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Zhou A, Ren H, Fu L, Ren C, Zhou J, Guan H, Ren X, Zhang W. Anti-Purkinje Cell Cytoplasmic Antibody Type 2-Associated Autoimmune Cerebellar Degeneration in Children: A Different Phenotype From Adults. Pediatr Neurol 2024; 160:26-29. [PMID: 39178650 DOI: 10.1016/j.pediatrneurol.2024.07.004] [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] [Received: 12/02/2022] [Revised: 06/17/2024] [Accepted: 07/05/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND Anti-Purkinje cell cytoplasmic antibody type 2 (PCA-2) is associated with various neurological conditions in adults. However, related studies have not been conducted in children. The present study aimed to characterize the clinical features and outcomes of PCA-2-related autoimmune cerebellar degeneration in pediatric patients. METHODS A total of 357 pediatric patients with acute or subacute cerebellar ataxia were recruited for the study from June 2015 to September 2022. Of these, PCA-2 was identified in four patients. Information on the clinical manifestations, patient response to treatment, and outcomes was collected and analyzed. RESULTS The patient cohort in the present study included two boys and two girls, with the age of onset from six to 12 years. Axial ataxia was the most remarkable symptom observed in the entire patient cohort (four of four), followed by dysmetria in 75% (three of four), dysarthria in 50% (two of four), and nystagmus in 25% (one of four) of patients. Cognitive impairment was present in one patient. Peripheral neuropathy, which is an extracerebellar symptom, was found in two patients. One patient was diagnosed with a pelvic neuroblastoma before the onset of ataxia. The presence of oligoclonal bands was confirmed in the cerebrospinal fluid, and cerebellar atrophy was observed. Immunotherapy, including glucocorticoids and/or intravenous immunoglobulin, was administered to all four patients immediately following diagnosis, and mycophenolate mofetil was administered to three patients. Three patients responded to immunotherapy. CONCLUSIONS In children, PCA2-associated autoimmune cerebellar degeneration is rare, and they show comparatively fewer symptoms than adults. Timely and appropriate immunotherapy is beneficial.
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Affiliation(s)
- Anna Zhou
- Department of Neurology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Libing Fu
- Department of Pathology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Changhong Ren
- Department of Neurology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Ji Zhou
- Department of Neurology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaotun Ren
- Department of Neurology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Weihua Zhang
- Department of Neurology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
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Liu M, Fan S, Geng C, Ren H, Chen S, Xie M, Cui R, Guan H. COVID-19-Associated Cerebellar Ataxia: A Case Series. CEREBELLUM (LONDON, ENGLAND) 2024:10.1007/s12311-024-01712-y. [PMID: 38985238 DOI: 10.1007/s12311-024-01712-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/16/2024] [Indexed: 07/11/2024]
Abstract
COVID-19-associated cerebellar ataxia has rarely been reported and its clinical characteristics remain understudied. This study aims to report patients with COVID-19-associated cerebellar ataxia from our institution. COVID-19-associated cerebellar ataxia was diagnosed based on the prodromal COVID-19 infection and the exclusion of other causes. This study provides a summary of the patients' clinical presentations, neuroimaging features, and the results of anti-cerebellar antibody examinations. Our study included 11 patients and 4 were male. The median onset age was 38 years. Five patients also demonstrated signs of encephalopathy. Brain magnetic resonance imaging (MRI) was either unremarkable (n = 6) or showed bilateral cerebellar lesions (n = 5), which were typically transient, although brain atrophy could be observed later in the disease course. Anti-Homer-3 and anti-Yo antibodies were each detected in one patient, respectively. All patients received immunotherapy and nine improved. Compared with the late-onset group, individuals who exhibited ataxia earlier following COVID-19 onset (interval<5 days) were significantly younger [median age 18 (15.5-31) vs. 53.5 (44-64.8) years, p = 0.009] and more likely to present with encephalopathy (5/5 vs. 0/6, p = 0.002).They also experienced more severe symptoms [median modified Rankin scale (mRS) score at zenith 5 (5-5) vs. 2 (1.75-2.75), p = 0.017] and had a less favorable prognosis [median mRS score at the last follow-up 4 (2-5) vs. 1 (0-1.25), p = 0.009]. COVID-19-associated cerebellar ataxia can appear with encephalopathy. Brain MRI may show transient bilateral cerebellar lesions and brain atrophy later. Patients who exhibited ataxia earlier following COVID-19 were younger, had more severe symptoms and poorer outcomes.
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Affiliation(s)
- Mange Liu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Chang Geng
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Sixian Chen
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Manqing Xie
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Ruixue Cui
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
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Adibi A, Rastegar-Kashkouli A, Yousefi P, Adibi I, Ahmadi E, Naghavi S. Plasmapheresis and IVIG for Treatment of Non-Tumor Anti-Tr/DNER Antibody-Associated Ataxia: A Case Report. CEREBELLUM (LONDON, ENGLAND) 2024:10.1007/s12311-024-01711-z. [PMID: 38874737 DOI: 10.1007/s12311-024-01711-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/10/2024] [Indexed: 06/15/2024]
Abstract
Autoimmune cerebellar ataxia (ACA) is a condition characterized by progressive ataxia resulting from an immune-mediated attack on cerebellar structures. The presence of anti-Tr/DNER antibodies, strongly associated with Hodgkin lymphoma, has been identified in ACA. However, cases with no underlying malignancy are rare. We report the case of a 49-year-old woman presenting with progressive ataxia, slurred speech, and dizziness over three months. The patient exhibited significant cerebellar symptoms, including dysarthria and limb ataxia, without signs of other systemic illnesses. Comprehensive investigations, including imaging, lumbar puncture, and autoantibody testing, were performed. The cerebrospinal fluid (CSF) sample revealed positivity for Tr/DNER antibodies, leading to a diagnosis of autoimmune cerebellar ataxia. The patient underwent nine sessions of plasmapheresis, followed by six doses of intravenous immunoglobulin (IVIG), resulting in significant clinical improvement. Despite extensive cancer screening, no underlying malignancy was detected, suggesting a non-tumor origin of anti-Tr/DNER antibodies. The patient's gait improved, ataxia resolved, and cerebellar tests normalized following treatment. The patient was further managed with rituximab treatment every six months. This case represents a presentation of anti-Tr/DNER-associated autoimmune cerebellar ataxia without malignancy. The successful treatment with plasmapheresis and IVIG suggests that these interventions may be effective in managing autoimmune cerebellar ataxia associated with anti-Tr/DNER antibodies. Further research is needed to understand the underlying mechanisms of this condition and to determine the optimal treatment strategies.
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Affiliation(s)
- Armin Adibi
- Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Neurology, Isfahan University of Medical Sciences, Isfahan, 8174675731, Iran
| | - Ali Rastegar-Kashkouli
- Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Neurology, Isfahan University of Medical Sciences, Isfahan, 8174675731, Iran
| | - Pourya Yousefi
- Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Neurology, Isfahan University of Medical Sciences, Isfahan, 8174675731, Iran
| | - Iman Adibi
- Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
- Department of Neurology, Isfahan University of Medical Sciences, Isfahan, 8174675731, Iran.
| | - Elahe Ahmadi
- Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Neurology, Isfahan University of Medical Sciences, Isfahan, 8174675731, Iran
| | - Saba Naghavi
- Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Neurology, Isfahan University of Medical Sciences, Isfahan, 8174675731, Iran
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Liu M, Ren H, Wang L, Fan S, Bai L, Guan H. Prognostic and relapsing factors of primary autoimmune cerebellar ataxia: a prospective cohort study. J Neurol 2024; 271:1072-1079. [PMID: 38141127 DOI: 10.1007/s00415-023-12128-9] [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: 10/12/2023] [Revised: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE The objective of this study was to investigate the factors influencing relapse and prognosis in patients with primary autoimmune cerebellar ataxia (PACA), an area previously not well understood. METHODS This prospective cohort study included patients who satisfied the modified diagnostic criteria of PACA. A modified Rankin scale score ≤ 2 at the last follow-up was defined as a favorable prognosis. Cox and Logistic regression were utilized to identify relapsing and prognostic factors, respectively. RESULTS A total of 68 patients were included and 35.3% were male. The median onset age was 42.9 years (IQR 22.1-54.0). Neuronal autoantibodies were detected in 33 (50.8%) patients. Of the 65 patients who received first-line immunotherapy, 55 (84.6%) were responsive and 10 (15.4%) were not. Responsiveness to first-line immunotherapy emerged as an independent factor for favorable prognosis (HR 16.762; 95% CI 2.877-97.655; p = 0.002), as did the absence of peripheral neuropathy/radiculopathy (HR 14.286; 95% CI 2.41-83.333; p = 0.003). Relapses occurred in 19 (27.9%) patients. Onset age ≤ 43 years (HR 5.245; 95% CI 1.499-18.35; p = 0.009), presence of peripheral neuropathy/radiculopathy (HR 4.280; 95% CI 1.622-11.298; p = 0.003) and elevated cerebrospinal fluid (CSF) protein concentration (HR 3.443; 95% CI 1.083-10.951; p = 0.036) were statistically significant relapsing factors. CONCLUSION This study identified younger onset age, presence of peripheral neuropathy/radiculopathy and elevated CSF protein concentration as relapsing factors, and absence of peripheral neuropathy/radiculopathy and responsiveness to first-line immunotherapy as independent factors for favorable prognosis in PACA patients. These findings may guide individualized treatment strategies and potentially improve patient outcomes.
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Affiliation(s)
- Mange Liu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Wang
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin Bai
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Li J, Deng B, Song W, Li K, Ai J, Liu X, Zhang H, Zhang Y, Lin K, Shao G, Liu C, Zhang W, Chen X, Zhang Y. Immunotherapies for the Effective Treatment of Primary Autoimmune Cerebellar Ataxia: a Case Series. CEREBELLUM (LONDON, ENGLAND) 2023; 22:1216-1222. [PMID: 36434494 DOI: 10.1007/s12311-022-01496-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 11/26/2022]
Abstract
Primary autoimmune cerebellar ataxia (PACA) is an idiopathic sporadic cerebellar ataxia that is thought to be immune-mediated but lacks biomarkers or a known cause. Here, we report two cases of immune-mediated cerebellar ataxia that responded favorably to immunotherapy, in which tissue-based indirect immunofluorescence test for serum or cerebrospinal fluid (CSF) samples yielded positive results. Case 1 was a 78-year-old man who presented with subacute progressive gait ataxia with truncal instability and dysarthria in response to steroids. Case 2 was a 62-year-old man who presented with relapses and remissions of acute progressive cerebellar ataxia occurring 1-2 times per year. Despite a favorable response to steroid treatment, he relapsed repeatedly in the absence of long-term immunosuppression. In the case of "idiopathic" cerebellar ataxia, immune-mediated causes should be investigated, and immunotherapy may have therapeutic effects.
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Affiliation(s)
- Jiao Li
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Bo Deng
- Department of Neurology, Huashan Hospital and Institute of Neurology, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Wenli Song
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Keru Li
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Jingwen Ai
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Xiaoni Liu
- Department of Neurology, Huashan Hospital and Institute of Neurology, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Haocheng Zhang
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Yi Zhang
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Ke Lin
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Guofu Shao
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Chunfeng Liu
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Wenhong Zhang
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Xiangjun Chen
- Department of Neurology, Huashan Hospital and Institute of Neurology, Fudan University, Shanghai, China.
- National Center for Neurological Disorders, Shanghai, China.
- Human Phenome Institute, Fudan University, Shanghai, China.
| | - Yanlin Zhang
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China.
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Meira AT, de Moraes MPM, Ferreira MG, Franklin GL, Rezende Filho FM, Teive HAG, Barsottini OGP, Pedroso JL. Immune-mediated ataxias: Guide to clinicians. Parkinsonism Relat Disord 2023; 117:105861. [PMID: 37748994 DOI: 10.1016/j.parkreldis.2023.105861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/13/2023] [Accepted: 09/17/2023] [Indexed: 09/27/2023]
Abstract
Immune-mediated cerebellar ataxias were initially described as a clinical entity in the 1980s, and since then, an expanding body of evidence has contributed to our understanding of this topic. These ataxias encompass various etiologies, including postinfectious cerebellar ataxia, gluten ataxia, paraneoplastic cerebellar degeneration, opsoclonus-myoclonus-ataxia syndrome and primary autoimmune cerebellar ataxia. The increased permeability of the brain-blood barrier could potentially explain the vulnerability of the cerebellum to autoimmune processes. In this manuscript, our objective is to provide a comprehensive review of the most prevalent diseases within this group, emphasizing clinical indicators, pathogenesis, and current treatment approaches.
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Affiliation(s)
- Alex T Meira
- Universidade Federal da Paraíba, Departamento de Medicina Interna, Serviço de Neurologia, João Pessoa, PB, Brazil.
| | | | - Matheus G Ferreira
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Serviço de Neurologia, Curitiba, PR, Brazil
| | - Gustavo L Franklin
- Pontifícia Universidade Católica, Departamento de Medicina Interna, Serviço de Neurologia, Curitiba, PR, Brazil
| | | | - Hélio A G Teive
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Serviço de Neurologia, Curitiba, PR, Brazil
| | | | - José Luiz Pedroso
- Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo, SP, Brazil
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Liu M, Ren H, Zhu Y, Fan S, Bai L, Wang J, Cui L, Guan H. Autoimmune Cerebellar Ataxia: Etiology and Clinical Characteristics of a Case Series from China. CEREBELLUM (LONDON, ENGLAND) 2023; 22:379-385. [PMID: 35618871 DOI: 10.1007/s12311-022-01412-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 04/25/2023]
Abstract
Autoimmune cerebellar ataxia (ACA) is an important and potentially treatable cause of sporadic cerebellar syndrome, but studies with large sample size are limited. This study reported a large ACA series in China and described its etiology and clinical characteristics. We reviewed all ACA patients from our hospital (2013-2021) and analyzed their clinical and paraclinical features, treatment, and outcome. ACA subtypes investigated included paraneoplastic cerebellar degeneration (PCD), primary autoimmune cerebellar ataxia (PACA), anti-glutamate decarboxylase (GAD)-associated cerebellar ataxia, opsoclonus-myoclonus syndrome (OMS), Miller Fisher syndrome (MFS), and ACA-associated with autoimmune encephalitis. A total of 127 patients were identified and 40.9% were male. The median onset age was 47.0 years. Gait ataxia was the most prevalent feature followed by limb ataxia, dizziness, and dysarthria/dysphagia. Extracerebellar manifestations included pyramidal signs (28.3%) and peripheral neuropathy/radiculopathy (15.0%). ACA subtypes were PCD (30.7%), PACA (37.8%), ACA associated with autoimmune encephalitis (12.6%), anti-GAD-associated ACA (8.7%), MFS (7.1%), and OMS (3.1%). Neuronal antibodies were positive in 67.7% of patients. Brain magnetic resonance imaging was unremarkable (55.7%) or showed atrophy (18.3%) or abnormal signal intensity (26.1%, most of which was extracerebellar). Although most patients received immunotherapy, the modified Rankin scale at last follow-up was ≤ 2 in only 47.3% patients. Thirteen patients died and 24 relapsed. Compared with PACA, PCD patients were older and had poorer outcome. This study illustrates the heterogeneity in the clinical features of ACA and suggests the importance of neuronal antibody testing in ACA diagnosis. PCD and PACA are the dominant ACA subtypes, and the former has a less favorable prognosis.
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Affiliation(s)
- Mange Liu
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yicheng Zhu
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Lin Bai
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Jing Wang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, 16 Lincui Road, Chaoyang District, Beijing, 100101, China
- University of Chinese Academy of Sciences, 19 A Yuquan Rd, Shijingshan District, Beijing, 100049, China
| | - Liying Cui
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China.
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.
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Woelfle S, Deshpande D, Feldengut S, Braak H, Del Tredici K, Roselli F, Deisseroth K, Michaelis J, Boeckers TM, Schön M. CLARITY increases sensitivity and specificity of fluorescence immunostaining in long-term archived human brain tissue. BMC Biol 2023; 21:113. [PMID: 37221592 PMCID: PMC10207789 DOI: 10.1186/s12915-023-01582-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 03/29/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Post mortem human brain tissue is an essential resource to study cell types, connectivity as well as subcellular structures down to the molecular setup of the central nervous system especially with respect to the plethora of brain diseases. A key method is immunostaining with fluorescent dyes, which allows high-resolution imaging in three dimensions of multiple structures simultaneously. Although there are large collections of formalin-fixed brains, research is often limited because several conditions arise that complicate the use of human brain tissue for high-resolution fluorescence microscopy. RESULTS In this study, we developed a clearing approach for immunofluorescence-based analysis of perfusion- and immersion-fixed post mortem human brain tissue, termed human Clear Lipid-exchanged Acrylamide-hybridized Rigid Imaging / Immunostaining / In situ hybridization-compatible Tissue-hYdrogel (hCLARITY). hCLARITY is optimized for specificity by reducing off-target labeling and yields very sensitive stainings in human brain sections allowing for super-resolution microscopy with unprecedented imaging of pre- and postsynaptic compartments. Moreover, hallmarks of Alzheimer's disease were preserved with hCLARITY, and importantly classical 3,3'-diaminobenzidine (DAB) or Nissl stainings are compatible with this protocol. hCLARITY is very versatile as demonstrated by the use of more than 30 well performing antibodies and allows for de- and subsequent re-staining of the same tissue section, which is important for multi-labeling approaches, e.g., in super-resolution microscopy. CONCLUSIONS Taken together, hCLARITY enables research of the human brain with high sensitivity and down to sub-diffraction resolution. It therefore has enormous potential for the investigation of local morphological changes, e.g., in neurodegenerative diseases.
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Affiliation(s)
- Sarah Woelfle
- Institute for Anatomy and Cell Biology, Ulm University, Albert-Einstein-Allee 11, 89081, Ulm, Germany
- International Graduate School in Molecular Medicine Ulm, IGradU, 89081, Ulm, Germany
| | - Dhruva Deshpande
- Institute of Biophysics, Ulm University, Albert-Einstein-Allee 11, 89081, Ulm, Germany
- Chemical and Systems Biology Department, Stanford School of Medicine, 269 Campus Drive, Stanford, CA, 94305, USA
| | - Simone Feldengut
- Clinical Neuroanatomy Section/Department of Neurology, Center for Biomedical Research, Ulm University, Helmholtzstraße 8/1, 89081, Ulm, Germany
| | - Heiko Braak
- Clinical Neuroanatomy Section/Department of Neurology, Center for Biomedical Research, Ulm University, Helmholtzstraße 8/1, 89081, Ulm, Germany
| | - Kelly Del Tredici
- Clinical Neuroanatomy Section/Department of Neurology, Center for Biomedical Research, Ulm University, Helmholtzstraße 8/1, 89081, Ulm, Germany
| | - Francesco Roselli
- Department of Neurology, Ulm University, 89081, Ulm, Germany
- Deutsches Zentrum für Neurodegenerative Erkrankungen, DZNE, Ulm Site, 89081, Ulm, Germany
| | - Karl Deisseroth
- Department of Bioengineering, Stanford University, Stanford, CA, 94305, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, 94305, USA
- Howard Hughes Medical Institute, Stanford, CA, 94305, USA
| | - Jens Michaelis
- Institute of Biophysics, Ulm University, Albert-Einstein-Allee 11, 89081, Ulm, Germany
| | - Tobias M Boeckers
- Institute for Anatomy and Cell Biology, Ulm University, Albert-Einstein-Allee 11, 89081, Ulm, Germany
- Deutsches Zentrum für Neurodegenerative Erkrankungen, DZNE, Ulm Site, 89081, Ulm, Germany
| | - Michael Schön
- Institute for Anatomy and Cell Biology, Ulm University, Albert-Einstein-Allee 11, 89081, Ulm, Germany.
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9
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Schwarzwald A, Salmen A, León Betancourt AX, Diem L, Hammer H, Radojewski P, Rebsamen M, Kamber N, Chan A, Hoepner R, Friedli C. Anti-neurochondrin antibody as a biomarker in primary autoimmune cerebellar ataxia-a case report and review of the literature. Eur J Neurol 2023; 30:1135-1147. [PMID: 36437687 DOI: 10.1111/ene.15648] [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: 09/14/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Neuronal autoantibodies can support the diagnosis of primary autoimmune cerebellar ataxia (PACA). Knowledge of PACA is still sparce. This article aims to highlight the relevance of anti-neurochondrin antibodies and possible therapeutical consequences in people with PACA. METHODS This is a case presentation and literature review of PACA associated with anti-neurochondrin antibodies. RESULTS A 33-year-old man noticed reduced control of the right leg in May 2020. During his first clinic appointment at our institution in September 2021, he complained about gait imbalance, fine motor disorders, tremor, intermittent diplopia and slurred speech. He presented a pancerebellar syndrome with stance, gait and limb ataxia, scanning speech and oculomotor dysfunction. Within 3 months the symptoms progressed. An initial cerebral magnetic resonance imaging, June 2020, was normal, but follow-up imaging in October 2021 and July 2022 revealed marked cerebellar atrophy (29% volume loss). Cerebrospinal fluid analysis showed lymphocytic pleocytosis of 11 x 103 /L (normal range 0-4) and oligoclonal bands type II. Anti-neurochondrin antibodies (immunoglobulin G) were detected in serum (1:10,000) and cerebrospinal fluid (1:320, by cell-based indirect immunofluorescence assay and immunoblot, analysed by the EUROIMMUN laboratory). After ruling out alternative causes and neoplasia, diagnosis of PACA was given and immunotherapy (steroids and cyclophosphamide) was started in January 2022. In March 2022 a stabilization of disease was observed. CONCLUSION Cerebellar ataxia associated with anti-neurochondrin antibodies has only been described in 19 cases; however, the number of unrecognized PACAs may be higher. As anti-neurochondrin antibodies target an intracellular antigen and exhibit a mainly cytotoxic T-cell-mediated pathogenesis, important therapeutic implications may result. Because of the severe and rapid clinical progression, aggressive immunotherapy was warranted. This case highlights the need for rapid diagnosis and therapy in PACA, as stabilization and even improvement of symptoms are attainable.
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Affiliation(s)
- Anina Schwarzwald
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
- Clinic Bethesda, Neurorehabilitation, Parkinson Centre, Epileptology, Tschugg, Switzerland
| | - Anke Salmen
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | | | - Lara Diem
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Helly Hammer
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Piotr Radojewski
- Support Center for Advanced Neuroimaging (SCAN), University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Michael Rebsamen
- Support Center for Advanced Neuroimaging (SCAN), University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Nicole Kamber
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Andrew Chan
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Robert Hoepner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Christoph Friedli
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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10
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Tierney P, Zekeridou A, Adam O. Phosphodiesterase 10A autoimmunity presenting as cerebellar ataxia responsive to plasma exchange: a case report. J Neurol 2023; 270:2325-2328. [PMID: 36571632 DOI: 10.1007/s00415-022-11542-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/16/2022] [Accepted: 12/17/2022] [Indexed: 12/27/2022]
Affiliation(s)
- Patrick Tierney
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Anastasia Zekeridou
- Department of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Octavian Adam
- The Parkinson Disease and Movement Disorders Center, Albany Medical College, 47 New Scotland Ave, Albany, NY, USA.
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11
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Miske R, Scharf M, Borowski K, Rieckhoff N, Teegen B, Denno Y, Probst C, Guthke K, Didrihsone I, Wildemann B, Ruprecht K, Komorowski L, Jarius S. Septin-3 autoimmunity in patients with paraneoplastic cerebellar ataxia. J Neuroinflammation 2023; 20:88. [PMID: 36997937 PMCID: PMC10061979 DOI: 10.1186/s12974-023-02718-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/03/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Septins are cytoskeletal proteins with filament forming capabilities, which have multiple roles during cell division, cellular polarization, morphogenesis, and membrane trafficking. Autoantibodies against septin-5 are associated with non-paraneoplastic cerebellar ataxia, and autoantibodies against septin-7 with encephalopathy with prominent neuropsychiatric features. Here, we report on newly identified autoantibodies against septin-3 in patients with paraneoplastic cerebellar ataxia. We also propose a strategy for anti-septin autoantibody determination. METHODS Sera from three patients producing similar immunofluorescence staining patterns on cerebellar and hippocampal sections were subjected to immunoprecipitation followed by mass spectrometry. The identified candidate antigens, all of which were septins, were expressed recombinantly in HEK293 cells either individually, as complexes, or combinations missing individual septins, for use in recombinant cell-based indirect immunofluorescence assays (RC-IIFA). Specificity for septin-3 was further confirmed by tissue IIFA neutralization experiments. Finally, tumor tissue sections were analyzed immunohistochemically for septin-3 expression. RESULTS Immunoprecipitation with rat cerebellum lysate revealed septin-3, -5, -6, -7, and -11 as candidate target antigens. Sera of all three patients reacted with recombinant cells co-expressing septin-3/5/6/7/11, while none of 149 healthy control sera was similarly reactive. In RC-IIFAs the patient sera recognized only cells expressing septin-3, individually and in complexes. Incubation of patient sera with five different septin combinations, each missing one of the five septins, confirmed the autoantibodies' specificity for septin-3. The tissue IIFA reactivity of patient serum was abolished by pre-incubation with HEK293 cell lysates overexpressing the septin-3/5/6/7/11 complex or septin-3 alone, but not with HEK293 cell lysates overexpressing septin-5 as control. All three patients had cancers (2 × melanoma, 1 × small cell lung cancer), presented with progressive cerebellar syndromes, and responded poorly to immunotherapy. Expression of septin-3 was demonstrated in resected tumor tissue available from one patient. CONCLUSIONS Septin-3 is a novel autoantibody target in patients with paraneoplastic cerebellar syndromes. Based on our findings, RC-IIFA with HEK293 cells expressing the septin-3/5/6/7/11 complex may serve as a screening tool to investigate anti-septin autoantibodies in serological samples with a characteristic staining pattern on neuronal tissue sections. Autoantibodies against individual septins can then be confirmed by RC-IIFA expressing single septins.
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Affiliation(s)
- Ramona Miske
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Madeleine Scharf
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany.
| | - Kathrin Borowski
- Clinical Immunological Laboratory Prof. Dr. med. Winfried Stöcker, Lübeck, Germany
| | - Nicole Rieckhoff
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Bianca Teegen
- Clinical Immunological Laboratory Prof. Dr. med. Winfried Stöcker, Lübeck, Germany
| | - Yvonne Denno
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Christian Probst
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Kersten Guthke
- Department of Neurology, Städtisches Klinikum Görlitz, Görlitz, Germany
| | - Ieva Didrihsone
- Department of Neurology, Hermann-Josef-Krankenhaus, Erkelenz, Germany
| | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lars Komorowski
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany.
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12
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Rho GTPase-activating protein 17 (ARHGAP17) as additional autoimmune target in ARHGAP26-IgG/anti-Ca autoantibody-associated autoimmune encephalitis. J Neurol 2023; 270:1776-1780. [PMID: 36333454 PMCID: PMC9971044 DOI: 10.1007/s00415-022-11417-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 09/30/2022] [Accepted: 10/01/2022] [Indexed: 11/06/2022]
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13
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Hansen N, Radenbach K, Rentzsch K, Fox J, Wiltfang J, Bartels C. Cerebrospinal Fluid Homer-3 Autoantibodies in a Patient with Amnestic Mild Cognitive Impairment. Brain Sci 2023; 13:brainsci13010125. [PMID: 36672107 PMCID: PMC9856294 DOI: 10.3390/brainsci13010125] [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: 12/14/2022] [Revised: 01/06/2023] [Accepted: 01/08/2023] [Indexed: 01/13/2023] Open
Abstract
(1) Background: Homer-3 antibodies are associated with cerebellar disease ranging from subacute degeneration to cerebellitis. However, cognitive impairment associated with Homer-3 autoantibodies has not been reported until now. (2) Methods: in retrospect, we systematically studied clinical, cranial magnetic resonance imaging (cMRI), electroencephalography (EEG) and lumbar puncture data, including neural autoantibodies of a clinical case. (3) Results: we describe the case of a 56-year-old woman presenting with amnestic mild cognitive impairment in association with serum and CSF detection of Homer-3 autoantibodies and a depressive syndrome. cMRI revealed cerebellar atrophy. CSF analysis showed elevated ptau181 protein. Applying the criteria for an autoimmune psychiatric syndrome revealed a plausible autoimmune basis for the mild cognitive impairment. (4) Discussions: our case report demonstrates an amnestic mild cognitive impairment and depressive symptoms associated with Homer-3 autoantibodies as a novel feature of Homer-3 antibody-related disease. We also propose that cognitive dysfunction might result from impaired AMPAR signaling in the hippocampus induced by Homer-3 antibodies, which will have to be verified in further research.
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Affiliation(s)
- Niels Hansen
- Department of Psychiatry and Psychotherapy, University Medical Center Goettingen, Von-Siebold-Str. 5, 37075 Goettingen, Germany
- Translational Psychoneuroscience, University Medical Center Goettingen, Von-Siebold-Str. 5, 37075 Goettingen, Germany
- Correspondence:
| | - Katrin Radenbach
- Department of Psychiatry and Psychotherapy, University Medical Center Goettingen, Von-Siebold-Str. 5, 37075 Goettingen, Germany
| | - Kristin Rentzsch
- Clinical Immunological Laboratory Prof. Stöcker, 23627 Groß Grönau, Germany
| | - Janosch Fox
- Department of Psychiatry and Psychotherapy, University Medical Center Goettingen, Von-Siebold-Str. 5, 37075 Goettingen, Germany
| | - Jens Wiltfang
- Department of Psychiatry and Psychotherapy, University Medical Center Goettingen, 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, 3810-193 Aveiro, Portugal
| | - Claudia Bartels
- Department of Psychiatry and Psychotherapy, University Medical Center Goettingen, Von-Siebold-Str. 5, 37075 Goettingen, Germany
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14
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Anti-Tr/DNER antibody-associated cerebellar ataxia: three rare cases report and literature review. Neurol Sci 2023; 44:397-403. [PMID: 36094774 DOI: 10.1007/s10072-022-06389-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/30/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND To report three cases of autoimmune cerebellar ataxia related to anti-delta/notch-like epidermal growth factor-related receptor (Tr/DNER) antibodies. CASE PRESENTATION Patients with unknown cerebellar ataxia were screened with autoimmune cerebellar ataxia (ACA)-related antibody panel. The anti-Tr antibody was positive in three female patients in whom the onset ages were 43 years, 35 years and 43 years old. The antibody titres of serum and cerebrospinal fluid were all 1:32. Cerebral ataxia was the most prominent presentation. Mild cerebellar atrophy was found in one of the patients. Immunotherapy was effective in all three patients. CONCLUSION The Tr antibody is associated with autoimmune ataxia, and it has been suggested that the anti-Tr antibody should be tested in patients with cerebellar ataxia who are negative for routine ACA antibodies. Early immunotherapy may improve patient prognoses.
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15
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Klötzsch C, Böhmert M, Hermann R, Teegen B, Rentzsch K, Till A. Anti-Homer-3 antibodies in cerebrospinal fluid and serum samples from a 58-year-old woman with subacute cerebellar degeneration and diffuse breast adenocarcinoma. Neurol Res Pract 2022; 4:29. [PMID: 35871640 PMCID: PMC9310468 DOI: 10.1186/s42466-022-00194-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/28/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Subacute cerebellar ataxia combined with cerebrospinal fluid (CSF) pleocytosis is the result of an immune response that can occur due to viral infections, paraneoplastic diseases or autoimmune-mediated mechanisms. In the following we present the first description of a patient with anti-Homer-3 antibodies in serum and CSF who has been diagnosed with paraneoplastic subacute cerebellar degeneration due to a papillary adenocarcinoma of the breast. Case presentation A 58-year-old female was admitted to our clinical department because of increasing gait and visual disturbances starting nine months ago. The neurological examination revealed a downbeat nystagmus, oscillopsia, a severe standing and gait ataxia and a slight dysarthria. Cranial MRI showed no pathological findings. Examination of CSF showed a lymphocytic pleocytosis of 11 cells/µl and an intrathecal IgG synthesis of 26%. Initially, standard serological testing in serum and CSF did not indicate any autoimmune or paraneoplastic aetiology. However, an antigen-specific indirect immunofluorescence test (IIFT) revealed the presence of anti-Homer-3 antibodies (IgG) with a serum titer of 1: 32,000 and a titer of 1: 100 in CSF. Subsequent histological examination of a right axillary lymph node mass showed papillary adenocarcinoma cells. Breast MRI detected multiple bilateral lesions as a diffuse tumour manifestation indicative of adenocarcinoma of the breast. Treatment with high-dose methylprednisolone followed by five plasmaphereses and treatment with 4-aminopyridine resulted in a moderate decrease of the downbeat nystagmus and she was able to move independently with a wheeled walker after 3 weeks. The patient was subsequently treated with chemotherapy (epirubicin, cyclophosphamide) and two series of immunoglobulins (5 × 30 g each). This resulted in a moderate improvement of the cerebellar symptoms with a decrease of ataxia and disappearance of the downbeat nystagmus. Conclusion The presented case of anti-Homer-3 antibody-associated cerebellar degeneration is the first that is clearly associated with the detection of a tumour. Interestingly, the Homer-3 protein interaction partner metabotropic glutamate receptor subtype 1A (mGluR1A) is predominantly expressed in Purkinje cells where its function is essential for motor coordination and motor learning. Based on our findings, in subacute cerebellar degeneration, we recommend considering serological testing for anti-Homer-3 antibodies in serum and cerebrospinal fluid together with tumor screening.
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16
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Jarius S, Bräuninger S, Chung HY, Geis C, Haas J, Komorowski L, Wildemann B, Roth C. Inositol 1,4,5-trisphosphate receptor type 1 autoantibody (ITPR1-IgG/anti-Sj)-associated autoimmune cerebellar ataxia, encephalitis and peripheral neuropathy: review of the literature. J Neuroinflammation 2022; 19:196. [PMID: 35907972 PMCID: PMC9338677 DOI: 10.1186/s12974-022-02545-4] [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: 02/27/2022] [Accepted: 06/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background In 2014, we first described novel autoantibodies to the inositol 1,4,5-trisphosphate receptor type 1 (ITPR1-IgG/anti-Sj) in patients with autoimmune cerebellar ataxia (ACA) in this journal. Here, we provide a review of the available literature on ITPR1-IgG/anti-Sj, covering clinical and paraclinical presentation, tumour association, serological findings, and immunopathogenesis. Methods Review of the peer-reviewed and PubMed-listed English language literature on ITPR1-IgG/anti-Sj. In addition, we provide an illustrative report on a new patient with ITPR1-IgG-associated encephalitis with cognitive decline and psychosis. Results So far, at least 31 patients with serum ITPR1-IgG/anti-Sj have been identified (clinical information available for 21). The most common manifestations were ACA, encephalopathy with seizures, myelopathy, and (radiculo)neuropathy, including autonomic neuropathy. In 45% of cases, an underlying tumour was present, making the condition a facultative paraneoplastic neurological disorder. The neurological syndrome preceded tumour diagnosis in all but one case. In most cases, immunotherapy had only moderate or no effect. The association of ITPR1-IgG/anti-Sj with manifestations other than ACA is corroborated by the case of a 48-year-old woman with high-titre ITPR1-IgG/anti-Sj antibodies and rapid cognitive decline, affecting memory, attention and executive function, and psychotic manifestations, including hallucinations, investigated here in detail. FDG-PET revealed right-temporal glucose hypermetabolism compatible with limbic encephalitis. Interestingly, ITPR1-IgG/anti-Sj mainly belonged to the IgG2 subclass in both serum and cerebrospinal fluid (CSF) in this and further patients, while it was predominantly IgG1 in other patients, including those with more severe outcome, and remained detectable over the entire course of disease. Immunotherapy with intravenous methylprednisolone, plasma exchange, and intravenous immunoglobulins, was repeatedly followed by partial or complete recovery. Long-term treatment with cyclophosphamide was paralleled by relative stabilization, although the patient noted clinical worsening at the end of each treatment cycle. Conclusions The spectrum of neurological manifestations associated with ITPR1 autoimmunity is broader than initially thought. Immunotherapy may be effective in some cases. Studies evaluating the frequency of ITPR1-IgG/anti-Sj in patients with cognitive decline and/or psychosis of unknown aetiology are warranted. Tumour screening is essential in patients presenting with ITPR1-IgG/anti-Sj.
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Affiliation(s)
- Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany.
| | | | - Ha-Yeun Chung
- Section Translational Neuroimmunology, Department of Neurology, Jena University Hospital, Jena, Germany
| | - Christian Geis
- Section Translational Neuroimmunology, Department of Neurology, Jena University Hospital, Jena, Germany
| | - Jürgen Haas
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Lars Komorowski
- Institute for Experimental Immunology, affiliated to EUROIMMUN Medizinische Labordiagnostika AG, Lübeck, Germany
| | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Christian Roth
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany.
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17
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Wu Q, Gong B, Jiang A, Qin X. Case report and literature analysis: Autoimmune cerebellar ataxia associated with homer-3 antibodies. Front Neurol 2022; 13:951659. [PMID: 35959384 PMCID: PMC9360609 DOI: 10.3389/fneur.2022.951659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/04/2022] [Indexed: 11/23/2022] Open
Abstract
Objective We present a case of autoimmune cerebellar ataxia (ACA) associated with Homer protein homolog 3 (Homer-3) antibodies. Then, a review of the literature was conducted to summarize its clinical spectrum to improve clinicians' understanding of this rare entity. Case presentation A 25-year-old man suffered from the subacute onset of cerebellar ataxia and psychiatric symptoms with abnormalities in the cerebellum on initial brain MRI and Homer-3 antibodies titers of 1:100 in the serum. His neurological symptoms did not improve after intravenous methylprednisolone but significantly improved following plasma exchange with a modified Rankin Scale (mRS) score of 1. However, 5 months later, he experienced relapse during oral prednisone tapering with enhanced cerebellar lesions and obvious cerebellar atrophy on repeated MRI. Various immunomodulatory approaches, including corticosteroids and plasma exchange, were utilized with no improvement. Then rituximab was given for the first time to treat Homer-3 autoimmunity with partial improvement of symptoms. However, the patient remained profoundly disabled with an mRS score of 4. Conclusion ACA associated with Homer-3 antibodies may have a suboptimal response to corticosteroid therapy. More intense immunotherapy such as rituximab may contribute to the improvement of cerebellar syndrome. Relapsing courses and presentation of cerebellar atrophy may suggest a poor prognosis in this entity.
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Affiliation(s)
- Qisi Wu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Beibei Gong
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Anan Jiang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xinyue Qin
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- *Correspondence: Xinyue Qin
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18
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Lancaster E. Autoantibody Encephalitis: Presentation, Diagnosis, and Management. J Clin Neurol 2022; 18:373-390. [PMID: 35796263 PMCID: PMC9262450 DOI: 10.3988/jcn.2022.18.4.373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/22/2022] [Accepted: 04/22/2022] [Indexed: 02/07/2023] Open
Abstract
Autoantibody encephalitis causes distinct clinical syndromes involving alterations in mentation, abnormal movements, seizures, psychiatric symptoms, sleep disruption, spasms, and neuromyotonia. The diagnoses can be confirmed by specific antibody tests, although some antibodies may be better detected in spinal fluid and others in serum. Each disorder conveys a risk of certain tumors which may inform diagnosis and be important for treatment. Autoantibodies to receptors and other neuronal membrane proteins are generally thought to be pathogenic and result in loss of function of the targets, so understanding the pharmacology of the receptors may inform our understanding of the syndromes. Patients may be profoundly ill but the syndromes usually respond to immune therapy, although there are differences in the types of immune therapy that are thought to be most effective for the various disorders.
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Affiliation(s)
- Eric Lancaster
- Department of Neurology, The University of Pennsylvania, Philadelphia, PA, USA.
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19
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Jia Y, Li M, Li D, Zhang M, Wang H, Jiao L, Huang Z, Ye J, Liu A, Wang Y. Immune-Mediated Cerebellar Ataxia Associated With Neuronal Surface Antibodies. Front Immunol 2022; 13:813926. [PMID: 35250990 PMCID: PMC8891139 DOI: 10.3389/fimmu.2022.813926] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/01/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Immune-mediated cerebellar ataxias (IMCAs) are common in paraneoplastic cerebellar degeneration (PCD) but rarely occur in patients with neuronal surface antibodies (NSAbs). Although cerebellar ataxias (CAs) associated with anti-NMDAR and anti-CASPR2 have been reported in a few cases, they have never been studied systematically. This study aimed to analyze the characteristics of anti-NSAbs-associated CAs. METHODS A retrospective investigation was conducted to identify patients using the keywords IMCAs and NSAbs. We collected the clinical data of 14 patients diagnosed with anti-NSAbs-associated CAs. RESULTS The median age was 33 years (16-66), and the male-to-female ratio was 4:3. Nine were positive for NMDAR-Ab, two for LGI1-Ab, two for CASPR2-Ab, and one for AMPA2R-Ab. CAs were initial symptoms in three patients and presented during the first two months of the disease course (10 days on average) among the rest of the patients. After the immunotherapy, two cases were free from symptoms, and eight cases recovered satisfactorily (10/14, 71.4%). Compared with other causes of IMCAs, anti-NSAbs were more frequently associated with additional extra-cerebellar symptoms (85.7%), mostly seizures (78.6%) and mental abnormalities (64.3%). In the CSF analysis, pleocytosis was detected in ten patients (71.4%) and oligoclonal bands (OB) were observed in nine patients (64.3%). Moreover, compared with PCD and anti-GAD65-Ab-associated CAs, anti-NSAbs-associated CAs showed a better response to immunotherapy. CONCLUSION IMCAs are rare and atypical in autoimmune encephalitis with neuronal surface antibodies. Compared with other forms of IMCAs, more symptoms of encephalopathy, a higher rate of pleocytosis and positive OB in CSF, and positive therapeutic effect were the key features of anti-NSAbs-associated CAs.
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Affiliation(s)
- Yu Jia
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Mingyu Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Dawei Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Mengyao Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Huifang Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lidong Jiao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhaoyang Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neuromodulation, Capital Medical University, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Capital Medical University, Ministry of Science and Technology, Beijing, China.,Institute of Sleep and Consciousness Disorders, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Jing Ye
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neuromodulation, Capital Medical University, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Capital Medical University, Ministry of Science and Technology, Beijing, China
| | - Aihua Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neuromodulation, Capital Medical University, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Capital Medical University, Ministry of Science and Technology, Beijing, China
| | - Yuping Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neuromodulation, Capital Medical University, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Capital Medical University, Ministry of Science and Technology, Beijing, China.,Institute of Sleep and Consciousness Disorders, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
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20
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Imai T, Shinohara K, Uchino K, Okuma H, Maki F, Hiruma K, Ariizumi Y, Yamano Y. Paraneoplastic cerebellar degeneration with anti-Yo antibodies and an associated submandibular gland tumor: a case report. BMC Neurol 2022; 22:165. [PMID: 35501715 PMCID: PMC9059384 DOI: 10.1186/s12883-022-02684-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 04/18/2022] [Indexed: 11/13/2022] Open
Abstract
Background As a debilitating syndrome, paraneoplastic cerebellar degeneration (PCD) remains challenging to treat. Further, anti-Yo antibody (directed against human cerebellar degeneration-related protein 2) detection in patients with PCD is associated with unsatisfactory responses to existing therapies. Here, we present the case of a 60-year-old woman who developed PCD with anti-Yo antibodies and a submandibular gland tumor. Case presentation A 60-year-old woman presented with a 5-day history of unsteadiness of gait and inadequate coordination of her extremities, along with truncal instability. Although walking without aid was possible, dysmetria of all four limbs, trunk, and gait ataxia was observed. While routine biochemical and hematological examinations were normal, the patient’s blood was positive for anti-Yo antibodies. When the neurological symptoms deteriorated despite administration of intravenous methylprednisolone, fluorodeoxyglucose-positron emission tomography (FDG-PET) and computed tomography (CT) images with contrast enhancement were performed, which showed a tumor in the left submaxillary gland. She underwent total left submandibular gland resection, including the tumor; histological and immunohistochemical results revealed a salivary duct carcinoma. She was administered intravenous methylprednisolone, followed by 10 plasma exchange sessions, intravenous immunoglobulins, and cyclophosphamide therapy. Following treatment, her symptoms were not alleviated, even after the reduction of anti-Yo titers. Conclusions Although tumor detection was delayed, early tumor detection, diagnosis, and PCD treatment are essential because any delay can result in the progression of the disorder and irreversible neurological damage. Therefore, we recommend that the possibility of a salivary gland tumor should be considered, and whole-body dual-modality CT, including the head and neck, and FDG-PET should be performed at the earliest for patients with well-characterized paraneoplastic antibodies when conventional imaging fails to identify a tumor.
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Affiliation(s)
- Takeshi Imai
- Department of Neurology, Kawasaki Municipal Tama Hospital: Kawasaki Shiritsu Tama Byoin, 1-30-37, Shukugawara Tama-ku Kawasaki-shi, Kawasaki, Kanagawa, Japan.
| | - Kensuke Shinohara
- Department of Neurology, Kawasaki Municipal Tama Hospital: Kawasaki Shiritsu Tama Byoin, 1-30-37, Shukugawara Tama-ku Kawasaki-shi, Kawasaki, Kanagawa, Japan
| | - Kenji Uchino
- Department of Neurology, Kawasaki Municipal Tama Hospital: Kawasaki Shiritsu Tama Byoin, 1-30-37, Shukugawara Tama-ku Kawasaki-shi, Kawasaki, Kanagawa, Japan
| | - Hirohisa Okuma
- Department of Neurology, Kawasaki Municipal Tama Hospital: Kawasaki Shiritsu Tama Byoin, 1-30-37, Shukugawara Tama-ku Kawasaki-shi, Kawasaki, Kanagawa, Japan
| | - Futaba Maki
- Department of Neurology, Shin Yurigaoka General Hospital: Shinyurigaoka Sogo Byoin, Kawasaki, Kanagawa, Japan
| | - Kiyoshi Hiruma
- Department of Otorhinolaryngology, Kawasaki Municipal Tama Hospital: Kawasaki Shiritsu Tama Byoin, Kawasaki, Kanagawa, Japan
| | - Yasushi Ariizumi
- Department of Diagnostic Pathology, St Marianna University School of Medicine Yokohama Seibu Hospital: Sei Marianna Ika Daigaku Yokohama-shi Seibu Byoin, Yokohama, Kanagawa, Japan
| | - Yoshihisa Yamano
- Department of Internal Medicine, Division of Neurology, St Marianna University School of Medicine: Sei Marianna Ika Daigaku, Kawasaki, Kanagawa, Japan
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21
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Hampe CS, Mitoma H. A Breakdown of Immune Tolerance in the Cerebellum. Brain Sci 2022; 12:brainsci12030328. [PMID: 35326284 PMCID: PMC8946792 DOI: 10.3390/brainsci12030328] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/22/2022] [Accepted: 02/25/2022] [Indexed: 11/21/2022] Open
Abstract
Cerebellar dysfunction can be associated with ataxia, dysarthria, dysmetria, nystagmus and cognitive deficits. While cerebellar dysfunction can be caused by vascular, traumatic, metabolic, genetic, inflammatory, infectious, and neoplastic events, the cerebellum is also a frequent target of autoimmune attacks. The underlying cause for this vulnerability is unclear, but it may be a result of region-specific differences in blood–brain barrier permeability, the high concentration of neurons in the cerebellum and the presence of autoantigens on Purkinje cells. An autoimmune response targeting the cerebellum—or any structure in the CNS—is typically accompanied by an influx of peripheral immune cells to the brain. Under healthy conditions, the brain is protected from the periphery by the blood–brain barrier, blood–CSF barrier, and blood–leptomeningeal barrier. Entry of immune cells to the brain for immune surveillance occurs only at the blood-CSF barrier and is strictly controlled. A breakdown in the barrier permeability allows peripheral immune cells uncontrolled access to the CNS. Often—particularly in infectious diseases—the autoimmune response develops because of molecular mimicry between the trigger and a host protein. In this review, we discuss the immune surveillance of the CNS in health and disease and also discuss specific examples of autoimmunity affecting the cerebellum.
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Affiliation(s)
- Christiane S. Hampe
- Department of Medicine, University of Washington, Seattle, WA 98195, USA
- Correspondence: ; Tel.: +1-206-554-9181
| | - Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, Tokyo 160-0023, Japan;
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22
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Update on Paraneoplastic Cerebellar Degeneration. Brain Sci 2021; 11:brainsci11111414. [PMID: 34827413 PMCID: PMC8615604 DOI: 10.3390/brainsci11111414] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 12/16/2022] Open
Abstract
Purpose of review: To provide an update on paraneoplastic cerebellar degeneration (PCD), the involved antibodies and tumors, as well as management strategies. Recent findings: PCD represents the second most common presentation of the recently established class of immune mediated cerebellar ataxias (IMCAs). Although rare in general, PCD is one of the most frequent paraneoplastic presentations and characterized clinically by a rapidly progressive cerebellar syndrome. In recent years, several antibodies have been described in association with the clinical syndrome related to PCD; their clinical significance, however, has yet to be determined. The 2021 updated diagnostic criteria for paraneoplastic neurologic symptoms help to establish the diagnosis of PCD, direct cancer screening, and to evaluate the presence of these newly identified antibodies. Recognition of the clinical syndrome and prompt identification of a specific antibody are essential for early detection of an underlying malignancy and initiation of an appropriate treatment, which represents the best opportunity to modulate the course of the disease. As clinical symptoms can precede tumor diagnosis by years, co-occurrence of specific symptoms and antibodies should prompt continuous surveillance of the patient. Summary: We provide an in-depth overview on PCD, summarize recent findings related to PCD, and highlight the transformed diagnostic approach.
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23
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Hodgkin Lymphoma With Diplopia and Nystagmus: A Paraneoplastic Cerebellar Degeneration With Ectopic Expression of DNER Antigen on Reed-Sternberg Cells. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 22:e124-e127. [PMID: 34782261 DOI: 10.1016/j.clml.2021.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/06/2021] [Indexed: 11/23/2022]
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24
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Cirkel A, Wandinger KP, Ditz C, Leppert J, Hanker L, Cirkel C, Neumann A, Brocke J, Höftberger R, Komorowski L, Perner S, Leypoldt F, Wagner-Altendorf T, Münte TF, Royl G. Paraneoplastic encephalomyeloradiculits with multiple autoantibodies against ITPR-1, GFAP and MOG: case report and literature review. Neurol Res Pract 2021; 3:48. [PMID: 34635185 PMCID: PMC8504129 DOI: 10.1186/s42466-021-00145-w] [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: 05/31/2021] [Accepted: 07/23/2021] [Indexed: 11/12/2022] Open
Abstract
Background Recently, antibodies against the alpha isoform of the glial-fibrillary-acidic-protein (GFAPα) were identified in a small series of patients with encephalomyelitis. Coexisting autoantibodies (NMDA receptor, GAD65 antibodies) have been described in a few of these patients. We describe a patient with rapidly progressive encephalomyeloradiculitis and a combination of anti-ITPR1, anti-GFAP and anti-MOG antibodies. Case presentation and literature review A 44-year old caucasian woman with a flu-like prodrome presented with meningism, progressive cerebellar signs and autonomic symptoms, areflexia, quadriplegia and respiratory insufficiency. MRI showed diffuse bilateral T2w-hyperintense brain lesions in the cortex, white matter, the corpus callosum as well as a longitudinal lesion of the medulla oblongata and the entire spinal cord. Anti-ITPR1, anti-GFAP and anti-MOG antibodies were detected in cerebrospinal fluid along with lymphocytic pleocytosis. Borderline tumor of the ovary was diagnosed. Thus, the disease of the patient was deemed to be paraneoplastic. The patient was treated by surgical removal of tumor, steroids, immunoglobulins, plasma exchange and rituximab. Four months after presentation, the patient was still tetraplegic, reacted with mimic expressions to pain or touch and could phonate solitary vowels. An extensive literature research was performed. Conclusion Our case and the literature review illustrate that multiple glial and neuronal autoantibodies can co-occur, that points to a paraneoplastic etiology, above all ovarian teratoma or thymoma. Clinical manifestation can be a mixture of typically associated syndromes, e.g. ataxia associated with anti-ITPR1 antibodies, encephalomyelitis with anti-GFAPα antibodies and longitudinal extensive myelitis with anti-MOG antibodies. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-021-00145-w.
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Affiliation(s)
- Anna Cirkel
- Department of Neurology, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany.
| | - Klaus-Peter Wandinger
- Department of Neurology, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany.,Institute of Clinical Chemistry, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Claudia Ditz
- Department of Neurosurgery, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany
| | - Jan Leppert
- Department of Neurosurgery, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany
| | - Lars Hanker
- Department of Gynecology, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany
| | - Christoph Cirkel
- Department of Gynecology, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany
| | - Alexander Neumann
- Department of Neuroradiology, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany
| | - Jan Brocke
- Neurological Rehabilitation Center, Segeberger Kliniken, Bad Segeberg, Germany
| | | | - Lars Komorowski
- Institute of Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Sven Perner
- Department of Pathology, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany.,Research Center Borstel, Leibniz Lung Center, 23538 Lübeck and, 23845, Borstel, Germany
| | - Frank Leypoldt
- Department of Neurosurgery, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany.,Department of Neurology, University Hospital of Schleswig-Holstein Kiel, Kiel, Germany
| | | | - Thomas F Münte
- Department of Neurology, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany.,Institute of Psychology II, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Georg Royl
- Department of Neurology, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany
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25
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Liu M, Ren H, Fan S, Zhang W, Xu Y, Zhao W, Guan H. Neurological Autoimmunity Associated With Homer-3 Antibody: A Case Series From China. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/6/e1077. [PMID: 34580182 PMCID: PMC8477375 DOI: 10.1212/nxi.0000000000001077] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/06/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE To present 6 new cases with Homer-3 antibodies that expand their clinical spectra and to evaluate the effect of immunotherapy. METHODS Patients with suspected autoimmune cerebellar disorder were tested for rare autoimmune cerebellar ataxia (ACA) antibodies (anti-Tr(DNER)/Zic4/ITPR1/Homer-3/NCDN/PKCγ/PCA-2/AP3B2/mGluR1/ATP1A3 antibodies) using both cell-based and tissue-based assays. Patients with positive serum or CSF results who were diagnosed with ACA were registered and followed up. This study reports and analyzes cases with Homer-3 antibodies. RESULTS Of the serum and CSF samples of 750 patients tested, 6 were positive for Homer-3 antibodies. All manifested subacute or insidious-onset cerebellar ataxia. Furthermore, 2 patients each exhibited encephalopathy, myeloradiculopathy, REM sleep behavior disorder, and autonomic dysfunction. Brain magnetic resonance images were normal (n = 1) or revealed cerebellar atrophy (n = 1), cerebellum and pons atrophy with the hot cross bun sign (n = 2), and bilateral cerebral abnormalities (n = 2). Definite leukocytosis was identified in the CSF of 2 patients, protein concentration elevation was observed in the CSF of 1 patient, and oligoclonal bands were present in 2 patients. All patients received immunotherapy, including corticosteroid, IV immunoglobulin, plasma exchange, and mycophenolate mofetil, after which the residual disability was still severe (modified Rankin Scale score ≥3 at the last follow-up in 4 patients and final Scale for the Assessment and Rating of Ataxia scores of 12-29), although 4 patients partially improved and 1 patient stabilized. The remaining 1 patient continued to deteriorate after repeated immunotherapy. Two patients relapsed. DISCUSSION Disorders associated with Homer-3 antibody can mimic multiple system atrophy with cerebellar features in both clinical and radiologic aspects. Accurate identification of autoimmune-mediated cases is critical. Timely, comprehensive immunotherapy is warranted, given the possibility of long-term clinical benefit.
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Affiliation(s)
- Mange Liu
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China
| | - Haitao Ren
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China
| | - Siyuan Fan
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China
| | - Weihe Zhang
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China
| | - Yao Xu
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China
| | - Weili Zhao
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China
| | - Hongzhi Guan
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China.
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Schiff JR, Fiorillo BP, Sadjadi R, Henry TL, Gruen JK, Gensler LM. Confabulation, amnesia and motor memory loss as a presentation of apparent ITPR1 antibody autoimmune encephalitis. BMJ Case Rep 2021; 14:e244316. [PMID: 34531236 PMCID: PMC8449935 DOI: 10.1136/bcr-2021-244316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 12/16/2022] Open
Abstract
A 59-year-old woman presented to the hospital with acute, hypoactive altered mental status. Her symptoms had begun 3 days prior when she developed hallucinations, urinary and faecal incontinence, and somnolence. She also exhibited confabulations, amnesia, motor memory loss and a wide-based gait. Medical, psychiatric and neurological evaluations including imaging and laboratory workup were unrevealing. Treatment for possible Wernicke encephalopathy and psychosis with high-dose intravenous thiamine and antipsychotic medications did not lead to improvement. After discharge, a send-out cerebrospinal fluid autoimmune encephalitis panel resulted positive for the newly identified neuronal inositol triphosphate receptor one (ITPR1) antibody. This prompted readmission for intravenous steroids, plasmapheresis and intravenous immunoglobulin, which yielded mild clinical improvement. Here, we describe confabulations and psychiatric symptoms as novel manifestations of the primary presentation of anti-ITPR1 encephalitis in an effort to promote faster recognition of this disease and early initiation of treatment in suspected cases.
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Affiliation(s)
- Julia R Schiff
- Department of Internal Medicine, Emory University, Atlanta, Georgia, USA
| | - Benjamin P Fiorillo
- Department of Anesthesia and Critical Care, Emory University, Atlanta, Georgia, USA
| | - Raha Sadjadi
- Department of Internal Medicine, Emory University, Atlanta, Georgia, USA
| | - Tracey L Henry
- Department of Internal Medicine, Emory University, Atlanta, Georgia, USA
| | - Judah K Gruen
- Department of Internal Medicine, Emory University, Atlanta, Georgia, USA
| | - Lauren M Gensler
- Department of Internal Medicine, Psychiatry, Emory University, Atlanta, Georgia, USA
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27
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Hansen N, Fitzner D, Stöcker W, Wiltfang J, Bartels C. Mild Cognitive Impairment in Chronic Brain Injury Associated with Serum Anti-AP3B2 Autoantibodies: Report and Literature Review. Brain Sci 2021; 11:1208. [PMID: 34573230 PMCID: PMC8471279 DOI: 10.3390/brainsci11091208] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/30/2021] [Accepted: 09/10/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Chronic traumatic brain injury is a condition that predisposes the brain to activate B-cells and produce neural autoantibodies. Anti-adaptor protein 3, subunit B2 (AP3B2) autoantibodies have thus far been associated with diseases affecting the cerebellum or vestibulocerebellum. Through this case report, we aim to broaden the spectrum of anti-AP3B2-associated disease. CASE DESCRIPTION We report on a 51-year-old woman with a brain injury approximately 28 years ago who recently underwent neuropsychological testing, magnetic resonance imaging of the brain (cMRI), and cerebrospinal fluid (CSF) analysis. Neural autoantibodies were determined in serum and CSF. Our patient suffered from mild cognitive impairment (amnestic MCI, multiple domains) with stable memory deficits and a decline in verbal fluency and processing speed within a two-year interval after the first presentation in our memory clinic. Brain MRI showed brain damage in the right temporoparietal, frontolateral region and thalamus, as well as in the left posterior border of the capsula interna and white matter in the frontal region. Since the brain damage, she suffered paresis of the upper extremities on the left side and lower extremities on the right side as well as gait disturbance. Our search for autoantibodies revealed anti-AP3B2 autoantibodies in serum. CONCLUSIONS Our report expands the spectrum of symptoms to mild cognitive impairment in addition to a gait disturbance associated with anti-AP3B2 autoantibodies. Furthermore, it is conceivable that a prior traumatic brain injury could initiate the development of anti-AP3B2-antibody-associated brain autoimmunity, reported here for the first time.
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Affiliation(s)
- Niels Hansen
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Von-Siebold-Str. 5, 37075 Goettingen, Germany; (J.W.); (C.B.)
| | - Dirk Fitzner
- Department of Neurology, University Medical Center Göttingen, Robert-Koch Str. 40, 37075 Goettingen, Germany;
| | - Winfried Stöcker
- Euroimmun Reference Laboratory, Seekamp 31, 23650 Luebeck, Germany;
| | - Jens Wiltfang
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Von-Siebold-Str. 5, 37075 Goettingen, Germany; (J.W.); (C.B.)
- 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, 3810-193 Aveiro, Portugal
| | - Claudia Bartels
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Von-Siebold-Str. 5, 37075 Goettingen, Germany; (J.W.); (C.B.)
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28
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Garza M, Piquet AL. Update in Autoimmune Movement Disorders: Newly Described Antigen Targets in Autoimmune and Paraneoplastic Cerebellar Ataxia. Front Neurol 2021; 12:683048. [PMID: 34489848 PMCID: PMC8416494 DOI: 10.3389/fneur.2021.683048] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/28/2021] [Indexed: 12/29/2022] Open
Abstract
Movement disorders are a common feature of many antibody-associated neurological disorders. In fact, cerebellar ataxia is one of the most common manifestations of autoimmune neurological diseases. Some of the first autoantibodies identified against antigen targets include anti-neuronal nuclear antibody type 1 (ANNA-1 or anti-Hu) and Purkinje cell cytoplasmic antibody (PCA-1) also known as anti-Yo have been identified in paraneoplastic cerebellar degeneration. Historically these antibodies have been associated with an underlying malignancy; however, recently discovered antibodies can occur in the absence of cancer as well, resulting in the clinical syndrome of autoimmune cerebellar ataxia. The pace of discovery of new antibodies associated with autoimmune or paraneoplastic cerebellar ataxia has increased rapidly over the last few years, and pathogenesis and potential treatment options remains to be explored. Here we will review the literature on recently discovered antibodies associated with autoimmune and paraneoplastic cerebellar ataxia including adaptor protein-3B2 (AP3B2); inositol 1,4,5-trisphophate receptor type 1 (ITPR1); tripartite motif-containing (TRIM) proteins 9, 67, and 46; neurochondrin; neuronal intermediate filament light chain (NIF); septin 5; metabotropic glutamate receptor 2 (mGluR2); seizure-related 6 homolog like 2 (SEZ6L2) and homer-3 antibodies. We will review their clinical characteristics, imaging and CSF findings and treatment response. In addition, we will discuss two clinical case examples of autoimmune cerebellar ataxia.
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Affiliation(s)
- Madeline Garza
- Department of Neurology, University of Colorado, Aurora, CO, United States
| | - Amanda L Piquet
- Department of Neurology, University of Colorado, Aurora, CO, United States
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29
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Mitoma H, Manto M, Hadjivassiliou M. Immune-Mediated Cerebellar Ataxias: Clinical Diagnosis and Treatment Based on Immunological and Physiological Mechanisms. J Mov Disord 2021; 14:10-28. [PMID: 33423437 PMCID: PMC7840241 DOI: 10.14802/jmd.20040] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/04/2020] [Indexed: 12/24/2022] Open
Abstract
Since the first description of immune-mediated cerebellar ataxias (IMCAs) by Charcot in 1868, several milestones have been reached in our understanding of this group of neurological disorders. IMCAs have diverse etiologies, such as gluten ataxia, postinfectious cerebellitis, paraneoplastic cerebellar degeneration, opsoclonus myoclonus syndrome, anti-GAD ataxia, and primary autoimmune cerebellar ataxia. The cerebellum, a vulnerable autoimmune target of the nervous system, has remarkable capacities (collectively known as the cerebellar reserve, closely linked to plasticity) to compensate and restore function following various pathological insults. Therefore, good prognosis is expected when immune-mediated therapeutic interventions are delivered during early stages when the cerebellar reserve can be preserved. However, some types of IMCAs show poor responses to immunotherapies, even if such therapies are introduced at an early stage. Thus, further research is needed to enhance our understanding of the autoimmune mechanisms underlying IMCAs, as such research could potentially lead to the development of more effective immunotherapies. We underscore the need to pursue the identification of robust biomarkers.
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Affiliation(s)
- Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, Tokyo, Japan
| | - Mario Manto
- Service de Neurologie, Médiathèque Jean Jacquy, CHU-Charleroi, Charleroi, Belgium.,Service des Neurosciences, University of Mons, Mons, Belgium
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30
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Xu L, Xian W, Li J, Yao X, Long Y. Purkinje cell (PC) antibody positivity in a patient with autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy. Int J Neurosci 2020; 132:1043-1048. [PMID: 33287611 DOI: 10.1080/00207454.2020.1860965] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE This case report is the first to describe the detection of antibodies against inositol 1,4,5-trisphosphate receptor 1 (ITPR1, I3PR) in a patient diagnosed with autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy. ITPR1 is known as one of the Purkinje cell antibodies present in autoimmune cerebellar ataxia (ACA). Here, we described the association between autoimmune GFAP astrocytopathy and autoimmune cerebellar disease (ACD). MATERIALS AND METHODS Demographic features, clinical characteristics, cerebrospinal fluid (CSF) parameters and neuroimaging findings were collected from this patient. Specifically, antibodies against GFAP and other proteins associated with neurological disorders were measured by immunofluorescence staining in both serum and CSF samples. RESULTS A 52-year-old woman was diagnosed with autoimmune inflammatory meningoencephalitis. She presented with cognitive dysfunction, psychiatric/behavioral abnormalities and serious insomnia with subacute onset. Brain magnetic resonance imaging (MRI) showed bilateral hyperintensity in the semioval centers on axial images and perivascular linear enhancement oriented radially to the ventricles on sagittal images. GFAP-IgG, oligoclonal bands (OBs), N-methyl-D-aspartate receptor (NMDAR)-IgG and ITPR1-IgG co-existed in her CSF. She responded well to immunoglobulin and steroid treatments. CONCLUSION Here, we describe the case of a patient with autoimmune GFAP astrocytopathy whose CSF was positive for ITPR1-IgG; however, she did not show typical ataxia manifestations or cerebellar lesions on her MRI scan. This suggests that ITPR1-IgG is not pathogenic, and the positivity of this antibody in CSF is probably associated with the presence of autoimmune inflammation.
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Affiliation(s)
- Li Xu
- Department of Neurology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, China.,Department of Neurology, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong Province, China
| | - Wenbiao Xian
- Department of Neurology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, China
| | - Jin Li
- Department of Neurology, Zhuzhou 331 Hospital, Zhuzhou, Hunan Province, China
| | - Xiaoli Yao
- Department of Neurology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, China
| | - Youming Long
- Department of Neurology, The Second Affiliated Hospital of GuangZhou Medical University, Guangzhou, Guangdong Province, China
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31
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Fundamental Mechanisms of Autoantibody-Induced Impairments on Ion Channels and Synapses in Immune-Mediated Cerebellar Ataxias. Int J Mol Sci 2020; 21:ijms21144936. [PMID: 32668612 PMCID: PMC7404345 DOI: 10.3390/ijms21144936] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 12/13/2022] Open
Abstract
In the last years, different kinds of limbic encephalitis associated with autoantibodies against ion channels and synaptic receptors have been described. Many studies have demonstrated that such autoantibodies induce channel or receptor dysfunction. The same mechanism is discussed in immune-mediated cerebellar ataxias (IMCAs), but the pathogenesis has been less investigated. The aim of the present review is to evaluate what kind of cerebellar ion channels, their related proteins, and the synaptic machinery proteins that are preferably impaired by autoantibodies so as to develop cerebellar ataxias (CAs). The cerebellum predictively coordinates motor and cognitive functions through a continuous update of an internal model. These controls are relayed by cerebellum-specific functions such as precise neuronal discharges with potassium channels, synaptic plasticity through calcium signaling pathways coupled with voltage-gated calcium channels (VGCC) and metabotropic glutamate receptors 1 (mGluR1), a synaptic organization with glutamate receptor delta (GluRδ), and output signal formation through chained GABAergic neurons. Consistently, the association of CAs with anti-potassium channel-related proteins, anti-VGCC, anti-mGluR1, and GluRδ, and anti-glutamate decarboxylase 65 antibodies is observed in IMCAs. Despite ample distributions of AMPA and GABA receptors, however, CAs are rare in conditions with autoantibodies against these receptors. Notably, when the autoantibodies impair synaptic transmission, the autoimmune targets are commonly classified into three categories: release machinery proteins, synaptic adhesion molecules, and receptors. This physiopathological categorization impacts on both our understanding of the pathophysiology and clinical prognosis.
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Yshii L, Bost C, Liblau R. Immunological Bases of Paraneoplastic Cerebellar Degeneration and Therapeutic Implications. Front Immunol 2020; 11:991. [PMID: 32655545 PMCID: PMC7326021 DOI: 10.3389/fimmu.2020.00991] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 04/27/2020] [Indexed: 12/14/2022] Open
Abstract
Paraneoplastic cerebellar degeneration (PCD) is a rare immune-mediated disease that develops mostly in the setting of neoplasia and offers a unique prospect to explore the interplay between tumor immunity and autoimmunity. In PCD, the deleterious adaptive immune response targets self-antigens aberrantly expressed by tumor cells, mostly gynecological cancers, and physiologically expressed by the Purkinje neurons of the cerebellum. Highly specific anti-neuronal antibodies in the serum and cerebrospinal fluid represent key diagnostic biomarkers of PCD. Some anti-neuronal antibodies such as anti-Yo autoantibodies (recognizing the CDR2/CDR2L proteins) are only associated with PCD. Other anti-neuronal antibodies, such as anti-Hu, anti-Ri, and anti-Ma2, are detected in patients with PCD or other types of paraneoplastic neurological manifestations. Importantly, these autoantibodies cannot transfer disease and evidence for a pathogenic role of autoreactive T cells is accumulating. However, the precise mechanisms responsible for disruption of self-tolerance to neuronal self-antigens in the cancer setting and the pathways involved in pathogenesis within the cerebellum remain to be fully deciphered. Although the occurrence of PCD is rare, the risk for such severe complication may increase with wider use of cancer immunotherapy, notably immune checkpoint blockade. Here, we review recent literature pertaining to the pathophysiology of PCD and propose an immune scheme underlying this disabling disease. Additionally, based on observations from patients' samples and on the pre-clinical model we recently developed, we discuss potential therapeutic strategies that could blunt this cerebellum-specific autoimmune disease.
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Affiliation(s)
- Lidia Yshii
- INSERM U1043, CNRS UMR 5282, Université Toulouse III, Center for Pathophysiology Toulouse Purpan, Toulouse, France
| | - Chloé Bost
- INSERM U1043, CNRS UMR 5282, Université Toulouse III, Center for Pathophysiology Toulouse Purpan, Toulouse, France.,Department of Immunology, Purpan University Hospital Toulouse, Toulouse, France
| | - Roland Liblau
- INSERM U1043, CNRS UMR 5282, Université Toulouse III, Center for Pathophysiology Toulouse Purpan, Toulouse, France.,Department of Immunology, Purpan University Hospital Toulouse, Toulouse, France
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33
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Garcez D, Marques J, Fernandes M, Coimbra MF, Lourenço MC, Machado D, Freire J. ATP1A3: an unusual antigen to consider in patients with subacute ataxia and vertical gaze palsy. Mult Scler Relat Disord 2020; 43:102160. [PMID: 32442884 DOI: 10.1016/j.msard.2020.102160] [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: 08/28/2019] [Revised: 01/06/2020] [Accepted: 04/26/2020] [Indexed: 10/24/2022]
Abstract
The anti-ATP1A3 antibody seems to be directed against a neuronal and cardiac surface protein of the proton ATPase. It was recently identified in a patient with a paraneoplastic syndrome characterized by cerebellar, neuro-ophthalmologic and other neurological symptoms. We report another patient with a similar clinical and radiological syndrome but with a different associated tumor and outcome.
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Affiliation(s)
- Daniela Garcez
- Neurology Department, Instituto Português de Oncologia, Lisbon, Portugal.
| | - Joana Marques
- Neurology Department, Instituto Português de Oncologia, Lisbon, Portugal
| | - Mariana Fernandes
- Neurology Department, Instituto Português de Oncologia, Lisbon, Portugal
| | | | | | - Duarte Machado
- Oncology Department, Instituto Português de Oncologia, Lisbon, Portugal
| | - João Freire
- Oncology Department, Instituto Português de Oncologia, Lisbon, Portugal
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34
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Paraneoplastic cerebellar degeneration in a patient with breast cancer associated with carbonic anhydrase-related protein VIII autoantibodies. J Neuroimmunol 2020; 344:577242. [PMID: 32325285 DOI: 10.1016/j.jneuroim.2020.577242] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 04/13/2020] [Indexed: 11/22/2022]
Abstract
Paraneoplastic cerebellar degeneration is a neurological syndrome resulting from immune-mediated dysfunction of Purkinje cells and commonly is associated with a tumor. In most cases, well-characterized onconeural antibodies are detected, such as anti-Yo and anti-Ri antibodies. Carbonic anhydrase-related protein VIII (CARP VIII) antibodies associated with paraneoplastic cerebellar degeneration have been previously described in only two cases. Herein, we present a 75-year-old female who developed progressive cerebellar ataxia. Anti-CARP VIII autoantibodies were found at high titres and screening for underlying malignancies revealed a breast cancer. Intravenous immunoglobulin was administered with poor results. Our report further confirms the role of CARP VIII antibodies in cerebellar degeneration.
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35
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Ayzenberg I, Faissner S, Tomaske L, Richter D, Behrendt V, Gold R. General principles and escalation options of immunotherapy in autoantibody-associated disorders of the CNS. Neurol Res Pract 2019; 1:32. [PMID: 33324898 PMCID: PMC7650108 DOI: 10.1186/s42466-019-0037-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/05/2019] [Indexed: 12/18/2022] Open
Abstract
Autoimmune diseases associated with antineuronal and antiglial autoantibodies (Abs) is one of the most rapidly expanding research fields in clinical neuroimmunology, with more than 30 autoantibodies described so far. Being associated with a wide range of clinical presentations these syndromes can be diagnostically challenging. Surface or intracellular antigen localizations are crucial for the treatment response and outcome. In the latter Abs are mostly of paraneoplastic cause and tumor management should be performed as soon as possible in order to stop peripheral antigen stimulation. Immunotherapy should be started early in both groups, before irreversible neuronal loss occurs. Despite serious prognosis, aggressive therapeutic approaches can be effective in many cases. In this article we review main pathogenic mechanisms leading to Abs-related syndromes and describe standard as well as emerging strategies of immunotherapy, including tocilizumab and bortezomib. Several special therapeutic approaches will be illustrated by clinical cases recently treated in our department.
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Affiliation(s)
- Ilya Ayzenberg
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany.,Department of Neurology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Simon Faissner
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Laura Tomaske
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Daniel Richter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Volker Behrendt
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
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36
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Shelly S, Kryzer TJ, Komorowski L, Miske R, Anderson MD, Flanagan EP, Hinson SR, Lennon VA, Pittock SJ, McKeon A. Neurochondrin neurological autoimmunity. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:6/6/e612. [PMID: 31511329 PMCID: PMC6745726 DOI: 10.1212/nxi.0000000000000612] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/30/2019] [Indexed: 11/19/2022]
Abstract
Objectives To describe the neurologic spectrum and treatment outcomes for neurochondrin-IgG positive cases identified serologically in the Mayo Clinic Neuroimmunology Laboratory. Methods Archived serum and CSF specimens previously scored positive for IgGs that stained mouse hippocampal tissue in a nonuniform synaptic pattern by immunofluorescence assay (89 among 616,025 screened, 1993–2019) were reevaluated. Antibody characterization experiments revealed specificity for neurochondrin, confirmed by recombinant protein assays. Results IgG in serum (9) or CSF (4) from 8 patients yielded identical neuron-restricted CNS patterns, most pronounced in hippocampus (stratum lucidum in particular), cerebellum (Purkinje cells and molecular layer), and amygdala. All were neurochondrin-IgG positive. Five were women; median symptom onset age was 43 years (range, 30–69). Of 7 with clinical data, 6 presented with rapidly progressive cerebellar ataxia, brainstem signs, or both; 1 had isolated unexplained psychosis 1 year prior. Five of 6 had cerebellar signs, 4 with additional brainstem symptoms or signs (eye movement abnormalities, 3; dysphagia, 2; nausea and vomiting, 1). One patient with brainstem signs (vocal cord paralysis and VII nerve palsy) had accompanying myelopathy (longitudinally extensive abnormality on MRI; aquaporin-4-IgG and myelin oligodendrocyte glycoprotein-IgG negative). The 7th patient had small fiber neuropathy only. Just 1 of 7 had contemporaneous cancer (uterine). Six patients with ataxia or brainstem signs received immunotherapy, but just 1 remained ambulatory. At last follow-up, 5 had MRI evidence of severe cerebellar atrophy. Conclusion In our series, neurochondrin autoimmunity was usually accompanied by a nonparaneoplastic rapidly progressive rhombencephalitis with poor neurologic outcomes. Other phenotypes and occasional paraneoplastic causes may occur.
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Affiliation(s)
- Shahar Shelly
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Thomas J Kryzer
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Lars Komorowski
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Ramona Miske
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Mark D Anderson
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Eoin P Flanagan
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Shannon R Hinson
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Vanda A Lennon
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Sean J Pittock
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Andrew McKeon
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS.
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37
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Zekeridou A, Lennon VA. Neurologic Autoimmunity in the Era of Checkpoint Inhibitor Cancer Immunotherapy. Mayo Clin Proc 2019; 94:1865-1878. [PMID: 31358366 DOI: 10.1016/j.mayocp.2019.02.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 01/30/2019] [Accepted: 02/20/2019] [Indexed: 01/21/2023]
Abstract
Neurologic autoimmune disorders in the context of systemic cancer reflect antitumor immune responses against onconeural proteins that are autoantigens in the nervous system. These responses observe basic principles of cancer immunity and are highly pertinent to oncological practice since the introduction of immune checkpoint inhibitor cancer therapy. The patient's autoantibody profile is consistent with the antigenic composition of the underlying malignancy. A major determinant of the pathogenic outcome is the anatomic and subcellular location of the autoantigen. IgGs targeting plasma membrane proteins (eg, muscle acetylcholine receptor -IgG in patients with paraneoplastic myasthenia gravis) have pathogenic potential. However, IgGs specific for intracellular antigens (eg, antineuronal nuclear antibody 1 [anti-Hu] associated with sensory neuronopathy and small cell lung cancer) are surrogate markers for CD8+ T lymphocytes targeting peptides derived from nuclear or cytoplasmic proteins. In an inflammatory milieu, those peptides translocate to neural plasma membranes as major histocompatibility complex class I protein complexes. Paraneoplastic neurologic autoimmunity can affect any level of the neuraxis and may be mistaken for cancer progression. Importantly, these disorders generally respond favorably to early-initiated immunotherapy and cancer treatment. Small cell lung cancer and thymoma are commonly associated with neurologic autoimmunity, but in the context of checkpoint inhibitor therapy, other malignancy associations are increasingly recognized.
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Affiliation(s)
- Anastasia Zekeridou
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN; Department of Neurology, Mayo Clinic, Rochester, MN.
| | - Vanda A Lennon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN; Department of Neurology, Mayo Clinic, Rochester, MN; Department of Immunology, Mayo Clinic, Rochester, MN
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38
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Do LD, Gupton SL, Tanji K, Bastien J, Brugière S, Couté Y, Quadrio I, Rogemond V, Fabien N, Desestret V, Honnorat J. TRIM9 and TRIM67 Are New Targets in Paraneoplastic Cerebellar Degeneration. THE CEREBELLUM 2019; 18:245-254. [PMID: 30350014 DOI: 10.1007/s12311-018-0987-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
To describe autoantibodies (Abs) against tripartite motif-containing (TRIM) protein 9 and 67 in two patients with paraneoplastic cerebellar degeneration (PCD) associated with lung adenocarcinoma. Abs were characterized using immunohistochemistry, Western blotting, cultures of murine cortical, and hippocampal neurons, immunoprecipitation, mass spectrometry, knockout mice for Trim9 and 67, and cell-based assay. Control samples included sera from 63 patients with small cell lung cancer without any paraneoplastic neurological syndrome, 36 patients with lung adenocarcinoma and PNS, CSF from 100 patients with autoimmune encephalitis, and CSF from 165 patients with neurodegenerative diseases. We found Abs targeting TRIM9 and TRIM67 at high concentration in the serum and the cerebrospinal fluid (CSF) of a 78-year-old woman and a 65-year-old man. Both developed subacute severe cerebellar ataxia. Brain magnetic resonance imaging found no abnormality and no cerebellar atrophy. Both had CSF inflammation with mild pleiocytosis and a few oligoclonal bands. We identified a pulmonary adenocarcinoma, confirming the paraneoplastic neurological syndrome in both patients. They received immunomodulatory and cancer treatments without improvement of cerebellar ataxia, even though both were in remission of their cancer (for more than 10 years in one patient). Anti-TRIM9 and anti-TRIM67 Abs were specific to these two patients. All control serum and CSF samples tested were negative for anti-TRIM9 and 67. Anti-TRIM9 and anti-TRIM67 Abs appeared to be specific biomarkers of PCD and should be added to the panel of antigens tested when this is suspected.
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Affiliation(s)
- Le Duy Do
- French Reference Center for Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Hôpital Neurologique, F-69677, Bron, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon - Université Claude Bernard Lyon 1, F-69372, Lyon, France.,University of Lyon, Université Claude Bernard Lyon 1, Lyon, F-69372, Lyon, France
| | - Stephanie L Gupton
- Department of Cell Biology and Physiology, University of North Carolina, Chapel Hill, NC, 27516, USA
| | - Kunikazu Tanji
- Department of Neuropathology, Institute of Brain Science, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562, Japan
| | - Joubert Bastien
- French Reference Center for Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Hôpital Neurologique, F-69677, Bron, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon - Université Claude Bernard Lyon 1, F-69372, Lyon, France.,University of Lyon, Université Claude Bernard Lyon 1, Lyon, F-69372, Lyon, France
| | - Sabine Brugière
- University Grenoble Alpes, CEA, Inserm, BIG-BGE, 38000, Grenoble, France
| | - Yohann Couté
- University Grenoble Alpes, CEA, Inserm, BIG-BGE, 38000, Grenoble, France
| | - Isabelle Quadrio
- Neurochemistry Unit, Biochemistry Department, Hospices Civils de Lyon, Groupement Hospitalier Est, Bron, France
| | - Veronique Rogemond
- French Reference Center for Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Hôpital Neurologique, F-69677, Bron, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon - Université Claude Bernard Lyon 1, F-69372, Lyon, France.,University of Lyon, Université Claude Bernard Lyon 1, Lyon, F-69372, Lyon, France
| | - Nicole Fabien
- Immunology department, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Virginie Desestret
- French Reference Center for Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Hôpital Neurologique, F-69677, Bron, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon - Université Claude Bernard Lyon 1, F-69372, Lyon, France.,University of Lyon, Université Claude Bernard Lyon 1, Lyon, F-69372, Lyon, France
| | - Jerome Honnorat
- French Reference Center for Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Hôpital Neurologique, F-69677, Bron, France. .,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon - Université Claude Bernard Lyon 1, F-69372, Lyon, France. .,University of Lyon, Université Claude Bernard Lyon 1, Lyon, F-69372, Lyon, France. .,Neuro-Oncologie, Hôpital Neurologique Pierre Wertheimer, 59 Boulevard Pinel, 69677, Bron Cedex, France.
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Weihua Z, Haitao R, Fang F, Xunzhe Y, Jing W, Hongzhi G. Neurochondrin Antibody Serum Positivity in Three Cases of Autoimmune Cerebellar Ataxia. THE CEREBELLUM 2019; 18:1137-1142. [DOI: 10.1007/s12311-019-01048-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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40
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Venkatesan A, Michael BD, Probasco JC, Geocadin RG, Solomon T. Acute encephalitis in immunocompetent adults. Lancet 2019; 393:702-716. [PMID: 30782344 DOI: 10.1016/s0140-6736(18)32526-1] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 10/01/2018] [Accepted: 10/04/2018] [Indexed: 01/26/2023]
Abstract
Encephalitis is a condition of inflammation of the brain parenchyma, occurs as a result of infectious or autoimmune causes, and can lead to encephalopathy, seizures, focal neurological deficits, neurological disability, and death. Viral causes account for the largest proportion, but in the last decade there has been growing recognition of anti-neuronal antibody syndromes. This Seminar focuses on the diagnosis and management of acute encephalitis in adults. Although viral and autoimmune causes are highlighted because of their prominent roles in encephalitis, other infectious pathogens are also considered. The role of cerebrospinal fluid studies, MRI, and novel diagnostic modalities (eg, next-generation sequencing) are discussed. Management approaches, including treatment of acute neurological complications and the use of immune suppressive and modulatory drugs for cases of suspected or confirmed autoimmune cause, are covered. Additionally, we discuss the remaining challenges in the diagnosis, management, and prognosis of encephalitis.
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Affiliation(s)
- Arun Venkatesan
- Johns Hopkins Encephalitis Center, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Benedict D Michael
- Center for Immune and Inflammatory Disease, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK; Department of Neurology, the Walton Center NHS Foundation Trust, Liverpool, UK
| | - John C Probasco
- Johns Hopkins Encephalitis Center, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Romergryko G Geocadin
- Johns Hopkins Encephalitis Center, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Anaesthesia/Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tom Solomon
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK; Department of Neurology, the Walton Center NHS Foundation Trust, Liverpool, UK
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41
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Screening for autoantibodies in inflammatory neurological syndrome using fluorescence pattern in a tissue-based assay: Cerebrospinal fluid findings from 793 patients. Mult Scler Relat Disord 2019; 28:177-183. [DOI: 10.1016/j.msard.2018.12.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/23/2018] [Accepted: 12/28/2018] [Indexed: 01/23/2023]
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42
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Mitoma H, Manto M, Hampe CS. Immune-mediated Cerebellar Ataxias: Practical Guidelines and Therapeutic Challenges. Curr Neuropharmacol 2019; 17:33-58. [PMID: 30221603 PMCID: PMC6341499 DOI: 10.2174/1570159x16666180917105033] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 07/06/2018] [Accepted: 09/03/2018] [Indexed: 12/11/2022] Open
Abstract
Immune-mediated cerebellar ataxias (IMCAs), a clinical entity reported for the first time in the 1980s, include gluten ataxia (GA), paraneoplastic cerebellar degenerations (PCDs), antiglutamate decarboxylase 65 (GAD) antibody-associated cerebellar ataxia, post-infectious cerebellitis, and opsoclonus myoclonus syndrome (OMS). These IMCAs share common features with regard to therapeutic approaches. When certain factors trigger immune processes, elimination of the antigen( s) becomes a priority: e.g., gluten-free diet in GA and surgical excision of the primary tumor in PCDs. Furthermore, various immunotherapeutic modalities (e.g., steroids, immunoglobulins, plasmapheresis, immunosuppressants, rituximab) should be considered alone or in combination to prevent the progression of the IMCAs. There is no evidence of significant differences in terms of response and prognosis among the various types of immunotherapies. Treatment introduced at an early stage, when CAs or cerebellar atrophy is mild, is associated with better prognosis. Preservation of the "cerebellar reserve" is necessary for the improvement of CAs and resilience of the cerebellar networks. In this regard, we emphasize the therapeutic principle of "Time is Cerebellum" in IMCAs.
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Affiliation(s)
- Hiroshi Mitoma
- Address correspondence to this author at the Medical Education Promotion Center, Tokyo Medical University, Tokyo, Japan;, E-mail:
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Honorat JA, Lopez-Chiriboga AS, Kryzer TJ, Fryer JP, Devine M, Flores A, Lennon VA, Pittock SJ, McKeon A. Autoimmune septin-5 cerebellar ataxia. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2018; 5:e474. [PMID: 29998156 PMCID: PMC6039209 DOI: 10.1212/nxi.0000000000000474] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 05/21/2018] [Indexed: 01/08/2023]
Abstract
Objective To report a form of autoimmune cerebellar ataxia in which antibodies target septin-5, a guanosine triphosphate (GTP)-binding neural protein involved in neurotransmitter exocytosis. Methods Archived sera and CSF specimens with unclassified synaptic antibodies were re-evaluated by tissue-based indirect immunofluorescence assay. Autoantigens were identified by Western blot and mass spectrometry. Recombinant protein assays (Western blot, cell based, and protein screening array) confirmed antigen specificity. Results Serum and CSF from 6 patients produced identical synaptic immunoglobulin G (IgG) staining patterns of synaptic regions (neuropil) of the mouse cerebrum and cerebellum. The molecular layer of the cerebellum and the thalamus demonstrated stronger immunoreactivity than the midbrain, hippocampus, cortex, and basal ganglia. The antigen revealed by mass spectrometry analysis of immunoprecipitated cerebellar proteins and confirmed by recombinant protein assays was septin-5. All 4 patients with records available had subacute onset of cerebellar ataxia with prominent eye movement symptoms (oscillopsia or vertigo). None had cancer detected. Improvements occurred after immunotherapies (2) or spontaneously (1). One patient died. Conclusion Septin-5 IgG represents a biomarker for a potentially fatal but treatable autoimmune ataxia.
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Affiliation(s)
- Josephe A Honorat
- Department of Laboratory Medicine and Pathology (J.A.H., T.J.K., J.P.F., V.A.L., S.J.P., A.M.), the Department of Neurology (A.S.L.-C., V.A.L., S.J.P., A.M.), and the Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Department of Neurology (M.D., A.F.), University of Texas, Southwestern, Dallas
| | - A Sebastian Lopez-Chiriboga
- Department of Laboratory Medicine and Pathology (J.A.H., T.J.K., J.P.F., V.A.L., S.J.P., A.M.), the Department of Neurology (A.S.L.-C., V.A.L., S.J.P., A.M.), and the Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Department of Neurology (M.D., A.F.), University of Texas, Southwestern, Dallas
| | - Thomas J Kryzer
- Department of Laboratory Medicine and Pathology (J.A.H., T.J.K., J.P.F., V.A.L., S.J.P., A.M.), the Department of Neurology (A.S.L.-C., V.A.L., S.J.P., A.M.), and the Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Department of Neurology (M.D., A.F.), University of Texas, Southwestern, Dallas
| | - James P Fryer
- Department of Laboratory Medicine and Pathology (J.A.H., T.J.K., J.P.F., V.A.L., S.J.P., A.M.), the Department of Neurology (A.S.L.-C., V.A.L., S.J.P., A.M.), and the Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Department of Neurology (M.D., A.F.), University of Texas, Southwestern, Dallas
| | - Michelle Devine
- Department of Laboratory Medicine and Pathology (J.A.H., T.J.K., J.P.F., V.A.L., S.J.P., A.M.), the Department of Neurology (A.S.L.-C., V.A.L., S.J.P., A.M.), and the Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Department of Neurology (M.D., A.F.), University of Texas, Southwestern, Dallas
| | - Angela Flores
- Department of Laboratory Medicine and Pathology (J.A.H., T.J.K., J.P.F., V.A.L., S.J.P., A.M.), the Department of Neurology (A.S.L.-C., V.A.L., S.J.P., A.M.), and the Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Department of Neurology (M.D., A.F.), University of Texas, Southwestern, Dallas
| | - Vanda A Lennon
- Department of Laboratory Medicine and Pathology (J.A.H., T.J.K., J.P.F., V.A.L., S.J.P., A.M.), the Department of Neurology (A.S.L.-C., V.A.L., S.J.P., A.M.), and the Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Department of Neurology (M.D., A.F.), University of Texas, Southwestern, Dallas
| | - Sean J Pittock
- Department of Laboratory Medicine and Pathology (J.A.H., T.J.K., J.P.F., V.A.L., S.J.P., A.M.), the Department of Neurology (A.S.L.-C., V.A.L., S.J.P., A.M.), and the Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Department of Neurology (M.D., A.F.), University of Texas, Southwestern, Dallas
| | - Andrew McKeon
- Department of Laboratory Medicine and Pathology (J.A.H., T.J.K., J.P.F., V.A.L., S.J.P., A.M.), the Department of Neurology (A.S.L.-C., V.A.L., S.J.P., A.M.), and the Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Department of Neurology (M.D., A.F.), University of Texas, Southwestern, Dallas
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Panja D, Vedeler CA, Schubert M. Paraneoplastic cerebellar degeneration: Yo antibody alters mitochondrial calcium buffering capacity. Neuropathol Appl Neurobiol 2018; 45:141-156. [PMID: 29679372 PMCID: PMC7379599 DOI: 10.1111/nan.12492] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 04/02/2018] [Indexed: 12/16/2022]
Abstract
Aim Neurodegeneration is associated with dysfunction of calcium buffering capacity and thereby sustained cellular and mitochondrial calcium overload. Paraneoplastic cerebellar degeneration (PCD), characterized by progressive Purkinje neurone degeneration following paraneoplastic Yo antibody internalization and binding to cerebellar degeneration‐related protein CDR2 and CDR2L, has been linked to intracellular calcium homeostasis imbalance due to calbindin D28k malfunction. Therefore, we hypothesized that Yo antibody internalization affects not only calbindin calcium binding capacity, but also calcium‐sensitive mitochondrial‐associated signalling, causing mitochondrial calcium overload and thereby Purkinje neurone death. Methods Immunohistochemically, we evaluated cerebellar organotypic slice cultures of rat brains after inducing PCD through the application of Yo antibody‐positive PCD patient sera or purified antibodies against CDR2 and CDR2L how pharmacologically biased mitochondrial signalling affected PCD pathology. Results We found that Yo antibody internalization into Purkinje neurons caused depletion of Purkinje neurone calbindin‐immunoreactivity, cannabinoid 1 receptor over‐activation and alterations in the actions of the mitochondria permeability transition pore (MPTP), voltage‐dependent anion channels, reactive oxygen species (ROS) and Na+/Ca2+ exchangers (NCX). The pathological mechanisms caused by Yo antibody binding to CDR2 or CDR2L differed between the two targets. Yo‐CDR2 binding did not alter the mitochondrial calcium retention capacity, cyclophilin D‐independent opening of MPTP or activity of NCX. Conclusion These findings suggest that minimizing intracellular calcium overload toxicity either directly with cyclosporin‐A or indirectly with cannabidiol or the ROS scavenger butylated hydroxytoluene promotes mitochondrial calcium homeostasis and may therefore be used as future neuroprotective therapy for PCD patients.
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Affiliation(s)
- D Panja
- Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway
| | - C A Vedeler
- Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - M Schubert
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Quintas S, López Ruiz R, Zapata-Wainberg G, Vivancos J. Rapidly progressing cerebellar ataxia associated with anti-GAD antibodies. NEUROLOGÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.nrleng.2016.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Quintas S, Ruiz RL, Zapata-Wainberg G, Vivancos J. Ataxia cerebelosa rápidamente progresiva asociada a anticuerpos anti-GAD. Neurologia 2018; 33:273-275. [DOI: 10.1016/j.nrl.2016.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 10/21/2022] Open
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Type 1 metabotropic glutamate receptor and its signaling molecules as therapeutic targets for the treatment of cerebellar disorders. Curr Opin Pharmacol 2018. [DOI: 10.1016/j.coph.2018.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Abstract
Immune-mediated cerebellar ataxia (CA) comprises a group of rare diseases that are still incompletely described, and are probably underdiagnosed. Both acute and progressive progressions are possible. Different syndromes have been identified, including CA associated with anti-GAD antibodies, the cerebellar type of Hashimoto encephalopathy, primary autoimmune CA, gluten ataxia, opsoclonus-myoclonus syndrome, and paraneoplastic cerebellar degenerations. Most of these syndromes are associated with autoantibodies targeting neuronal antigens. Additionally, autoimmune CA can be triggered by infections, especially in children, and in rare cases occur in the context of an autoimmune multisystem disease, such as systemic lupus erythematosus, sarcoidosis, or Behçet disease. A careful workup is needed to distinguish autoimmune CA from other causes. In adults, a paraneoplastic origin must be ruled out, especially in cases with subacute onset. Neurologic outcome in adults is frequently poor, and optimal therapeutic strategies remain ill defined. The outcome in children is in general good, but children with a poor recovery are on record. The precise pathophysiologic mechanisms even in the presence of detectable autoantibodies are still largely unknown. Further research is needed on both the clinical and mechanistic aspects of immune-mediated CA, and to determine optimal therapeutic strategies.
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Affiliation(s)
- Bastien Joubert
- French Reference Centre for Paraneoplastic Neurological Syndromes, Lyon Neurological Hospital, Lyon, France; Institut NeuroMyoGene, Université Claude Bernard Lyon 1, Lyon, France
| | - Kevin Rostásy
- Department of Pediatric Neurology, Witten/Herdecke University, Children's Hospital Datteln, Datteln, Germany
| | - Jérôme Honnorat
- French Reference Centre for Paraneoplastic Neurological Syndromes, Lyon Neurological Hospital, Lyon, France; Institut NeuroMyoGene, Université Claude Bernard Lyon 1, Lyon, France.
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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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