features in Autoimmune-Mediated Movement Disorders. J Mov Disord 2022; 15:95-105. [PMID: 35670020 PMCID: PMC9171305 DOI: 10.14802/jmd.21077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 04/16/2022] [Accepted: 04/18/2022] [Indexed: 11/24/2022] Open
Abstract
Movement disorders are common manifestations in autoimmune-mediated encephalitis. This group of diseases is suspected to be triggered by infection or neoplasm. Certain phenotypes correlate with specific autoantibody-related neurological disorders, such as orofacial-lingual dyskinesia with N-methyl-D-aspartate receptor encephalitis and faciobrachial dystonic seizures with leucine-rich glioma-inactivated protein 1 encephalitis. Early diagnosis and treatment, especially for autoantibodies targeting neuronal surface antigens, can improve prognosis. In contrast, the presence of autoantibodies against intracellular neuronal agents warrants screening for underlying malignancy. However, early clinical diagnosis is challenging because these diseases can be misdiagnosed. In this article, we review the distinctive clinical phenotypes, magnetic resonance imaging findings, and current treatment options for autoimmune-mediated encephalitis.
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Affiliation(s)
- Pei-Chen Hsieh
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Yih-Ru Wu
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- Department of Neurology, Chang Gung University, College of Medicine, Taoyuan, Taiwan
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6
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Zoccarato M, Grisold W, Grisold A, Poretto V, Boso F, Giometto B. Paraneoplastic Neuropathies: What's New Since the 2004 Recommended Diagnostic Criteria. Front Neurol 2021; 12:706169. [PMID: 34659082 PMCID: PMC8517070 DOI: 10.3389/fneur.2021.706169] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/30/2021] [Indexed: 12/22/2022] Open
Abstract
The diagnostic criteria published by the PNS (Paraneoplastic Neurological Syndromes) Euronetwork in 2004 provided a useful classification of PNS, including paraneoplastic neuropathies. Subacute sensory neuronopathy (SSN) was the most frequently observed peripheral PNS, whereas other forms of neuropathy, as sensory polyneuropathy, sensorimotor polyneuropathy, demyelinating neuropathies, autonomic neuropathies, and focal nerve or plexus lesions, were less frequent. At the time of publication, the main focus was on onconeural antibodies, but knowledge regarding the mechanisms has since expanded. The antibodies associated with PNS are commonly classified as onconeural (intracellular) and neuronal surface antibodies (NSAbs). Since 2004, the number of antibodies and the associated tumors has increased. Knowledge has grown on the mechanisms underlying the neuropathies observed in lymphoma, paraproteinemia, and multiple myeloma. Moreover, other unrevealed mechanisms underpin sensorimotor neuropathies and late-stage neuropathies, where patients in advanced stages of cancer—often associated with weight loss—experience some mild sensorimotor neuropathy, without concomitant use of neurotoxic drugs. The spectrum of paraneoplastic neuropathies has increased to encompass motor neuropathies, small fiber neuropathies, and autonomic and nerve hyperexcitability syndromes. In addition, also focal neuropathies, as cranial nerves, plexopathies, and mononeuropathies, are considered in some cases to be of paraneoplastic origin. A key differential diagnosis for paraneoplastic neuropathy, during the course of cancer disease (the rare occurrence of a PNS), is chemotherapy-induced peripheral neuropathy (CIPN). Today, novel complications that also involve the peripheral nervous system are emerging from novel anti-cancer therapies, as targeted and immune checkpoint inhibitor (ICH) treatment. Therapeutic options are categorized into causal and symptomatic. Causal treatments anecdotally mention tumor removal. Immunomodulation is sometimes performed for immune-mediated conditions but is still far from constituting evidence. Symptomatic treatment must always be considered, consisting of both drug therapy (e.g., pain) and attempts to treat disability and neuropathic pain.
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Affiliation(s)
- Marco Zoccarato
- Neurology Unit O.S.A., Azienda Ospedale-Università di Padova, Padova, Italy
| | - Wolfgang Grisold
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology Donaueschingenstraße 13 A-1200 Vienna, Vienna, Austria
| | - Anna Grisold
- Department of Neurology, Medical University Vienna, Vienna, Austria
| | - Valentina Poretto
- Neurology Unit, Ospedale S Chiara, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Federica Boso
- Neurology Unit, Ospedale S Chiara, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Bruno Giometto
- Neurology Unit, Ospedale S Chiara, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy.,Department of Neurology, University of Trieste, Trieste, Italy
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Totland C, Haugen M, Vedeler C. CRMP5 Antibodies-Diagnostic Challenges. Front Neurol 2021; 12:729075. [PMID: 34630302 PMCID: PMC8492982 DOI: 10.3389/fneur.2021.729075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/23/2021] [Indexed: 11/13/2022] Open
Abstract
CRMP5-associated paraneoplastic neurological syndromes (PNS) are rare, and only few studies describe larger cohorts of patients with CRMP5 antibodies. We have included 24 patients with CRMP5 antibodies and compared clinical findings with diagnostic findings from two different line assays (Ravo and Euroimmun), staining of cerebellar sections and results of a newly developed cell-based assay for detection of CRMP5 antibodies, CRMP5-CBA. We found that peripheral neuropathy and cerebellar ataxia together with lung cancer were the most common diagnoses associated with CRMP5 antibodies. CRMP5-CBA was easy to perform, identified all relevant cases for CRMP5-associated PNS and is therefore a valuable add-on for verification of CRMP5 positivity in diagnosis of PNS.
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Affiliation(s)
- Cecilie Totland
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Mette Haugen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Christian Vedeler
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Hansen N, Lipp M, Vogelgsang J, Vukovich R, Zindler T, Luedecke D, Gingele S, Malchow B, Frieling H, Kühn S, Denk J, Gallinat J, Skripuletz T, Moschny N, Fiehler J, Riedel C, Wiedemann K, Wattjes MP, Zerr I, Esselmann H, Bleich S, Wiltfang J, Neyazi A. Autoantibody-associated psychiatric symptoms and syndromes in adults: A narrative review and proposed diagnostic approach. Brain Behav Immun Health 2021; 9:100154. [PMID: 34589896 PMCID: PMC8474611 DOI: 10.1016/j.bbih.2020.100154] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/26/2020] [Indexed: 12/13/2022] Open
Abstract
Background Autoimmune-mediated encephalitis is a disease that often encompasses psychiatric symptoms as its first clinical manifestation’s predominant and isolated characteristic. Novel guidelines even distinguish autoimmune psychosis from autoimmune encephalitis. The aim of this review is thus to explore whether a wide range of psychiatric symptoms and syndromes are associated or correlate with autoantibodies. Methods We conducted a PubMed search to identify appropriate articles concerning serum and/or cerebrospinal fluid (CSF) autoantibodies associated with psychiatric symptoms and syndromes between 2000 and 2020. Relying on this data, we developed a diagnostic approach to optimize the detection of autoantibodies in psychiatric patients, potentially leading to the approval of an immunotherapy. Results We detected 10 major psychiatric symptoms and syndromes often reported to be associated with serum and/or CSF autoantibodies comprising altered consciousness, disorientation, memory impairment, obsessive-compulsive behavior, psychosis, catatonia, mood dysfunction, anxiety, behavioral abnormalities (autism, hyperkinetic), and sleeping dysfunction. The following psychiatric diagnoses were associated with serum and/or CSF autoantibodies: psychosis and schizophrenia spectrum disorders, mood disorders, minor and major neurocognitive impairment, obsessive-compulsive disorder, autism spectrum disorders (ASD), attention deficit hyperactivity disorder (ADHD), anxiety disorders, eating disorders and addiction. By relying on these symptom clusters and diagnoses in terms of onset and their duration, we classified a subacute or subchronic psychiatric syndrome in patients that should be screened for autoantibodies. We propose further diagnostics entailing CSF analysis, electroencephalography and magnetic resonance imaging of the brain. Exploiting these technologies enables standardized and accurate diagnosis of autoantibody-associated psychiatric symptoms and syndromes to deliver early immunotherapy. Conclusions We have developed a clinical diagnostic pathway for classifying subgroups of psychiatric patients whose psychiatric symptoms indicate a suspected autoimmune origin. Autoantibodies are associated with a broad spectrum of psychiatric syndromes. More systematic studies are needed to elucidate the significance of autoantibodies. We developed a pathway to identify autoantibody-associated psychiatric syndromes.
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Affiliation(s)
- Niels Hansen
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Von-Siebold-Str. 5, 37075, Goettingen, Germany
| | - Michael Lipp
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Jonathan Vogelgsang
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Von-Siebold-Str. 5, 37075, Goettingen, Germany
| | - Ruth Vukovich
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Von-Siebold-Str. 5, 37075, Goettingen, Germany
| | - Tristan Zindler
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Daniel Luedecke
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Stefan Gingele
- Department of Neurology, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Berend Malchow
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Von-Siebold-Str. 5, 37075, Goettingen, Germany
| | - Helge Frieling
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Simone Kühn
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Johannes Denk
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Jürgen Gallinat
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Thomas Skripuletz
- Department of Neurology, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Nicole Moschny
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Christian Riedel
- Department of Neuroradiology, University of Goettingen, Robert-Koch Str. 40, 37075, Goettingen, Germany
| | - Klaus Wiedemann
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Mike P Wattjes
- Department of Neuroradiology, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Inga Zerr
- Department of Neurology, University of Goettingen, Robert-Koch Str. 40, 37075, Goettingen, Germany.,German Center for Neurodegenerative Diseases (DZNE), Von-Siebold-Str. 3a, 37075, Goettingen, Germany
| | - Hermann Esselmann
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Von-Siebold-Str. 5, 37075, Goettingen, Germany
| | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Jens Wiltfang
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Von-Siebold-Str. 5, 37075, Goettingen, Germany.,German Center for Neurodegenerative Diseases (DZNE), Von-Siebold-Str. 3a, 37075, Goettingen, Germany.,Neurosciences and Signaling Group, Institute of Biomedicine (iBiMED), Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
| | - Alexandra Neyazi
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
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Langenbruch L, Wiendl H, Groß C, Kovac S. Diagnostic utility of cerebrospinal fluid (CSF) findings in seizures and epilepsy with and without autoimmune-associated disease. Seizure 2021; 91:233-243. [PMID: 34233238 DOI: 10.1016/j.seizure.2021.06.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/12/2021] [Accepted: 06/17/2021] [Indexed: 01/17/2023] Open
Abstract
Patients with seizures and epilepsy routinely undergo multiple diagnostic tests, which may include cerebrospinal fluid (CSF) analysis. This review aims to outline different CSF parameters and their alterations in seizures or epilepsy. We then discuss the utility of CSF analysis in seizure patients in different clinical settings in depth. Some routine CSF parameters are frequently altered after seizures, but are not specific such as CSF protein and lactate. Pleocytosis and CSF specific oligoclonal bands are rare and should be considered as signs of infectious or immune mediated seizures and epilepsy. Markers of neuronal damage show conflicting results, and are as yet not established in clinical practice. Parameters of neuronal degeneration and more specific immune parameters are less well studied, and are areas of further research. CSF analysis in new-onset seizures or status epilepticus serves well in the differential diagnosis of seizure etiology. Here, considerations should include autoimmune-associated seizures. CSF findings in these disorders are a special focus of this review and are summarized in a comprehensive overview. Until now, CSF analysis has not yielded clinically helpful biomarkers for refractory epilepsy or for assessment of neuronal damage which is a subject of further studies.
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Affiliation(s)
- Lisa Langenbruch
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149 Münster, Germany; Department of Neurology, Klinikum Osnabrück, Am Finkenhügel 1, 49076 Osnabrück, Germany.
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149 Münster, Germany.
| | - Catharina Groß
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149 Münster, Germany.
| | - Stjepana Kovac
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149 Münster, Germany.
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10
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Seeliger T, Gingele S, Bönig L, Konen FF, Körner S, Prenzler N, Thiele T, Ernst D, Witte T, Stangel M, Skripuletz T. CIDP associated with Sjögren's syndrome. J Neurol 2021; 268:2908-2912. [PMID: 33611611 DOI: 10.1007/s00415-021-10459-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/09/2021] [Accepted: 02/09/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study addresses the challenging characterisation and differentiation of CIDP versus CIDP in association with Sjögren's syndrome to facilitate the process in clinical routine. METHODS Patients with both CIDP and Sjögren's syndrome and CIDP without Sjögren's syndrome were compared concerning relevant differences in clinical, laboratory and electrophysiological findings. 154 patients who fulfilled the diagnostic EFNS/PNS criteria for CIDP were included in the analysis. 54 of these patients additionally fulfilled the ACR/EULAR classification criteria for Sjögren's syndrome. RESULTS The frequency of female patients was higher in patients with CIDP and Sjögren's syndrome (52%) versus CIDP patients without Sjögren's syndrome (28%). Furthermore, the occurrence of cranial nerve impairment was significantly higher in patients with Sjögren's syndrome (39% versus 14%). There were no significant group differences in the evaluation of initial symptoms, severity of disability judged by INCAT disability scale score, presence or distribution of sensory deficits, limb weakness and the presence of ataxia, pain or dysautonomia, CSF laboratory or electrophysiological findings. CONCLUSIONS In conclusion, our data indicate that cranial nerve impairment and female gender might represent red flags for an additional Sjögren's syndrome in patients with CIDP. The patterns of clinical disabilities and electrophysiological findings due to peripheral nerve damage are similar in both CIDP entities.
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Affiliation(s)
- Tabea Seeliger
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Stefan Gingele
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Lena Bönig
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Franz Felix Konen
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Sonja Körner
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Nils Prenzler
- Department of Otolaryngology, Hannover Medical School, Hannover, Germany
| | - Thea Thiele
- Department of Rheumatology and Immunology, Hannover Medical School, Hannover, Germany
| | - Diana Ernst
- Department of Rheumatology and Immunology, Hannover Medical School, Hannover, Germany
| | - Torsten Witte
- Department of Rheumatology and Immunology, Hannover Medical School, Hannover, Germany
| | - Martin Stangel
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Thomas Skripuletz
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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11
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Diagnosis and Differential Diagnosis of Neurological Adverse Events during Immune Checkpoint Inhibitor Therapy. JOURNAL OF ONCOLOGY 2021; 2020:8865054. [PMID: 33381178 PMCID: PMC7749779 DOI: 10.1155/2020/8865054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/13/2020] [Accepted: 11/21/2020] [Indexed: 01/05/2023]
Abstract
Therapy with immune checkpoint inhibitors (ICIs) has improved overall survival and cancer-related morbidity of cancer treatment even in cancer entities with poor prognosis. Since the approval of the first ICI, ipilimumab, for treatment of advanced melanoma by the Food and Drug Administration (FDA) in 2011, the spectrum of indications and approved ICIs has grown, rapidly. Up to now, seven different ICIs for more than 20 indications are available. However, their mechanisms of action can lead to immune-related adverse events (irAEs). In particular, neurological irAEs are clinically relevant. Although they are rare, an early and accurate diagnosis is challenging and neurological disease course and sequelae are potentially fatal. Between 08/2017 and 03/2020, 31 patients received ICI treatment at Hannover Medical School and presented with neurological adverse events (N-irAEs). Treated malignancies were metastatic melanoma, bronchial carcinoma, and urothelial cell carcinoma. All patients received comprehensive neurological diagnostics including clinical examination and magnetic resonance imaging (MRI). Cerebrospinal fluid (CSF) analysis was obtained in 21 patients and electroneurography was performed in 22 patients. Although N-irAEs were suspected in all 31 patients, 11 patients had other conditions leading to neurological symptoms including tumor metastases in seven patients and hemorrhagic or ischemic stroke in four patients. In the following, these patients are referred to as the differential diagnosis (DD) group. Patients with N-irAEs suffered from immune mediated neuropathy (9/20), myositis and/or myasthenic syndrome (6/20), or encephalitis/cerebellitis (5/20). Except for cell count, CSF results did not differ between the N-irAEs and the DD group. Symptoms related to N-irAEs are rather unspecific potentially mimicking other tumor-related symptoms such as metastases. Patients with malignancy are predominantly not treated by neurologists. Because of the complexity of neurological symptoms, detailed neurological investigations in specialized institutions are necessary in patients with new neurological symptoms and need to be critically discussed with treating oncologists.
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12
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Evidence of Oligoclonal Bands Does Not Exclude Non-Inflammatory Neurological Diseases. Diagnostics (Basel) 2020; 11:diagnostics11010037. [PMID: 33379245 PMCID: PMC7824674 DOI: 10.3390/diagnostics11010037] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/17/2022] Open
Abstract
Cerebrospinal fluid analysis is an essential part of the diagnostic workup in various neurological disorders. Evidence of an intrathecal immunoglobulin synthesis, as demonstrated by Reiber’s diagram or the more sensitive oligoclonal bands (OCB), are typical for neuroinflammatory diseases, and normally not expected in non-inflammatory neurological diseases. Therefore, patients with non-inflammatory neurological diseases are often used in control groups in studies investigating autoimmune diseases of the central nervous system. However, data about the frequency of intrathecal immunoglobulin synthesis in non-inflammatory neurological disease are scarce. The cerebrospinal fluid (CSF) records of a total of 3622 patients were screened and 2114 patients included with presumably non-inflammatory neurological diseases like dementia, idiopathic peripheral neuropathy, motoneuron disease, stroke, and epileptic seizures. Evidence of an intrathecal immunoglobulin synthesis can be found with low frequency also in non-inflammatory neurological diseases. A much higher rate of patients showed intrathecal immunoglobulin synthesis as demonstrated by OCB than by Reiber’s diagram. In patients with disorders of the peripheral nervous system the frequency of OCB was much lower than in patients presenting with central nervous system manifestations. Evidence of an intrathecal immunoglobulin synthesis should not automatically lead to exclusion of non-inflammatory neurological diseases but should rather prompt the way to investigate for the origin of the intrathecal immunoglobulin synthesis.
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13
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Anti-Hu associated paraneoplastic neuropathy simulating an axonal variant of Guillain-Barré syndrome. NEUROLOGÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.nrleng.2017.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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14
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Möhn N, Pfeuffer S, Ruck T, Gross CC, Skripuletz T, Klotz L, Wiendl H, Stangel M, Meuth SG. Alemtuzumab therapy changes immunoglobulin levels in peripheral blood and CSF. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 7:7/2/e654. [PMID: 31826986 PMCID: PMC7007635 DOI: 10.1212/nxi.0000000000000654] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 11/04/2019] [Indexed: 11/25/2022]
Abstract
Objective The use of alemtuzumab, a humanized monoclonal anti-CD52 antibody has changed the therapy of highly active relapsing-remitting MS (RRMS). Alemtuzumab infusion depletes most lymphocytes in peripheral blood, whereas differential recovery of immune cells, probably those with a less CNS-autoreactive phenotype, is supposed to underlie its long-lasting effects. To determine whether alemtuzumab significantly reduces immunoglobulin levels in blood and CSF of treated patients, we analyzed blood and CSF samples of 38 patients with MS treated with alemtuzumab regarding changes in immunoglobulin levels. Methods Blood and CSF samples of patients were collected at the beginning of alemtuzumab treatment and at 12, 24, and 36 months after the first administration of the drug. Specimens were analyzed regarding immunoglobulin concentrations in blood and CSF. Results We observed significant and dose-dependent reductions of immunoglobulin levels (IgG, IgM, and IgA) in serum and CSF 12 and 24 months following 2 courses of alemtuzumab. Patients with persistent or returning disease activity who were treated with a third course of alemtuzumab exhibited even further decrease in IgG levels compared with matched controls treated twice. Here, alemtuzumab-treated patients with IgG levels below the lower limits of normal were more susceptible to pneumonia, sinusitis, and otitis, whereas upper respiratory tract and urinary tract infections were not associated therewith. Conclusions Our results suggest to monitor IgG levels for safety reasons in patients treated with alemtuzumab—in particular when additional treatment courses are required—and to consider preventive action in critical cases. Classification of evidence This study provides Class IV evidence that for patients with RRMS alemtuzumab reduces immunoglobulin levels.
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Affiliation(s)
- Nora Möhn
- From the Department of Neurology and Clinical Neuroimmunology and Neurochemistry (N.M., T.S., M.S.), Hannover Medical School, Hannover, Germany; and Neurology Clinic with Institute of Translational Neurology (S.P., T.R., C.C.G., L.K., H.W., S.G.M.), University of Münster, Münster, Germany
| | - Steffen Pfeuffer
- From the Department of Neurology and Clinical Neuroimmunology and Neurochemistry (N.M., T.S., M.S.), Hannover Medical School, Hannover, Germany; and Neurology Clinic with Institute of Translational Neurology (S.P., T.R., C.C.G., L.K., H.W., S.G.M.), University of Münster, Münster, Germany
| | - Tobias Ruck
- From the Department of Neurology and Clinical Neuroimmunology and Neurochemistry (N.M., T.S., M.S.), Hannover Medical School, Hannover, Germany; and Neurology Clinic with Institute of Translational Neurology (S.P., T.R., C.C.G., L.K., H.W., S.G.M.), University of Münster, Münster, Germany
| | - Catharina C Gross
- From the Department of Neurology and Clinical Neuroimmunology and Neurochemistry (N.M., T.S., M.S.), Hannover Medical School, Hannover, Germany; and Neurology Clinic with Institute of Translational Neurology (S.P., T.R., C.C.G., L.K., H.W., S.G.M.), University of Münster, Münster, Germany
| | - Thomas Skripuletz
- From the Department of Neurology and Clinical Neuroimmunology and Neurochemistry (N.M., T.S., M.S.), Hannover Medical School, Hannover, Germany; and Neurology Clinic with Institute of Translational Neurology (S.P., T.R., C.C.G., L.K., H.W., S.G.M.), University of Münster, Münster, Germany
| | - Luisa Klotz
- From the Department of Neurology and Clinical Neuroimmunology and Neurochemistry (N.M., T.S., M.S.), Hannover Medical School, Hannover, Germany; and Neurology Clinic with Institute of Translational Neurology (S.P., T.R., C.C.G., L.K., H.W., S.G.M.), University of Münster, Münster, Germany
| | - Heinz Wiendl
- From the Department of Neurology and Clinical Neuroimmunology and Neurochemistry (N.M., T.S., M.S.), Hannover Medical School, Hannover, Germany; and Neurology Clinic with Institute of Translational Neurology (S.P., T.R., C.C.G., L.K., H.W., S.G.M.), University of Münster, Münster, Germany
| | - Martin Stangel
- From the Department of Neurology and Clinical Neuroimmunology and Neurochemistry (N.M., T.S., M.S.), Hannover Medical School, Hannover, Germany; and Neurology Clinic with Institute of Translational Neurology (S.P., T.R., C.C.G., L.K., H.W., S.G.M.), University of Münster, Münster, Germany.
| | - Sven G Meuth
- From the Department of Neurology and Clinical Neuroimmunology and Neurochemistry (N.M., T.S., M.S.), Hannover Medical School, Hannover, Germany; and Neurology Clinic with Institute of Translational Neurology (S.P., T.R., C.C.G., L.K., H.W., S.G.M.), University of Münster, Münster, Germany
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15
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Skripuletz T, Pars K, Schulte A, Schwenkenbecher P, Yildiz Ö, Ganzenmueller T, Kuhn M, Spreer A, Wurster U, Pul R, Stangel M, Sühs KW, Trebst C. Varicella zoster virus infections in neurological patients: a clinical study. BMC Infect Dis 2018; 18:238. [PMID: 29801466 PMCID: PMC5970536 DOI: 10.1186/s12879-018-3137-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 05/09/2018] [Indexed: 12/15/2022] Open
Abstract
Background Varicella zoster virus (VZV) reactivation is a common infectious disease in neurology and VZV the second most frequent virus detected in encephalitis. This study investigated characteristics of clinical and laboratory features in patients with VZV infection. Methods Two hundred eighty two patients with VZV reactivation that were hospitalized in the department of neurology in the time from 2005 to 2013 were retrospectively evaluated. Results from cerebrospinal fluid (CSF) analysis were available from 85 patients. Results Trigeminal rash was the most common clinical manifestation, followed by segmental rash, CNS infection, facial nerve palsy, postherpetic neuralgia, and radiculitis. MRI of the brain performed in 25/33 patients with encephalitis/meningitis did not show any signs of infection in the brain parenchyma. Only one patient showed contrast enhancement in the hypoglossal nerve. General signs of infection such as fever or elevated CRP values were found in only half of the patients. Furthermore, rash was absent in a quarter of patients with CNS infection and facial nerve palsy, and thus, infection could only be proven by CSF analysis. Although slight inflammatory CSF changes occurred in few patients with isolated rash, the frequency was clearly higher in patients with CNS infection and facial nerve palsy. Conclusion Monosegmental herpes zoster is often uncomplicated and a diagnostic lumbar puncture is not essential. In contrast, CSF analysis is an essential diagnostic tool in patients with skin lesions and cranial nerve or CNS affection. In patients with neuro-psychiatric symptoms and inflammatory CSF changes analysis for VZV should be performed even in the absence of skin lesions.
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Affiliation(s)
- Thomas Skripuletz
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str-1, 30625, Hannover, Germany.
| | - Kaweh Pars
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str-1, 30625, Hannover, Germany
| | - Alina Schulte
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str-1, 30625, Hannover, Germany
| | - Philipp Schwenkenbecher
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str-1, 30625, Hannover, Germany
| | - Özlem Yildiz
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str-1, 30625, Hannover, Germany
| | | | - Maike Kuhn
- TWINCORE Centre for Experimental and Clinical Infection Research, Hannover and Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Annette Spreer
- Department of Neurology, University Medical Center of Mainz, Mainz, Germany
| | - Ulrich Wurster
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str-1, 30625, Hannover, Germany
| | - Refik Pul
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str-1, 30625, Hannover, Germany.,Department of Neurology, University Clinic Essen, Essen, Germany
| | - Martin Stangel
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str-1, 30625, Hannover, Germany
| | - Kurt-Wolfram Sühs
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str-1, 30625, Hannover, Germany
| | - Corinna Trebst
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str-1, 30625, Hannover, Germany
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16
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Gadoth A, Zekeridou A, Klein CJ, Thoreson CJ, Majed M, Dubey D, Flanagan EP, McKeon A, Jenkins SM, Lennon VA, Pittock SJ. Elevated LGI1-IgG CSF index predicts worse neurological outcome. Ann Clin Transl Neurol 2018; 5:646-650. [PMID: 29761127 PMCID: PMC5945965 DOI: 10.1002/acn3.561] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 02/22/2018] [Accepted: 02/23/2018] [Indexed: 01/17/2023] Open
Abstract
To determine whether CSF leucine‐rich glioma‐inactivated 1(LGI1)‐IgG titer, index or IgG subclass has prognostic significance, we tested serum and CSF specimens collected concomitantly from 39 seropositive patients. LGI1‐IgG index was elevated (>1) in 21 patients (54%), suggesting intrathecal synthesis. Patients with worse outcome at last follow‐up (modified Rankin Scale >2) had significantly higher index (median 6.57 vs. 0.5, P = 0.048) compared to those with better outcome. Higher CSF LGI1‐IgG4 subclass‐specific titer and index correlated with worse outcome (P < 0.005 for both). These data suggest that evidence of intrathecal LGI1‐IgG synthesis may correlate with neuronal injury and warrant consideration of aggressive immunotherapy.
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Affiliation(s)
- Avi Gadoth
- Department of Neurology Mayo Clinic Rochester Minnesota.,Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota
| | - Anastasia Zekeridou
- Department of Neurology Mayo Clinic Rochester Minnesota.,Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota
| | - Christopher J Klein
- Department of Neurology Mayo Clinic Rochester Minnesota.,Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota
| | | | - Masoud Majed
- Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota
| | - Divyanshu Dubey
- Department of Neurology Mayo Clinic Rochester Minnesota.,Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota
| | - Eoin P Flanagan
- Department of Neurology Mayo Clinic Rochester Minnesota.,Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota
| | - Andrew McKeon
- Department of Neurology Mayo Clinic Rochester Minnesota.,Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota
| | - Sarah M Jenkins
- Department of Health Sciences Research Mayo Clinic Rochester Minnesota
| | - Vanda A Lennon
- Department of Neurology Mayo Clinic Rochester Minnesota.,Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota.,Department of Immunology Mayo Clinic Rochester Minnesota
| | - Sean J Pittock
- Department of Neurology Mayo Clinic Rochester Minnesota.,Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota
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17
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Schwenkenbecher P, Chacko L, Pul R, Sühs KW, Wegner F, Wurster U, Stangel M, Skripuletz T. Paraneoplastic cerebellar syndromes associated with antibodies against Purkinje cells. Int J Neurosci 2017; 128:721-728. [DOI: 10.1080/00207454.2017.1412967] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Philipp Schwenkenbecher
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Lisa Chacko
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Refik Pul
- Department of Neurology, Essen University Hospital, Essen, Germany
| | - Kurt-Wolfram Sühs
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Florian Wegner
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Ulrich Wurster
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Martin Stangel
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Thomas Skripuletz
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hannover Medical School, Hannover, Germany
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18
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Pérez Sánchez S, Pérez Noguera R, Sánchez Sánchez V, López Domínguez JM. Anti-Hu associated paraneoplastic neuropathy simulating an axonal variant of Guillain-Barré syndrome. Neurologia 2017; 35:346-347. [PMID: 29169808 DOI: 10.1016/j.nrl.2017.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 08/19/2017] [Accepted: 09/12/2017] [Indexed: 10/18/2022] Open
Affiliation(s)
- S Pérez Sánchez
- Servicio de Neurología, Hospital Universitario Virgen Macarena, Sevilla, España.
| | - R Pérez Noguera
- Servicio de Neurología, Hospital Universitario Virgen Macarena, Sevilla, España
| | - V Sánchez Sánchez
- Servicio de Neurología, Hospital Universitario Virgen Macarena, Sevilla, España
| | - J M López Domínguez
- Servicio de Neurología, Hospital Universitario Virgen Macarena, Sevilla, España
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19
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Schwenkenbecher P, Sarikidi A, Bönig L, Wurster U, Bronzlik P, Sühs KW, Pul R, Stangel M, Skripuletz T. Clinically Isolated Syndrome According to McDonald 2010: Intrathecal IgG Synthesis Still Predictive for Conversion to Multiple Sclerosis. Int J Mol Sci 2017; 18:ijms18102061. [PMID: 28953254 PMCID: PMC5666743 DOI: 10.3390/ijms18102061] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 09/20/2017] [Accepted: 09/22/2017] [Indexed: 12/27/2022] Open
Abstract
While the revised McDonald criteria of 2010 allow for the diagnosis of multiple sclerosis (MS) in an earlier stage, there is still a need to identify the risk factors for conversion to MS in patients with clinically isolated syndrome (CIS). Since the latest McDonald criteria were established, the prognostic role of cerebrospinal fluid (CSF) and visual evoked potentials (VEP) in CIS patients is still poorly defined. We conducted a monocentric investigation including patients with CIS in the time from 2010 to 2015. Follow-ups of 120 patients revealed that 42% converted to MS. CIS patients with positive oligoclonal bands (OCB) were more than twice as likely to convert to MS as OCB negative patients (hazard ratio = 2.6). The probability to develop MS was even higher when a quantitative intrathecal IgG synthesis was detected (hazard ratio = 3.8). In patients with OCB, VEP did not add further information concerning the conversion rate to MS. In patients with optic neuritis and negative OCB, a significantly higher rate converted to MS when VEP were delayed. In conclusion, the detection of an intrathecal IgG synthesis increases the conversion probability to MS. Pathological VEP can help to predict the conversion rate to MS in patients with optic neuritis without an intrathecal IgG synthesis.
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Affiliation(s)
- Philipp Schwenkenbecher
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hannover Medical School, 30625 Hannover, Germany.
| | - Anastasia Sarikidi
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hannover Medical School, 30625 Hannover, Germany.
| | - Lena Bönig
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hannover Medical School, 30625 Hannover, Germany.
| | - Ulrich Wurster
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hannover Medical School, 30625 Hannover, Germany.
| | - Paul Bronzlik
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, 30625 Hannover, Germany.
| | - Kurt-Wolfram Sühs
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hannover Medical School, 30625 Hannover, Germany.
| | - Refik Pul
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hannover Medical School, 30625 Hannover, Germany.
- Department of Neurology, University Clinic Essen, 45147 Essen, Germany.
| | - Martin Stangel
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hannover Medical School, 30625 Hannover, Germany.
| | - Thomas Skripuletz
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hannover Medical School, 30625 Hannover, Germany.
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20
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Sæther SG, Schou M, Kondziella D. What is the significance of onconeural antibodies for psychiatric symptomatology? A systematic review. BMC Psychiatry 2017; 17:161. [PMID: 28468645 PMCID: PMC5415831 DOI: 10.1186/s12888-017-1325-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 04/24/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Patients with intracellular onconeural antibodies may present with neuro-psychiatric syndromes. We aimed to evaluate the evidence for an association between well-characterized onconeural antibodies and psychiatric symptoms in patients with and without paraneoplastic central nervous system syndromes. METHODS Eligible studies were selected from 1980 until February 2017 according to standardized review criteria and evaluated using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). We included studies describing the psychiatric symptomatology of onconeural antibody positive patients and the prevalence of onconeural antibodies in patients with psychiatric disorders. RESULTS Twenty-seven studies met the inclusion criteria. Six studies reported on the prevalence of well-characterized onconeural antibodies in patients with different psychiatric disorders, ranging from 0% to 4.9%. Antibody prevalence in controls was available from three studies, ranging from 0% to 2.8%. Data heterogeneity precluded a meta-analysis. Two cerebrospinal fluid studies found well-characterized onconeural antibodies in 3.5% and 0% of patients with psychotic and depressive syndromes, respectively. CONCLUSIONS The available evidence suggests that the prevalence of well-characterized onconeural antibodies in patients with psychiatric disorders is generally low. However, the question whether onconeural antibodies are important in select patients with a purely psychiatric phenotype needs to be addressed by appropriately designed studies in the future.
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Affiliation(s)
- Sverre Georg Sæther
- Department of Psychiatry, St. Olav's University Hospital, Pb. 3008, Lade, 7441, Trondheim, Norway. .,Department of Mental Health, Norwegian University of Science and Technology, Faculty of Medicine and Health Science, Pb. 8905, 7491, Trondheim, Norway.
| | - Morten Schou
- 0000 0004 0627 3560grid.52522.32Department of Psychiatry, St. Olav’s University Hospital, Pb. 3008, Lade, 7441 Trondheim, Norway ,0000 0001 1516 2393grid.5947.fDepartment of Mental Health, Norwegian University of Science and Technology, Faculty of Medicine and Health Science, Pb. 8905, 7491 Trondheim, Norway
| | - Daniel Kondziella
- 0000 0001 1516 2393grid.5947.fDepartment of Mental Health, Norwegian University of Science and Technology, Faculty of Medicine and Health Science, Pb. 8905, 7491 Trondheim, Norway ,0000 0004 0646 7373grid.4973.9Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvei 9; DK, -2100 Copenhagen, Denmark
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Schwenkenbecher P, Pul R, Wurster U, Conzen J, Pars K, Hartmann H, Sühs KW, Sedlacek L, Stangel M, Trebst C, Skripuletz T. Common and uncommon neurological manifestations of neuroborreliosis leading to hospitalization. BMC Infect Dis 2017; 17:90. [PMID: 28109263 PMCID: PMC5251276 DOI: 10.1186/s12879-016-2112-z] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 12/13/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neuroborreliosis represents a relevant infectious disease and can cause a variety of neurological manifestations. Different stages and syndromes are described and atypical symptoms can result in diagnostic delay or misdiagnosis. The aim of this retrospective study was to define the pivotal neurological deficits in patients with neuroborreliosis that were the reason for admission in a hospital. METHODS We retrospectively evaluated data of patients with neuroborreliosis. Only patients who fulfilled the diagnostic criteria of an intrathecal antibody production against Borrelia burgdorferi were included in the study. RESULTS Sixty-eight patients were identified with neuroborreliosis. Cranial nerve palsy was the most frequent deficit (50%) which caused admission to a hospital followed by painful radiculitis (25%), encephalitis (12%), myelitis (7%), and meningitis/headache (6%). In patients with a combination of deficits, back pain was the first symptom, followed by headache, and finally by cranial nerve palsy. Indeed, signs of meningitis were often found in patients with neuroborreliosis, but usually did not cause admission to a hospital. Unusual cases included patients with sudden onset paresis that were initially misdiagnosed as stroke and one patient with acute delirium. Cerebrospinal fluid (CSF) analysis revealed typical changes including elevated CSF cell count in all but one patient, a blood-CSF barrier dysfunction (87%), CSF oligoclonal bands (90%), and quantitative intrathecal synthesis of immunoglobulins (IgM in 74%, IgG in 47%, and IgA in 32% patients). Importantly, 6% of patients did not show Borrelia specific antibodies in the blood. CONCLUSION In conclusion, the majority of patients presented with typical neurological deficits. However, unusual cases such as acute delirium indicate that neuroborreliosis has to be considered in a wide spectrum of neurological diseases. CSF analysis is essential for a reliable diagnosis of neuroborreliosis.
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Affiliation(s)
- Philipp Schwenkenbecher
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Refik Pul
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Ulrich Wurster
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Josef Conzen
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Kaweh Pars
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Hans Hartmann
- Department of Paediatrics, Hannover Medical School, Hannover, Germany
| | - Kurt-Wolfram Sühs
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Ludwig Sedlacek
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - Martin Stangel
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Corinna Trebst
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Thomas Skripuletz
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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