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Warren N, McKeon G, Scott JG. Replacing universal anti-neuronal antibody screening with clinical assessment and testing of high probability cases in psychotic disorders. Aust N Z J Psychiatry 2024; 58:453-456. [PMID: 38679857 DOI: 10.1177/00048674241249575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Affiliation(s)
- Nicola Warren
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Metro South Addiction and Mental Health, Brisbane, QLD, Australia
| | - Gemma McKeon
- Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Brisbane, QLD, Australia
- West Moreton Health Psychology, The Park Centre for Mental Health, Brisbane, QLD, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - James G Scott
- Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Brisbane, QLD, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Child and Youth Mental Health Service, Children's Health Queensland, Brisbane, QLD, Australia
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Kang MJY, Eratne D, Wannan C, Santillo AF, Velakoulis D, Pantelis C, Cropley V. Plasma neurofilament light chain is not elevated in people with first-episode psychosis or those at ultra-high risk for psychosis. Schizophr Res 2024; 267:269-272. [PMID: 38581830 DOI: 10.1016/j.schres.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 02/02/2024] [Accepted: 04/01/2024] [Indexed: 04/08/2024]
Abstract
INTRODUCTION Neurofilament light chain (NfL), a blood biomarker of neuronal injury, shows promise in distinguishing neurodegenerative disorders from psychiatric conditions. This is especially relevant in psychosis, given neurological conditions such as autoimmune encephalitis and Niemann Pick Type C disease (NPC) may initially present with psychotic symptoms. Whilst NfL levels have been studied in established schizophrenia cases, their levels in first-episode psychosis (FEP) and ultra-high risk (UHR) for psychosis individuals remain largely unexplored. This study aimed to compare plasma NfL in people with FEP or UHR with healthy controls, as well as explore its associations with clinical data. METHOD We retrospectively analysed plasma NfL in 63 participants, consisting of 29 individuals with FEP, 10 individuals with UHR, and 24 healthy controls. We used general linear models (GLM), which were bootstrapped, to compute bias-corrected and accelerated (BCa) 95 % confidence intervals (CIs). RESULTS Mean NfL levels were 5.2 pg/mL in FEP, 4.9 pg/mL in UHR, and 5.9 pg/mL in healthy controls. Compared to healthy controls, there were no significant differences in NfL levels in the FEP group (β = -0.22, 95 % CI [-0.86, 0.39], p = 0.516) nor UHR group (β = -0.37, 95 % CI [-0.90, 0.19], p = 0.182). There were no significant associations between NfL levels and clinical variables in the FEP group. DISCUSSION Our study is the first to demonstrate that plasma NfL levels are not significantly elevated in individuals at UHR for psychosis compared to healthy controls, a finding also observed in the FEP cohort. These findings bolster the potential diagnostic utility of NfL in differentiating between psychiatric and neurodegenerative disorders.
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Affiliation(s)
- Matthew J Y Kang
- Neuropsychiatry Centre, Royal Melbourne Hospital, Australia; Melbourne Neuropsychiatry Centre & Department of Psychiatry, University of Melbourne, Australia.
| | - Dhamidhu Eratne
- Neuropsychiatry Centre, Royal Melbourne Hospital, Australia; Melbourne Neuropsychiatry Centre & Department of Psychiatry, University of Melbourne, Australia.
| | - Cassandra Wannan
- Melbourne Neuropsychiatry Centre & Department of Psychiatry, University of Melbourne, Australia; Orygen, Parkville, Victoria, Australia; Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia.
| | | | - Dennis Velakoulis
- Neuropsychiatry Centre, Royal Melbourne Hospital, Australia; Melbourne Neuropsychiatry Centre & Department of Psychiatry, University of Melbourne, Australia.
| | - Christos Pantelis
- Melbourne Neuropsychiatry Centre & Department of Psychiatry, University of Melbourne, Australia.
| | - Vanessa Cropley
- Melbourne Neuropsychiatry Centre & Department of Psychiatry, University of Melbourne, Australia; Orygen, Parkville, Victoria, Australia; Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia.
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Khannanova AN, Brylev LV, Prusova AA, Aksenova EV, Kondrasheva EA, Kovaleva IS. [Autoimmune encephalitis: psychiatric aspects]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:20-27. [PMID: 38465807 DOI: 10.17116/jnevro202412402120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Autoimmune encephalitis is a group of diseases researched by both neurologists and psychiatrists. Despite a large number of studies and practical recommendations, the differential diagnosis and early diagnostics still remains an important issue. The most difficult to diagnose are cases that debut as mental disorders and/or occur without neurological symptoms. The literature review presents the current state of the problem with an emphasis on the practice of a psychiatrist.
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Affiliation(s)
- A N Khannanova
- Gannushkin Psychiatric Clinical Hospital No. 4, Moscow, Russia
- Russian Biotechnological University, Moscow, Russia
| | - L V Brylev
- V.M. Bujanov Moscow Clinical Hospital, Moscow, Russia
- Institute of Higher Nervous Activity and Neurophysiology, Moscow, Russia
| | - A A Prusova
- Gannushkin Psychiatric Clinical Hospital No. 4, Moscow, Russia
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Warren N, Freier K, Siskind D, O'Gorman C, Blum S, Gillis D, Scott JG. Anti-glutamic acid decarboxylase antibody screening in first-episode psychosis. Aust N Z J Psychiatry 2023; 57:603-612. [PMID: 35362325 DOI: 10.1177/00048674221089560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The Royal Australian and New Zealand College of Psychiatrists recommends screening for a range of antibodies in first-episode psychosis, including anti-glutamic acid decarboxylase antibodies. Glutamic acid decarboxylase antibody-associated encephalitis occurs with high antibody titres and may cause cognitive dysfunction, seizures and psychiatric symptoms. However, glutamic acid decarboxylase antibodies are more frequently found in lower titre in association with other autoimmune disorders (such as diabetes mellitus type 1) and in healthy individuals. The utility of testing unselected populations of consumers with psychosis is unclear. The psychiatric manifestations of this disorder are also poorly described. METHODS First, systematic review of cohort and case-control studies that tested for IgG glutamic acid decarboxylase antibodies in psychiatric populations was conducted. Random-effects meta-analysis of odds ratio for antibody positivity in cases with psychosis and controls assessed prevalence. Second, literature review of all published cases and case series of glutamic acid decarboxylase antibody-associated limbic encephalitis was assessed for frequency and description of psychotic symptoms. RESULTS There were 17 studies, in which 2754 individuals with psychotic disorders were tested for glutamic acid decarboxylase IgG antibodies. Thirty-one consumers with psychosis (0.7%) had positive glutamic acid decarboxylase antibodies compared to 24 controls (1.0%), all at low titre and not fulfilling diagnostic criteria for autoimmune encephalitis. Meta-analysis found no significant difference in rates of glutamic acid decarboxylase antibody positivity (odds ratio = 1.8, 95% confidence interval: [0.90, 3.63]). Literature review found 321 cases of glutamic acid decarboxylase antibody-associated limbic encephalitis, with psychosis in 15 (4.3%) cases. Clinical screening would have identified all cases that presented to psychiatric services. CONCLUSION Glutamic acid decarboxylase antibodies were uncommon in consumers with psychosis, with no significant difference in prevalence from controls and no cases of encephalitis identified. In cases with established glutamic acid decarboxylase antibody-associated limbic encephalitis, psychotic symptoms were uncommon and identifiable by clinical assessment. Targeted antibody testing guidelines should be further considered.
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Affiliation(s)
- Nicola Warren
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Karen Freier
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Dan Siskind
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Cullen O'Gorman
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Neurology, The Princess Alexandra Hospital, Brisbane, QLD, Australia
- Mater Centre for Clinical Neurosciences, Mater Hospital, Brisbane, QLD, Australia
| | - Stefan Blum
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Neurology, The Princess Alexandra Hospital, Brisbane, QLD, Australia
- Mater Centre for Clinical Neurosciences, Mater Hospital, Brisbane, QLD, Australia
| | - David Gillis
- Pathology Queensland Central Laboratory, Division of Immunology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - James G Scott
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
- Metro North Mental Health Service, Brisbane, QLD, Australia
- Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
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Approach to New-Onset Psychosis in Pediatrics: A Review of Current Practice and an Interdisciplinary Consensus-Driven Clinical Pathway at a Single-Center Institution. J Child Neurol 2023; 38:216-222. [PMID: 37165651 DOI: 10.1177/08830738231156804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
New-onset psychosis in the pediatric population poses many diagnostic challenges. Given the diversity of underlying causes, which fall under the purview of multiple medical specialties, a timely, targeted, yet thorough workup requires a systematic and coordinated approach. A committee of expert pediatric physicians from the divisions of emergency medicine, psychiatry, neurology, hospitalist medicine, and radiology convened to create and implement a novel clinical pathway and approach to the pediatric patient presenting with new-onset psychosis. Here we provide background and review the evidence supporting the investigations recommended in our pathway to screen for a comprehensive range of etiologies of pediatric psychosis.
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Cohn SL, Mohan A, Lappin JM, Curtis J, Scott JG. Anti- N-Methyl-d-Aspartate Receptor Antibody Testing in First-Episode Psychosis: Universal or Targeted Testing. J Neuropsychiatry Clin Neurosci 2023; 35:98-101. [PMID: 36128677 DOI: 10.1176/appi.neuropsych.21080214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is an immune-mediated disorder that typically presents with rapid development of neuropsychiatric symptoms. As a potentially reversible cause of psychosis, there have been calls internationally for routine serological screening for anti-NMDAR antibodies in patients presenting with first-episode psychosis (FEP). Increased serological testing has, however, exposed several limitations of universal screening and rekindled debate as to which patients should be tested. Screening criteria have been proposed for high-risk clinical features in FEP in which antineuronal antibody testing is indicated. The authors present a clinical vignette and a service audit as well as discuss the limitations of universal screening advocating instead for targeted testing for antineuronal antibodies in patients diagnosed as having FEP.
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Affiliation(s)
- Sarah L Cohn
- Neuropsychiatric Institute, Prince of Wales Hospital, Sydney, Australia (Cohn, Mohan); University of New South Wales, Sydney (Cohn, Mohan, Lappin, Curtis); South Eastern Sydney Local Health District, Sydney (Cohn, Mohan, Lappin, Curtis); Mindgardens Neuroscience Network, Sydney (Curtis); Child and Youth Research Group, QIMR Berghofer Medical Research Institute, and Early Psychosis Service, Metro North Mental Health Service, Herston, Australia (Scott); Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Australia (Scott)
| | - Adith Mohan
- Neuropsychiatric Institute, Prince of Wales Hospital, Sydney, Australia (Cohn, Mohan); University of New South Wales, Sydney (Cohn, Mohan, Lappin, Curtis); South Eastern Sydney Local Health District, Sydney (Cohn, Mohan, Lappin, Curtis); Mindgardens Neuroscience Network, Sydney (Curtis); Child and Youth Research Group, QIMR Berghofer Medical Research Institute, and Early Psychosis Service, Metro North Mental Health Service, Herston, Australia (Scott); Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Australia (Scott)
| | - Julia M Lappin
- Neuropsychiatric Institute, Prince of Wales Hospital, Sydney, Australia (Cohn, Mohan); University of New South Wales, Sydney (Cohn, Mohan, Lappin, Curtis); South Eastern Sydney Local Health District, Sydney (Cohn, Mohan, Lappin, Curtis); Mindgardens Neuroscience Network, Sydney (Curtis); Child and Youth Research Group, QIMR Berghofer Medical Research Institute, and Early Psychosis Service, Metro North Mental Health Service, Herston, Australia (Scott); Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Australia (Scott)
| | - Jackie Curtis
- Neuropsychiatric Institute, Prince of Wales Hospital, Sydney, Australia (Cohn, Mohan); University of New South Wales, Sydney (Cohn, Mohan, Lappin, Curtis); South Eastern Sydney Local Health District, Sydney (Cohn, Mohan, Lappin, Curtis); Mindgardens Neuroscience Network, Sydney (Curtis); Child and Youth Research Group, QIMR Berghofer Medical Research Institute, and Early Psychosis Service, Metro North Mental Health Service, Herston, Australia (Scott); Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Australia (Scott)
| | - James G Scott
- Neuropsychiatric Institute, Prince of Wales Hospital, Sydney, Australia (Cohn, Mohan); University of New South Wales, Sydney (Cohn, Mohan, Lappin, Curtis); South Eastern Sydney Local Health District, Sydney (Cohn, Mohan, Lappin, Curtis); Mindgardens Neuroscience Network, Sydney (Curtis); Child and Youth Research Group, QIMR Berghofer Medical Research Institute, and Early Psychosis Service, Metro North Mental Health Service, Herston, Australia (Scott); Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Australia (Scott)
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Perkes IE, Eggleston M, Jacobs B, McEvoy P, Fung D, Robertson PG. The making of child and adolescent psychiatrists in Australia and New Zealand. Aust N Z J Psychiatry 2022; 56:899-904. [PMID: 34772296 DOI: 10.1177/00048674211055654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Child and adolescent psychiatry has an opportunity to adapt alongside the advancements in medical knowledge, post-graduate training, epidemiological realities and clinical service models. Here, we are guided by the mental health needs of our community's young and their families in our review of child and adolescent psychiatry training in Australia and New Zealand. We recognise that training must respond to clinical demand and service reform while ensuring a range of clinical and educational experiences to deliver expectable competencies in order to produce child and adolescent psychiatrists that meet the communities' needs now and in the future. We argue that training programmes be subject to rigorous evaluation by embedding continuing cycles of improvement including regular review and international bench marking.
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Affiliation(s)
- Iain E Perkes
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
- Department of Psychological Medicine, Sydney Children's Hospital Network, Randwick, NSW, Australia
| | - Matthew Eggleston
- Child, Adolescent and Family Service, Canterbury District Health Board, Christchurch, New Zealand
| | - Brian Jacobs
- The Department of Child and Adolescent Psychiatry, South London and Maudsley National Health Service Foundation Trust, London, UK
- The Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology, and Neuroscience, London, UK
| | - Prue McEvoy
- Department of Child Protection, Government of South Australia, Adelaide, SA, Australia
- Department of Child Protection, Adelaide, SA, Australia
| | - Daniel Fung
- Department of Developmental Psychiatry, Institute of Mental Health, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- DUKE NUS Medical School, National University of Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Paul G Robertson
- Mindful, Department of Psychiatry, The University of Melbourne, Travancore, VIC, Australia
- Eastern Health Child and Youth Mental Health Service, Eastern Health, Melbourne, VIC, Australia
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Lennox BR. Challenging the psychiatry-neurology divide: the case of autoimmune encephalitis. Nat Rev Neurol 2022; 18:253-254. [PMID: 35236924 DOI: 10.1038/s41582-022-00636-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Murashko AA, Pavlov KA, Pavlova OV, Gurina OI, Shmukler A. Antibodies against N-Methyl D-Aspartate Receptor in Psychotic Disorders: A Systematic Review. Neuropsychobiology 2022; 81:1-18. [PMID: 34000730 DOI: 10.1159/000515930] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 03/15/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The objective of this study was to provide comprehensive evidence synthesis including all available up-to-date data about the prevalence of N-methyl D-aspartate receptor (NMDAR) antibodies (ABs) in psychotic patients in order to evaluate the clinical relevance of ABs as well as to specify potential explanations of the heterogeneity of the findings and determine areas for further research. METHODS A literature search was conducted using the PubMed/Medline, Web of Knowledge, and Scopus databases. RESULTS Forty-seven studies and 4 systematic reviews (including 2 meta-analyses) were included in the present review. Studies that used cell-based assays (CBAs) provided heterogeneous results on AB prevalence, obviously depending on the type of detection assay and sample characteristics. Improvement of AB detection methods is necessary to determine the real prevalence of ABs across different groups of patients and healthy people. Live CBAs seem to have better sensitivity but probably poorer specificity than fixed CBAs. Moreover, some links between AB-positive status and acute symptoms are possible. A small amount of data on immunotherapy in AB-positive patients raises the possibility of its effectiveness but obviously require further research. CONCLUSIONS NMDAR ABs are definitely present in a subset of psychotic patients. NMDAR ABs might shape psychosis and underlie some symptoms, and immunotherapy might be regarded as a treatment option for patients failing to respond to other therapies.
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Affiliation(s)
- Alexey A Murashko
- Department of Translational Psychiatry, Moscow Research Institute of Psychiatry, The Branch of V. Serbsky National Medical Research Centre for Psychiatry and Narcology, Moscow, Russian Federation
| | - Konstantin A Pavlov
- Department of Fundamental and Applied Neurobiology, V. Serbsky National Medical Research Centre for Psychiatry and Narcology, Moscow, Russian Federation
| | - Olga V Pavlova
- Department of Fundamental and Applied Neurobiology, V. Serbsky National Medical Research Centre for Psychiatry and Narcology, Moscow, Russian Federation
| | - Olga I Gurina
- Department of Fundamental and Applied Neurobiology, V. Serbsky National Medical Research Centre for Psychiatry and Narcology, Moscow, Russian Federation
| | - Alexander Shmukler
- Department of Translational Psychiatry, Moscow Research Institute of Psychiatry, The Branch of V. Serbsky National Medical Research Centre for Psychiatry and Narcology, Moscow, Russian Federation
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Sami MB, Liddle P. Neurobiology of Psychosis and Schizophrenia 2021: Nottingham Meeting. Schizophr Bull 2022; 48:289-291. [PMID: 35064266 PMCID: PMC8886577 DOI: 10.1093/schbul/sbab152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Musa Basseer Sami
- Institute of Mental Health, University of Nottingham, Nottingham,UK
- Nottinghamshire Healthcare, NHS Foundation Trust, Nottingham, UK
- To whom correspondence should be addressed; Institute of Mental Health, University of Nottingham, Nottingham, UK; tel: +44 115 823 1294, e-mail:
| | - Peter Liddle
- Institute of Mental Health, University of Nottingham, Nottingham,UK
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Screening for pathogenic neuronal autoantibodies in serum and CSF of patients with first-episode psychosis. Transl Psychiatry 2021; 11:566. [PMID: 34741015 PMCID: PMC8571405 DOI: 10.1038/s41398-021-01701-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/16/2021] [Accepted: 10/20/2021] [Indexed: 12/25/2022] Open
Abstract
Patients with autoimmune encephalitides, especially those with antibodies to the N-methyl-D-aspartate receptor (NMDAR), often present with prominent psychosis and respond well to immunotherapies. Although most patients progress to develop various neurological symptoms, it has been hypothesised that a subgroup of patients with first-episode psychosis (FEP) suffer from a forme fruste of autoimmune encephalitis. Without accurate identification, this immunotherapy-responsive subgroup may be denied disease-modifying treatments. Thirty studies addressing aspects of this hypothesis were identified in a systematic review. Amongst other shortcomings, 15/30 reported no control group and only 6/30 determined cerebrospinal fluid (CSF) autoantibodies. To ourselves address these-and other-limitations, we investigated a prospectively ascertained clinically well-characterised cohort of 71 FEP patients without traditional neurological features, and 48 healthy controls. Serum and CSF were tested for autoantibodies against seven neuronal surface autoantigens using live cell-based assays. These identified 3/71 (4%) patient sera with weak binding to either contactin-associated protein-like 2, the NMDAR or glycine receptor versus no binding from 48 control samples (p = 0.28, Fisher's test). The three seropositive individuals showed no CSF autoantibodies and no differences from the autoantibody-negative patients in their clinical phenotypes, or across multiple parameters of peripheral and central inflammation. All individuals were negative for CSF NMDAR antibodies. In conclusion, formes frustes of autoimmune encephalitis are not prevalent among FEP patients admitted to psychiatric care. Our findings do not support screening for neuronal surface autoantibodies in unselected psychotic patients.
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Hansen N, Lipp M, Vogelgsang J, Vukovich R, Zindler T, Luedecke D, Gingele S, Malchow B, Frieling H, Kühn S, Denk J, Gallinat J, Skripuletz T, Moschny N, Fiehler J, Riedel C, Wiedemann K, Wattjes MP, Zerr I, Esselmann H, Bleich S, Wiltfang J, Neyazi A. Autoantibody-associated psychiatric symptoms and syndromes in adults: A narrative review and proposed diagnostic approach. Brain Behav Immun Health 2021; 9:100154. [PMID: 34589896 PMCID: PMC8474611 DOI: 10.1016/j.bbih.2020.100154] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/26/2020] [Indexed: 12/13/2022] Open
Abstract
Background Autoimmune-mediated encephalitis is a disease that often encompasses psychiatric symptoms as its first clinical manifestation’s predominant and isolated characteristic. Novel guidelines even distinguish autoimmune psychosis from autoimmune encephalitis. The aim of this review is thus to explore whether a wide range of psychiatric symptoms and syndromes are associated or correlate with autoantibodies. Methods We conducted a PubMed search to identify appropriate articles concerning serum and/or cerebrospinal fluid (CSF) autoantibodies associated with psychiatric symptoms and syndromes between 2000 and 2020. Relying on this data, we developed a diagnostic approach to optimize the detection of autoantibodies in psychiatric patients, potentially leading to the approval of an immunotherapy. Results We detected 10 major psychiatric symptoms and syndromes often reported to be associated with serum and/or CSF autoantibodies comprising altered consciousness, disorientation, memory impairment, obsessive-compulsive behavior, psychosis, catatonia, mood dysfunction, anxiety, behavioral abnormalities (autism, hyperkinetic), and sleeping dysfunction. The following psychiatric diagnoses were associated with serum and/or CSF autoantibodies: psychosis and schizophrenia spectrum disorders, mood disorders, minor and major neurocognitive impairment, obsessive-compulsive disorder, autism spectrum disorders (ASD), attention deficit hyperactivity disorder (ADHD), anxiety disorders, eating disorders and addiction. By relying on these symptom clusters and diagnoses in terms of onset and their duration, we classified a subacute or subchronic psychiatric syndrome in patients that should be screened for autoantibodies. We propose further diagnostics entailing CSF analysis, electroencephalography and magnetic resonance imaging of the brain. Exploiting these technologies enables standardized and accurate diagnosis of autoantibody-associated psychiatric symptoms and syndromes to deliver early immunotherapy. Conclusions We have developed a clinical diagnostic pathway for classifying subgroups of psychiatric patients whose psychiatric symptoms indicate a suspected autoimmune origin. Autoantibodies are associated with a broad spectrum of psychiatric syndromes. More systematic studies are needed to elucidate the significance of autoantibodies. We developed a pathway to identify autoantibody-associated psychiatric syndromes.
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Affiliation(s)
- Niels Hansen
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Von-Siebold-Str. 5, 37075, Goettingen, Germany
| | - Michael Lipp
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Jonathan Vogelgsang
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Von-Siebold-Str. 5, 37075, Goettingen, Germany
| | - Ruth Vukovich
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Von-Siebold-Str. 5, 37075, Goettingen, Germany
| | - Tristan Zindler
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Daniel Luedecke
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Stefan Gingele
- Department of Neurology, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Berend Malchow
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Von-Siebold-Str. 5, 37075, Goettingen, Germany
| | - Helge Frieling
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Simone Kühn
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Johannes Denk
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Jürgen Gallinat
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Thomas Skripuletz
- Department of Neurology, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Nicole Moschny
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Christian Riedel
- Department of Neuroradiology, University of Goettingen, Robert-Koch Str. 40, 37075, Goettingen, Germany
| | - Klaus Wiedemann
- Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Mike P Wattjes
- Department of Neuroradiology, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Inga Zerr
- Department of Neurology, University of Goettingen, Robert-Koch Str. 40, 37075, Goettingen, Germany.,German Center for Neurodegenerative Diseases (DZNE), Von-Siebold-Str. 3a, 37075, Goettingen, Germany
| | - Hermann Esselmann
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Von-Siebold-Str. 5, 37075, Goettingen, Germany
| | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Jens Wiltfang
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Von-Siebold-Str. 5, 37075, Goettingen, Germany.,German Center for Neurodegenerative Diseases (DZNE), Von-Siebold-Str. 3a, 37075, Goettingen, Germany.,Neurosciences and Signaling Group, Institute of Biomedicine (iBiMED), Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
| | - Alexandra Neyazi
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
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McKeon G, Parker S, Warren N, Scott JG. The Patient Experience of Recovery Following Anti-NMDA Receptor Encephalitis: A Qualitative Content Analysis. J Neuropsychiatry Clin Neurosci 2021; 33:57-63. [PMID: 32873136 DOI: 10.1176/appi.neuropsych.20030049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors examined patients' perceptions of the factors affecting their recovery from anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis, which is a rare, severe immune-mediated neurological disorder. METHODS Seven patients completed semistructured interviews exploring their experience of recovery. Participants were interviewed between 7 and 41 months after the initiation of treatment. Interviews were transcribed and subjected to qualitative content analysis. RESULTS Facilitators of recovery included the presence of a support system and treatment-related factors. Barriers to recovery included perceived psychiatric stigma, insufficient illness education, and lifestyle disruptions to accommodate ongoing treatment. Adverse physical, psychological, and neurocognitive sequelae of anti-NMDAR encephalitis continued to affect participants' daily functioning. Most participants described strategies to manage neurocognitive deficits, fatigue, and anxiety. CONCLUSIONS Anti-NMDAR encephalitis contributes to persistent burden on patients, their families, and health services after the resolution of acute symptoms. Physical, psychological, and cognitive changes contribute to long-term disease morbidity. To optimize recovery and reduce disability, further attention must be directed toward illness education, reducing stigma, and role disruption. Longer-term disability support may benefit those who do not fully recover.
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Affiliation(s)
- Gemma McKeon
- Metro South Addiction and Mental Health Services, Brisbane, Australia (McKeon, Parker, Warren);University of Queensland Centre for Clinical Research, Herston, Australia (McKeon, Scott); Child and Youth Mental Health Group, Queensland Centre for Mental Health Research, Wacol, Australia (McKeon, Scott); School of Medicine, University of Queensland, Herston, Australia (Parker, Warren); and Child and Youth Mental Health Group, Queensland Institute of Medical Research Berghofer Medical Research Institute, Herston, Australia (McKeon, Scott)
| | - Stephen Parker
- Metro South Addiction and Mental Health Services, Brisbane, Australia (McKeon, Parker, Warren);University of Queensland Centre for Clinical Research, Herston, Australia (McKeon, Scott); Child and Youth Mental Health Group, Queensland Centre for Mental Health Research, Wacol, Australia (McKeon, Scott); School of Medicine, University of Queensland, Herston, Australia (Parker, Warren); and Child and Youth Mental Health Group, Queensland Institute of Medical Research Berghofer Medical Research Institute, Herston, Australia (McKeon, Scott)
| | - Nicola Warren
- Metro South Addiction and Mental Health Services, Brisbane, Australia (McKeon, Parker, Warren);University of Queensland Centre for Clinical Research, Herston, Australia (McKeon, Scott); Child and Youth Mental Health Group, Queensland Centre for Mental Health Research, Wacol, Australia (McKeon, Scott); School of Medicine, University of Queensland, Herston, Australia (Parker, Warren); and Child and Youth Mental Health Group, Queensland Institute of Medical Research Berghofer Medical Research Institute, Herston, Australia (McKeon, Scott)
| | - James G Scott
- Metro South Addiction and Mental Health Services, Brisbane, Australia (McKeon, Parker, Warren);University of Queensland Centre for Clinical Research, Herston, Australia (McKeon, Scott); Child and Youth Mental Health Group, Queensland Centre for Mental Health Research, Wacol, Australia (McKeon, Scott); School of Medicine, University of Queensland, Herston, Australia (Parker, Warren); and Child and Youth Mental Health Group, Queensland Institute of Medical Research Berghofer Medical Research Institute, Herston, Australia (McKeon, Scott)
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Autoantibody profiles associated with clinical features in psychotic disorders. Transl Psychiatry 2021; 11:474. [PMID: 34518517 PMCID: PMC8438048 DOI: 10.1038/s41398-021-01596-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 08/12/2021] [Accepted: 08/26/2021] [Indexed: 11/23/2022] Open
Abstract
Autoimmune processes are suspected to play a role in the pathophysiology of psychotic disorders. Better understanding of the associations between auto-immunoglobulin G (IgG) repertoires and clinical features of mental illness could yield novel models of the pathophysiology of psychosis, and markers for biological patient stratification. We undertook cross-sectional detection and quantification of auto-IgGs in peripheral blood plasma of 461 people (39% females) with established psychotic disorder diagnoses. Broad screening of 24 individuals was carried out on group level in eight clinically defined groups using planar protein microarrays containing 42,100 human antigens representing 18,914 proteins. Autoantibodies indicated by broad screening and in the previous literature were measured using a 380-plex bead-based array for autoantibody profiling of all 461 individuals. Associations between autoantibody profiles and dichotomized clinical characteristics were assessed using a stepwise selection procedure. Broad screening and follow-up targeted analyses revealed highly individual autoantibody profiles. Females, and people with family histories of obesity or of psychiatric disorders other than schizophrenia had the highest overall autoantibody counts. People who had experienced subjective thought disorder and/or were treated with clozapine (trend) had the lowest overall counts. Furthermore, six autoantibodies were associated with specific psychopathology symptoms: anti-AP3B2 (persecutory delusions), anti-TDO2 (hallucinations), anti-CRYGN (initial insomnia); anti-APMAP (poor appetite), anti-OLFM1 (above-median cognitive function), and anti-WHAMMP3 (anhedonia and dysphoria). Future studies should clarify whether there are causal biological relationships, and whether autoantibodies could be used as clinical markers to inform diagnostic patient stratification and choice of treatment.
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Lee TY, Jo HJ. Differential diagnosis and comorbid physical illness of schizophrenia. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2021. [DOI: 10.5124/jkma.2021.64.8.551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Schizophrenia is a neurodevelopmental disorder that generally develops during adolescence or early adulthood. However, differentiating it from psychosis caused by a physical illness is difficult due to the phenotypebased diagnostic system. In this review, differential diagnosis of schizophrenia and the comorbid physical illnesses of patients with schizophrenia will be discussed.Current Concepts: Psychotic symptoms can be caused by various physical illnesses, and patients with schizophrenia have many physical comorbidities. Symptoms of psychosis can also be expressed by physical illness including brain tumors, encephalitis, temporal lobe epilepsy, autoimmune disease, and genetic disease. For the differential diagnosis of other physical illnesses that can cause psychosis, biological tests are essential. Depending on the cause, antipsychotics and treatment of physical diseases are required. In addition, patients with schizophrenia have many comorbid medical conditions such as obesity, diabetes, cardiovascular disease, but the diagnosis rate is low, and the mortality is higher than that of the general population due to untreated medical diseases.Discussion and Conclusion: The differential diagnoses of schizophrenia and physical illness causing psychosis are important. To decrease the high mortality of patients with schizophrenia, periodic physical condition examinations and mental status examinations should be conducted.
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Shoham N. Serum NMDA Receptor Antibodies Do Not Predict Treatment Response in a Sample of People With First-Episode Psychosis. Biol Psychiatry 2021; 90:e1-e2. [PMID: 34140122 DOI: 10.1016/j.biopsych.2021.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Natalie Shoham
- Division of Psychiatry, University College London, and the Camden and Islington NHS Foundation Trust, London, United Kingdom.
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Pollak TA, Vincent A, Iyegbe C, Coutinho E, Jacobson L, Rujescu D, Stone J, Jezequel J, Rogemond V, Jamain S, Groc L, David A, Egerton A, Kahn RS, Honnorat J, Dazzan P, Leboyer M, McGuire P. Relationship Between Serum NMDA Receptor Antibodies and Response to Antipsychotic Treatment in First-Episode Psychosis. Biol Psychiatry 2021; 90:9-15. [PMID: 33536130 PMCID: PMC8191702 DOI: 10.1016/j.biopsych.2020.11.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/03/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND When psychosis develops in NMDA receptor (NMDAR) antibody encephalitis, it usually has an acute or subacute onset, and antipsychotic treatment may be ineffective and associated with adverse effects. Serum NMDAR antibodies have been reported in a minority of patients with first-episode psychosis (FEP), but their role in psychosis onset and response to antipsychotic treatment is unclear. METHODS Sera from 387 patients with FEP (duration of psychosis <2 years, minimally or never treated with antipsychotics) undergoing initial treatment with amisulpride as part of the OPTiMiSE (Optimization of Treatment and Management of Schizophrenia in Europe) trial (ClinicalTrials.gov number NCT01248195) were tested for NMDAR IgG antibodies using a live cell-based assay. Symptom severity was assessed using the Positive and Negative Syndrome Scale and the Clinical Global Impressions Scale at baseline and again after 4 weeks of treatment with amisulpride. RESULTS At baseline, 15 patients were seropositive for NMDAR antibodies and 372 were seronegative. The seropositive patients had similar symptom profiles and demographic features to seronegative patients but a shorter duration of psychosis (median 1.5 vs. 4.0 months; p = .031). Eleven seropositive and 284 seronegative patients completed 4 weeks of amisulpride treatment: after treatment, there was no between-groups difference in improvement in Positive and Negative Syndrome Scale scores or in the frequency of adverse medication effects. CONCLUSIONS These data suggest that in FEP, NMDAR antibody seropositivity alone is not an indication for using immunotherapy instead of antipsychotic medications. Further studies are required to establish what proportion of patients with FEP who are NMDAR antibody seropositive have coexisting cerebrospinal fluid inflammatory changes or other paraclinical evidence suggestive of a likely benefit from immunotherapy.
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Affiliation(s)
- Thomas A Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, London, United Kingdom; South London and Maudsley NHS Foundation Trust, University College London, London, United Kingdom.
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom
| | - Conrad Iyegbe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, London, United Kingdom
| | - Ester Coutinho
- Division of Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, London, United Kingdom
| | - Leslie Jacobson
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom
| | - Dan Rujescu
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - James Stone
- Department of Neuroimaging, Centre for Neuroimaging Sciences, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, London, United Kingdom; South London and Maudsley NHS Foundation Trust, University College London, London, United Kingdom
| | - Julie Jezequel
- Centre for Developmental Neurobiology, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, London, United Kingdom; Interdisciplinary Institute for Neuroscience, University of Bordeaux, Bordeaux, France
| | - Veronique Rogemond
- Rare Disease Reference Center on Autoimmune Encephalitis, Hospices Civils de Lyon, Institut NeuroMyoGene Institut National de la Santé et de la Recherche Médicale U1217/Centre National de la Recherche Scientifique, University Claude Bernard, Universite de Lyon, Lyon, France
| | - Stephane Jamain
- Psychiatry and Addictology Department (DMU IMPACT), University Paris Est Créteil, Hopitaux Universitaires Henri Mondor, L'Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Laurent Groc
- Interdisciplinary Institute for Neuroscience, University of Bordeaux, Bordeaux, France
| | - Anthony David
- Institute of Mental Health, University College London, London, United Kingdom
| | - Alice Egerton
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, London, United Kingdom
| | - Rene S Kahn
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jerome Honnorat
- Rare Disease Reference Center on Autoimmune Encephalitis, Hospices Civils de Lyon, Institut NeuroMyoGene Institut National de la Santé et de la Recherche Médicale U1217/Centre National de la Recherche Scientifique, University Claude Bernard, Universite de Lyon, Lyon, France
| | - Paola Dazzan
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, London, United Kingdom
| | - Marion Leboyer
- Psychiatry and Addictology Department (DMU IMPACT), University Paris Est Créteil, Hopitaux Universitaires Henri Mondor, L'Assistance Publique-Hôpitaux de Paris, Créteil, France; Translational Neuropsychiatry Laboratory, Institut National de la Santé et de la Recherche Médicale U955, Créteil, France; FondaMental Foundation, Créteil, France
| | - Philip McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, King's College London, London, United Kingdom; South London and Maudsley NHS Foundation Trust, University College London, London, United Kingdom
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Beattie M, Goodfellow J, Oto M, Krishnadas R. Anti-NMDAR encephalitis for psychiatrists: the essentials. BJPsych Bull 2021; 46:1-7. [PMID: 34075874 PMCID: PMC9768510 DOI: 10.1192/bjb.2021.35] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 02/14/2021] [Accepted: 03/19/2021] [Indexed: 12/31/2022] Open
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis predominantly presents with psychiatric symptoms. Psychiatrists need to be alert to this diagnostic possibility, especially in female adolescents and young adults, as exemplified by the real (de-identified) case outlined below. Earlier diagnosis and immunotherapy improves long-term outcomes. Collaboration with neurology colleagues is essential for optimal care. 'Red flags' for autoimmune encephalitis and 'diagnostic clues' act as helpful aide memoires for this uncommon condition. The gold standard for testing is the detection of NMDAR antibodies in cerebrospinal fluid, but serum can be tested as a more accessible (but less reliable) preliminary step. The results of routine blood tests, magnetic resonance imaging of the head and electroencephalograms can be normal or show non-specific changes. Diagnostic criteria exist to define probable and definite cases. Immunotherapy for anti-NMDAR encephalitis is effective for many patients, but recovery is prolonged and relapses can occur.
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Affiliation(s)
- Matthew Beattie
- Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, UK
| | - John Goodfellow
- Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, UK
| | - Maria Oto
- Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, UK
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Ketheesan S, Bertram G, Adam R, Stark A, Scott JG. Muddying the waters? A false positive case of autoimmune psychosis. Australas Psychiatry 2021; 29:278-281. [PMID: 33070625 DOI: 10.1177/1039856220965041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To discuss challenges with the diagnosis of autoimmune psychosis (AP) in people with chronic psychotic disorders. METHOD We present a case of a 23-year-old man with an exacerbation of treatment-refractory psychosis after receiving intravenous immunoglobulin (IVIG) for suspected AP, diagnosed 4 years after the onset of psychosis. We highlight the diagnostic and management challenges in such cases. RESULTS The diagnosis of AP in people with long-standing illness relies on the interpretation of non-specific clinical and laboratory findings in individuals with psychosocial problems and challenges of acceptance and adherence to complex medical investigations and treatments. Equivocal results from investigations undertaken without logical clinical reasoning can lead to inappropriate interventions that are costly and can cause iatrogenic harm. CONCLUSION Psychiatrists should restrict screening for antineuronal antibodies in people with chronic psychosis to those with higher risk features such as persistent treatment refractory symptoms with concurrent neurological signs and symptoms. Further research informing the clinical circumstances for antineuronal antibody testing is needed.
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Affiliation(s)
- Sarangan Ketheesan
- Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,Metro North Mental Health Service, Herston, QLD, Australia.,Laboratory of Psychiatric Neuroscience, James Cook University, Douglas, QLD, Australia
| | - Georgia Bertram
- Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,Metro North Mental Health Service, Herston, QLD, Australia
| | - Robert Adam
- Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,University of Queensland Centre for Clinical Research, Herston, QLD, Australia.,QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Anne Stark
- Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,Metro North Mental Health Service, Herston, QLD, Australia
| | - James G Scott
- Metro North Mental Health Service, Herston, QLD, Australia.,QIMR Berghofer Medical Research Institute, Herston, QLD, Australia.,Queensland Centre for Mental Health Research, Wacol, QLD, Australia
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20
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Dorney K, Murphy M. Recommendations for the medical work-up of first episode psychosis, including specific relevance to Indigenous Australians: A narrative review. Early Interv Psychiatry 2021; 15:423-438. [PMID: 32543124 DOI: 10.1111/eip.12980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 03/24/2020] [Accepted: 04/28/2020] [Indexed: 12/15/2022]
Abstract
AIMS To collate existing literature for busy practicing psychiatrists about the medical work-up for first-episode psychosis (FEP). Therefore, (a) to review current guidelines for the medical work-up of first episode psychosis. (b) To examine whether any specific recommendations for Indigenous Australians exist. (c) To produce an easy reference table of evidence based investigations. METHOD A multi-part narrative review process was undertaken. Step 1 "Source identification and summary": identified key existing national and international guidelines and expert opinions related to the medical work-up of FEP and summarised these suggestions. Step 2 "Exploration of each investigation": examined each of the identified investigations for its importance. Step 3 "Relevance to Indigenous Australians": reviewed any particular relevance to the Indigenous Australian population. Step 4 "Clinician guide": involved presenting recommended investigations in a simple table. RESULTS Multiple guidelines were identified. There was clear consensus for many aspects. However, there were also differences in the approach for some investigations. Clinical reasoning for the proposed investigations was commonly absent. There were limited specific recommendations for Indigenous Australians. Evidence and importance was explored for each investigation and auseful table for the practicing psychiatrist was constructed. Investigations were stratified into those considered to be "universal," "low yield," or "unecessary." CONCLUSION A narrative review of multiple guidelines relating to the medical work-up of FEP identified many similarities and some differences to their approach. Little additional information exists for the Indigenous Australian context. A clinician friendly worksheet for everyday use may be helpful to busy clinicians.
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Affiliation(s)
- Kiernan Dorney
- Department of Psychiatry, Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Michael Murphy
- Department of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia
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21
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Guasp M, Giné-Servén E, Maudes E, Rosa-Justicia M, Martínez-Hernández E, Boix-Quintana E, Bioque M, Casado V, Módena-Ouarzi Y, Guanyabens N, Muriana D, Sugranyes G, Pacchiarotti I, Davi-Loscos E, Torres-Rivas C, Ríos J, Sabater L, Saiz A, Graus F, Castro-Fornieles J, Parellada E, Dalmau J. Clinical, Neuroimmunologic, and CSF Investigations in First Episode Psychosis. Neurology 2021; 97:e61-e75. [PMID: 33980703 DOI: 10.1212/wnl.0000000000012191] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/26/2021] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES To report the neuropsychiatric features and frequency of NMDA receptor (NMDAR) and other neuronal immunoglobulin G antibodies in patients with first episode psychosis (FEP) and to assess the performance of reported warning signs and criteria for autoimmune psychosis (AP). METHODS This was a prospective observational study of patients with FEP assessed for neuropsychiatric symptoms, serum and CSF neuronal antibodies (brain immunohistochemistry, cell-based assays, live neurons), and warning signs and criteria of AP. Previous autoimmune FEP series were reviewed. RESULTS One hundred five patients were included; their median age was 30 (range 14-75) years, and 44 (42%) were female. None had neuronal antibodies. Two of 105 (2%) had CSF pleocytosis, 4 of 100 (4%) had brain MRI abnormalities, and 3 of 73 (4%) EEG alterations. Thirty-four (32%) and 39 (37%) patients fulfilled 2 sets of warning signs of AP, and 21 (20%) fulfilled criteria of possible or probable AP, yet none developed AP. The cause of FEP was psychiatric in 101 (96%) and nonpsychiatric in 4 (4%). During this study, 3 patients with psychosis caused by anti-NMDAR encephalitis were transferred to our center; 2 did not meet criteria for possible AP. Of 1,159 reported patients with FEP, only 7 (1%) had CSF studies; 36 (3%) had serum NMDAR antibodies (without definite diagnosis of AP), and 4 had CSF NMDAR antibodies (3 classic anti-NMDAR encephalitis and 1 with isolated psychiatric features). CONCLUSIONS NMDAR antibodies were not found in patients with FEP unless they had anti-NMDAR encephalitis. Warning signs and criteria for AP have limited utility when neurologic symptoms are absent or paraclinical tests are normal. A diagnostic algorithm for autoimmune FEP is provided.
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Affiliation(s)
- Mar Guasp
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Eloi Giné-Servén
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Estibaliz Maudes
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Mireia Rosa-Justicia
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Eugenia Martínez-Hernández
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Ester Boix-Quintana
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Miquel Bioque
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Virginia Casado
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Yasmina Módena-Ouarzi
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Nicolau Guanyabens
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Desiree Muriana
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Gisela Sugranyes
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Isabella Pacchiarotti
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Eva Davi-Loscos
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Cristina Torres-Rivas
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - José Ríos
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Lidia Sabater
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Albert Saiz
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Francesc Graus
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Josefina Castro-Fornieles
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Eduard Parellada
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Josep Dalmau
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., E.M., E.M.-H., M.B., Y.M.-O., G.S., I.P, L.S., A.S., F.G., J.C.-F., E.P., J.D.), Hospital Clínic, and Department of Medicine (M.B., A.S., J.C.-F., E.P.), Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.S., J.D.), Department of Child and Adolescent Psychiatry and Psychology (M.R.-J., G.S., J.C.-F.), Barcelona Clínic Schizophrenia Unit (BCSU) (M.B., E.P.), and Bipolar and Depressive Disorders Unit (I.P.), Institute of Neuroscience, Hospital Clínic; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER); Psychiatry Department (E.G.-S., E.B.-Q., E.D.-L.), Hospital de Mataró Consorci Sanitari del Maresme, Mataró; Centro de Investigación Biomédica en Red (M.B., G.S., I.P., J.C.-F., E.P.), Salud Mental (CIBERSAM); Neurology Department (V.C., N.G., D.M., C.T.-R.), Hospital de Mataró Consorci Sanitari del Maresme; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic, Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain.
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22
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Swayne A, Warren N, Prain K, Gillis D, O'Gorman C, Tsang BKT, Muller C, Broadley S, Adam RJ, McCombe P, Wong RC, Blum S. An Australian State-Based Cohort Study of Autoimmune Encephalitis Cases Detailing Clinical Presentation, Investigation Results, and Response to Therapy. Front Neurol 2021; 12:607773. [PMID: 33692738 PMCID: PMC7937705 DOI: 10.3389/fneur.2021.607773] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 01/25/2021] [Indexed: 01/17/2023] Open
Abstract
Introduction: Autoimmune encephalitis is a disorder associated with antibodies directed against central nervous system proteins with variable clinical features. This study aims to add to knowledge of the disease by reporting the details of a cohort of patients with autoimmune encephalitis in Queensland, Australia. Methodology: We surveyed patients with autoimmune encephalitis diagnosed and managed through public hospitals in Queensland, Australia between 2010 and the end of 2019. Cases were identified via case detection through a centralized diagnostic neuroimmunology laboratory (Division of Immunology, HSQ Pathology Queensland Central Laboratory, Brisbane, Queensland, Australia) and a survey of neurologists. Data including demographic details, clinical presentation, investigation results, treatments including immune therapy and outcomes was collected. Results: Sixty cases of antibody positive autoimmune encephalitis were identified. Twenty-eight were of anti-NMDA-receptor encephalitis with other cases associated with antibodies against LGi1, Caspr2, glycine receptor, DPPX, GABAB receptor, IgLON5, GFAP, and SOX1. The number of diagnosed cases, especially of anti-NMDA-receptor encephalitis has markedly increased over the period 2017 to 2019. Clinical presentations were marked by heterogeneous symptom complexes and prolonged hospital admissions. Imaging studies were largely normal or non-specific. There was a response to immune therapy and a low mortality rate. Most cases affected by this disorder were left with ongoing symptoms associated with mild disability. Conclusion: Autoimmune encephalitis in Queensland, Australia is an increasingly common but complex clinical entity marked by heterogeneous presentations, response to immune therapy and outcome results marked by low mortality and incomplete recovery.
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Affiliation(s)
- Andrew Swayne
- Mater Centre for Neurosciences, Mater Hospital, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Nicola Warren
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Psychiatry, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Kerri Prain
- Health Support Queensland, Pathology Queensland Central Laboratory, Division of Immunology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - David Gillis
- Health Support Queensland, Pathology Queensland Central Laboratory, Division of Immunology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Cullen O'Gorman
- Mater Centre for Neurosciences, Mater Hospital, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Benjamin K-T Tsang
- Department of Neurology, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia
| | - Claire Muller
- Department of Neurology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Simon Broadley
- Department of Neurology, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Robert J Adam
- Department of Neurology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Pamela McCombe
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Neurology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Richard C Wong
- Health Support Queensland, Pathology Queensland Central Laboratory, Division of Immunology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Department of Immunology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Stefan Blum
- Mater Centre for Neurosciences, Mater Hospital, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia
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23
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Cullen AE, Palmer-Cooper EC, Hardwick M, Vaggers S, Crowley H, Pollak TA, Lennox BR. Influence of methodological and patient factors on serum NMDAR IgG antibody detection in psychotic disorders: a meta-analysis of cross-sectional and case-control studies. Lancet Psychiatry 2021; 8:109-120. [PMID: 33357497 DOI: 10.1016/s2215-0366(20)30432-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/18/2020] [Accepted: 09/23/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Antibodies targeting the N-methyl-D-aspartate receptor (NMDAR) have been detected in patients with psychosis. However, studies measuring the IgG subclass in serum have provided variable estimates of prevalence, and it is unclear whether these antibodies are more common in patients than controls. Because these inconsistencies could be due to methodological approaches and patient characteristics, we aimed to investigate the effect of these factors on heterogeneity. METHODS We searched Web of Science and Ovid (MEDLINE and PsycINFO) for cross-sectional and case-control studies published between Jan 1, 2000, and May 5, 2019, that reported NMDAR IgG antibody seropositivity in patients with psychosis. Pooled proportions and odds ratios (ORs) were derived using random-effects models. We estimated between-study variance (τ2) and the proportion of observed variance due to heterogeneity (I2). We then used univariable random-effects meta-regression analysis to investigate the effect of study factors on heterogeneity of proportions and ORs. Our protocol was registered on PROSPERO (CRD42018099874). FINDINGS Of 1276 articles in the initial search, 28 studies were eligible for inclusion, including 14 cross-sectional studies and 14 case-control studies. In cross-sectional studies, NMDAR IgG antibodies were detected in 0·73% (95% CI 0·09-1·38; I2 56%; p=0·026) of patients with psychosis, and in case-control studies, patients with psychosis were not significantly more likely to be seropositive than healthy individuals (OR 1·57, 95% CI 0·78-3·16; I2 15%; p=0·20). Meta-regression analyses indicated that heterogeneity was significantly associated with assay type across both study designs, illness stage in cross-sectional studies, and study quality in case-control studies. Compared with studies using a fixed cell-based assay, cross-sectional and case-control studies using the live method yielded higher pooled prevalence estimates (0·36% [95% CI -0·23 to 0·95] vs 2·97% [0·70 to 5·25]) and higher ORs (0·65 [0·33 to 1·29] vs 4·43 [1·73 to 11·36]). In cross-sectional studies, the prevalence was higher in exclusively first-episode samples than in multi-episode or mixed samples (2·18% [0·25 to 4·12] vs 0·16% [-0·31 to 0·63]), and in case-control studies, higher ORs were reported in low-quality studies than in high-quality studies (3·80 [1·47 to 9·83] vs 0·72 [0·36 to 1·42]). INTERPRETATION Higher estimates of NMDAR IgG antibody prevalence have been obtained with the live cell-based assay, and studies using this method find that seropositivity is more common in patients with psychosis than in controls. The effects of illness stage and study quality on heterogeneity were not consistent across study designs, and we provide clear recommendations for clinicians and researchers regarding interpreting these findings. FUNDING None.
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Affiliation(s)
- Alexis E Cullen
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
| | - Emma C Palmer-Cooper
- Department of Psychiatry, University of Oxford, Oxford, UK; School of Psychology, University of Southampton, Southampton, UK
| | - Marc Hardwick
- Department of Psychiatry, University of Oxford, Oxford, UK; University of Oxford Medical School, Oxford, UK
| | - Sophie Vaggers
- Department of Psychiatry, University of Oxford, Oxford, UK; University of Oxford Medical School, Oxford, UK
| | - Hannah Crowley
- Department of Psychiatry, University of Oxford, Oxford, UK; University of Oxford Medical School, Oxford, UK
| | - Thomas A Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Belinda R Lennox
- Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Health National Health Service Foundation Trust, Warneford Hospital, Oxford, UK
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24
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Bien CG, Rohleder C, Mueller JK, Bien CI, Koethe D, Leweke FM. Neural Autoantibodies in Cerebrospinal Fluid and Serum in Clinical High Risk for Psychosis, First-Episode Psychosis, and Healthy Volunteers. Front Psychiatry 2021; 12:654602. [PMID: 33841216 PMCID: PMC8032926 DOI: 10.3389/fpsyt.2021.654602] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/04/2021] [Indexed: 12/13/2022] Open
Abstract
The pathophysiological role of neural autoantibodies in acute psychotic disorders is receiving increased attention. However, there is still an ongoing debate, whether predominantly psychotic manifestations of autoimmune encephalitides exist that may remain undetected and, thus, untreated. Furthermore, it is discussed if such conditions can be diagnosed based on serum antibody results or if a reliable diagnosis requires additional cerebrospinal fluids (CSF) results. In this study, we screened pairs of serum and CSF samples from antipsychotic-naïve individuals with first-episode schizophrenic psychosis (FEP, n = 103), clinical high risk for psychosis (CHR, n = 47), and healthy volunteers (HV, n = 40) for eight different antibodies against various antigens that have been shown to be associated with autoimmune encephalitides: N-methyl-D-aspartate receptor (NMDAR, NR1 subunits only), glutamic acid decarboxylase (GAD65), leucine-rich glioma inactivated protein 1 (LGI1), contactin-associated protein-like 2 protein (CASPR2), α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) subunit 1, AMPAR subunit 2, γ-aminobutyric acid-B receptors (GABABR), and glycine receptors. All patients were within the norm with regards to a careful neurological examination, a magnetic resonance imaging (MRI) of the brain, an electroencephalogram (EEG), and routine blood pathology. All CSF samples were autoantibody-negative. In three serum samples of individuals with FEP, we detected low-titer CASPR2 immunoglobulin (Ig) G antibodies (≤1:160, n = 2) and non-IgG antibodies against NMDAR (n = 1) (overall serum-autoantibody prevalence in FEP: 2.91%). However, the IgG titers were below the laboratory cut-off defined for positivity, and non-IgG antibodies are of no clinical relevance. This suggests that there were no cases of autoimmune encephalitis in our cohort. Our results highlight the importance and the high specificity of CSF analysis to reliably detect autoantibodies. They confirm the hypothesis that pure psychotic manifestations of antibody-associated autoimmune encephalitides without any additional neuropsychiatric findings are very rare. However, special attention must be paid to those presenting with atypical mental illnesses with additional neurological symptoms, evidence of clinically-significant cognitive involvement, profound sleep-wake perturbations, seizures, electroencephalographic, or magnetic resonance imaging pathologies to be able to identify cases with autoimmune-mediated psychiatric syndromes.
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Affiliation(s)
- Christian G Bien
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany.,Laboratory Krone, Bad Salzuflen, Germany
| | - Cathrin Rohleder
- Brain and Mind Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Department of Psychiatry and Psychotherapy, Medical Faculty Mannheim, Central Institute of Mental Health, Heidelberg University, Mannheim, Germany
| | - Juliane K Mueller
- Brain and Mind Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Department of Psychiatry, Psychosomatics, and Psychotherapy, Goethe University, Frankfurt, Germany
| | | | - Dagmar Koethe
- Brain and Mind Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Department of Psychiatry and Psychotherapy, Medical Faculty Mannheim, Central Institute of Mental Health, Heidelberg University, Mannheim, Germany.,Sydney Local Health District, New South Wales Health, Sydney, NSW, Australia
| | - F Markus Leweke
- Brain and Mind Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Department of Psychiatry and Psychotherapy, Medical Faculty Mannheim, Central Institute of Mental Health, Heidelberg University, Mannheim, Germany.,Sydney Local Health District, New South Wales Health, Sydney, NSW, Australia
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25
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Novel neuronal surface autoantibodies in plasma of patients with depression and anxiety. Transl Psychiatry 2020; 10:404. [PMID: 33230123 PMCID: PMC7683539 DOI: 10.1038/s41398-020-01083-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 10/12/2020] [Accepted: 10/21/2020] [Indexed: 12/11/2022] Open
Abstract
Neuronal surface autoantibodies (NSAbs) against various antigens cause autoimmune encephalitis. Some of these antigens are also involved in the pathology of depression and anxiety. To study whether NSAbs are more common in plasma of individuals with depression and anxiety than in controls, and to investigate if NSAbs correlate with disease status, plasma samples of 819 individuals with a current diagnosis of depression and/or anxiety, 920 in remission and 492 individuals without these disorders were included in this study. Samples were tested by a combination of immunohistochemistry (IHC), staining on live rat hippocampus neurons and cell-based assay (CBA). By IHC, 50 (2.2%) samples showed immunoreactivity to rat brain tissue, with no significant differences between the aforementioned groups (22/819 vs 18/920 vs 11/492, P > 0.99). In addition, eight IHC positive samples were positive for NSAbs on live neurons (7/819 vs 0/920 vs 1/492, P = 0.006). The IHC-staining patterns of these eight samples were atypical for autoimmune encephalitis and accordingly, they tested negative for known NSAbs by CBA. No obvious difference in the clinical characteristics between individuals with or without NSAbs was observed. In conclusion, novel NSAbs were rare but predominately found in patients with current anxiety or depression indicating they might affect mental health in a small group of patients.
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26
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Warren N, Swayne A, Siskind D, O'Gorman C, Prain K, Gillis D, Blum S. Serum and CSF Anti-NMDAR Antibody Testing in Psychiatry. J Neuropsychiatry Clin Neurosci 2020; 32:154-160. [PMID: 31530118 DOI: 10.1176/appi.neuropsych.19030079] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors examined and compared the clinical presentation of CSF positive and negative N-methyl-d-aspartate receptor (NMDAR) antibody. METHODS The investigators performed a retrospective chart review of NMDAR-antibody-positive cases (serum or CSF) involving patients presenting to psychiatric services from 2010 to 2018 in Queensland, Australia. Presentation, progress, investigations, and efficacy of treatment are detailed. RESULTS There were 24 serum or CSF NMDAR-antibody-positive cases and three equivocal serum results. High rates of prodromal cognitive deficits, catatonia, speech disturbance, and antipsychotic sensitivity were observed in the 16 CSF NMDAR-antibody-positive case patients and two CSF NMDAR-antibody-negative case patients, all evident before neurological deterioration with seizures, movement disorder, and autonomic disturbance occurring in the weeks following admission. The majority of these patients (N=17) were treated successfully with immunomodulatory therapy. The nine remaining patients, who were CSF NMDAR antibody negative or equivocal, did not demonstrate any of these features and improved with psychiatric care alone. CONCLUSIONS These findings suggest that traditional psychiatric care may be appropriate for patients with isolated psychiatric symptoms who have positive serum NMDAR testing when CSF is negative and there are no key clinical features such as cognitive deficits, catatonia, speech disturbance, and antipsychotic sensitivity. However, if these key features are present, a trial of immunomodulatory treatment should be considered with repeated examination of CSF for neuronal antibodies.
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Affiliation(s)
- Nicola Warren
- Metro South Addiction and Mental Health Services, Brisbane, Queensland, Australia (Warren, Siskind); the Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Warren, Swayne, Siskind, O'Gorman, Blum); the Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); the Mater Centre for Neurosciences, Mater Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); and the Division of Immunology, Pathology Queensland Central Laboratory, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia (Prain, Gillis)
| | - Andrew Swayne
- Metro South Addiction and Mental Health Services, Brisbane, Queensland, Australia (Warren, Siskind); the Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Warren, Swayne, Siskind, O'Gorman, Blum); the Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); the Mater Centre for Neurosciences, Mater Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); and the Division of Immunology, Pathology Queensland Central Laboratory, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia (Prain, Gillis)
| | - Dan Siskind
- Metro South Addiction and Mental Health Services, Brisbane, Queensland, Australia (Warren, Siskind); the Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Warren, Swayne, Siskind, O'Gorman, Blum); the Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); the Mater Centre for Neurosciences, Mater Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); and the Division of Immunology, Pathology Queensland Central Laboratory, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia (Prain, Gillis)
| | - Cullen O'Gorman
- Metro South Addiction and Mental Health Services, Brisbane, Queensland, Australia (Warren, Siskind); the Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Warren, Swayne, Siskind, O'Gorman, Blum); the Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); the Mater Centre for Neurosciences, Mater Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); and the Division of Immunology, Pathology Queensland Central Laboratory, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia (Prain, Gillis)
| | - Kerri Prain
- Metro South Addiction and Mental Health Services, Brisbane, Queensland, Australia (Warren, Siskind); the Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Warren, Swayne, Siskind, O'Gorman, Blum); the Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); the Mater Centre for Neurosciences, Mater Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); and the Division of Immunology, Pathology Queensland Central Laboratory, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia (Prain, Gillis)
| | - David Gillis
- Metro South Addiction and Mental Health Services, Brisbane, Queensland, Australia (Warren, Siskind); the Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Warren, Swayne, Siskind, O'Gorman, Blum); the Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); the Mater Centre for Neurosciences, Mater Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); and the Division of Immunology, Pathology Queensland Central Laboratory, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia (Prain, Gillis)
| | - Stefan Blum
- Metro South Addiction and Mental Health Services, Brisbane, Queensland, Australia (Warren, Siskind); the Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Warren, Swayne, Siskind, O'Gorman, Blum); the Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); the Mater Centre for Neurosciences, Mater Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); and the Division of Immunology, Pathology Queensland Central Laboratory, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia (Prain, Gillis)
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27
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Ross EL, Becker JE, Linnoila JJ, Soeteman DI. Cost-Effectiveness of Routine Screening for Autoimmune Encephalitis in Patients With First-Episode Psychosis in the United States. J Clin Psychiatry 2020; 82:19m13168. [PMID: 33211912 PMCID: PMC7919384 DOI: 10.4088/jcp.19m13168] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 05/18/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Autoimmune encephalitis (AE) is a highly treatable neurologic condition that can cause psychosis. Screening for AE is not currently recommended in routine workup for first-episode psychosis (FEP), owing partly to the high cost of testing for AE-associated neuronal autoantibodies. METHODS This study used a decision-analytic model to estimate the cost-effectiveness of routine serum screening for AE compared with clinically targeted screening in patients with FEP. Model parameters drawn from prior published literature included the prevalence of neuronal autoantibodies in FEP (4.5%), serum autoantibody panel cost (US $291), remission probability with antipsychotics (0.58), and remission probability with immunotherapy for patients diagnosed with AE (0.85). Outcomes included quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs), assessed over a 5-year horizon from the US health care sector and societal perspectives. ICER thresholds of $50,000/QALY to $150,000/QALY were used to define cost-effectiveness. The analysis was conducted between June 2018 and January 2020. RESULTS Routine screening led to mean QALY gains of 0.008 among all patients and 0.174 among the subgroup of patients with neuronal autoantibodies. Mean costs increased by $780 from a societal perspective and $1,150 from a health care sector perspective, resulting in ICERs of $99,330/QALY and $147,460/QALY, respectively. Incorporating joint input data uncertainty, the likelihood routine screening has an ICER ≤ $150,000/QALY was 55% from a societal perspective and 37% from a health care sector perspective. The model parameter with the greatest contribution to overall uncertainty was the effectiveness of immunotherapy relative to antipsychotics. CONCLUSIONS Routine screening for AE in patients with FEP may be cost-effective in the United States. As further immunotherapy effectiveness data become available, a more definitive recommendation to perform routine screening could be warranted.
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Affiliation(s)
- Eric L. Ross
- Department of Psychiatry, McLean Hospital, Belmont, MA,Department of Psychiatry, Massachusetts General Hospital, Boston, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Jessica E. Becker
- Department of Psychiatry, McLean Hospital, Belmont, MA,Department of Psychiatry, Massachusetts General Hospital, Boston, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Jenny J. Linnoila
- Department of Neurology, Massachusetts General Hospital, Boston, MA,Department of Neurology, Harvard Medical School, Boston, MA
| | - Djøra I. Soeteman
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA
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28
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Perna R, Arenivas A. Limbic encephalitis and Post-Acute neuropsychology rehabilitation: A review and case examples. APPLIED NEUROPSYCHOLOGY-ADULT 2020; 29:874-880. [PMID: 32776797 DOI: 10.1080/23279095.2020.1796669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Rehabilitation research on limbic encephalitis (LE), a rare disorder characterized by inflammation of the brain caused by autoimmunity or infection, has focused on acute rather than post-acute management of symptoms. The frequency of clinical relapse in encephalitis ranges from 12% to 35%. Commonly, individuals diagnosed with LE experience relapses or breakthrough seizures during their post-acute treatment. The treating neuropsychologist will often need to do family and staff education regarding the disorder, possible unusual pattern of recovery and discuss the risk of relapse. Additionally, staff may need help with behavior management and the potential need for a behavior management plan. This manuscript presents a review of these complex issues and reviews how these issues manifest in five individuals who were admitted to a post-acute brain injury rehabilitation program. Only one achieved significant functional gains, as measured by the Mayo Portland Adaptability Inventory(MPAI-4). Each had a low level of functioning on admission with low scores on the Orientation-Log (O-Log) and high scores on the MPAI-4. Relapse involving need for re-admission to an acute setting occurred in four cases and medication side effects (sedation) in three. As a whole, these cases highlight the complex and potentially unusual course of recovery in individuals with LE.
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Affiliation(s)
| | - Ana Arenivas
- Neuropsychology, The Institute of Rehabilitation Research (TIRR), Baylor College of Medicine, Houston, TX, USA
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Kelleher E, McNamara P, Dunne J, Fitzmaurice B, Heron EA, Whitty P, Walsh R, Mooney C, Hogan D, Conlon N, Gill M, Vincent A, Doherty CP, Corvin A. Prevalence of N-Methyl-d-Aspartate Receptor antibody (NMDAR-Ab) encephalitis in patients with first episode psychosis and treatment resistant schizophrenia on clozapine, a population based study. Schizophr Res 2020; 222:455-461. [PMID: 32499165 DOI: 10.1016/j.schres.2019.11.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 08/19/2019] [Accepted: 11/12/2019] [Indexed: 12/31/2022]
Abstract
INTRODUCTION N-methyl-d-aspartate receptor antibody (NMDAR-Ab) encephalitis consensus criteria has recently been defined. We aimed to examine the prevalence of NMDAR-Ab encephalitis in patients with first episode psychosis (FEP) and treatment resistant schizophrenia (TRS) on clozapine, using clinical investigations, antibody testing and to retrospectively apply diagnostic consensus criteria. METHODS Adult (18-65 years old) cases of FEP meeting inclusion criteria were recruited over three years and assessed using the Structured Clinical Interview for DSM-IV disorders (SCID). NMDAR-Ab was identified using a live cell-based assay (L-CBA). Seropositive cases were clinically investigated for features of encephalitis including neuro-imaging, EEG and CSF where possible. Serum was retested using immunohistochemistry (IHC) as part of diagnostic criteria guidelines. A cohort of patients with TRS was also recruited. RESULTS 112 FEP patients were recruited over 3 years. NMDAR-Ab seroprevalence was 4/112 (3.5%) cases. One case (<1%) was diagnosed with definite NMDAR-Ab encephalitis and treated with immunotherapy. One of the three other seropositive cases met criteria for probable encephalitis. However all three were ultimately diagnosed with mood disorders with psychotic features. None have developed neurological features at three year follow up. 1/100 (1%) of patients with TRS was 100 patients with TRS were recruited. One case (1%) seropositive for NMDAR-Ab but did not meet criteria for encephalitis. CONCLUSIONS NMDAR-Ab encephalitis as defined by consensus guidelines occured rarely in psychiatric services in this study. Further studies are needed to establish pathogenicity of serum NMDAR-Ab antibodies. Psychiatric services should be aware of the clinical features of encephalitis.
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Affiliation(s)
- Eric Kelleher
- Department of Psychiatry, Trinity College Dublin, Ireland; Department of Psychiatry, St James's Hospital, Dublin, Ireland; Department of Psychiatry, University College Cork, Ireland.
| | - Patricia McNamara
- National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Jean Dunne
- Department of Immunology, St James's Hospital, Dublin, Ireland
| | - Brian Fitzmaurice
- Department of Psychiatry, Trinity College Dublin, Ireland; Department of Psychiatry, St James's Hospital, Dublin, Ireland
| | | | - Peter Whitty
- Department of Psychiatry, Tallaght University Hospital, Dublin, Ireland
| | - Richard Walsh
- Department of Neurology, Tallaght University Hospital, Dublin, Ireland
| | | | - Denise Hogan
- Department of Psychiatry, Trinity College Dublin, Ireland
| | - Niall Conlon
- Department of Immunology, St James's Hospital, Dublin, Ireland
| | - Michael Gill
- Department of Psychiatry, Trinity College Dublin, Ireland; Department of Psychiatry, St James's Hospital, Dublin, Ireland
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Colin P Doherty
- Department of Neurology, St James's Hospital, Dublin, Ireland; FutureNeuro, Royal College of Surgeons of Ireland, 123 St Stephen's Green, Dublin, Ireland
| | - Aiden Corvin
- Department of Psychiatry, Trinity College Dublin, Ireland; Department of Psychiatry, St James's Hospital, Dublin, Ireland
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Warren N, Flavell J, O'Gorman C, Swayne A, Blum S, Kisely S, Siskind D. Screening for anti-NMDAR encephalitis in psychiatry. J Psychiatr Res 2020; 125:28-32. [PMID: 32203736 DOI: 10.1016/j.jpsychires.2020.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/02/2020] [Accepted: 03/13/2020] [Indexed: 12/19/2022]
Abstract
Anti-NMDAR encephalitis most commonly presents to psychiatric services, so early identification of this disorder is essential. We aim to validate the two screening criteria (Scott et al. and Herken and Pruss) which have been proposed to identify first episode psychosis patients who should have anti-NMDAR antibody testing. The performance of the screening criteria were assessed using anti-NMDAR encephalitis cases published in the literature, and antibody positive and negative cases from a state-wide cohort (Queensland, Australia). Sensitivity, specificity and area under receiver operator characteristic curve analysis was performed. There were 258 anti-NMDAR encephalitis cases and 103 control cases, which demonstrated high performance of both Scott et al. "screening recommended" criteria (sensitivity 97.3%, specificity 85.4%, AUC 0.914) and Herken and Pruss "yellow flags" criteria (sensitivity 91.5%, specificity 83.5%, AUC 0.875). These criteria remained accurate when neurological variables were excluded, and in cases without psychosis. The Scott et al. "screening not recommended", and Herken and Pruss "red flags" criteria did not demonstrate clinical utility for first episode psychosis case screening. The screening criteria with good performance identify an atypical picture of psychiatric presentation with increased risk of anti-NMDAR positivity prior to overt neurological symptoms or investigations and may be beneficial to include in the routine psychiatric assessment process.
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Affiliation(s)
- Nicola Warren
- Metro South Addiction and Mental Health, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia.
| | - Joshua Flavell
- Metro South Addiction and Mental Health, Brisbane, Australia
| | - Cullen O'Gorman
- Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia; Mater Centre for Neurosciences, Mater Hospital, Brisbane, Australia
| | - Andrew Swayne
- Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia; Mater Centre for Neurosciences, Mater Hospital, Brisbane, Australia
| | - Stefan Blum
- Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia; Mater Centre for Neurosciences, Mater Hospital, Brisbane, Australia
| | - Steve Kisely
- Metro South Addiction and Mental Health, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Dan Siskind
- Metro South Addiction and Mental Health, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia
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Kaufman KR. BJPsych Open fifth anniversary editorial: history, accomplishments, trajectory and passion. BJPsych Open 2020; 6:e52. [PMID: 32475364 PMCID: PMC7345524 DOI: 10.1192/bjo.2020.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BJPsych Open has come of age. This editorial celebrates the journal's fifth anniversary by reviewing the history of BJPsych Open, what we have accomplished, where we strive to go (our planned trajectory) and the passion of being an Editor-in-Chief.
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Affiliation(s)
- Kenneth R Kaufman
- Departments of Psychiatry, Neurology and Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Jersey, USA; and Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
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Pollak TA, Prüss H, van Elst LT, Vincent A, Najjar S, Bechter K. Autoimmune psychosis - Authors' reply. Lancet Psychiatry 2020; 7:123-125. [PMID: 31981531 DOI: 10.1016/s2215-0366(19)30527-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Thomas A Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK.
| | - Harald Prüss
- Department of Neurology, Charité-Universitätsmedizin Berlin, and German Center for Neurodegenerative Diseases Berlin, CharitéCrossOver, Berlin, Germany
| | - Ludger Tebartz van Elst
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Souhel Najjar
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA
| | - Karl Bechter
- Department of Psychiatry and Psychotherapy II, Ulm University, Bezirkskrankenhaus Günzburg, Günzburg, Germany
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Pollak TA, Lennox BR, Müller S, Benros ME, Prüss H, Tebartz van Elst L, Klein H, Steiner J, Frodl T, Bogerts B, Tian L, Groc L, Hasan A, Baune BT, Endres D, Haroon E, Yolken R, Benedetti F, Halaris A, Meyer JH, Stassen H, Leboyer M, Fuchs D, Otto M, Brown DA, Vincent A, Najjar S, Bechter K. Autoimmune psychosis: an international consensus on an approach to the diagnosis and management of psychosis of suspected autoimmune origin. Lancet Psychiatry 2020; 7:93-108. [PMID: 31669058 DOI: 10.1016/s2215-0366(19)30290-1] [Citation(s) in RCA: 203] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 12/27/2022]
Abstract
There is increasing recognition in the neurological and psychiatric literature of patients with so-called isolated psychotic presentations (ie, with no, or minimal, neurological features) who have tested positive for neuronal autoantibodies (principally N-methyl-D-aspartate receptor antibodies) and who have responded to immunotherapies. Although these individuals are sometimes described as having atypical, mild, or attenuated forms of autoimmune encephalitis, some authors feel that that these cases are sufficiently different from typical autoimmune encephalitis to establish a new category of so-called autoimmune psychosis. We briefly review the background, discuss the existing evidence for a form of autoimmune psychosis, and propose a novel, conservative approach to the recognition of possible, probable, and definite autoimmune psychoses for use in psychiatric practice. We also outline the investigations required and the appropriate therapeutic approaches, both psychiatric and immunological, for probable and definite cases of autoimmune psychoses, and discuss the ethical issues posed by this challenging diagnostic category.
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Affiliation(s)
- Thomas A Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Belinda R Lennox
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Sabine Müller
- Department of Psychiatry and Psychotherapy Charité Campus Mitte (CCM), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Michael E Benros
- Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Harald Prüss
- Department of Neurology, Charité - Universitätsmedizin Berlin, Germany; German Center for Neurodegenerative Diseases, CharitéCrossOver, Berlin, Germany
| | - Ludger Tebartz van Elst
- Department of Psychiatry and Psychotherapy, Medical Center, and Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Hans Klein
- Department of Assertive Community Treatment, Lentis Mental Health Institute, Leek, Netherlands; Department of Assertive Community Treatment, VNN Addiction Care Institute, Groningen, Netherlands; Medical Imaging Centre, University of Groningen, Groningen, Netherlands
| | - Johann Steiner
- Department of Psychiatry and Psychotherapy and Center for Behavioral Brain Sciences, Otto von Guericke University of Magdeburg, Magdeburg, Germany
| | - Thomas Frodl
- Department of Psychiatry and Psychotherapy and Center for Behavioral Brain Sciences, Otto von Guericke University of Magdeburg, Magdeburg, Germany
| | - Bernhard Bogerts
- Department of Psychiatry and Psychotherapy and Center for Behavioral Brain Sciences, Otto von Guericke University of Magdeburg, Magdeburg, Germany
| | - Li Tian
- Psychiatry Research Centre, Beijing Huilongguan Hospital, Peking University, Beijing, China; Department of Physiology, Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia
| | - Laurent Groc
- Interdisciplinary Institute for NeuroSciences, Université de Bordeaux, Bordeaux, France
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
| | - Bernhard T Baune
- Department of Psychiatry, Melbourne Medical School, The University of Melbourne, Melbourne, VIC, Australia; The Florey Institute of Mental Health and Neurosciences, The University of Melbourne, Parkville, VIC, Australia; Department of Psychiatry, University of Münster, Münster, Germany
| | - Dominique Endres
- Department of Psychiatry and Psychotherapy, Medical Center, and Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Ebrahim Haroon
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Robert Yolken
- Department of Pediatrics, Stanley Neurovirology Division, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Francesco Benedetti
- Psychiatry and Clinical Psychobiology, Division of Neuroscience, Scientific Institute Ospedale San Raffaele, Milano, Italy; University Vita-Salute San Raffaele, Milano, Italy
| | - Angelos Halaris
- Department of Psychiatry, Loyola University Medical Center, Maywood, IL, USA
| | - Jeffrey H Meyer
- Research Imaging Centre, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Institute of Medical Science, Toronto, ON, Canada; Departments of Psychiatry and Department of Pharmacology and Toxicology, Institute of Medical Science, Toronto, ON, Canada
| | - Hans Stassen
- Institute for Response-Genetics, Psychiatric University Hospital, Zurich, Switzerland
| | - Marion Leboyer
- Inserm U955, Fondation FondaMental, Department of Psychiatry and Addiction, Mondor University Hospital, University Paris-Est-Créteil, Créteil, France
| | - Dietmar Fuchs
- Division of Biological Chemistry, Biocenter, Innsbruck Medical University, Innsbruck, Austria
| | - Markus Otto
- Department of Neurology, University Clinic, Ulm University, Ulm, Germany
| | - David A Brown
- Department of Immunopathology and Department Clinical Immunology, New South Wales Health Pathology, Institute for Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Souhel Najjar
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA
| | - Karl Bechter
- Department of Psychiatry and Psychotherapy II, Ulm University, Bezirkskrankenhaus Günzburg, Günzburg, Germany
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A prospective three-year follow-up study on the clinical significance of anti-neuronal antibodies in acute psychiatric disorders. Sci Rep 2019; 10:35. [PMID: 31896766 PMCID: PMC6940359 DOI: 10.1038/s41598-019-56934-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 12/19/2019] [Indexed: 01/05/2023] Open
Abstract
The clinical significance of anti-neuronal antibodies for psychiatric disorders is controversial. We investigated if a positive anti-neuronal antibody status at admission to acute psychiatric inpatient care was associated with a more severe neuropsychiatric phenotype and more frequent abnormalities during clinical work-up three years later. Patients admitted to acute psychiatric inpatient care who tested positive for N-methyl-D-aspartate receptor (NMDAR), contactin-associated protein 2 (CASPR2) and/or glutamic acid decarboxylase 65 (GAD65) antibodies (n = 24) were age - and sex matched with antibody-negative patients (1:2) from the same cohort (n = 48). All patients were invited to follow-up including psychometric testing (e.g. Symptom Checklist-90-Revised), serum and cerebrospinal fluid (CSF) sampling, EEG and 3 T brain MRI. Twelve antibody-positive (ab+) and 26 antibody-negative (ab-) patients consented to follow-up. Ab+ patients had more severe symptoms of depression (p = 0.03), psychoticism (p = 0.04) and agitation (p = 0.001) compared to ab- patients. There were no differences in CSF analysis (n = 6 ab+/12 ab-), EEG (n = 7 ab+/19 ab-) or brain MRI (n = 7 ab+/17 ab-) between the groups. In conclusion, anti-neuronal ab+ status during index admission was associated with more severe symptoms of depression, psychoticism and agitation at three-year follow-up. This supports the hypothesis that anti-neuronal antibodies may be of clinical significance in a subgroup of psychiatric patients.
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Colijn MA, Ismail Z. Clinically Relevant Anti-Neuronal Cell Surface Antibodies in Schizophrenia Spectrum Disorders. Neuropsychobiology 2019; 78:70-78. [PMID: 31096226 DOI: 10.1159/000499714] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/19/2019] [Indexed: 11/19/2022]
Abstract
Schizophrenia is a phenotypically heterogeneous and poorly understood disorder. While its etiology is likely multifactorial, immune system dysfunction has increasingly been implicated in its development. As hallucinations and delusions occur frequently and prominently in autoimmune encephalitis (AE), numerous studies have sought to determine whether a small subset of individuals diagnosed with schizophrenia possess anti-neuronal antibodies implicated in AE. Exploring this possibility is of clinical relevance, as identifying individuals with AE who have been misdiagnosed as having a primary psychotic disorder may allow for the implementation of appropriate immune-related therapies as early as possible in the course of the illness, in order to optimize outcomes, reduce illness chronicity, and minimize adverse events. This qualitative review serves to provide an overview of the existing literature on this topic, as well as to update previously published reviews. Although there is some evidence to suggest that in rare cases AE may be misdiagnosed as a primary psychotic disorder, particularly early in the course of the illness, numerous methodological differences between studies likely account for the highly variable findings, and interpretation of the results is particularly limited by a paucity of cerebrospinal fluid data. Moreover, the prevalence of misdiagnosis in chronic and treatment-resistant populations remains understudied. This is particularly problematic, as treatment resistance may represent an enriched population with respect to the presence of anti-neuronal antibodies, and given that such patients have few evidence-based treatment options available to them beyond clozapine.
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Affiliation(s)
| | - Zahinoor Ismail
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada.,Mathison Centre for Mental HealthResearch and Education, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University ofCalgary, Calgary, Alberta, Canada
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Behrman S, Lennox B. Autoimmune encephalitis in the elderly: who to test and what to test for. EVIDENCE-BASED MENTAL HEALTH 2019; 22:172-176. [PMID: 31537612 PMCID: PMC10231602 DOI: 10.1136/ebmental-2019-300110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/04/2019] [Accepted: 09/06/2019] [Indexed: 02/03/2023]
Abstract
The awareness and understanding of autoimmune encephalitis are blossoming in neurology, and patients are being diagnosed and successfully treated with immunotherapy. The diverse symptomatology associated with autoimmune encephalitis means that patients may present initially to mental health services, which are, as yet, less well equipped to identify and investigate such phenomena. Older adult mental health services are used to managing complexity, but the range of pathologies presenting with unusual symptoms that may mimic autoimmune encephalitis is wide and there is no clear guidance as to when and how to investigate for possible autoimmune encephalitis. This paper examines the evidence supporting investigation and management strategies for patients with possible autoimmune encephalitis presenting to older adult psychiatrists.
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Abstract
BACKGROUND The diagnosis of anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis relies on the detection of NMDAR IgG autoantibodies in the serum or cerebrospinal fluid (CSF) of symptomatic patients. Commercial kits are available that allow NMDAR IgG autoantibodies to be measured in local laboratories. However, the performance of these tests outside of reference laboratories is unknown. OBJECTIVES To report an unexpectedly low rate of NMDAR autoantibody detection in serum from patients with anti-NMDAR encephalitis tested using a commercially available diagnostic kit in an exemplar clinical laboratory. METHODS Paired CSF and serum samples from seven patients with definite anti-NMDAR encephalitis were tested for NMDAR IgG autoantibodies using commercially available cell-based assays run according to manufacturer's recommendations. Rates of autoantibody detection in serum tested at our center were compared with those derived from systematic review and meta-analyses incorporating studies published during or before March 2019. RESULTS NMDAR IgG autoantibodies were detected in the CSF of all patients tested at our clinical laboratory but not in paired serum samples. Rates of the detection were lower than those previously reported. A similar association was recognized through meta-analyses, with lower odds of NMDAR IgG autoantibody detection associated with serum testing performed in nonreference laboratories. CONCLUSIONS Commercial kits may yield lower-than-expected rates of NMDAR IgG autoantibody detection in serum when run in exemplar clinical (nonreference) laboratories. Additional studies are needed to decipher the factors that contribute to lower-than-expected rates of serum positivity. CSF testing is recommended in patients with suspected anti-NMDAR encephalitis.
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Dalmau J, Armangué T, Planagumà J, Radosevic M, Mannara F, Leypoldt F, Geis C, Lancaster E, Titulaer MJ, Rosenfeld MR, Graus F. An update on anti-NMDA receptor encephalitis for neurologists and psychiatrists: mechanisms and models. Lancet Neurol 2019; 18:1045-1057. [PMID: 31326280 DOI: 10.1016/s1474-4422(19)30244-3] [Citation(s) in RCA: 417] [Impact Index Per Article: 83.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 06/04/2019] [Accepted: 06/05/2019] [Indexed: 12/18/2022]
Abstract
The identification of anti-NMDA receptor (NMDAR) encephalitis about 12 years ago made it possible to recognise that some patients with rapidly progressive psychiatric symptoms or cognitive impairment, seizures, abnormal movements, or coma of unknown cause, had an autoimmune disease. In this disease, autoantibodies serve as a diagnostic marker and alter NMDAR-related synaptic transmission. At symptom onset, distinguishing the disease from a primary psychiatric disorder is challenging. The severity of symptoms often requires intensive care. Other than clinical assessment, no specific prognostic biomarkers exist. The disease is more prevalent in women (with a female to male ratio of around 8:2) and about 37% of patients are younger than 18 years at presentation of the disease. Tumours, usually ovarian teratoma, and herpes simplex encephalitis are known triggers of NMDAR autoimmunity. About 80% of patients improve with immunotherapy and, if needed, tumour removal, but the recovery is slow. Animal models have started to reveal the complexity of the underlying pathogenic mechanisms and will lead to novel treatments beyond immunotherapy. Future studies should aim at identifying prognostic biomarkers and treatments that accelerate recovery.
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Affiliation(s)
- Josep Dalmau
- Neuroimmunology Programme, Institut d'Investigacions Biomèdiques August Pi i Sunyer Hospital Clínic, University of Barcelona, Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA; Centro de Investigación Biomédica en Red para Enfermedades Raras, Madrid, Spain; Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain.
| | - Thais Armangué
- Neuroimmunology Programme, Institut d'Investigacions Biomèdiques August Pi i Sunyer Hospital Clínic, University of Barcelona, Barcelona, Spain; Pediatric Neuroimmunology Unit, Department of Neurology, Sant Joan de Déu Children's Hospital, University of Barcelona, Barcelona, Spain
| | - Jesús Planagumà
- Neuroimmunology Programme, Institut d'Investigacions Biomèdiques August Pi i Sunyer Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Marija Radosevic
- Neuroimmunology Programme, Institut d'Investigacions Biomèdiques August Pi i Sunyer Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Francesco Mannara
- Neuroimmunology Programme, Institut d'Investigacions Biomèdiques August Pi i Sunyer Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Frank Leypoldt
- Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Kiel, Germany; Department of Neurology, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
| | - Christian Geis
- Translational Neuroimmunology, Department of Neurology, Jena University Hospital, Jena, Germany
| | - Eric Lancaster
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Maarten J Titulaer
- Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Myrna R Rosenfeld
- Neuroimmunology Programme, Institut d'Investigacions Biomèdiques August Pi i Sunyer Hospital Clínic, University of Barcelona, Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Francesc Graus
- Neuroimmunology Programme, Institut d'Investigacions Biomèdiques August Pi i Sunyer Hospital Clínic, University of Barcelona, Barcelona, Spain
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Silverman M, Frankovich J, Nguyen E, Leibold C, Yoon J, Mark Freeman G, Karpel H, Thienemann M. Psychotic symptoms in youth with Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) may reflect syndrome severity and heterogeneity. J Psychiatr Res 2019; 110:93-102. [PMID: 30605785 DOI: 10.1016/j.jpsychires.2018.11.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 11/04/2018] [Accepted: 11/13/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE In the clinical syndrome Pediatric Acute-onset Neuropsychiatric Syndrome (PANS), obsessive compulsive disorder (OCD) and/or food refusal symptoms have an abrupt-onset (over 48 h) coupled with at least two other specified neuropsychiatric symptoms. We aimed to characterize in detail for the first time, psychotic symptoms experienced by children with PANS as well as the impact of psychotic symptoms on disease severity and course of illness. We inform about the diagnosis of the clinical description: PANS and hope to improve evaluation, treatment, diagnostic validity and future investigation. METHODS Retrospective review of 143 consecutive PANS clinic patient charts meeting inclusion criteria. The Caregiver Burden Inventory, Global Impairment Score, and Children's Global Assessment Scale were used to assess impairment. RESULTS Visual and auditory hallucinations were each experienced by 36%, of which most (83%) were transient and complex (non-threatening voices or figures). 6.3% and 5.5% of patients experienced delusions and thought disorganization respectively. Those with psychotic symptoms showed statistically significant differences in disease impairment and caregiver burden. There were no differences in time to treatment access or length of illness. CONCLUSIONS Over 1/3 of children with PANS experienced transient hallucinations. They were more impaired than those without psychotic symptoms, but showed no differences in disease progression. This difference may point toward heterogeneity in PANS. When evaluating children with acute psychotic symptoms, clinicians should screen for abrupt-onset of a symptom cluster including OCD and/or food refusal, with neuropsychiatric symptoms (enuresis, handwriting changes, tics, hyperactivity, sleep disorder) before initiating treatment.
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Affiliation(s)
- Melissa Silverman
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States; Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States.
| | - Jennifer Frankovich
- Pediatric Division of Allergy, Immunology, and Rheumatology, Stanford University, Stanford, CA, United States; Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States
| | - Emily Nguyen
- Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States
| | - Collin Leibold
- Pediatric Division of Allergy, Immunology, and Rheumatology, Stanford University, Stanford, CA, United States; Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States
| | - Jong Yoon
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States; VA Palo Alto Health Care System, 3801 Miranda Ave., Building 4, 2nd Floor, Palo Alto, CA, 94304, United States
| | - G Mark Freeman
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States
| | - Hannah Karpel
- Pediatric Division of Allergy, Immunology, and Rheumatology, Stanford University, Stanford, CA, United States; Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States
| | - Margo Thienemann
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States; Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States
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Al-Diwani A, Handel A, Townsend L, Pollak T, Leite MI, Harrison PJ, Lennox BR, Okai D, Manohar SG, Irani SR. The psychopathology of NMDAR-antibody encephalitis in adults: a systematic review and phenotypic analysis of individual patient data. Lancet Psychiatry 2019; 6:235-246. [PMID: 30765329 PMCID: PMC6384244 DOI: 10.1016/s2215-0366(19)30001-x] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/11/2018] [Accepted: 12/17/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Early immunotherapy administration improves outcomes in patients with N-methyl-D-aspartate receptor (NMDAR)-antibody encephalitis. As most patients with NMDAR-antibody encephalitis present to psychiatrists, the psychopathology of NMDAR-antibody encephalitis needs to be clearly defined to encourage accurate clinical identification and prompt treatment. METHODS For this systematic review, we searched PubMed for all studies published in English between Jan 1, 2005, and Oct 7, 2017, to identify individually reported adult patients (≥18 years) who satisfied consensus criteria for definite NMDAR-antibody encephalitis. After generating a list of 50 fine-grained, lower-level features, we extracted psychopathological data in addition to demographic and aetiological data. The lower-level features were later ordered within higher-level categories. As a means of quality control, we filtered the data according to proxy markers of psychiatric involvement in their description. Subsequently, we compared lower-level features from individual patient data with operationalised psychiatric syndromes using a constrained combination approach and principal component analysis, and did a network analysis to explore the inter-relationships between multiple lower-level features. The review protocol was prospectively registered with PROSPERO, number CRD42017068981. FINDINGS Of 1096 records identified in PubMed, 333 satisfied inclusion criteria and described 1100 patients in total with NMDAR-antibody encephalitis. The psychopathology of 505 (46%) patients with reported psychiatric symptoms was described in more detailed terms than only psychiatric or behavioural. 464 (91%) of the 505 patients were from papers in which patient data were reported individually. The remainder of the analyses focused exclusively on these 464 patients. Median age was 27 years (IQR 22-34), 368 (79%) of 464 patients were female and in 147 (32%), NMDAR-antibody encephalitis was associated with ovarian teratoma. The five higher-level categories into which the 464 patients most frequently grouped were behaviour (316 [68%]), psychosis (310 [67%]), mood (219 [47%]), catatonia (137 [30%]), and sleep disturbance (97 [21%]). The overall pattern of lower-level features was statistically stable across subgroups classified by age, sex, pregnancy association, presence of ovarian teratoma, prior herpes simplex virus encephalitis, and isolated psychiatric presentations (two-way ANOVA p=0·6-0·9). Constrained combination and principal component analyses found that mixtures of mood and psychosis syndromes fit each patient better than any single diagnosis alone, particularly for the patients in the psychiatric-described subgroup (mean ΔAkaike information criterion -0·04 in non-psychiatric-described subgroup vs 0·61 in psychiatric-described subgroup). The overlapping nature of the higher-level features was also enriched upon analysis of the psychiatric-described data (221 [67%] of 329 overlaps in non-psychiatric-described subgroup vs 96 [81%] of 118 overlaps in psychiatric-described subgroup, p=0·0052). Network analysis confirmed that the features were closely related and consistent between individual patients; the psychiatric-described subgroup had a markedly high and narrow range of closeness centralities (92% above 0·93 in psychiatric-described subgroup vs 51% above 0·93 in the non-psychiatric group). INTERPRETATION The distinctive aspect of NMDAR-antibody encephalitis psychopathology is complexity; core aspects of mood and psychotic disorders consistently coexist within individual patients. Alongside the predominant young female demographic, these psychopathological features could help psychiatrists identify patients who would benefit from cerebrospinal fluid testing and immunotherapies. Well-controlled prospective studies with bespoke inventories are needed to advance this clinically grounded approach. FUNDING Wellcome Trust, NIHR Oxford Biomedical Research Centre, NIHR Oxford Health Biomedical Research Centre, British Medical Association Foundation for Medical Research.
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Affiliation(s)
- Adam Al-Diwani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom; Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Adam Handel
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Leigh Townsend
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Thomas Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's Health Partners, London, UK
| | - M Isabel Leite
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom; Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Paul J Harrison
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Belinda R Lennox
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - David Okai
- Department of Psychological Medicine, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sanjay G Manohar
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom; Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom; Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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Kelleher E, Barry H, Cotter DR, Corvin A, Murphy KC. Autoantibodies and Psychosis. Curr Top Behav Neurosci 2019; 44:85-123. [PMID: 31292938 DOI: 10.1007/7854_2019_90] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Research into antibody-mediated disease, in response to immune dysfunction or to tumour development, has rapidly expanded in recent years. Antibodies binding to neuroreceptors can cause psychiatric features, including psychosis, in a minority of patients as well as neurological features. The responsiveness of some of these cases to immunotherapy supports the hypothesis that antibody-associated mechanisms play a role in the pathogenesis of psychotic diseases. The purpose of this chapter is to review autoantibodies that are most likely to be relevant for patients with psychotic symptoms. Herein, we describe receptor structure and mechanism of action, clinical and psychiatric features for the growing number of neuronal surface antibodies, including those to the N-methyl-D-aspartate (NMDA) receptor. The identification of a subgroup of patients with psychiatric features having antibody-mediated disease highlights the importance of considering the diagnosis, particularly in those patients presenting with a first episode of psychosis.
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Affiliation(s)
- Eric Kelleher
- Department of Psychiatry and Neurobehavioral Science, University College Cork, Cork, Ireland.
| | - Helen Barry
- Department of Psychiatry, Royal College of Surgeons of Ireland, Dublin, Ireland
| | - David R Cotter
- Department of Psychiatry, Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Aiden Corvin
- Department of Psychiatry, Trinity College Dublin, Dublin, Ireland
| | - Kieran C Murphy
- Department of Psychiatry, Royal College of Surgeons of Ireland, Dublin, Ireland
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Warren N, Siskind D, O'Gorman C. Refining the psychiatric syndrome of anti-N-methyl-d-aspartate receptor encephalitis. Acta Psychiatr Scand 2018; 138:401-408. [PMID: 29992532 DOI: 10.1111/acps.12941] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/25/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To review the psychiatric symptoms of anti-N-methyl-d-aspartate (NMDA) receptor encephalitis, in an attempt to differentiate the presentation from a primary psychiatric disorder. METHOD A systematic literature review of PubMed and EMBASE of all published cases of anti-NMDA receptor encephalitis was performed from inception to January 2018. RESULTS There were 706 cases of anti-NMDA receptor encephalitis identified. Cases were typically young (mean age 22.6 years, SD 14.8), female (F : M ratio 3.5 : 1) and presented with significant behavioural disturbance. Reported behaviour was most commonly severe agitation and aggression, abnormal speech, and catatonia. Psychosis occurred in 45.8% of cases. Investigation results were inconsistent (MRI abnormal in 35.6%, EEG abnormal in 83.0%) and non-specific. Psychiatric treatment often required multiple psychotropics, and there may be increased risk of significant side-effects such as neuroleptic malignant syndrome. Prognosis was usually good; however, cognitive and behavioral symptoms remained prominent during recovery, and psychiatrist involvement was required in this period. CONCLUSION The presentation of anti-NMDA receptor encephalitis is variable. However, there are often psychiatric features which are atypical to a primary psychiatric illness, such as severe agitation, speech abnormalities, and catatonia, which may help early identification.
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Affiliation(s)
- N Warren
- School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Metro South Addiction and Mental Health, Brisbane, QLD, Australia
| | - D Siskind
- School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Metro South Addiction and Mental Health, Brisbane, QLD, Australia
| | - C O'Gorman
- School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia
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Scott JG, Gillis D, Swayne A, Blum S. Testing for antibodies to N-methyl-d-aspartate receptor and other neuronal cell surface antigens in patients with early psychosis. Aust N Z J Psychiatry 2018; 52:727-729. [PMID: 29923413 DOI: 10.1177/0004867418782421] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- James G Scott
- 1 Faculty of Medicine, The University of Queensland, Herston, QLD, Australia.,2 Metro North Mental Health, Royal Brisbane and Women's Hospital (RBWH), Herston, QLD, Australia.,3 Queensland Centre for Mental Health Research (QCMHR), Wacol, QLD, Australia.,4 Centre for Clinical Research, The University of Queensland, Herston, QLD, Australia
| | - David Gillis
- 5 Division of Immunology, Pathology Queensland Central Laboratory, Royal Brisbane and Women's Hospital (RBWH), Herston, QLD, Australia
| | - Andrew Swayne
- 1 Faculty of Medicine, The University of Queensland, Herston, QLD, Australia.,6 Department of Neurology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.,7 Mater Centre for Neurosciences, Brisbane, QLD, Australia
| | - Stefan Blum
- 1 Faculty of Medicine, The University of Queensland, Herston, QLD, Australia.,6 Department of Neurology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.,7 Mater Centre for Neurosciences, Brisbane, QLD, Australia
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Pollak TA, Lennox BR. Time for a change of practice: the real-world value of testing for neuronal autoantibodies in acute first-episode psychosis. BJPsych Open 2018; 4:262-264. [PMID: 30083377 PMCID: PMC6068314 DOI: 10.1192/bjo.2018.27] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 01/03/2023] Open
Abstract
UNLABELLED It is time that all patients with acute-onset psychosis are screened for autoimmune encephalitis, that lumbar puncture becomes a routine psychiatric investigation and that immunotherapy is available in indicated cases. We call for a culture change in the management of psychosis by psychiatry. DECLARATION OF INTEREST None.
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Affiliation(s)
- Thomas A Pollak
- Wellcome Trust Clinical Research Training Fellow, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, UK
| | - Belinda R Lennox
- Clinical Senior Lecturer, Department of Psychiatry, University of Oxford, UK
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