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Pasricha PJ, McKnight M, Villatoro L, Barahona G, Brinker J, Hui K, Polydefkis M, Burns R, McMahan ZH, Gould N, Goodman B, Hentz J, Treisman G. Joint Hypermobility, Autonomic Dysfunction, Gastrointestinal Dysfunction, and Autoimmune Markers: Clinical Associations and Response to Intravenous Immunoglobulin Therapy. Am J Gastroenterol 2024:00000434-990000000-01204. [PMID: 38912927 DOI: 10.14309/ajg.0000000000002910] [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] [Received: 11/09/2023] [Accepted: 05/30/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION We examined autoimmunity markers (AIM) and autonomic dysfunction in patients with chronic neurogastroenterological symptoms and their relationship to joint hypermobility/hypermobility spectrum disorder (JH/HSD). METHODS AIM positivity was defined as a diagnosis of known autoimmune/autoinflammatory disorder with at least 1 positive seromarker of autoimmunity or at least 2 positive seromarkers by themselves. Three cohorts were studied: (i) retrospective (n = 300), (ii) prospective validation cohort (n = 133), and (iii) treatment cohort (n = 40), administered open-label intravenous immunoglobulin (IVIG). RESULTS AIM positivity was found in 40% and 29% of the retrospective and prospective cohorts, the majority of whom (71% and 69%, respectively) had autoinflammatory disorder. Significantly more patients with AIM had elevations of C-reactive protein (31% vs 15%, P < 0.001) along with an increased proportion of cardiovascular autonomic dysfunction (48% vs 29%; P < 0.001), small fiber neuropathy (20% vs 9%; P = 0.002), and HLADQ8 positivity (24% vs 13%, P = 0.01). Patients with JH/HSD were more likely to have AIM (43% vs 15%, P = 0.001) along with more severe autonomic and gastrointestinal (GI) symptom scores. IVIG treatment was associated with robust improvement in pain, GI, and autonomic symptoms, but adverse events were experienced by 62% of patients. DISCUSSION Autoimmune markers and autonomic dysfunction are common in patients with unexplained GI symptoms, especially in those with JH/HSD. Many patients seem to respond to IVIG treatment, but this needs to be confirmed by controlled trials. These results highlight the need for vigilance for autoimmune and autonomic factors and JH/HSD in patients with neurogastroenterological disorders. Clinicaltrials.gov , NCT04859829.
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Affiliation(s)
| | - Megan McKnight
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - Jeffrey Brinker
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ken Hui
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Robert Burns
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Neda Gould
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - Glenn Treisman
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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2
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Kirschstein T, Köhling R. Functional changes in neuronal circuits due to antibody-driven autoimmune response. Neurobiol Dis 2023:106221. [PMID: 37414365 DOI: 10.1016/j.nbd.2023.106221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 06/26/2023] [Accepted: 07/03/2023] [Indexed: 07/08/2023] Open
Abstract
Autoimmune-mediated encephalitis syndromes are increasingly being recognized as important clinical entities. They need to be thought of as differential diagnosis in any patient presenting with fast-onset psychosis or psychiatric problems, memory deficits or other cognitive problems, including aphasias, as well as seizures or motor automatisms, but also rigidity, paresis, ataxia or dystonic / parkinsonian symptoms. Diagnosis including imaging and CSF search for antibodies needs to be fast, as progression of these inflammatory processes is often causing scarring of brain tissue, with hypergliosis and atrophy. As these symptoms show, the autoantibodies present in these cases appear to act within the CNS. Several of such antibodies have by now been identified such as IgG directed against NMDA-receptors, AMPA receptors, GABAA and GABAB receptors, and voltage gated potassium channels and proteins of the potassium channel complex (i.e. LGI1 and CASPR2). These are neuropil / surface antigens where antibody interaction can well be envisaged to cause dysfunction of the target protein, including internalization. Others, such as antibodies directed against GAD65 (an intracellular enzyme responsible for GABA-synthesis from glutamate), are discussed to constitute epiphenomena, but not causal agents in disease progression. This review will focus on the current knowledge of antibody interaction mechanisms, especially discussing cellular excitability changes and synaptic interactions in hippocampal and other brain networks. One challenge in this context is to find viable hypotheses for the emergence of both, hyperexcitability and seizures, and presumably reduced synaptic plasticity and underlying cognitive dysfunction.
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Affiliation(s)
- Timo Kirschstein
- Oscar-Langendorff-Institute of Physiology, Rostock University Medical Center, Gertrudenstraße 9, 18057 Rostock, Germany; Center for Translational Neuroscience Research, Rostock University Medical Center, 18057 Rostock, Germany
| | - Rüdiger Köhling
- Oscar-Langendorff-Institute of Physiology, Rostock University Medical Center, Gertrudenstraße 9, 18057 Rostock, Germany; Center for Translational Neuroscience Research, Rostock University Medical Center, 18057 Rostock, Germany.
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3
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Autoimmune Encephalitis in COVID-19 Infection: Our Experience and Systematic Review of the Literature. Biomedicines 2022; 10:biomedicines10040774. [PMID: 35453524 PMCID: PMC9024859 DOI: 10.3390/biomedicines10040774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 03/02/2022] [Accepted: 03/21/2022] [Indexed: 01/08/2023] Open
Abstract
The neurologic complications of COVID-19 infection are frequent in hospitalized patients; a high percentage of them present neurologic manifestations at some point during the course of their disease. Headache, muscle pain, encephalopathy and dizziness are among the most common complications. Encephalitis is an inflammatory condition with many etiologies. There are several forms of encephalitis associated with antibodies against intracellular neuronal proteins, cell surfaces or synaptic proteins, referred to as autoimmune encephalitis. Several case reports published in the literature document autoimmune encephalitis cases triggered by COVID-19 infection. Our paper first presents our experience in this issue and then systematically reviews the literature on autoimmune encephalitis that developed in the background of SARS-CoV-2 infections and also discusses the possible pathophysiological mechanisms of auto-immune-mediated damage to the nervous system. This review contributes to improve the management and prognosis of COVID-19-related autoimmune encephalitis.
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Boyd MA, Davis AM, Chambers NR, Tran P, Prindle A, Kamat NP. Vesicle-Based Sensors for Extracellular Potassium Detection. Cell Mol Bioeng 2021; 14:459-469. [PMID: 34777604 DOI: 10.1007/s12195-021-00688-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 07/07/2021] [Indexed: 10/20/2022] Open
Abstract
Introduction The design of sensors that can detect biological ions in situ remains challenging. While many fluorescent indicators exist that can provide a fast, easy readout, they are often nonspecific, particularly to ions with similar charge states. To address this issue, we developed a vesicle-based sensor that harnesses membrane channels to gate access of potassium (K+) ions to an encapsulated fluorescent indicator. Methods We assembled phospholipid vesicles that incorporated valinomycin, a K+ specific membrane transporter, and that encapsulated benzofuran isophthalate (PBFI), a K+ sensitive dye that nonspecifically fluoresces in the presence of other ions, like sodium (Na+). The specificity, kinetics, and reversibility of encapsulated PBFI fluorescence was determined in a plate reader and fluorimeter. The sensors were then added to E. coli bacterial cultures to evaluate K+ levels in media as a function of cell density. Results Vesicle sensors significantly improved specificity of K+ detection in the presence of a competing monovalent ion, sodium (Na+), and a divalent cation, calcium (Ca2+), relative to controls where the dye was free in solution. The sensor was able to report both increases and decreases in K+ concentration. Finally, we observed our vesicle sensors could detect changes in K+ concentration in bacterial cultures. Conclusion Our data present a new platform for extracellular ion detection that harnesses ion-specific membrane transporters to improve the specificity of ion detection. By changing the membrane transporter and encapsulated sensor, our approach should be broadly useful for designing biological sensors that detect an array of biological analytes in traditionally hard-to-monitor environments. Supplementary Information The online version contains supplementary material available at 10.1007/s12195-021-00688-7.
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Affiliation(s)
- Margrethe A Boyd
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL 60208 USA
| | - Anna M Davis
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL 60208 USA
| | - Nora R Chambers
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL 60208 USA
| | - Peter Tran
- Department of Chemical and Biological Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL 60208 USA
| | - Arthur Prindle
- Center for Synthetic Biology, McCormick School of Engineering, Northwestern University, Evanston, IL 60208 USA.,Department of Chemical and Biological Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL 60208 USA.,Department of Biochemistry and Molecular Genetics, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611 USA
| | - Neha P Kamat
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL 60208 USA.,Center for Synthetic Biology, McCormick School of Engineering, Northwestern University, Evanston, IL 60208 USA
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5
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Jędrychowska J, Korzh V. Kv2.1 voltage-gated potassium channels in developmental perspective. Dev Dyn 2019; 248:1180-1194. [PMID: 31512327 DOI: 10.1002/dvdy.114] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 09/01/2019] [Accepted: 09/03/2019] [Indexed: 11/11/2022] Open
Abstract
Kv2.1 voltage-gated potassium channels consist of two types of α-subunits: (a) electrically-active Kcnb1 α-subunits and (b) silent or modulatory α-subunits plus β-subunits that, similar to silent α-subunits, also regulate electrically-active subunits. Voltage-gated potassium channels were traditionally viewed, mainly by electrophysiologists, as regulators of the electrical activity of the plasma membrane in excitable cells, a role that is performed by transmembrane protein domains of α-subunits that form the electric pore. Genetic studies revealed a role for this region of α-subunits of voltage-gated potassium channels in human neurodevelopmental disorders, such as epileptic encephalopathy. The N- and C-terminal domains of α-subunits interact to form the cytoplasmic subunit of heterotetrameric potassium channels that regulate electric pores. Subsequent animal studies revealed the developmental functions of Kcnb1-containing voltage-gated potassium channels and illustrated their role during brain development and reproduction. These functions of potassium channels are discussed in this review in the context of regulatory interactions between electrically-active and regulatory subunits.
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Affiliation(s)
- Justyna Jędrychowska
- International Institute of Molecular and Cell Biology in Warsaw, Warsaw, Poland.,Postgraduate School of Molecular Medicine, Warsaw Medical University, Warsaw, Poland
| | - Vladimir Korzh
- International Institute of Molecular and Cell Biology in Warsaw, Warsaw, Poland
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6
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Mohanakkannan S, Perumal SR, Velayudham S, Jeyaraj KM, Arunan S. A Case of Morvan's Syndrome Associated with Heavy Metal Poisoning after Ayurvedic Drug Intake. J Neurosci Rural Pract 2019; 9:431-433. [PMID: 30069108 PMCID: PMC6050783 DOI: 10.4103/jnrp.jnrp_555_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Morvan's syndrome is an autoimmune disorder of peripheral and central nervous system mediated by VGKC antibody. Here we report a case of Morvans syndrome who presented 1 month after ayurvedic drug intake. She presented with symptoms of peripheral nerve hyperexcitablity and autoimmune testing revealed positive result for VGKC antibody. Heavy metals level was also significantly raised. She improved after a course of steroids. This case report tries to highlight the association of VGKC mediated Morvans syndrome with heavy metal poisoning and its incidental occurence after Ayurvedic drug intake.
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Affiliation(s)
- S Mohanakkannan
- Department of Neurology, Stanley Medical College and Hospital, Chennai, Tamil Nadu, India
| | - Sowmini R Perumal
- Department of Neurology, Stanley Medical College and Hospital, Chennai, Tamil Nadu, India
| | - Sakthi Velayudham
- Department of Neurology, Stanley Medical College and Hospital, Chennai, Tamil Nadu, India
| | - K Malcolm Jeyaraj
- Department of Neurology, Stanley Medical College and Hospital, Chennai, Tamil Nadu, India
| | - S Arunan
- Department of Neurology, Stanley Medical College and Hospital, Chennai, Tamil Nadu, India
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7
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Saint-Martin M, Pieters A, Déchelotte B, Malleval C, Pinatel D, Pascual O, Karagogeos D, Honnorat J, Pellier-Monnin V, Noraz N. Impact of anti-CASPR2 autoantibodies from patients with autoimmune encephalitis on CASPR2/TAG-1 interaction and Kv1 expression. J Autoimmun 2019; 103:102284. [PMID: 31176559 DOI: 10.1016/j.jaut.2019.05.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/08/2019] [Accepted: 05/14/2019] [Indexed: 12/19/2022]
Abstract
Autoantibodies against CASPR2 (contactin-associated protein-like 2) have been linked to autoimmune limbic encephalitis that manifests with memory disorders and temporal lobe seizures. According to the growing number of data supporting a role for CASPR2 in neuronal excitability, CASPR2 forms a molecular complex with transient axonal glycoprotein-1 (TAG-1) and shaker-type voltage-gated potassium channels (Kv1.1 and Kv1.2) in compartments critical for neuronal activity and is required for Kv1 proper positioning. Whereas the perturbation of these functions could explain the symptoms observed in patients, the pathogenic role of anti-CASPR2 antibodies has been poorly studied. In the present study, we find that patient autoantibodies alter Caspr2 distribution at the cell membrane promoting cluster formation. We confirm in a HEK cellular model that the anti-CASPR2 antibodies impede CASPR2/TAG-1 interaction and we identify the domains of CASPR2 and TAG-1 taking part in this interaction. Moreover, introduction of CASPR2 into HEK cells induces a marked increase of the level of Kv1.2 surface expression and in cultures of hippocampal neurons Caspr2-positive inhibitory neurons appear to specifically express high levels of Kv1.2. Importantly, in both cellular models, anti-CASPR2 patient autoAb increase Kv1.2 expression. These results provide new insights into the pathogenic role of autoAb in the disease.
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Affiliation(s)
- Margaux Saint-Martin
- INSERM U1217, Institut NeuroMyoGène, Lyon, F-69000, France; CNRS UMR5310, Institut NeuroMyoGène, Lyon, F-69000, France; University Claude Bernard Lyon 1, Lyon, F-69000, France
| | - Alanah Pieters
- INSERM U1217, Institut NeuroMyoGène, Lyon, F-69000, France; CNRS UMR5310, Institut NeuroMyoGène, Lyon, F-69000, France; University Claude Bernard Lyon 1, Lyon, F-69000, France
| | - Benoît Déchelotte
- INSERM U1217, Institut NeuroMyoGène, Lyon, F-69000, France; CNRS UMR5310, Institut NeuroMyoGène, Lyon, F-69000, France; University Claude Bernard Lyon 1, Lyon, F-69000, France
| | - Céline Malleval
- INSERM U1217, Institut NeuroMyoGène, Lyon, F-69000, France; CNRS UMR5310, Institut NeuroMyoGène, Lyon, F-69000, France; University Claude Bernard Lyon 1, Lyon, F-69000, France
| | - Delphine Pinatel
- INSERM U1217, Institut NeuroMyoGène, Lyon, F-69000, France; CNRS UMR5310, Institut NeuroMyoGène, Lyon, F-69000, France; University Claude Bernard Lyon 1, Lyon, F-69000, France
| | - Olivier Pascual
- INSERM U1217, Institut NeuroMyoGène, Lyon, F-69000, France; CNRS UMR5310, Institut NeuroMyoGène, Lyon, F-69000, France; University Claude Bernard Lyon 1, Lyon, F-69000, France
| | - Domna Karagogeos
- University of Crete Medical School and IMBB-FORTH, Heraklion, Crete GR, 70013, Greece
| | - Jérôme Honnorat
- INSERM U1217, Institut NeuroMyoGène, Lyon, F-69000, France; CNRS UMR5310, Institut NeuroMyoGène, Lyon, F-69000, France; University Claude Bernard Lyon 1, Lyon, F-69000, France; Hospices Civils de Lyon, Lyon, F-69000, France
| | - Véronique Pellier-Monnin
- INSERM U1217, Institut NeuroMyoGène, Lyon, F-69000, France; CNRS UMR5310, Institut NeuroMyoGène, Lyon, F-69000, France; University Claude Bernard Lyon 1, Lyon, F-69000, France
| | - Nelly Noraz
- INSERM U1217, Institut NeuroMyoGène, Lyon, F-69000, France; CNRS UMR5310, Institut NeuroMyoGène, Lyon, F-69000, France; University Claude Bernard Lyon 1, Lyon, F-69000, France.
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8
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Sveinsson O, Al Nimer F, Piehl F. Morvan's syndrome treated successfully with rituximab and lacosamide. BMJ Case Rep 2019; 12:12/2/e226832. [PMID: 30765442 DOI: 10.1136/bcr-2018-226832] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
We describe a woman with both central and peripheral nervous system symptoms consistent with Morvan's syndrome who was successfully treated with immunosuppression including rituximab and the new antiepileptic drug lacosamide against peripheral nerve hyperexcitability. Despite being over 8 months in hospital and 4 months in an intensive care unit she recovered fully. It is also the first case where cerebrospinal fluid neurofilament-light (NfL) levels were followed during the disease course. The clinical course resembled that of anti-NMDA receptor encephalitis, where patients often recover surprisingly well despite severe symptoms and an extensive time in intensive care. A possible explanation is the comparatively low levels of NfL, indicating disease processes that are not characterised by extensive neuroaxonal degeneration.
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Affiliation(s)
- Olafur Sveinsson
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Faiez Al Nimer
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Center for Neurology, Academic Specialist Center, Stockholm Health Services, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Center for Neurology, Academic Specialist Center, Stockholm Health Services, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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9
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Saint-Martin M, Joubert B, Pellier-Monnin V, Pascual O, Noraz N, Honnorat J. Contactin-associated protein-like 2, a protein of the neurexin family involved in several human diseases. Eur J Neurosci 2018; 48:1906-1923. [PMID: 30028556 DOI: 10.1111/ejn.14081] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/08/2018] [Accepted: 07/02/2018] [Indexed: 12/11/2022]
Abstract
Contactin-associated protein-like 2 (CASPR2) is a cell adhesion protein of the neurexin family. Proteins of this family have been shown to play a role in the development of the nervous system, in synaptic functions, and in neurological diseases. Over recent years, CASPR2 function has gained an increasing interest as demonstrated by the growing number of publications. Here, we gather published data to comprehensively review CASPR2 functions within the nervous system in relation to CASPR2-related diseases in humans. On the one hand, studies on Cntnap2 (coding for CASPR2) knockout mice revealed its role during development, especially, in setting-up the inhibitory network. Consistent with this result, mutations in the CNTNAP2 gene coding for CASPR2 in human have been identified in neurodevelopmental disorders such as autism, intellectual disability, and epilepsy. On the other hand, CASPR2 was shown to play a role beyond development, in the localization of voltage-gated potassium channel (VGKC) complex that is composed of TAG-1, Kv1.1, and Kv1.2. This complex was found in several subcellular compartments essential for action potential propagation: the node of Ranvier, the axon initial segment, and the synapse. In line with a role of CASPR2 in the mature nervous system, neurological autoimmune diseases have been described in patients without neurodevelopmental disorders but with antibodies directed against CASPR2. These autoimmune diseases were of two types: central with memory disorders and temporal lobe seizures, or peripheral with muscular hyperactivity. Overall, we review the up-to-date knowledge on CASPR2 function and pinpoint confused or lacking information that will need further investigation.
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Affiliation(s)
- Margaux Saint-Martin
- Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Bastien Joubert
- Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France.,French Reference Center on Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
| | - Véronique Pellier-Monnin
- Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Olivier Pascual
- Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Nelly Noraz
- Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Jérôme Honnorat
- Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France.,French Reference Center on Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
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11
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Dalmau J, Geis C, Graus F. Autoantibodies to Synaptic Receptors and Neuronal Cell Surface Proteins in Autoimmune Diseases of the Central Nervous System. Physiol Rev 2017; 97:839-887. [PMID: 28298428 PMCID: PMC5539405 DOI: 10.1152/physrev.00010.2016] [Citation(s) in RCA: 340] [Impact Index Per Article: 48.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Investigations in the last 10 years have revealed a new category of neurological diseases mediated by antibodies against cell surface and synaptic proteins. There are currently 16 such diseases all characterized by autoantibodies against neuronal proteins involved in synaptic signaling and plasticity. In clinical practice these findings have changed the diagnostic and treatment approach to potentially lethal, but now treatable, neurological and psychiatric syndromes previously considered idiopathic or not even suspected to be immune-mediated. Studies show that patients' antibodies can impair the surface dynamics of the target receptors eliminating them from synapses (e.g., NMDA receptor), block the function of the antigens without changing their synaptic density (e.g., GABAb receptor), interfere with synaptic protein-protein interactions (LGI1, Caspr2), alter synapse formation (e.g., neurexin-3α), or by unclear mechanisms associate to a new form of tauopathy (IgLON5). Here we first trace the process of discovery of these diseases, describing the triggers and symptoms related to each autoantigen, and then review in detail the structural and functional alterations caused by the autoantibodies with special emphasis in those (NMDA receptor, amphiphysin) that have been modeled in animals.
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Affiliation(s)
- Josep Dalmau
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania; Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain; Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany; Servei de Neurologia, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Christian Geis
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania; Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain; Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany; Servei de Neurologia, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Francesc Graus
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania; Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain; Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany; Servei de Neurologia, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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Zandi MS. Autoimmune Encephalitis. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2016; 14:432-436. [PMID: 31975823 DOI: 10.1176/appi.focus.20160019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Antibodies to brain cell-surface proteins have recently been identified in patients whose symptoms cross the boundary between neurology and psychiatry and are associated with syndromes that are responsive to treatment with immunosuppression-based treatments. This has led to an expansion in the field of autoimmune encephalitis. The common syndromes, with particular relevance to psychiatry, are discussed, in particular the N-methyl-d-aspartate receptor antibody encephalitis syndrome, which is most often associated with a psychosis and cognitive prodrome resembling acute or first-episode psychosis. The recognition, clinical diagnosis and associations, and evidence for disease mechanisms are discussed in this brief review.
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Affiliation(s)
- Michael S Zandi
- Dr. Zandi is with the Institute of Neurology, University College London, London, United Kingdom, and with the National Institute for Health Research, University College London Hospitals Biomedical Research Centre. Address correspondence to Dr. Zandi at the UCL Institute of Neurology, Queen Square House, Queen Square, London, United Kingdom
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13
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Bicknell AB. 60 YEARS OF POMC: N-terminal POMC peptides and adrenal growth. J Mol Endocrinol 2016; 56:T39-48. [PMID: 26759392 DOI: 10.1530/jme-15-0269] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 01/12/2016] [Indexed: 11/08/2022]
Abstract
The peptide hormones contained within the sequence of proopiomelanocortin (POMC) have diverse roles ranging from pigmentation to regulation of adrenal function to control of our appetite. It is generally acknowledged to be the archetypal hormone precursor, and as its biology has been unravelled, so too have many of the basic principles of hormone biosynthesis and processing. This short review focuses on one group of its peptide products, namely, those derived from the N-terminal of POMC and their role in the regulation of adrenal growth. From a historical and a personal perspective, it describes how their role in regulating proliferation of the adrenal cortex was identified and also highlights the key questions that remain to be answered.
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Affiliation(s)
- Andrew B Bicknell
- School of Biological SciencesUniversity of Reading, Whiteknights, Reading, UK
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14
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Clark AJL. 60 YEARS OF POMC: The proopiomelanocortin gene: discovery, deletion and disease. J Mol Endocrinol 2016; 56:T27-37. [PMID: 26643913 DOI: 10.1530/jme-15-0268] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 12/04/2015] [Indexed: 11/08/2022]
Abstract
The cloning of the bovine proopiomelanocortin (POMC) cDNA in 1978 by Nakanishi and colleagues was the result of a remarkable series of exacting and ingenious experiments. With this work, they instantly confirmed the single precursor hypothesis for adrenocorticotrophic hormone-β-lipotropin, as it was then known, and in so doing revealed the existence of additional, largely unpredicted, N-terminal peptides that together formed the POMC precursor peptide. This work paved the way for a host of additional studies into the physiology of these peptides and their regulation. Furthermore, the cloning of the murine Pomc gene was essential for subsequent studies, in which Pomc was intentionally deleted in the mouse illuminating its substantial role in body weight regulation and adrenal function. Contemporaneously with this work, naturally occurring mutations in human POMC came to light underlining the vital role of this gene in appetite regulation. This article reviews each of these aspects of POMC with the benefit of several decades of hindsight and informed by more recent genomic and transcriptomic data.
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Affiliation(s)
- Adrian J L Clark
- Centre for EndocrinologyWilliam Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London, UK
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Poyraz M, Matur Z, Aysal F, Tüzün E, Hanoğlu L, Öge AE. Clinical, Electrophysiological, and Serological Evaluation of Patients with Cramp-Fasciculation Syndrome. Noro Psikiyatr Ars 2016; 54:183-186. [PMID: 28680318 DOI: 10.5152/npa.2016.14816] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 02/18/2016] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Cramp-fasciculation syndrome (CFS) is a rare peripheral nerve hyperexcitability syndrome. There are only a few reports on clinical and serological profile of a CFS cohort that was followed up by a single outpatient clinic. METHODS Clinical, electrophysiological, and serological features of 6 CFS patients (5 men, 1 woman; 27-65 years old) were investigated. RESULTS All patients presented with cramps, fasciculations, muscle pain, and autonomic symptoms, and 2 also reported numbness and burning sensation in limbs, suggestive of neuropathic pain. Antibodies to uncharacterized voltage-gated potassium channel (VGKC)-complex proteins were found in 2 patients and to contactin-associated protein-like 2 (CASPR2) in 1 patient. None of the patients had a tumor. Most of the patients revealed prolonged after-discharges following tibial nerve stimulation. Nerve conduction studies and R-R interval variability tests were normal, whereas sympathetic skin responses were increased in amplitude in 3 seronegative patients. Five patients showed favorable response to carbamazepine or pregabalin treatment, whereas 1 VGKC-antibody-positive patient was resistant to carbamazepine and immunosuppressant treatment. CONCLUSION Neuropathic pain and VGKC-complex antibodies may be encountered in CFS patients. Although autonomic symptoms are commonly found in CFS, routine autonomic system tests which are done in electrophysiology laboratories might yield normal results.
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Affiliation(s)
- Mürüvvet Poyraz
- Department of Neurology, İstanbul Medipol University School of Medicine, İstanbul, Turkey
| | - Zeliha Matur
- Department of Neurology, İstanbul Bilim University School of Medicine, İstanbul, Turkey
| | - Fikret Aysal
- Department of Neurology, İstanbul Medipol University School of Medicine, İstanbul, Turkey
| | - Erdem Tüzün
- Department of Neurology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Lütfü Hanoğlu
- Department of Neurology, İstanbul Medipol University School of Medicine, İstanbul, Turkey
| | - A Emre Öge
- Department of Neurology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
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Saeed AA, Mohammed ZA, Saeed RR. Case Report: A 72 Years Old Man with Isaacs’ Syndrome: A Rare Entity with Different Outcomes. ACTA ACUST UNITED AC 2016. [DOI: 10.4236/wjns.2016.62010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Montojo M, Petit-Pedrol M, Graus F, Dalmau J. Clinical spectrum and diagnostic value of antibodies against the potassium channel-related protein complex. NEUROLOGÍA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.nrleng.2013.12.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Wilkinson TCI, Gardener MJ, Williams WA. Discovery of Functional Antibodies Targeting Ion Channels. ACTA ACUST UNITED AC 2014; 20:454-67. [DOI: 10.1177/1087057114560698] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ion channels play critical roles in physiology and disease by modulation of cellular functions such as electrical excitability, secretion, cell migration, and gene transcription. Ion channels represent an important target class for drug discovery that has been largely addressed, to date, using small-molecule approaches. A significant opportunity exists to target these channels with antibodies and alternative formats of biologics. Antibodies display high specificity and affinity for their target antigen, and they have the potential to target ion channels very selectively. Nevertheless, isolating antibodies to this target class is challenging due to the difficulties in expression and purification of ion channels in a format suitable for antibody drug discovery in addition to the complexity of screening for function. In this article, we will review the current state of ion channel biologics discovery and the progress that has been made. We will also highlight the challenges in isolating functional antibodies to these targets and how these challenges may be addressed. Finally, we also illustrate successful approaches to isolating functional monoclonal antibodies targeting ion channels by way of a number of case studies drawn from recent publications.
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Affiliation(s)
| | | | - Wendy A. Williams
- Antibody Discovery and Protein Engineering, MedImmune, Cambridge, UK
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Abstract
We are emphasising the importance of considering a rare diagnosis, voltage-gated Potassium channel antibody-associated limbic encephalitis, in an 80-year-old gentleman who presented with memory impairment, seizure and hyponatraemia. He was found to have high titre of voltage-gated potassium channel antibodies in his serum. He was given high-dose steroids and he responded biochemically and clinically with marked improvement in symptomatology.
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Affiliation(s)
- Atif Saleem
- Medicine, Yeovil District Hospital NHS Foundation Trust, Yeovil District Hospital Higher Kingston, Yeovil, Somerset BA21 4AT, UK
| | - Rani Sophia
- Medicine (Care of the Elderly), Yeovil District Hospital NHS Foundation Trust, Yeovil, Somerset, UK
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Clinical spectrum and diagnostic value of antibodies against the potassium channel related protein complex. Neurologia 2014; 30:295-301. [PMID: 24485651 DOI: 10.1016/j.nrl.2013.12.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 12/05/2013] [Accepted: 12/11/2013] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Antibodies against a protein complex that includes voltage-gated potassium channels (VGKC) have been reported in patients with limbic encephalitis, peripheral nerve hyperexcitability, Morvan's syndrome, and a large variety of neurological syndromes. REVIEW SUMMARY In this article, a review is presented of the syndromes associated with antibodies against VGKC-related proteins and the main antigens of this protein complex, the proteins LGI1 (leucine rich glioma inactivated protein 1) and Caspr2 (contactin-associated protein-like 2). The conceptual problems and clinical implications of the description of antibodies against VGKC-related proteins other than LGI1 and Caspr2 are also discussed. Although initial studies indicated the occurrence of antibodies against VGKC, recent investigations have shown that the main antigens are a neuronal secreted protein known as LGI1 which modulates synaptic excitability, and a protein called Caspr2 located on the cell surface and processes of neurons of different brain regions, and at the juxtaparanodal region of myelinated axons. While antibodies against LGI1 preferentially associate with classical limbic encephalitis, antibodies against Caspr2 associate with a wider spectrum of symptoms, including Morvan's syndrome, peripheral nerve hyperexcitability or neuromyotonia, and limbic or more extensive encephalitis. In addition there are reports of patients with antibodies against VGKC-related proteins that are different from LGI1 or Caspr2. In these cases, the identity and location of the antigens are unknown, the syndrome association is not specific, and the response to treatment uncertain. CONCLUSIONS The discovery of antigens such as LGI1 and Caspr2 has resulted in a clinical and molecular definition of the broad group of diseases previously attributed to antibodies against VGKC. Considering the literature that describes the presence of antibodies against VGKC other than LGI1 and Caspr2 proteins, we propose a practical algorithm for the diagnosis and treatment of these patients.
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Faivre-Sarrailh C, Devaux JJ. Neuro-glial interactions at the nodes of Ranvier: implication in health and diseases. Front Cell Neurosci 2013; 7:196. [PMID: 24194699 PMCID: PMC3810605 DOI: 10.3389/fncel.2013.00196] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 10/08/2013] [Indexed: 01/06/2023] Open
Abstract
Specific cell adhesion molecules (CAMs) are dedicated to the formation of axo-glial contacts at the nodes of Ranvier of myelinated axons. They play a central role in the organization and maintenance of the axonal domains: the node, paranode, and juxtaparanode. In particular, CAMs are essential for the accumulation of voltage-gated sodium channels at the nodal gap that ensures the rapid and saltatory propagation of the action potentials (APs). The mechanisms regulating node formation are distinct in the central and peripheral nervous systems, and recent studies have highlighted the relative contribution of paranodal junctions and nodal extracellular matrix. In addition, CAMs at the juxtaparanodal domains mediate the clustering of voltage-gated potassium channels which regulate the axonal excitability. In several human pathologies, the axo-glial contacts are altered leading to disruption of the nodes of Ranvier or mis-localization of the ion channels along the axons. Node alterations and the failure of APs to propagate correctly from nodes to nodes along the axons both contribute to the disabilities in demyelinating diseases. This article reviews the mechanisms regulating the association of the axo-glial complexes and the role of CAMs in inherited and acquired neurological diseases.
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22
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Eymard B. [Myasthenia, from the internist's point of view]. Rev Med Interne 2013; 35:421-9. [PMID: 24112993 DOI: 10.1016/j.revmed.2013.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 08/21/2013] [Indexed: 01/02/2023]
Abstract
Myasthenia gravis is an autoimmune disease due to specific antibodies inducing a neuromuscular transmission defect causing muscle fatigability. If onset of the disease may be at any age, myasthenia gravis concerns mostly young adults, in majority females. The disease characteristic features are the following: ocular symptoms (ptosis or diplopia) as main initial manifestation, extension to other muscles in 80 % of the cases, variability of the deficit, effort induced worsening, successive periods of exacerbation during the disease course, severity depending on respiratory and swallowing impairment (if rapid worsening, a myasthenic crisis is to be suspected), association with thymoma in 20 % of patients and with other various autoimmune diseases, most commonly hyperthyroidism and Hashimoto's disease. Diagnosis relies on the clinical features, improvement with cholinesterase inhibitors, detection of specific autoantibodies (anti-AChR or anti-MuSK), and significant decrement evidenced by electrophysiological tests. The points concerning specifically the internist have been highlighted in this article: diagnostic traps, associated autoimmune diseases, including inflammatory myopathies that may mimic myasthenia gravis, adverse effects of medications commonly used in internal medicine, some of them inducing myasthenic syndromes. The treatment is well codified: the treatment is well codified: (1) respect of adverse drugs contra-indications, systematically use of cholinesterase inhibitors, (2) thymectomy if thymoma completed with radiotherapy if malignant, (3) corticosteroids or immunosuppressive agent in severe or disabling form, (4) intensive care unit monitoring, plasmapheresis or intravenous immunoglobulins for patients with myasthenic crisis.
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Affiliation(s)
- B Eymard
- Unité de pathologie neuromusculaire, service de neurologie 2, centre de référence de pathologie neuromusculaire Paris Est, hôpital de la Pitié-Salpêtrière, institut de myologie, bâtiment Babinski, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France. anne-marie.maronne.@psl.aphp.fr
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Klein R, Marx A, Ströbel P, Schalke B, Nix W, Willcox N. Autoimmune associations and autoantibody screening show focused recognition in patient subgroups with generalized myasthenia gravis. Hum Immunol 2013; 74:1184-93. [DOI: 10.1016/j.humimm.2013.06.020] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 05/22/2013] [Accepted: 06/07/2013] [Indexed: 11/25/2022]
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Dimitrov AG, Dimitrova NA. Internodal mechanism of pathological afterdischarges in myelinated axons. Muscle Nerve 2013; 49:47-55. [PMID: 23580322 DOI: 10.1002/mus.23874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2013] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Recent optical recordings of transmembrane potentials in the axons of pyramidal neurons have shown that the internodal action potentials (APs) predicted in our previous studies do exist. These novel processes are not well understood. In this study we aim to clarify electrical phenomena in peripheral myelinated axons (MAs). METHODS We used a multi-cable Hodgkin-Huxley-type model to simulate MAs with potassium channels that were either normal or inhibited along a short region of the internodal membrane. A brief stimulus was applied to the first node. RESULTS We demonstrated peculiarities in the internodal APs induced by a saltatory AP: They existed across internodal membranes, were detectable in periaxonal space but not in intracellular space, propagated continuously, collided near the mid-internodes, and produced internodal sources of afterdischarges. CONCLUSIONS These results highlight the importance of the MA internodal regions as new therapeutic targets for avoiding afterdischarges provoked by reduced axonal fast potassium channel expression.
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Affiliation(s)
- Alexander G Dimitrov
- Institute of Biophysics and Biomedical Engineering, Bulgarian Academy of Sciences, Acad. G. Bonchev Str., Bl. 105, Sofia, 1113, Bulgaria
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25
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van Sonderen A, Wirtz PW, Verschuuren JJGM, Titulaer MJ. Paraneoplastic syndromes of the neuromuscular junction: therapeutic options in myasthenia gravis, lambert-eaton myasthenic syndrome, and neuromyotonia. Curr Treat Options Neurol 2013; 15:224-39. [PMID: 23263888 DOI: 10.1007/s11940-012-0213-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OPINION STATEMENT Myasthenia gravis (MG), Lambert-Eaton myasthenic syndrome (LEMS) and neuromyotonia are neuromuscular transmission disorders occurring with or without associated malignancy. Due to the common antibody-mediated pathophysiology, immunosuppression has an important role in the treatment of each of these disorders. Symptomatic treatment is more variable. Pyridostigmine is first-line treatment in generalized MG. Response seems to be better in patients with acetylcholine receptor (AChR) antibodies than in patients with antibodies against muscle-specific tyrosine kinase (MuSK). Pyridostigmine can be sufficient in mild MG, although most patients need additional immunosuppressive therapy. If so, prednisolone is efficient in the majority of the patients, with a relatively early onset of clinical effect. High drug dosage and treatment duration should be limited as much as possible because of serious corticosteroid-related side effects. As long-term treatment is needed in most patients for sustainable remission, adding non-steroid immunosuppressive drugs should be considered. Their therapeutic response is usually delayed and often takes a period of several months. In the meantime, corticosteroids are continued and doses are tapered down over a period of several months. There are no trials comparing different immunosuppressive drugs. Choice is mainly based on the clinician's familiarity with certain drugs and their side effects, combined with patients' characteristics. Most commonly used is azathioprine. Alternatively, tacrolimus, cyclosporine A, mycophenolate mofetil or rituximab can be used. The use of cyclophosphamide is limited to refractory cases, due to serious side effects. Plasma exchange and intravenous immunoglobulin induce rapid but temporary improvement, and are reserved for severe disease exacerbations because of high costs of treatment. It is recommended that computed tomography (CT) of the thorax is performed in every AChR-positive MG patient, and that patients are referred for thymectomy in case of thymoma. In patients without thymoma, thymectomy can be considered as well, especially in younger, AChR-positive patients with severe disease. However, definite proof of benefit is lacking and an international randomized trial to clarify this topic is currently ongoing. When LEMS is suspected, always search for malignancy, especially small cell lung carcinoma with continued screening up to two years. In paraneoplastic LEMS, cancer treatment usually results in clinical improvement of the myasthenic symptoms. 3,4-Diaminopyridine is first-line symptomatic treatment in LEMS. It is usually well tolerated and effective. When immunosuppressive therapy is needed, the same considerations apply to LEMS as described for MG. Peripheral nerve hyperexcitability in neuromyotonia can be treated with anticonvulsant drugs such as phenytoin, valproic acid or carbamazepine. When response in insufficient, start prednisolone in mild disease and consider the addition of azathioprine. Plasma exchange or intravenous immunoglobulin is indicated in severe neuromyotonia and in patients with neuromyotonia combined with central nervous system symptoms, a clinical picture known as Morvan's syndrome.
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Kaneko K, Tano O, Kikuchi A, Hasegawa T, Tateyama M, Yoshioka M, Saito H, Watanabe O, Takeda A, Aoki M. Anti-voltage-gated potassium channel antibody is associated with chronic autonomic and sensory neuropathy. J Neurol 2012; 260:315-7. [PMID: 23117295 DOI: 10.1007/s00415-012-6730-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 10/13/2012] [Accepted: 10/19/2012] [Indexed: 11/30/2022]
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Abstract
Morvan syndrome is characterized by central, autonomic, and peripheral hyperactivity. Examples of central hyperactivity include confusion, memory problems, hallucinations, insomnia, and myoclonus; examples of autonomic hyperactivity include hyperhidrosis and fluctuations in blood pressure; examples of peripheral hyperreactivity include clinical or electrophysiological evidence of painful cramps, myokymia, and neuromyotonia. We present a typical case of Morvan syndrome and the first detailed review of the clinical and therapeutic literature of all 27 cases from the English language literature. Morvan syndrome is considered to be an autoimmune disorder and antibodies against voltage-gated potassium channels are found in most cases. Oral immunomodulatory therapy, intravenous immunoglobulin, and plasmapharesis may be entertained. Thymoma is found in approximately 50% of cases and thymectomy may be curative as in our particular case.
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Meeusen JW, Lennon VA, Klein CJ. Immunotherapy-responsive pain in an abattoir worker with fluctuating potassium channel-complex IgG. Neurology 2012; 79:1824-5. [PMID: 23054232 DOI: 10.1212/wnl.0b013e31827040a3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jeffrey W Meeusen
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Meeusen JW, Klein CJ, Pirko I, Haselkorn KE, Kryzer TJ, Pittock SJ, Lachance DH, Dyck PJ, Lennon VA. Potassium channel complex autoimmunity induced by inhaled brain tissue aerosol. Ann Neurol 2012; 71:417-26. [PMID: 22451206 PMCID: PMC3315155 DOI: 10.1002/ana.22674] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To test the hypothesis that autoimmunity induced by inhalation of aerosolized brain tissue caused outbreaks of sensory-predominant polyradiculoneuropathy among swine abattoir employees in the Midwestern United States. METHODS Mice were exposed intranasally, 5 days per week, to liquefied brain tissue. Serum from exposed mice, patients, and unaffected abattoir employees were analyzed for clinically pertinent neural autoantibodies. RESULTS Patients, coworkers, and mice exposed to liquefied brain tissue had an autoantibody profile dominated by neural cation channel immunoglobulin Gs (IgGs). The most compelling link between patients and exposed mice was magnetic resonance imaging (MRI) evidence of grossly swollen spinal nerve roots. Autoantibody responses in patients and mice were dose-dependent and declined after antigen exposure ceased. Autoantibodies detected most frequently, and at high levels, bound to detergent-solubilized macromolecular complexes containing neuronal voltage-gated potassium channels ligated with a high affinity Kv1 channel antagonist, 125I-α-dendrotoxin. Exposed mice exhibited a behavioral phenotype consistent with potassium channel dysfunction recognized in drosophila with mutant ("shaker") channels: reduced sensitivity to isoflurane-induced anesthesia. Pathological and electrophysiological findings in patients supported peripheral nerve hyperexcitability over destructive axonal loss. The pain-predominant symptoms were consistent with sensory nerve hyperexcitability. INTERPRETATION Our observations establish that inhaled neural antigens readily induce neurological autoimmunity and identify voltage-gated potassium channel complexes as a major immunogen.
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Affiliation(s)
- Jeffrey W. Meeusen
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Christopher J. Klein
- Department of Laboratory Neurology and College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Istvan Pirko
- Department of Laboratory Neurology and College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Keegan E. Haselkorn
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Thomas J. Kryzer
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Sean J. Pittock
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
- Department of Laboratory Neurology and College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Daniel H. Lachance
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
- Department of Laboratory Neurology and College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - P. James Dyck
- Department of Laboratory Neurology and College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Vanda A. Lennon
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
- Department of Laboratory Neurology and College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
- Department of Immunology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
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Rosenfeld MR, Dalmau J. Central nervous system paraneoplastic disease. HANDBOOK OF CLINICAL NEUROLOGY 2012; 105:853-64. [PMID: 22230537 DOI: 10.1016/b978-0-444-53502-3.00027-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Illingworth MA, Hanrahan D, Anderson CE, O'Kane K, Anderson J, Casey M, de Sousa C, Cross JH, Wright S, Dale RC, Vincent A, Kurian MA. Elevated VGKC-complex antibodies in a boy with fever-induced refractory epileptic encephalopathy in school-age children (FIRES). Dev Med Child Neurol 2011; 53:1053-7. [PMID: 21592118 DOI: 10.1111/j.1469-8749.2011.04008.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Fever-induced refractory epileptic encephalopathy in school-age children (FIRES) is a clinically recognized epileptic encephalopathy of unknown aetiology. Presentation in previously healthy children is characterized by febrile status epilepticus. A pharmacoresistant epilepsy ensues, occurring in parallel with dramatic cognitive decline and behavioural difficulties. We describe a case of FIRES in a 4-year-old boy that was associated with elevated voltage-gated potassium channel (VGKC) complex antibodies and a significant clinical and immunological response to immunomodulation. This case, therefore, potentially expands the clinical phenotype of VGKC antibody-associated disease to include that of FIRES. Prior to immunomodulation, neuropsychology assessment highlighted significant attention, memory, and word-finding difficulties. The UK version of the Wechsler Preschool and Primary Scale of Intelligence assessment indicated particular difficulties with verbal skills (9th centile). Immunomodulation was initially administered as intravenous methylprednisolone (followed by maintenance oral prednisolone) and later in the disease course as regular monthly intravenous immunoglobulin infusions and low-dose azathioprine. Now aged 6 years, the seizure burden in this child is much reduced, although increased seizure frequency is observed in the few days before his monthly immunoglobulin infusions. Formal IQ assessment has not been repeated but there is no clinical suggestion of further cognitive regression. VGKC complex antibodies have been reported in a range of central and peripheral neurological disorders (predominantly presenting in adulthood), and the identification of elevated VGKC complex antibodies, combined with the response to immunotherapies in this child, supports an autoimmune pathogenesis in FIRES with potential diagnostic and therapeutic implications.
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Provini F, Marconi S, Amadori M, Guaraldi P, Pierangeli G, Cortelli P, Lugaresi E, Montagna P, Tinuper P. Morvan chorea and agrypnia excitata: when video-polysomnographic recording guides the diagnosis. Sleep Med 2011; 12:1041-3. [PMID: 22033118 DOI: 10.1016/j.sleep.2011.05.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 05/17/2011] [Accepted: 05/19/2011] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Morvan chorea is an antibody-mediated limbic encephalopathy characterized by severe insomnia, mental confusion, hallucinations, enacted dreams, hyperhidrosis, and neuromyotonia. CASE DESCRIPTION In a 78 years old man presenting with progressive insomnia apathy and depression, a video-polysomnogram documented enacted dreams mimicking daily life activity (oneiric stupor). This finding led us to perform a search for serum antibodies to voltage-gated K+ channels, which was positive. A diagnosis of Morvan chorea was done. The patient underwent plasma exchange with complete resolution of the clinical picture. CONCLUSIONS Oneiric stupor may represent a useful precocious diagnostic marker in Morvan chorea.
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Affiliation(s)
- Federica Provini
- Department of Neurological Sciences, University of Bologna, Bologna, Italy.
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Abstract
PURPOSE OF REVIEW The most relevant advances in immune-mediated movement disorders are described, with emphasis on the clinical--immunological associations, novel antigens, and treatment. RECENT FINDINGS Many movement disorders previously considered idiopathic or degenerative are now recognized as immune-mediated. Some disorders are paraneoplastic, such as anti-CRMP5-associated chorea, anti-Ma2 hypokinesis and rigidity, anti-Yo cerebellar ataxia and tremor, and anti-Hu ataxia and pesudoathetosis. Other disorders such as Sydenham's chorea, or chorea related to systemic lupus erythematosus and antiphospholipid syndrome occur in association with multiple antibodies, are not paraneoplastic, and are triggered by molecular mimicry or unknown mechanisms. Recent studies have revealed a new category of disorders that can be paraneoplastic or not, and associate with antibodies against cell-surface or synaptic proteins. They include anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis, which may cause dyskinesias, chorea, ballismus or dystonia (NMDAR antibodies), the spectrum of Stiff-person syndrome/muscle rigidity (glutamic acid decarboxylase, amphiphysin, GABA(A)-receptor-associated protein, or glycine receptor antibodies), neuromyotonia (Caspr2 antibodies), and opsoclonus--myoclonus--ataxia (unknown antigens). SUMMARY Neurologists should be aware that many movement disorders are immune-mediated. Recognition of these disorders is important because it may lead to the diagnosis of an occult cancer, and a substantial number of patients, mainly those with antibodies to cell-surface or synaptic proteins, respond to immunotherapy.
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Affiliation(s)
- Jessica Panzer
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Dalmau J, Rosenfeld MR. Paraneoplastic syndromes causing movement disorders. HANDBOOK OF CLINICAL NEUROLOGY 2011; 100:315-21. [PMID: 21496591 DOI: 10.1016/b978-0-444-52014-2.00024-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Paraneoplastic neurological disorders are an extensive group of neurological syndromes that occur in patients with cancer and often present before the presence of an underlying tumor is known. Many of these disorders appear to be immune-mediated, with targets throughout the nervous system, including basal ganglia and brainstem, in which case they may result in movement disorders. Recent descriptions of new immune-mediated encephalitides in children and adults have substantially increased the number of patients with paraneoplastic movement disorders. There are several key concepts that assist in the identification of a movement disorder as likely paraneoplastic, including a rapid onset, the presence of cerebrospinal fluid inflammatory changes, and in some patients the identification of specific serum and cerebrospinal fluid antineuronal antibodies. Once identified, prompt diagnosis and treatment of the tumor can result in neurological symptom improvement or stabilization, although some patients may require immunotherapy only. Understanding the natural course of each immune-mediated paraneoplastic movement disorder minimizes unnecessary testing and the use of potentially toxic therapies.
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Affiliation(s)
- Josep Dalmau
- Division of Neuro-oncology, Department of Neurology, University of Pennsylvania, Philadelphia 19104, USA
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Abstract
Limbic encephalitis (LE) was first described in 1960 by Brierley et al. and was defined by an acute or subacute temporal lobe epilepsy, memory loss and psychiatric disturbances. Corsellis et al. then demonstrated that LE was associated with small-cell lung cancer and a paraneoplastic origin of LE was suggested. In the 1980s, onconeuronal antibodies specific to paraneoplastic neurological syndromes were described and some of them, such as Hu-Ab, were clearly associated with LE. In the last 20 years, other onconeuronal antibodies targeting intracellular antigens were subsequently identified and LE was considered as a rare paraneoplastic neurological syndrome with a poor outcome and as mainly being associated with Hu-Ab, Ma2-Ab or CV2/CRMP5-Ab. The concept of LE has dramatically evolved since 2004, with the description of LE becoming associated with novel autoantibodies that target neuronal surface rather than intracellular antigens. In these cases, LE was not always paraneoplastic. Interestingly, these newly described LE cases offer a much better prognosis than the previous ones. At present, LE is considered to be an autoimmune disorder that can be paraneoplastic or not and could be more frequent than previously suspected. The associated antibodies lead to the classification of different subtypes of LE and are used as prognostic markers. Those that are directed against cell surface antigens could play a direct role in the neurological symptoms of LE.
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Affiliation(s)
- Adrien Didelot
- Centre de Référence de Diagnostic et de Traitement des Syndromes Neurologiques Paranéoplasiques, Hôpital Pierre Wertheimer, 59 Boulevard Pinel, Lyon F-69003, France
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Investigation of LGI1 as the antigen in limbic encephalitis previously attributed to potassium channels: a case series. Lancet Neurol 2010; 9:776-85. [PMID: 20580615 DOI: 10.1016/s1474-4422(10)70137-x] [Citation(s) in RCA: 694] [Impact Index Per Article: 49.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Voltage-gated potassium channels are thought to be the target of antibodies associated with limbic encephalitis. However, antibody testing using cells expressing voltage-gated potassium channels is negative; hence, we aimed to identify the real autoantigen associated with limbic encephalitis. METHODS We analysed sera and CSF of 57 patients with limbic encephalitis and antibodies attributed to voltage-gated potassium channels and 148 control individuals who had other disorders with or without antibodies against voltage-gated potassium channels. Immunohistochemistry, immunoprecipitation, and mass spectrometry were used to characterise the antigen. An assay with HEK293 cells transfected with leucine-rich, glioma-inactivated 1 (LGI1) and disintegrin and metalloproteinase domain-containing protein 22 (ADAM22) or ADAM23 was used as a serological test. The identity of the autoantigen was confirmed by immunoabsorption studies and immunostaining of Lgi1-null mice. FINDINGS Immunoprecipitation and mass spectrometry analyses showed that antibodies from patients with limbic encephalitis previously attributed to voltage-gated potassium channels recognise LGI1, a neuronal secreted protein that interacts with presynaptic ADAM23 and postsynaptic ADAM22. Immunostaining of HEK293 cells transfected with LGI1 showed that sera or CSF from patients, but not those from control individuals, recognised LGI1. Co-transfection of LGI1 with its receptors, ADAM22 or ADAM23, changed the pattern of reactivity and improved detection. LGI1 was confirmed as the autoantigen by specific abrogation of reactivity of sera and CSF from patients after immunoabsorption with LGI1-expressing cells and by comparative immunostaining of wild-type and Lgi1-null mice, which showed selective lack of reactivity in brains of Lgi1-null mice. One patient with limbic encephalitis and antibodies against LGI1 also had antibodies against CASPR2, an autoantigen we identified in some patients with encephalitis and seizures, Morvan's syndrome, and neuromyotonia. INTERPRETATION LGI1 is the autoantigen associated with limbic encephalitis previously attributed to voltage-gated potassium channels. The term limbic encephalitis associated with antibodies against voltage-gated potassium channels should be changed to limbic encephalitis associated with LGI1 antibodies, and this disorder should be classed as an autoimmune synaptic encephalopathy. FUNDING National Institutes of Health, National Cancer Institute, and Euroimmun.
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Abstract
When patients with cancer develop neurologic symptoms, common causes include metastasis, infections, coagulopathy, metabolic or nutritional disturbances, and neurotoxicity from treatments. A thorough clinical history, temporal association with cancer therapies, and results of ancillary tests usually reveal one of these mechanisms as the etiology. When no etiology is identified, the diagnosis considered is often that of a paraneoplastic neurologic disorder (PND). With the recognition that PNDs are more frequent than previously thought, the availability of diagnostic tests, and the fact that, for some PNDs, treatment helps, PNDs should no longer be considered diagnostic zebras, and when appropriate should be included in the differential diagnosis early in the evaluation.
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Affiliation(s)
- Myrna R Rosenfeld
- Division of Neuro-oncology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104, USA
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Tüzün E, Kürtüncü M, Lang B, İçöz S, Akman-Demir G, Eraksoy M, Vincent A. Bickerstaff’s encephalitis and Miller Fisher syndrome associated with voltage-gated potassium channel and novel anti-neuronal antibodies. Eur J Neurol 2010; 17:1304-7. [DOI: 10.1111/j.1468-1331.2010.02993.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bradl M, Misu T, Takahashi T, Watanabe M, Mader S, Reindl M, Adzemovic M, Bauer J, Berger T, Fujihara K, Itoyama Y, Lassmann H. Neuromyelitis optica: pathogenicity of patient immunoglobulin in vivo. Ann Neurol 2009; 66:630-43. [PMID: 19937948 DOI: 10.1002/ana.21837] [Citation(s) in RCA: 422] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Severe inflammation and astrocyte loss with profound demyelination in spinal cord and optic nerves are typical pathological features of neuromyelitis optica (NMO). A diagnostic hallmark of this disease is the presence of serum autoantibodies against the water channel aquaporin-4 (AQP-4) on astrocytes. METHODS We induced acute T-cell-mediated experimental autoimmune encephalomyelitis in Lewis rats and confronted the animals with an additional application of immunoglobulins from AQP-4 antibody-positive and -negative NMO patients, multiple sclerosis patients, and control subjects. RESULTS The immunoglobulins from AQP-4 antibody-positive NMO patients are pathogenic. When they reach serum titers in experimental animals comparable with those seen in NMO patients, they augment clinical disease and induce lesions in the central nervous system that are similar in structure and distribution to those seen in NMO patients, consisting of AQP-4 and astrocyte loss, granulocytic infiltrates, T cells and activated macrophages/microglia cells, and an extensive immunoglobulin and complement deposition on astrocyte processes of the perivascular and superficial glia limitans. AQP-4 antibody containing NMO immunoglobulin injected into naïve rats, young rats with leaky blood-brain barrier, or after transfer of a nonencephalitogenic T-cell line did not induce disease or neuropathological alterations in the central nervous system. Absorption of NMO immunoglobulins with AQP-4-transfected cells, but not with mock-transfected control cells, reduced the AQP-4 antibody titers and was associated with a reduction of astrocyte pathology after transfer. INTERPRETATION Human anti-AQP-4 antibodies are not only important in the diagnosis of NMO but also augment disease and induce NMO-like lesions in animals with T-cell-mediated brain inflammation.
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Affiliation(s)
- Monika Bradl
- Department of Neuroimmunology, Medical University Vienna, Center for Brain Research, Vienna, Austria
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Nwosu VK, Royer JA, Stickler DE. Voltage gated potassium channel antibodies in amyotrophic lateral sclerosis. ACTA ACUST UNITED AC 2009; 11:392-4. [DOI: 10.3109/17482960903452283] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Dimitrov AG. A possible mechanism of repetitive firing of myelinated axon. Pflugers Arch 2009; 458:547-61. [DOI: 10.1007/s00424-009-0640-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Revised: 12/19/2008] [Accepted: 01/17/2009] [Indexed: 10/21/2022]
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Takahashi H, Mori M, Sekiguchi Y, Misawa S, Sawai S, Hattori T, Kuwabara S. Development of Isaacs' syndrome following complete recovery of voltage-gated potassium channel antibody-associated limbic encephalitis. J Neurol Sci 2008; 275:185-7. [DOI: 10.1016/j.jns.2008.07.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2008] [Revised: 07/27/2008] [Accepted: 07/31/2008] [Indexed: 12/29/2022]
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Ballok DA, Sakic B. Purine receptor antagonist modulates serology and affective behaviors in lupus-prone mice: evidence of autoimmune-induced pain? Brain Behav Immun 2008; 22:1208-16. [PMID: 18601998 PMCID: PMC2783694 DOI: 10.1016/j.bbi.2008.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Revised: 06/09/2008] [Accepted: 06/09/2008] [Indexed: 12/31/2022] Open
Abstract
Neurologic and psychiatric (NP) manifestations are severe complications of systemic lupus erythematosus (SLE). As commonly seen in patients, spontaneous disease onset in the MRL/MpJ-Fas(lpr)/J (MRL-lpr) mouse model of NP-SLE is accompanied by increased autoantibodies, pro-inflammatory cytokines and behavioral dysfunction which precede neuroinflammation and structural brain lesions. The role of purinergic receptors in the regulation of immunity and behavior remains largely unexplored in the field of neuropsychiatry. To examine the possibility that purinoception is involved in the development of affective behaviors, the P2X purinoceptor antagonist, suramin, was administered to lupus-prone mice from 5 to 14 weeks of age. In addition to food and water measures, novel object and sucrose preference tests were performed to assess neophobic anxiety- and anhedonic-like behaviors. Enzyme-linked immunosorbant assays for anti-nuclear antibodies (ANA) and pro-inflammatory cytokines were employed in immunopathological analyses. Changes in dendritic morphology in the hippocampal CA1 region were examined by a Golgi impregnation method. Suramin significantly lowered serum ANA and prevented behavioral deficits, but did not prevent neuronal atrophy in MRL-lpr animals. In a new batch of asymptomatic mice, systemic administration of corticosterone was found to induce aberrations in CA1 dendrites, comparable to the "stress" of chronic disease. The precise mechanism(s) through which purine receptor inhibition exerted beneficial effects is not known. The present data supports the hypothesis that activation of the peripheral immune system induces nociceptive-related behavioral symptomatology which is attenuated by the analgesic effects of suramin. Hypercortisolemia may also initiate neuronal damage, and metabolic perturbations may underlie neuro-immuno-endocrine imbalances in MRL-lpr mice.
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Affiliation(s)
- David A Ballok
- Department of Surgery (Neurosurgery, Neurobiology), McMaster University, Canada L8N 3Z5.
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Serratrice J, Amri AB, Bouabdallah R, Ceccaldi M, Weiller PJ. [Relapsing meningitis and confusion: limbic encephalitis revealing Hodgkin's disease]. Rev Neurol (Paris) 2008; 165:76-80. [PMID: 18930300 DOI: 10.1016/j.neurol.2008.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Revised: 07/25/2008] [Accepted: 08/21/2008] [Indexed: 10/21/2022]
Abstract
INTRODUCTION An observation of limbic encephalitis associated with Hodgkin's disease is compared with rare cases of the literature. The clinical presentation was relapsing episodes of febrile cognitive disorders with confusion and meningitis, curable after treatment of Hodgkin's disease. Recent concepts on limbic encephalitis are discussed. CASE REPORT A seventy-five-year-old patient was hospitalized because of relapsing feverish confusion episodes with meningitis. During the year before his admission he had experienced four spontaneously regressive episodes of feverish confusion. Exploration of these episodes disclosed a paraneoplastic limbic encephalitis due to an underlying Hodgkin's disease. The treatment of Hodgkin's disease led to perfect recovery of cognitive function, so that the patient could drive his car. CONCLUSION Lymphoproliferative disease, such as Hodgkin's disease, is a possible diagnosis in patients with limbic encephalitis. A dysimmune process underlying Hodgkin's disease might be operating in this association.
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Affiliation(s)
- J Serratrice
- Service de médecine interne, 264, rue Saint-Pierre, CHU de la Timone, 13385 Marseille cedex 05, France.
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Montiel P, Sellal F, Clerc C, Richard P, Bataillard M. Encéphalite limbique avec anticorps anticanaux potassiques voltage dépendants et troubles sévères du sommeil. Rev Neurol (Paris) 2008; 164:181-4. [DOI: 10.1016/j.neurol.2007.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2007] [Revised: 07/06/2007] [Accepted: 08/28/2007] [Indexed: 11/29/2022]
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Sommer N, Tackenberg B, Hohlfeld R. The immunopathogenesis of myasthenia gravis. HANDBOOK OF CLINICAL NEUROLOGY 2008; 91:169-212. [PMID: 18631843 DOI: 10.1016/s0072-9752(07)01505-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Norbert Sommer
- Clinical Neuroimmunology Group, Philipps-University, Marburg, Germany
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Törnblom H, Lang B, Clover L, Knowles CH, Vincent A, Lindberg G. Autoantibodies in patients with gut motility disorders and enteric neuropathy. Scand J Gastroenterol 2007; 42:1289-93. [PMID: 17918010 DOI: 10.1080/00365520701396216] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Enteric neuropathy with mild inflammation (ganglionitis) has been described in several motility disorders including irritable bowel syndrome (IBS), enteric dysmotility (ED), slow-transit constipation (STC) and chronic intestinal pseudo-obstruction (CIPO). The purpose of this study was to test the hypothesis that autoantibodies directed against specific neural antigens including ion channels may be associated with this finding. MATERIAL AND METHODS Comprehensive routine and immunohistochemical analyses of full-thickness jejunal laparoscopic biopsies were performed on patients fulfilling the international criteria for IBS, ED, STC and CIPO. Patients with ganglionitis had sera screened for specific antibodies to voltage-gated calcium channels (VGCCs) of P/Q- and N-type, voltage-gated potassium channels (VGKCs), glutamic acid decarboxylase (GAD) and neuronal alpha3-AChR by validated immunoprecipitation assays. RESULTS Thirty-three patients were included in the study. Two of them, both with IBS, were found to have positive antibody titres. One had anti-VGKC antibodies and one had anti-alpha3-AChR antibodies. No antibodies were detected in GAD or VGCCs (case reports presented). CONCLUSIONS A small proportion of patients with inflammatory enteric neuropathy have antibodies directed towards neuronal ion channels. The pathogenic role of such antibodies requires determination but may represent a possible aetiology of severe functional symptoms in these groups of patients.
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Affiliation(s)
- Hans Törnblom
- Karolinska Institutet, Department of Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
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Reduplicative paramnesia in Morvan's syndrome. J Neurol Sci 2007; 267:154-7. [PMID: 17928004 DOI: 10.1016/j.jns.2007.09.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Revised: 08/30/2007] [Accepted: 09/20/2007] [Indexed: 01/24/2023]
Abstract
BACKGROUND Morvan's syndrome is characterized by peripheral nervous system hyperexcitibility (myokymia and neuromyotonia), hyperhydrosis, sleep disorder, limb paresthesias, and encephalopathy. Voltage gated potassium channel antibodies (VGKC abs) are frequently present. Reduplicative paramnesia (RP) has not been reported with this disorder. OBJECTIVE To describe a patient with Morvan's syndrome presenting with RP. DESIGN Single case study. PATIENT A 64-year-old man with several years of myokymia and myoclonus with escalating parasomnia and confusion developed the delusion that a replica of his house and its contents existed 40 mi away. RESULTS Serum VGKC ab titer was elevated. Neuropsychological testing disclosed executive function and memory deficits. Electromyography demonstrated diffuse myokymia. Treatment with intravenous immunoglobulin and prednisone produced improvement of RP and myoclonus, but not myokymia. CONCLUSION RP may occur in patients with VGKC ab-associated Morvan's syndrome. Both RP and nervous system hyperexcitability may respond to immunotherapy including intravenous immunoglobulin and corticosteroids.
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Abstract
A number of illnesses and other factors can affect the function of the neuromuscular junction (NMJ). These may have an affect at pre- or post-junctional sites. This review outlines the anatomy and the physiology of the NMJ. It also describes the mechanisms and physiological basis of many of the disorders of the NMJ. Finally, the importance of these disorders in anaesthetic practice is discussed.
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Affiliation(s)
- N P Hirsch
- The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK.
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