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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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2
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Budhram A, Sechi E. Antibodies to neural cell surface and synaptic proteins in paraneoplastic neurologic syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:347-364. [PMID: 38494289 DOI: 10.1016/b978-0-12-823912-4.00006-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Among patients with paraneoplastic neurologic syndromes (PNS), emphasis has historically been placed on neural antibodies against intracellular proteins that have a strong association with malignancy. Because of the intracellular location of their antigenic targets, these antibodies are typically considered to be non-pathogenic surrogate markers of immune cell-mediated neural injury. Unfortunately, patients with these antibodies often have suboptimal response to immunotherapy and poor prognosis. Over the last two decades, however, dramatic advancements have been made in the discovery and clinical characterization of neural antibodies against extracellular targets. These antibodies are generally considered to be pathogenic, given their potential to directly alter antigen structure or function, and patients with these antibodies often respond favorably to prompt immunotherapy. These antibodies also associate with tumors and may thus occur as PNS, albeit more variably than neural antibodies against intracellular targets. The updated 2021 PNS diagnostic criteria, which classifies antibodies as high-risk, intermediate-risk, or lower-risk for an associated cancer, better clarifies how neural antibodies against extracellular targets relate to PNS. Using this recently created framework, the clinical presentations, ancillary test findings, oncologic associations, and treatment responses of syndromes associated with these antibodies are discussed.
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Affiliation(s)
- Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, ON, Canada; Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada.
| | - Elia Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
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3
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Kerstens J, Titulaer MJ. Overview of treatment strategies in paraneoplastic neurological syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:97-112. [PMID: 38494299 DOI: 10.1016/b978-0-12-823912-4.00015-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Treatment strategies in paraneoplastic neurological syndromes rely on the three pillars of tumor treatment, immunotherapy, and symptomatic treatment, the first one being by far the most important in the majority of patients and syndromes. Classically, antibodies against extracellular antigens are directly pathogenic, and patients with these syndromes are more responsive to immunomodulatory or immunosuppressive treatments than the ones with antibodies against intracellular targets. This chapter first discusses some general principles of tumor treatment and immunotherapy, followed by a closer look at specific treatment options for different clinical syndromes, focusing on symptomatic treatments.
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Affiliation(s)
- Jeroen Kerstens
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Maarten J Titulaer
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands.
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Ryding M, Mikkelsen AW, Nissen MS, Nilsson AC, Blaabjerg M. Pathophysiological Effects of Autoantibodies in Autoimmune Encephalitides. Cells 2023; 13:15. [PMID: 38201219 PMCID: PMC10778077 DOI: 10.3390/cells13010015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
The heterogeneity of autoantibody targets in autoimmune encephalitides presents a challenge for understanding cellular and humoral pathophysiology, and the development of new treatment strategies. Thus, current treatment aims at autoantibody removal and immunosuppression, and is primarily based on data generated from other autoimmune neurological diseases and expert consensus. There are many subtypes of autoimmune encephalitides, which now entails both diseases with autoantibodies targeting extracellular antigens and classical paraneoplastic syndromes with autoantibodies targeting intracellular antigens. Here, we review the current knowledge of molecular and cellular effects of autoantibodies associated with autoimmune encephalitis, and evaluate the evidence behind the proposed pathophysiological mechanisms of autoantibodies in autoimmune encephalitis.
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Affiliation(s)
- Matias Ryding
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark;
- Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5000 Odense, Denmark
| | - Anne With Mikkelsen
- Department of Clinical Immunology, Odense University Hospital, 5000 Odense, Denmark;
| | | | - Anna Christine Nilsson
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark;
- Department of Clinical Immunology, Odense University Hospital, 5000 Odense, Denmark;
| | - Morten Blaabjerg
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark;
- Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5000 Odense, Denmark
- Department of Neurology, Odense University Hospital, 5000 Odense, Denmark;
- Brain Research—Inter Disciplinary Guided Excellence (BRIDGE), 5000 Odense, Denmark
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5
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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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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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7
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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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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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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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10
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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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11
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Schegk E, Beiser I, Achtnichts L, Nedeltchev K, Bertschi M, Gschwind M. Untreated anti-Ca/ARHGAP26 autoantibody-associated cerebellar ataxia progressing over 27 years. J Neurol 2023; 270:3258-3260. [PMID: 36856845 DOI: 10.1007/s00415-023-11632-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 03/02/2023]
Affiliation(s)
- E Schegk
- Department of Neurology, University Hospital and University of Berne, Berne, Switzerland
| | - I Beiser
- Department of Neurology, Cantonal Hospital Aarau, Tellstrasse 25, CH-5011, Aarau, Switzerland
| | - L Achtnichts
- Department of Neurology, Cantonal Hospital Aarau, Tellstrasse 25, CH-5011, Aarau, Switzerland
| | - K Nedeltchev
- Department of Neurology, Cantonal Hospital Aarau, Tellstrasse 25, CH-5011, Aarau, Switzerland
| | - M Bertschi
- Department of Neurology, Cantonal Hospital Aarau, Tellstrasse 25, CH-5011, Aarau, Switzerland
| | - M Gschwind
- Department of Neurology, Cantonal Hospital Aarau, Tellstrasse 25, CH-5011, Aarau, Switzerland.
- Department of Neurology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland.
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12
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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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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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14
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Heterogeneity and Functions of Tumor-Infiltrating Antibody Secreting Cells: Lessons from Breast, Ovarian, and Other Solid Cancers. Cancers (Basel) 2022; 14:cancers14194800. [PMID: 36230721 PMCID: PMC9563085 DOI: 10.3390/cancers14194800] [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: 08/22/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary B cells are gaining increasing recognition as important contributors to the tumor microenvironment, influencing, positively or negatively, tumor growth, patient survival, and response to therapies. Antibody secreting cells (ASCs) constitute a variable fraction of tumor-infiltrating B cells in most solid tumors, and they produce tumor-specific antibodies that can drive distinct immune responses depending on their isotypes and specificities. In this review, we discuss the current knowledge of the heterogeneity of ASCs infiltrating solid tumors and how both their canonical and noncanonical functions shape antitumor immunity, with a special emphasis on breast and ovarian cancers. Abstract Neglected for a long time in cancer, B cells and ASCs have recently emerged as critical actors in the tumor microenvironment, with important roles in shaping the antitumor immune response. ASCs indeed exert a major influence on tumor growth, patient survival, and response to therapies. The mechanisms underlying their pro- vs. anti-tumor roles are beginning to be elucidated, revealing the contributions of their secreted antibodies as well as of their emerging noncanonical functions. Here, concentrating mostly on ovarian and breast cancers, we summarize the current knowledge on the heterogeneity of tumor-infiltrating ASCs, we discuss their possible local or systemic origin in relation to their immunoglobulin repertoire, and we review the different mechanisms by which antibody (Ab) subclasses and isoforms differentially impact tumor cells and anti-tumor immunity. We also discuss the emerging roles of cytokines and other immune modulators produced by ASCs in cancer. Finally, we propose strategies to manipulate the tumor ASC compartment to improve cancer therapies.
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15
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Rare Etiologies in Immune-Mediated Cerebellar Ataxias: Diagnostic Challenges. Brain Sci 2022; 12:brainsci12091165. [PMID: 36138901 PMCID: PMC9496914 DOI: 10.3390/brainsci12091165] [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: 07/19/2022] [Revised: 08/06/2022] [Accepted: 08/26/2022] [Indexed: 12/03/2022] Open
Abstract
The cerebellum is particularly enriched in antigens and represents a vulnerable target to immune attacks. Immune-mediated cerebellar ataxias (IMCAs) have diverse etiologies, such as gluten ataxia (GA), post-infectious cerebellitis (PIC), Miller Fisher syndrome (MFS), paraneoplastic cerebellar degeneration (PCD), opsoclonus myoclonus syndrome (OMS), and anti-GAD ataxia. Apart from these well-established entities, cerebellar ataxia (CA) occurs also in association with autoimmunity against ion channels and related proteins, synaptic adhesion/organizing proteins, transmitter receptors, glial cells, as well as the brainstem antigens. Most of these conditions manifest diverse neurological clinical features, with CAs being one of the main clinical phenotypes. The term primary autoimmune cerebellar ataxia (PACA) refers to ataxic conditions suspected to be autoimmune even in the absence of specific well-characterized pathogenic antibody markers. We review advances in the field of IMCAs and propose a clinical approach for the understanding and diagnosis of IMCAs, focusing on rare etiologies which are likely underdiagnosed. The frontiers of PACA are discussed. The identification of rare immune ataxias is of importance since they are potentially treatable and may lead to a severe clinical syndrome in absence of early therapy.
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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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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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20
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The role of GTPase-activating protein ARHGAP26 in human cancers. Mol Cell Biochem 2021; 477:319-326. [PMID: 34716859 PMCID: PMC8755663 DOI: 10.1007/s11010-021-04274-3] [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: 05/09/2021] [Accepted: 10/07/2021] [Indexed: 12/11/2022]
Abstract
Rho GTPases are molecular switches that play an important role in regulating the behavior of a variety of tumor cells. RhoA GTPase-activating protein 26 (ARHGAP26) is a GTPase-activating protein and inhibits the activity of Rho GTPases by promoting the hydrolytic ability of Rho GTPases. It also affects tumorigenesis and progression of various tumors through several methods, including formation of abnormal fusion genes and circular RNA. This review summarizes the biological functions and molecular mechanisms of ARHGAP26 in different tumors, proposes the potential clinical value of ARHGAP26 in cancer treatment, and discusses current issues that need to be addressed.
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21
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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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22
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Segal Y, Bukstein F, Raz M, Aizenstein O, Alcalay Y, Gadoth A. PD-1-inhibitor-induced PCA-2 (MAP1B) Autoimmunity in a Patient with Renal Cell Carcinoma. THE CEREBELLUM 2021; 21:328-331. [PMID: 34176072 DOI: 10.1007/s12311-021-01298-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/18/2021] [Indexed: 11/25/2022]
Abstract
Immune check point inhibitors (ICIs) are a group of anti-cancer pharmacological agents which modify T cell activity in order to potentiate an effective immune response against tumor cells. While these drugs prove extremely potent against several types of malignancies, they may be associated with significant autoimmune adverse events. We report a patient who developed a subacute cerebellar syndrome shortly after starting treatment with nivolumab, a PD-1 inhibitor, for renal clear cell carcinoma, with detectable paraneoplastic PCA-2 antibodies. The tumor specimen stained positively for MAP1B, the antigen of PCA-2. The patient responded well to treatment with glucocorticosteroids. This is the first case to our knowledge of PCA-2 paraneoplastic cerebellar degeneration associated with ICI use, which presents in a patient with a malignancy not typically associated with neurological paraneoplastic phenomena. Treatment with immune checkpoint inhibitors (ICIs) is extremely effective in potentiating an immune response against tumor cells, but bears a substantial risk for the development of autoimmune phenomena, including paraneoplastic neurological syndromes. Increasing use of ICIs is leading to increasing numbers of patients with new-onset neurological symptoms. Awareness of these novel entities will aid in early diagnosis and proper treatment.
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Affiliation(s)
- Yahel Segal
- Departments of Neurology, affiliated to the Sackler Faculty of Medicine, Tel-Aviv Medical Center, Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel
| | - Felix Bukstein
- Departments of Neuro-Oncology, affiliated to the Sackler Faculty of Medicine, Tel-Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Michal Raz
- Departments of Pathology, affiliated to the Sackler Faculty of Medicine, Tel-Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Orna Aizenstein
- Departments of Radiology, affiliated to the Sackler Faculty of Medicine, Tel-Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
- Departments of Encephalitis Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Yifat Alcalay
- Departments of Encephalitis Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
- Departments of Immunology Laboratory, affiliated to the Sackler Faculty of Medicine, Tel-Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Avi Gadoth
- Departments of Neurology, affiliated to the Sackler Faculty of Medicine, Tel-Aviv Medical Center, Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel.
- Departments of Encephalitis Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel.
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23
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Schmitz-Hübsch T, Lux S, Bauer P, Brandt AU, Schlapakow E, Greschus S, Scheel M, Gärtner H, Kirlangic ME, Gras V, Timmann D, Synofzik M, Giorgetti A, Carloni P, Shah JN, Schöls L, Kopp U, Bußenius L, Oberwahrenbrock T, Zimmermann H, Pfueller C, Kadas EM, Rönnefarth M, Grosch AS, Endres M, Amunts K, Paul F, Doss S, Minnerop M. Spinocerebellar ataxia type 14: refining clinicogenetic diagnosis in a rare adult-onset disorder. Ann Clin Transl Neurol 2021; 8:774-789. [PMID: 33739604 PMCID: PMC8045942 DOI: 10.1002/acn3.51315] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 12/29/2020] [Accepted: 01/13/2021] [Indexed: 12/29/2022] Open
Abstract
Objectives Genetic variant classification is a challenge in rare adult‐onset disorders as in SCA‐PRKCG (prior spinocerebellar ataxia type 14) with mostly private conventional mutations and nonspecific phenotype. We here propose a refined approach for clinicogenetic diagnosis by including protein modeling and provide for confirmed SCA‐PRKCG a comprehensive phenotype description from a German multi‐center cohort, including standardized 3D MR imaging. Methods This cross‐sectional study prospectively obtained neurological, neuropsychological, and brain imaging data in 33 PRKCG variant carriers. Protein modeling was added as a classification criterion in variants of uncertain significance (VUS). Results Our sample included 25 cases confirmed as SCA‐PRKCG (14 variants, thereof seven novel variants) and eight carriers of variants assigned as VUS (four variants) or benign/likely benign (two variants). Phenotype in SCA‐PRKCG included slowly progressive ataxia (onset at 4–50 years), preceded in some by early‐onset nonprogressive symptoms. Ataxia was often combined with action myoclonus, dystonia, or mild cognitive‐affective disturbance. Inspection of brain MRI revealed nonprogressive cerebellar atrophy. As a novel finding, a previously not described T2 hyperintense dentate nucleus was seen in all SCA‐PRKCG cases but in none of the controls. Interpretation In this largest cohort to date, SCA‐PRKCG was characterized as a slowly progressive cerebellar syndrome with some clinical and imaging features suggestive of a developmental disorder. The observed non‐ataxia movement disorders and cognitive‐affective disturbance may well be attributed to cerebellar pathology. Protein modeling emerged as a valuable diagnostic tool for variant classification and the newly described T2 hyperintense dentate sign could serve as a supportive diagnostic marker of SCA‐PRKCG.
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Affiliation(s)
- Tanja Schmitz-Hübsch
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health Berlin, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Silke Lux
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Peter Bauer
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, Tübingen, Germany.,CENTOGENE AG, Rostock, Germany
| | - Alexander U Brandt
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health Berlin, Berlin, Germany.,Department of Neurology, University of California, Irvine, CA, USA
| | - Elena Schlapakow
- Department of Neurology, University Hospital Bonn, Bonn, Germany.,Center for Rare Diseases, University of Bonn, Bonn, Germany
| | - Susanne Greschus
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | - Michael Scheel
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health Berlin, Berlin, Germany.,Department of Neuroradiology, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Hanna Gärtner
- Institute of Neuroscience and Medicine (INM-1), Research Centre Juelich, Juelich, Germany
| | - Mehmet E Kirlangic
- Institute of Neuroscience and Medicine (INM-1), Research Centre Juelich, Juelich, Germany.,Institute for Biomedical Engineering and Computer Science, Technische Universität Ilmenau, Ilmenau, Germany
| | - Vincent Gras
- Institute of Neuroscience and Medicine (INM-4), Research Centre Juelich, Juelich, Germany
| | - Dagmar Timmann
- Department of Neurology, Essen University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Matthis Synofzik
- Department of Neurodegenerative Diseases, Center for Neurology, Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany
| | - Alejandro Giorgetti
- Computational Biophysics, German Research School for Simulation Sciences, and Computational Biomedicine, Institute for Advanced Simulation (IAS-5) and Institute of Neuroscience and Medicine (INM-9), Research Centre Juelich, Juelich, Germany.,Department of Biotechnology, University of Verona, Verona, 37134, Italy
| | - Paolo Carloni
- Computational Biophysics, German Research School for Simulation Sciences, and Computational Biomedicine, Institute for Advanced Simulation (IAS-5) and Institute of Neuroscience and Medicine (INM-9), Research Centre Juelich, Juelich, Germany
| | - Jon N Shah
- Institute of Neuroscience and Medicine (INM-4), Research Centre Juelich, Juelich, Germany.,Department of Neurology, Faculty of Medicine, JARA, RWTH Aachen University, Aachen, Germany
| | - Ludger Schöls
- Department of Neurodegenerative Diseases, Center for Neurology, Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany
| | - Ute Kopp
- Klinik und Hochschulambulanz für Neurologie, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Lisa Bußenius
- Institute of Neuroscience and Medicine (INM-1), Research Centre Juelich, Juelich, Germany.,Institute for Biochemistry and Molecular Cell Biology, Center for Experimental Medicine, University Clinic Hamburg Eppendorf, Hamburg, Germany
| | - Timm Oberwahrenbrock
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health Berlin, Berlin, Germany
| | - Hanna Zimmermann
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health Berlin, Berlin, Germany
| | - Caspar Pfueller
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health Berlin, Berlin, Germany
| | - Ella-Maria Kadas
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health Berlin, Berlin, Germany
| | - Maria Rönnefarth
- Klinik und Hochschulambulanz für Neurologie, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Anne-Sophie Grosch
- Klinik und Hochschulambulanz für Neurologie, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Matthias Endres
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Katrin Amunts
- Institute of Neuroscience and Medicine (INM-1), Research Centre Juelich, Juelich, Germany.,C. and O. Vogt Institute for Brain Research, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Friedemann Paul
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health Berlin, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Sarah Doss
- Klinik und Hochschulambulanz für Neurologie, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Movement Disorders Section, Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Martina Minnerop
- Institute of Neuroscience and Medicine (INM-1), Research Centre Juelich, Juelich, Germany.,Department of Neurology, Center for Movement Disorders and Neuromodulation, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
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24
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Lucken-Ardjomande Häsler S, Vallis Y, Pasche M, McMahon HT. GRAF2, WDR44, and MICAL1 mediate Rab8/10/11-dependent export of E-cadherin, MMP14, and CFTR ΔF508. J Cell Biol 2021; 219:151714. [PMID: 32344433 PMCID: PMC7199855 DOI: 10.1083/jcb.201811014] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 11/07/2019] [Accepted: 02/26/2020] [Indexed: 02/07/2023] Open
Abstract
In addition to the classical pathway of secretion, some transmembrane proteins reach the plasma membrane through alternative routes. Several proteins transit through endosomes and are exported in a Rab8-, Rab10-, and/or Rab11-dependent manner. GRAFs are membrane-binding proteins associated with tubules and vesicles. We found extensive colocalization of GRAF1b/2 with Rab8a/b and partial with Rab10. We identified MICAL1 and WDR44 as direct GRAF-binding partners. MICAL1 links GRAF1b/2 to Rab8a/b and Rab10, and WDR44 binds Rab11. Endogenous WDR44 labels a subset of tubular endosomes, which are closely aligned with the ER via binding to VAPA/B. With its BAR domain, GRAF2 can tubulate membranes, and in its absence WDR44 tubules are not observed. We show that GRAF2 and WDR44 are essential for the export of neosynthesized E-cadherin, MMP14, and CFTR ΔF508, three proteins whose exocytosis is sensitive to ER stress. Overexpression of dominant negative mutants of GRAF1/2, WDR44, and MICAL1 also interferes with it, facilitating future studies of Rab8/10/11-dependent exocytic pathways of central importance in biology.
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Affiliation(s)
| | - Yvonne Vallis
- Medical Research Council Laboratory of Molecular Biology, Cambridge, UK
| | - Mathias Pasche
- Medical Research Council Laboratory of Molecular Biology, Cambridge, UK
| | - Harvey T McMahon
- Medical Research Council Laboratory of Molecular Biology, Cambridge, UK
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25
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Pan MK, Li YS, Wong SB, Ni CL, Wang YM, Liu WC, Lu LY, Lee JC, Cortes EP, Vonsattel JPG, Sun Q, Louis ED, Faust PL, Kuo SH. Cerebellar oscillations driven by synaptic pruning deficits of cerebellar climbing fibers contribute to tremor pathophysiology. Sci Transl Med 2021; 12:12/526/eaay1769. [PMID: 31941824 DOI: 10.1126/scitranslmed.aay1769] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 11/15/2019] [Indexed: 12/13/2022]
Abstract
Essential tremor (ET) is one of the most common movement disorders and the prototypical disorder for abnormal rhythmic movements. However, the pathophysiology of tremor generation in ET remains unclear. Here, we used autoptic cerebral tissue from patients with ET, clinical data, and mouse models to report that synaptic pruning deficits of climbing fiber (CF)-to-Purkinje cell (PC) synapses, which are related to glutamate receptor delta 2 (GluRδ2) protein insufficiency, cause excessive cerebellar oscillations and might be responsible for tremor. The CF-PC synaptic pruning deficits were correlated with the reduction in GluRδ2 expression in the postmortem ET cerebellum. Mice with GluRδ2 insufficiency and CF-PC synaptic pruning deficits develop ET-like tremor that can be suppressed with viral rescue of GluRδ2 protein. Step-by-step optogenetic or pharmacological inhibition of neuronal firing, axonal activity, or synaptic vesicle release confirmed that the activity of the excessive CF-to-PC synapses is required for tremor generation. In vivo electrophysiology in mice showed that excessive cerebellar oscillatory activity is CF dependent and necessary for tremor and optogenetic-driven PC synchronization was sufficient to generate tremor in wild-type animals. Human validation by cerebellar electroencephalography confirmed that excessive cerebellar oscillations also exist in patients with ET. Our findings identify a pathophysiologic contribution to tremor at molecular (GluRδ2), structural (CF-to-PC synapses), physiological (cerebellar oscillations), and behavioral levels (kinetic tremor) that might have clinical applications for treating ET.
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Affiliation(s)
- Ming-Kai Pan
- Department of Medical Research, National Taiwan University Hospital, Taipei City 10002, Taiwan. .,Institute of Pharmacology, College of Medicine, National Taiwan University Hospital, Taipei City 10051, Taiwan.,Neurobiology and Cognitive Science Center, National Taiwan University, Taipei City 10051, Taiwan.,Molecular Imaging Center, National Taiwan University, Taipei City 10051, Taiwan.,Department of Neurology, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin 64041, Taiwan
| | - Yong-Shi Li
- Department of Neurology, Columbia University, New York, NY 10032, USA
| | - Shi-Bing Wong
- Department of Neurology, Columbia University, New York, NY 10032, USA.,Department of Pediatrics, Taipei Tzu Chi Hospital, Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan
| | - Chun-Lun Ni
- Department of Neurology, Columbia University, New York, NY 10032, USA
| | - Yi-Mei Wang
- Department of Neurology, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin 64041, Taiwan
| | - Wen-Chuan Liu
- Department of Medical Research, National Taiwan University Hospital, Taipei City 10002, Taiwan.,Institute of Pharmacology, College of Medicine, National Taiwan University Hospital, Taipei City 10051, Taiwan
| | - Liang-Yin Lu
- Neurobiology and Cognitive Science Center, National Taiwan University, Taipei City 10051, Taiwan
| | - Jye-Chang Lee
- Molecular Imaging Center, National Taiwan University, Taipei City 10051, Taiwan
| | - Etty P Cortes
- Department of Pathology and Cell Biology, Columbia University, New York, NY 10032, USA
| | - Jean-Paul G Vonsattel
- Department of Pathology and Cell Biology, Columbia University, New York, NY 10032, USA
| | - Qian Sun
- Department of Neuroscience, Columbia University, New York, NY 10032, USA.,Department of Neurosciences, Case Western Reserve University, Cleveland, OH 44016, USA
| | - Elan D Louis
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, CT 06519, USA.,Department of Chronic Disease Epidemiology, Yale School of Public Health, Yale University, New Haven, CT 06510, USA
| | - Phyllis L Faust
- Department of Pathology and Cell Biology, Columbia University, New York, NY 10032, USA
| | - Sheng-Han Kuo
- Department of Neurology, Columbia University, New York, NY 10032, USA. .,Initiative of Columbia Ataxia and Tremor, New York, NY 10032, USA
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26
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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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27
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Burada AP, Vinnakota R, Bharti P, Dutta P, Dubey N, Kumar J. Emerging insights into the structure and function of ionotropic glutamate delta receptors. Br J Pharmacol 2020; 179:3612-3627. [DOI: 10.1111/bph.15313] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 12/22/2022] Open
Affiliation(s)
- Ananth Prasad Burada
- Laboratory of Membrane Protein Biology National Centre for Cell Science, NCCS Complex, S. P. Pune University Pune India
| | - Rajesh Vinnakota
- Laboratory of Membrane Protein Biology National Centre for Cell Science, NCCS Complex, S. P. Pune University Pune India
| | - Pratibha Bharti
- Laboratory of Membrane Protein Biology National Centre for Cell Science, NCCS Complex, S. P. Pune University Pune India
| | - Priyanka Dutta
- Laboratory of Membrane Protein Biology National Centre for Cell Science, NCCS Complex, S. P. Pune University Pune India
| | - Neelima Dubey
- Molecular Neuroscience Research Lab Dr. D. Y. Patil Biotechnology and Bioinformatics Institute, Dr. D. Y. Patil Vidyapeeth Tathawade Pune 411033 India
| | - Janesh Kumar
- Laboratory of Membrane Protein Biology National Centre for Cell Science, NCCS Complex, S. P. Pune University Pune India
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28
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Ren H, Zhao D, Xu X, Yang Y, Fan S, Li W, Guan H. Paraneoplastic cerebellar degeneration associated with anti-protein kinase Cgamma antibodies in a Chinese patient. J Neuroimmunol 2020; 350:577408. [PMID: 33217719 DOI: 10.1016/j.jneuroim.2020.577408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/11/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022]
Abstract
Anti-protein kinase Cgamma (anti-PKCγ) antibodies are rare onconeural antibodies associated with paraneoplastic cerebellar degeneration (PCD). To date, only two patients with PCD and anti-PKCγ antibodies have been reported. Here, we report a Chinese patient with PCD and anti-PKCγ antibodies. Screening for tumor revealed lymphoepithelial carcinoma in tonsil. The patient's symptoms improved gradually after radiotherapy for the lymphoepithelial carcinoma and intravenous immunoglobulin immunotherapy.
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Affiliation(s)
- Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Dachun Zhao
- Department of Pathology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaolu Xu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yingmai Yang
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Wenhan Li
- Oumeng V Medical Laboratory, Hangzhou, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
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29
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Liapi A, Sarivalasis A. Paraneoplastic Cerebellar Ataxia Can Affect Prognosis in High-Grade Serous Ovarian Cancer: A Case Report. Case Rep Oncol 2020; 13:1006-1012. [PMID: 32999664 PMCID: PMC7506384 DOI: 10.1159/000509029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 05/27/2020] [Indexed: 11/20/2022] Open
Abstract
The reported case is a 61-year-old woman, admitted for gradual onset of gait disturbances and dysphonia. The serum immunological panel revealed anti-Yo autoantibodies, suggestive of a paraneoplastic syndrome (PNS). A PET-CT revealed a suspicious left ovarian mass with retroperitoneal nodal involvement, and the histological assessment of surgical samples confirmed a FIGO IIIC high-grade serous ovarian cancer (HGSOC). Deemed inoperable at first, the patient was treated by carboplatin and paclitaxel chemotherapy, after which she refused surgical debulking. At the end of her systemic treatment, the patient only experienced a transient improvement of the cerebellar ataxia. Despite the suboptimal oncological treatment, the patient still presents stable disease and is free of progression 7 years from her diagnosis. This case study illustrates the favorable effect of PNS occurrence on oncological outcome in a patient with advanced HGSOC. The absence of recurrence despite the presence of residual disease after the systemic treatment is unusual and could be related to the PNS.
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Affiliation(s)
- Aikaterini Liapi
- *Aikaterini Liapi, Oncology Department, CHUV – Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, CH–1011 Lausanne (Switzerland),
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30
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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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31
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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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32
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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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33
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González Martín-Moro J. Medusa head injection: A Greek myth behind a clinical metaphor. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2019; 94:e60-e62. [PMID: 30799121 DOI: 10.1016/j.oftal.2018.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/17/2018] [Accepted: 12/26/2018] [Indexed: 06/09/2023]
Affiliation(s)
- J González Martín-Moro
- Departamento de Oftalmología, Hospital Universitario del Henares, Coslada (Madrid), España; Universidad Francisco de Vitoria, Madrid, España.
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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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35
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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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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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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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Yan L, Dong X, Xu H, Huang J, Wang W, Huang L, Wan Q, Gong J. Paraneoplastic cerebellar degeneration associated with breast cancer: A case report and review of the literature. Mol Clin Oncol 2018; 9:163-167. [PMID: 30101014 PMCID: PMC6083401 DOI: 10.3892/mco.2018.1638] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 04/25/2018] [Indexed: 01/19/2023] Open
Abstract
Paraneoplastic cerebellar degeneration (PCD) is a rare neurological complication of cancer characterized by rapid development of cerebellar ataxia. We herein present a case of a 67-year-old female patient with PCD caused by breast cancer. The patient presented with progressively worsening cerebellar deficits that had been misdiagnosed for several months prior to the identification of the anti-Yo autoantibodies in the serum. A whole-body positron emission tomography/computed tomography scan revealed a lesion in the lower outer quadrant of the left breast with slightly increased metabolism. On mammography, a lobulated high-density mass was identified in the left breast. The patient underwent left breast lumpectomy and the histological examination confirmed the presence of an invasive ductal carcinoma. After breast surgery, the patient exhibited marked neurological improvement at the 12-month follow-up. Therefore, it is crucial that clinicians include paraneoplastic neurological syndromes in the differential diagnosis of neurological disorders. The detection of characterized onconeural antibodies in the serum or cerebrospinal fluid may provide guidance in the search for an underlying tumor.
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Affiliation(s)
- Lanyun Yan
- Department of Neurology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Xin Dong
- Department of Neurology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Huan Xu
- Department of Neurology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Jingjing Huang
- Department of Gerontology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210011, P.R. China
| | - Wei Wang
- Department of Neurology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Lin Huang
- Department of Neurology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Qi Wan
- Department of Neurology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Jie Gong
- Department of Neurology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
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Expression of the onconeural protein CDR1 in cerebellum and ovarian cancer. Oncotarget 2018; 9:23975-23986. [PMID: 29844866 PMCID: PMC5963614 DOI: 10.18632/oncotarget.25252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 04/04/2018] [Indexed: 12/23/2022] Open
Abstract
Cerebellar degeneration related protein 1 (CDR1) is expressed in the cerebellum, and CDR1 antibodies have been associated with paraneoplastic cerebellar degeneration (PCD). In this study, we examined CDR1 expression in cerebellum and in ovarian and breast tumors, as well as the intracellular localization of CDR1 in cancer cells in culture. CDR1 was strongly expressed in the cytosol and dendrites of Purkinje cells and in interneurons of the molecular layer in cerebellum. CDR1 was also present in ovarian and breast tumors, as well as in ovarian and breast cancer cell lines, but was not present in normal breast or ovarian tissue. In cells overexpressing CDR1, CDR1 localized close to the plasma membrane in a polarized pattern at one edge. CDR1 was strongly expressed on the outer surface, apparently in filopodias or lamellipodias, in cells endogenously expressing CDR1. Overexpression of CDR1 showed a 37 and a 45 kDa band in western blot. The 37-kDa isoform was present in 16 ovarian cancer lysates, while the 45-kDa isoform was only found in three ovarian cancer patients. The presence of CDR1 in ovarian cancer was not associated with PCD. CDR1 antibodies were only found in serum from one patient with PCD and ovarian tumor with metastases. Therefore, CDR1 is probably not a marker for PCD. However, CDR1 may be associated with cell migration and differentiation.
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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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Abstract
Autoimmune movement disorders are caused by an aberrant immune response to neural self-antigens. These disorders may be paraneoplastic, parainfectious, or (most commonly) idiopathic. The neurological presentations are diverse, and sometimes multifocal. Movement disorders can occur as part of the spectrum with phenotypes including chorea, myoclonus, ataxia, CNS hyperexcitability (including stiff-person syndrome), dystonia, and parkinsonism. Symptoms are subacute in onset and may have a fluctuating course. The best characterized disorders are unified by neural autoantibodies identified in serum or cerebrospinal fluid. The antibody specificity may predict the association with cancer and the response to immunotherapy. In this article, we review autoimmune-mediated movement disorders, associated cancers, diagnosis, and treatment.
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43
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Mitoma H, Manto M, Hampe CS. Immune-mediated cerebellar ataxias: from bench to bedside. CEREBELLUM & ATAXIAS 2017; 4:16. [PMID: 28944066 PMCID: PMC5609024 DOI: 10.1186/s40673-017-0073-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 09/07/2017] [Indexed: 02/08/2023]
Abstract
The cerebellum is a vulnerable target of autoimmunity in the CNS. The category of immune-mediated cerebellar ataxias (IMCAs) was recently established, and includes in particular paraneoplastic cerebellar degenerations (PCDs), gluten ataxia (GA) and anti-GAD65 antibody (Ab) associated-CA, all characterized by the presence of autoantibodies. The significance of onconeuronal autoantibodies remains uncertain in some cases. The pathogenic role of anti-GAD65Ab has been established both in vitro and in vivo, but a consensus has not been reached yet. Recent studies of anti-GAD65 Ab-associated CA have clarified that (1) autoantibodies are generally polyclonal and elicit pathogenic effects related to epitope specificity, and (2) the clinical course can be divided into two phases: a phase of functional disorder followed by cell death. These features provide the rationale for prompt diagnosis and therapeutic strategies. The concept “Time is brain” has been completely underestimated in the field of immune ataxias. We now put forward the concept “Time is cerebellum” to underline the importance of very early therapeutic strategies in order to prevent or stop the loss of neurons and synapses. The diagnosis of IMCAs should depend not only on Ab testing, but rather on a rapid and comprehensive assessment of the clinical/immune profile. Treatment should be applied during the period of preserved cerebellar reserve, and should encompass early removal of the conditions (such as remote primary tumors) or diseases that trigger the autoimmunity, followed by the combinations of various immunotherapies.
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Affiliation(s)
- Hiroshi Mitoma
- Tokyo Medical University, Medical Education Promotion Center, 6-7-1 Nishi-Shinjyuku, Shinjyuku-ku, Tokyo, 160-0023 Japan
| | - Mario Manto
- Unité d'Etude du Mouvement (UEM), FNRS, ULB-Erasme, 1070 Bruxelles, Belgium.,Service des Neurosciences, University of Mons, 7000 Mons, Belgium
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From dizziness to severe ataxia and dysarthria: New cases of anti-Ca/ARHGAP26 autoantibody-associated cerebellar ataxia suggest a broad clinical spectrum. J Neuroimmunol 2017; 309:77-81. [DOI: 10.1016/j.jneuroim.2017.05.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 05/12/2017] [Accepted: 05/20/2017] [Indexed: 11/18/2022]
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Lewerenz J, Jarius S, Wildemann B, Wandinger KP, Leypoldt F. [Autoantibody-associated autoimmune encephalitis and cerebellitis : Clinical presentation, diagnostic work-up and treatment]. DER NERVENARZT 2017; 87:1293-1299. [PMID: 27847964 DOI: 10.1007/s00115-016-0235-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
There is no other field of neurology where clinically relevant serological biomarkers have witnessed a surge in importance over the past decade resembling that in autoimmune encephalitis and cerebellitis. A multitude of newly discovered neuronal autoantibodies facilitate early diagnosis, estimation of prognosis, and therapeutic decision-making. However, this has led to growing uncertainty with regard to meaningful patient selection, the appropriate extent of testing, and management of seronegative cases. This review summarizes the essential aspects of the clinical presentation, diagnostic work-up, pathophysiology, and treatment of autoimmune encephalitis and cerebellitis.
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Affiliation(s)
- J Lewerenz
- Neurologische Universitätsklinik, Universität Ulm und Universitäts- und Rehabilitationskliniken Ulm, Ulm, Deutschland
| | - S Jarius
- AG Molekulare Neuroimmunologie, Neurologische Klinik, Universität Heidelberg, Heidelberg, Deutschland
| | - B Wildemann
- AG Molekulare Neuroimmunologie, Neurologische Klinik, Universität Heidelberg, Heidelberg, Deutschland
| | - K-P Wandinger
- Bereich Neuroimmunologie, Institut für Klinische Chemie, Universitätsklinikum Schleswig-Holstein, Kiel/Lübeck, Deutschland.,Klinik für Neurologie, Universitätsklinikum Schleswig-Holstein, Lübeck, Deutschland
| | - F Leypoldt
- Bereich Neuroimmunologie, Institut für Klinische Chemie, Universitätsklinikum Schleswig-Holstein, Kiel/Lübeck, Deutschland. .,Klinik für Neurologie, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland.
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46
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Berzero G, Hacohen Y, Komorowski L, Scharf M, Dehais C, Leclercq D, Fourchotte V, Buecher B, Honnorat J, Graus F, Delattre JY, Psimaras D. Paraneoplastic cerebellar degeneration associated with anti-ITPR1 antibodies. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2017; 4:e326. [PMID: 28203616 PMCID: PMC5292928 DOI: 10.1212/nxi.0000000000000326] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 12/08/2016] [Indexed: 12/28/2022]
Affiliation(s)
- Giulia Berzero
- AP-HP Pitié-Salpêtrière (G.B., C.D., J.-Y.D., D.P.), Service de Neurologie Mazarin, Paris, France; Neuroscience Consortium (G.B.), University of Pavia, Monza Policlinico and Pavia Mondino, Italy; Nuffield Department of Clinical Neurosciences (Y.H.), John Radcliffe Hospital, University of Oxford, United Kingdom; Institute of Experimental Immunology (L.K., M.S.), affiliated to Euroimmun AG, Lübeck, Germany; AP-HP Pitié-Salpêtrière (D.L.), Service de Neuroradiologie; Département de Chirurgie Oncologique (V.F.); Département de Biologie des Tumeurs (B.B.), Service Génétique, Institut Curie, Paris; Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (J.H.), Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, France; and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (F.G.), Service of Neurology, Hospital Clinic, Barcelona, Spain
| | - Yael Hacohen
- AP-HP Pitié-Salpêtrière (G.B., C.D., J.-Y.D., D.P.), Service de Neurologie Mazarin, Paris, France; Neuroscience Consortium (G.B.), University of Pavia, Monza Policlinico and Pavia Mondino, Italy; Nuffield Department of Clinical Neurosciences (Y.H.), John Radcliffe Hospital, University of Oxford, United Kingdom; Institute of Experimental Immunology (L.K., M.S.), affiliated to Euroimmun AG, Lübeck, Germany; AP-HP Pitié-Salpêtrière (D.L.), Service de Neuroradiologie; Département de Chirurgie Oncologique (V.F.); Département de Biologie des Tumeurs (B.B.), Service Génétique, Institut Curie, Paris; Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (J.H.), Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, France; and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (F.G.), Service of Neurology, Hospital Clinic, Barcelona, Spain
| | - Lars Komorowski
- AP-HP Pitié-Salpêtrière (G.B., C.D., J.-Y.D., D.P.), Service de Neurologie Mazarin, Paris, France; Neuroscience Consortium (G.B.), University of Pavia, Monza Policlinico and Pavia Mondino, Italy; Nuffield Department of Clinical Neurosciences (Y.H.), John Radcliffe Hospital, University of Oxford, United Kingdom; Institute of Experimental Immunology (L.K., M.S.), affiliated to Euroimmun AG, Lübeck, Germany; AP-HP Pitié-Salpêtrière (D.L.), Service de Neuroradiologie; Département de Chirurgie Oncologique (V.F.); Département de Biologie des Tumeurs (B.B.), Service Génétique, Institut Curie, Paris; Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (J.H.), Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, France; and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (F.G.), Service of Neurology, Hospital Clinic, Barcelona, Spain
| | - Madeleine Scharf
- AP-HP Pitié-Salpêtrière (G.B., C.D., J.-Y.D., D.P.), Service de Neurologie Mazarin, Paris, France; Neuroscience Consortium (G.B.), University of Pavia, Monza Policlinico and Pavia Mondino, Italy; Nuffield Department of Clinical Neurosciences (Y.H.), John Radcliffe Hospital, University of Oxford, United Kingdom; Institute of Experimental Immunology (L.K., M.S.), affiliated to Euroimmun AG, Lübeck, Germany; AP-HP Pitié-Salpêtrière (D.L.), Service de Neuroradiologie; Département de Chirurgie Oncologique (V.F.); Département de Biologie des Tumeurs (B.B.), Service Génétique, Institut Curie, Paris; Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (J.H.), Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, France; and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (F.G.), Service of Neurology, Hospital Clinic, Barcelona, Spain
| | - Caroline Dehais
- AP-HP Pitié-Salpêtrière (G.B., C.D., J.-Y.D., D.P.), Service de Neurologie Mazarin, Paris, France; Neuroscience Consortium (G.B.), University of Pavia, Monza Policlinico and Pavia Mondino, Italy; Nuffield Department of Clinical Neurosciences (Y.H.), John Radcliffe Hospital, University of Oxford, United Kingdom; Institute of Experimental Immunology (L.K., M.S.), affiliated to Euroimmun AG, Lübeck, Germany; AP-HP Pitié-Salpêtrière (D.L.), Service de Neuroradiologie; Département de Chirurgie Oncologique (V.F.); Département de Biologie des Tumeurs (B.B.), Service Génétique, Institut Curie, Paris; Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (J.H.), Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, France; and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (F.G.), Service of Neurology, Hospital Clinic, Barcelona, Spain
| | - Delphine Leclercq
- AP-HP Pitié-Salpêtrière (G.B., C.D., J.-Y.D., D.P.), Service de Neurologie Mazarin, Paris, France; Neuroscience Consortium (G.B.), University of Pavia, Monza Policlinico and Pavia Mondino, Italy; Nuffield Department of Clinical Neurosciences (Y.H.), John Radcliffe Hospital, University of Oxford, United Kingdom; Institute of Experimental Immunology (L.K., M.S.), affiliated to Euroimmun AG, Lübeck, Germany; AP-HP Pitié-Salpêtrière (D.L.), Service de Neuroradiologie; Département de Chirurgie Oncologique (V.F.); Département de Biologie des Tumeurs (B.B.), Service Génétique, Institut Curie, Paris; Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (J.H.), Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, France; and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (F.G.), Service of Neurology, Hospital Clinic, Barcelona, Spain
| | - Virginie Fourchotte
- AP-HP Pitié-Salpêtrière (G.B., C.D., J.-Y.D., D.P.), Service de Neurologie Mazarin, Paris, France; Neuroscience Consortium (G.B.), University of Pavia, Monza Policlinico and Pavia Mondino, Italy; Nuffield Department of Clinical Neurosciences (Y.H.), John Radcliffe Hospital, University of Oxford, United Kingdom; Institute of Experimental Immunology (L.K., M.S.), affiliated to Euroimmun AG, Lübeck, Germany; AP-HP Pitié-Salpêtrière (D.L.), Service de Neuroradiologie; Département de Chirurgie Oncologique (V.F.); Département de Biologie des Tumeurs (B.B.), Service Génétique, Institut Curie, Paris; Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (J.H.), Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, France; and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (F.G.), Service of Neurology, Hospital Clinic, Barcelona, Spain
| | - Bruno Buecher
- AP-HP Pitié-Salpêtrière (G.B., C.D., J.-Y.D., D.P.), Service de Neurologie Mazarin, Paris, France; Neuroscience Consortium (G.B.), University of Pavia, Monza Policlinico and Pavia Mondino, Italy; Nuffield Department of Clinical Neurosciences (Y.H.), John Radcliffe Hospital, University of Oxford, United Kingdom; Institute of Experimental Immunology (L.K., M.S.), affiliated to Euroimmun AG, Lübeck, Germany; AP-HP Pitié-Salpêtrière (D.L.), Service de Neuroradiologie; Département de Chirurgie Oncologique (V.F.); Département de Biologie des Tumeurs (B.B.), Service Génétique, Institut Curie, Paris; Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (J.H.), Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, France; and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (F.G.), Service of Neurology, Hospital Clinic, Barcelona, Spain
| | - Jérôme Honnorat
- AP-HP Pitié-Salpêtrière (G.B., C.D., J.-Y.D., D.P.), Service de Neurologie Mazarin, Paris, France; Neuroscience Consortium (G.B.), University of Pavia, Monza Policlinico and Pavia Mondino, Italy; Nuffield Department of Clinical Neurosciences (Y.H.), John Radcliffe Hospital, University of Oxford, United Kingdom; Institute of Experimental Immunology (L.K., M.S.), affiliated to Euroimmun AG, Lübeck, Germany; AP-HP Pitié-Salpêtrière (D.L.), Service de Neuroradiologie; Département de Chirurgie Oncologique (V.F.); Département de Biologie des Tumeurs (B.B.), Service Génétique, Institut Curie, Paris; Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (J.H.), Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, France; and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (F.G.), Service of Neurology, Hospital Clinic, Barcelona, Spain
| | - Francesc Graus
- AP-HP Pitié-Salpêtrière (G.B., C.D., J.-Y.D., D.P.), Service de Neurologie Mazarin, Paris, France; Neuroscience Consortium (G.B.), University of Pavia, Monza Policlinico and Pavia Mondino, Italy; Nuffield Department of Clinical Neurosciences (Y.H.), John Radcliffe Hospital, University of Oxford, United Kingdom; Institute of Experimental Immunology (L.K., M.S.), affiliated to Euroimmun AG, Lübeck, Germany; AP-HP Pitié-Salpêtrière (D.L.), Service de Neuroradiologie; Département de Chirurgie Oncologique (V.F.); Département de Biologie des Tumeurs (B.B.), Service Génétique, Institut Curie, Paris; Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (J.H.), Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, France; and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (F.G.), Service of Neurology, Hospital Clinic, Barcelona, Spain
| | - Jean-Yves Delattre
- AP-HP Pitié-Salpêtrière (G.B., C.D., J.-Y.D., D.P.), Service de Neurologie Mazarin, Paris, France; Neuroscience Consortium (G.B.), University of Pavia, Monza Policlinico and Pavia Mondino, Italy; Nuffield Department of Clinical Neurosciences (Y.H.), John Radcliffe Hospital, University of Oxford, United Kingdom; Institute of Experimental Immunology (L.K., M.S.), affiliated to Euroimmun AG, Lübeck, Germany; AP-HP Pitié-Salpêtrière (D.L.), Service de Neuroradiologie; Département de Chirurgie Oncologique (V.F.); Département de Biologie des Tumeurs (B.B.), Service Génétique, Institut Curie, Paris; Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (J.H.), Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, France; and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (F.G.), Service of Neurology, Hospital Clinic, Barcelona, Spain
| | - Dimitri Psimaras
- AP-HP Pitié-Salpêtrière (G.B., C.D., J.-Y.D., D.P.), Service de Neurologie Mazarin, Paris, France; Neuroscience Consortium (G.B.), University of Pavia, Monza Policlinico and Pavia Mondino, Italy; Nuffield Department of Clinical Neurosciences (Y.H.), John Radcliffe Hospital, University of Oxford, United Kingdom; Institute of Experimental Immunology (L.K., M.S.), affiliated to Euroimmun AG, Lübeck, Germany; AP-HP Pitié-Salpêtrière (D.L.), Service de Neuroradiologie; Département de Chirurgie Oncologique (V.F.); Département de Biologie des Tumeurs (B.B.), Service Génétique, Institut Curie, Paris; Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (J.H.), Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, France; and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (F.G.), Service of Neurology, Hospital Clinic, Barcelona, Spain
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Jarius S, Ringelstein M, Haas J, Serysheva II, Komorowski L, Fechner K, Wandinger KP, Albrecht P, Hefter H, Moser A, Neuen-Jacob E, Hartung HP, Wildemann B, Aktas O. Inositol 1,4,5-trisphosphate receptor type 1 autoantibodies in paraneoplastic and non-paraneoplastic peripheral neuropathy. J Neuroinflammation 2016; 13:278. [PMID: 27776522 PMCID: PMC5078930 DOI: 10.1186/s12974-016-0737-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 09/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recently, we described a novel autoantibody, anti-Sj/ITPR1-IgG, that targets the inositol 1,4,5-trisphosphate receptor type 1 (ITPR1) in patients with cerebellar ataxia. However, ITPR1 is expressed not only by Purkinje cells but also in the anterior horn of the spinal cord, in the substantia gelatinosa and in the motor, sensory (including the dorsal root ganglia) and autonomic peripheral nervous system, suggesting that the clinical spectrum associated with autoimmunity to ITPR1 may be broader than initially thought. Here we report on serum autoantibodies to ITPR1 (up to 1:15,000) in three patients with (radiculo)polyneuropathy, which in two cases was associated with cancer (ITPR1-expressing adenocarcinoma of the lung, multiple myeloma), suggesting a paraneoplastic aetiology. METHODS Serological and other immunological studies, and retrospective analysis of patient records. RESULTS The clinical findings comprised motor, sensory (including severe pain) and autonomic symptoms. While one patient presented with subacute symptoms mimicking Guillain-Barré syndrome (GBS), the symptoms progressed slowly in two other patients. Electrophysiology revealed delayed F waves; a decrease in motor and sensory action potentials and conduction velocities; delayed motor latencies; signs of denervation, indicating sensorimotor radiculopolyneuropathy of the mixed type; and no conduction blocks. ITPR1-IgG belonged to the complement-activating IgG1 subclass in the severely affected patient but exclusively to the IgG2 subclass in the two more mildly affected patients. Cerebrospinal fluid ITPR1-IgG was found to be of predominantly extrathecal origin. A 3H-thymidine-based proliferation assay confirmed the presence of ITPR1-reactive lymphocytes among peripheral blood mononuclear cells (PBMCs). Immunophenotypic profiling of PBMCs protein demonstrated predominant proliferation of B cells, CD4 T cells and CD8 memory T cells following stimulation with purified ITPR1 protein. Patient ITPR1-IgG bound both to peripheral nervous tissue and to lung tumour tissue. A nerve biopsy showed lymphocyte infiltration (including cytotoxic CD8 cells), oedema, marked axonal loss and myelin-positive macrophages, indicating florid inflammation. ITPR1-IgG serum titres declined following tumour removal, paralleled by clinical stabilization. CONCLUSIONS Our findings expand the spectrum of clinical syndromes associated with ITPR1-IgG and suggest that autoimmunity to ITPR1 may underlie peripheral nervous system diseases (including GBS) in some patients and may be of paraneoplastic origin in a subset of cases.
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Affiliation(s)
- Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University Hospital Heidelberg, Otto Meyerhof Center, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany.
| | - Marius Ringelstein
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Jürgen Haas
- Molecular Neuroimmunology Group, Department of Neurology, University Hospital Heidelberg, Otto Meyerhof Center, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany
| | - Irina I Serysheva
- Department of Biochemistry and Molecular Biology, The University of Texas Medical School at Houston, 6431 Fannin Street, Houston, TX, 77030, USA
| | - Lars Komorowski
- Institute of Experimental Immunology, affiliated to Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Kai Fechner
- Institute of Experimental Immunology, affiliated to Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Klaus-Peter Wandinger
- Department of Neurology, University of Schleswig Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Philipp Albrecht
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Harald Hefter
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Andreas Moser
- Department of Neurology, University of Schleswig Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Eva Neuen-Jacob
- Department of Neuropathology, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University Hospital Heidelberg, Otto Meyerhof Center, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany.
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MOG-IgG in NMO and related disorders: a multicenter study of 50 patients. Part 2: Epidemiology, clinical presentation, radiological and laboratory features, treatment responses, and long-term outcome. J Neuroinflammation 2016; 13:280. [PMID: 27793206 PMCID: PMC5086042 DOI: 10.1186/s12974-016-0718-0] [Citation(s) in RCA: 610] [Impact Index Per Article: 76.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 09/09/2016] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND A subset of patients with neuromyelitis optica spectrum disorders (NMOSD) has been shown to be seropositive for myelin oligodendrocyte glycoprotein antibodies (MOG-IgG). OBJECTIVE To describe the epidemiological, clinical, radiological, cerebrospinal fluid (CSF), and electrophysiological features of a large cohort of MOG-IgG-positive patients with optic neuritis (ON) and/or myelitis (n = 50) as well as attack and long-term treatment outcomes. METHODS Retrospective multicenter study. RESULTS The sex ratio was 1:2.8 (m:f). Median age at onset was 31 years (range 6-70). The disease followed a multiphasic course in 80 % (median time-to-first-relapse 5 months; annualized relapse rate 0.92) and resulted in significant disability in 40 % (mean follow-up 75 ± 46.5 months), with severe visual impairment or functional blindness (36 %) and markedly impaired ambulation due to paresis or ataxia (25 %) as the most common long-term sequelae. Functional blindess in one or both eyes was noted during at least one ON attack in around 70 %. Perioptic enhancement was present in several patients. Besides acute tetra-/paraparesis, dysesthesia and pain were common in acute myelitis (70 %). Longitudinally extensive spinal cord lesions were frequent, but short lesions occurred at least once in 44 %. Fourty-one percent had a history of simultaneous ON and myelitis. Clinical or radiological involvement of the brain, brainstem, or cerebellum was present in 50 %; extra-opticospinal symptoms included intractable nausea and vomiting and respiratory insufficiency (fatal in one). CSF pleocytosis (partly neutrophilic) was present in 70 %, oligoclonal bands in only 13 %, and blood-CSF-barrier dysfunction in 32 %. Intravenous methylprednisolone (IVMP) and long-term immunosuppression were often effective; however, treatment failure leading to rapid accumulation of disability was noted in many patients as well as flare-ups after steroid withdrawal. Full recovery was achieved by plasma exchange in some cases, including after IVMP failure. Breakthrough attacks under azathioprine were linked to the drug-specific latency period and a lack of cotreatment with oral steroids. Methotrexate was effective in 5/6 patients. Interferon-beta was associated with ongoing or increasing disease activity. Rituximab and ofatumumab were effective in some patients. However, treatment with rituximab was followed by early relapses in several cases; end-of-dose relapses occurred 9-12 months after the first infusion. Coexisting autoimmunity was rare (9 %). Wingerchuk's 2006 and 2015 criteria for NMO(SD) and Barkhof and McDonald criteria for multiple sclerosis (MS) were met by 28 %, 32 %, 15 %, 33 %, respectively; MS had been suspected in 36 %. Disease onset or relapses were preceded by infection, vaccination, or pregnancy/delivery in several cases. CONCLUSION Our findings from a predominantly Caucasian cohort strongly argue against the concept of MOG-IgG denoting a mild and usually monophasic variant of NMOSD. The predominantly relapsing and often severe disease course and the short median time to second attack support the use of prophylactic long-term treatments in patients with MOG-IgG-positive ON and/or myelitis.
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Jarius S, Ruprecht K, Kleiter I, Borisow N, Asgari N, Pitarokoili K, Pache F, Stich O, Beume LA, Hümmert MW, Trebst C, Ringelstein M, Aktas O, Winkelmann A, Buttmann M, Schwarz A, Zimmermann H, Brandt AU, Franciotta D, Capobianco M, Kuchling J, Haas J, Korporal-Kuhnke M, Lillevang ST, Fechner K, Schanda K, Paul F, Wildemann B, Reindl M. MOG-IgG in NMO and related disorders: a multicenter study of 50 patients. Part 1: Frequency, syndrome specificity, influence of disease activity, long-term course, association with AQP4-IgG, and origin. J Neuroinflammation 2016; 13:279. [PMID: 27788675 PMCID: PMC5084340 DOI: 10.1186/s12974-016-0717-1] [Citation(s) in RCA: 312] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 09/09/2016] [Indexed: 01/18/2023] Open
Abstract
Background Antibodies to myelin oligodendrocyte glycoprotein (MOG-IgG) have been suggested to play a role in a subset of patients with neuromyelitis optica and related disorders. Objective To assess (i) the frequency of MOG-IgG in a large and predominantly Caucasian cohort of patients with optic neuritis (ON) and/or myelitis; (ii) the frequency of MOG-IgG among AQP4-IgG-positive patients and vice versa; (iii) the origin and frequency of MOG-IgG in the cerebrospinal fluid (CSF); (iv) the presence of MOG-IgG at disease onset; and (v) the influence of disease activity and treatment status on MOG-IgG titers. Methods 614 serum samples from patients with ON and/or myelitis and from controls, including 92 follow-up samples from 55 subjects, and 18 CSF samples were tested for MOG-IgG using a live cell-based assay (CBA) employing full-length human MOG-transfected HEK293A cells. Results MOG-IgG was detected in 95 sera from 50 patients with ON and/or myelitis, including 22/54 (40.7 %) patients with a history of both ON and myelitis, 22/103 (21.4 %) with a history of ON but no myelitis and 6/45 (13.3 %) with a history of longitudinally extensive transverse myelitis but no ON, and in 1 control patient with encephalitis and a connective tissue disorder, all of whom were negative for AQP4-IgG. MOG-IgG was absent in 221 further controls, including 83 patients with AQP4-IgG-seropositive neuromyelitis optica spectrum disorders and 85 with multiple sclerosis (MS). MOG-IgG was found in 12/18 (67 %) CSF samples from MOG-IgG-seropositive patients; the MOG-IgG-specific antibody index was negative in all cases, indicating a predominantly peripheral origin of CSF MOG-IgG. Serum and CSF MOG-IgG belonged to the complement-activating IgG1 subclass. MOG-IgG was present already at disease onset. The antibodies remained detectable in 40/45 (89 %) follow-up samples obtained over a median period of 16.5 months (range 0–123). Serum titers were higher during attacks than during remission (p < 0.0001), highest during attacks of simultaneous myelitis and ON, lowest during acute isolated ON, and declined following treatment. Conclusions To date, this is the largest cohort studied for IgG to human full-length MOG by means of an up-to-date CBA. MOG-IgG is present in a substantial subset of patients with ON and/or myelitis, but not in classical MS. Co-existence of MOG-IgG and AQP4-IgG is highly uncommon. CSF MOG-IgG is of extrathecal origin. Serum MOG-IgG is present already at disease onset and remains detectable in the long-term course. Serum titers depend on disease activity and treatment status.
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Affiliation(s)
- Sven Jarius
- Molecular Neuroimmunology Group, Otto Meyerhof Center, Department of Neurology, University Hospital Heidelberg, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany.
| | - Klemens Ruprecht
- Department of Neurology, Charité-University Medicine Berlin, Berlin, Germany
| | - Ingo Kleiter
- Department of Neurology, Ruhr University Bochum, Bochum, Germany
| | - Nadja Borisow
- NeuroCure Clinical Research Center and Clinical and Experimental Multiple Sclerosis Research Center, Department of Neurology, Charité University Medicine, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, Charité University Medicine Berlin, Berlin, Germany
| | - Nasrin Asgari
- Department of Neurology and Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | | | - Florence Pache
- NeuroCure Clinical Research Center and Clinical and Experimental Multiple Sclerosis Research Center, Department of Neurology, Charité University Medicine, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, Charité University Medicine Berlin, Berlin, Germany
| | - Oliver Stich
- Department of Neurology, Albert Ludwigs University, Freiburg, Germany
| | | | - Martin W Hümmert
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Corinna Trebst
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Orhan Aktas
- Department of Neurology, Heinrich Heine University, Düsseldorf, Germany
| | | | - Mathias Buttmann
- Department of Neurology, Julius Maximilians University, Würzburg, Germany
| | - Alexander Schwarz
- Molecular Neuroimmunology Group, Otto Meyerhof Center, Department of Neurology, University Hospital Heidelberg, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany
| | - Hanna Zimmermann
- Department of Neurology, Charité-University Medicine Berlin, Berlin, Germany
| | - Alexander U Brandt
- Department of Neurology, Charité-University Medicine Berlin, Berlin, Germany
| | | | - Marco Capobianco
- Centro di Riferimento Regionale SM, Azienda Ospedaliero Universitaria San Luigi Gonzaga, Orbassano, Italy
| | - Joseph Kuchling
- Department of Neurology, Charité-University Medicine Berlin, Berlin, Germany
| | - Jürgen Haas
- Molecular Neuroimmunology Group, Otto Meyerhof Center, Department of Neurology, University Hospital Heidelberg, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany
| | - Mirjam Korporal-Kuhnke
- Molecular Neuroimmunology Group, Otto Meyerhof Center, Department of Neurology, University Hospital Heidelberg, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany
| | | | - Kai Fechner
- Institute of Experimental Immunology, affiliated to Euroimmun AG, Lübeck, Germany
| | - Kathrin Schanda
- Clinical Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Friedemann Paul
- NeuroCure Clinical Research Center and Clinical and Experimental Multiple Sclerosis Research Center, Department of Neurology, Charité University Medicine, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, Charité University Medicine Berlin, Berlin, Germany
| | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Otto Meyerhof Center, Department of Neurology, University Hospital Heidelberg, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany
| | - Markus Reindl
- Clinical Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
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Jarius S, Metz I, König FB, Ruprecht K, Reindl M, Paul F, Brück W, Wildemann B. Screening for MOG-IgG and 27 other anti-glial and anti-neuronal autoantibodies in 'pattern II multiple sclerosis' and brain biopsy findings in a MOG-IgG-positive case. Mult Scler 2016; 22:1541-1549. [PMID: 26869529 DOI: 10.1177/1352458515622986] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 11/17/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Histopathological studies have revealed four different immunopathological patterns of lesion pathology in early multiple sclerosis (MS). Pattern II MS is characterised by immunoglobulin and complement deposition in addition to T-cell and macrophage infiltration and is more likely to respond to plasma exchange therapy, suggesting a contribution of autoantibodies. OBJECTIVE To assess the frequency of anti-myelin oligodendrocyte glycoprotein (MOG), anti-M1-aquaporin-4 (AQP4), anti-M23-AQP4, anti-N-methyl-d-aspartate-type glutamate receptors (NMDAR) and 25 other anti-neural antibodies in pattern II MS. METHODS Thirty-nine serum samples from patients with MS who had undergone brain biopsy (n = 24; including 13 from patients with pattern II MS) and from histopathologically non-classified MS patients (n = 15) were tested for anti-MOG, anti-M1-AQP4, anti-M23-AQP4, anti-NMDAR, anti-α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor-type glutamate receptors (AMPAR), anti-gamma-aminobutyric acid receptors (GABABR), anti-leucine-rich, glioma-activated protein 1 (LGI1), anti-contactin-associated protein 2 (CASPR2), anti-dipeptidyl-peptidase-like protein-6 (DPPX), anti-Tr/Delta/notch-like epidermal growth factor-related receptor (DNER), anti-Hu, anti-Yo, anti-Ri, anti-Ma1/Ma2, anti-CV2/collapsin response mediator protein 5 (CRMP5), anti-glutamic acid decarboxylase (GAD), anti-amphiphysin, anti-Ca/RhoGTPase-activating protein 26 (ARHGAP26), anti-Sj/inositol-1,4,5-trisphosphate receptor 1 (ITPR1), anti-Homer3, anti-carbonic anhydrase-related protein (CARPVIII), anti-protein kinase gamma (PKCgamma), anti-glutamate receptor delta 2 (GluRdelta2), anti-metabotropic glutamate receptor 1 (mGluR1) and anti-mGluR5, as well as for anti-glial nuclei antibodies (AGNA) and Purkinje cell antibody 2 (PCA2). RESULTS Antibodies to MOG belonging to the complement-activating immunoglobulin G1 (IgG1) subclass were detected in a patient with pattern II MS. Detailed brain biopsy findings are shown. CONCLUSION This is the largest study on established anti-neural antibodies performed in MS so far. MOG-IgG may play a role in a small percentage of patients diagnosed with pattern II MS.
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Affiliation(s)
- Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Imke Metz
- Department of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| | - Fatima Barbara König
- Department of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Markus Reindl
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Friedemann Paul
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; NeuroCure Clinical Research Center and Clinical and Experimental Multiple Sclerosis Research Center, Berlin, Germany
| | - Wolfgang Brück
- Department of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
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