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Gao Y, Zhang Y, Chunyu H, Xu Y, Wang Y, Liu S, Chang J, Tang B, Xu C, Lu Y, Zhou J, Kong X, Zhu X, Chen S, Zhou Q, Meng H. Expanding the clinical spectrum of anti-DPPX encephalitis: a multicenter retrospective study. Front Neurosci 2024; 18:1379933. [PMID: 38756408 PMCID: PMC11098017 DOI: 10.3389/fnins.2024.1379933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/15/2024] [Indexed: 05/18/2024] Open
Abstract
Objective Anti-dipeptidyl-peptidase-like protein-6 (DPPX) encephalitis is a rare autoimmune encephalitis, and clinical and experimental information regarding this disease is limited. We conducted this study to comprehensively describe the clinical characteristics, ancillary test results, neuroimaging results, and treatment response in a group of Chinese patients with anti-DPPX encephalitis for better understanding this disease. Methods We recruited 14 patients who tested positive for anti-DPPX antibodies in the serum and/or cerebrospinal fluid from 11 medical centers between March 2021 and June 2023. This retrospective study evaluated data on symptoms, autoantibody test, auxiliary examinations, treatments, and outcomes. Results The average age at diagnosis was 45.93 ± 4.62 years (range: 11-72 years), and 9 of the 14 patients were males. The main symptoms included cognitive impairment (50.0%, 7/14), central nervous system hyperexcitability (42.9%, 6/14), gastrointestinal dysfunction (35.7%, 5/14), and psychiatric disorders (35.7%, 5/14). Notably, we discovered specific findings on 18F-fluorodeoxyglucose positron-emission tomography (PET)/magnetic resonance imaging in two patients. Co-existing autoantibodies were identified in two patients. Parainfection was identified in four patients. One patient had other autoimmune diseases, and one had tumor. Eleven patients received immunotherapy and most patients improved at discharge. Surprisingly, three male patients but no female patients relapsed during the 6 months of follow-up. Conclusion The development and outcome of anti-DPPX encephalitis are variable. Male patients were predominant in our cohort. The most common symptoms were the classical triad of prodromal gastrointestinal dysfunction, cognitive and mental disorders, and central nervous system hyperexcitability. Infections, immune dysregulation, and tumors may be important etiologies. Long-term monitoring of disease development should be done in male patients. Overall, our results highlight novel clinical characteristics of anti-DPPX encephalitis.
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Affiliation(s)
- Yining Gao
- Department of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yizongheng Zhang
- Department of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hangxing Chunyu
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yongfeng Xu
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Ying Wang
- Department of Neurology, Taizhou Hospital of Zhejiang Province, Zhejiang, China
| | - Suzhi Liu
- Department of Neurology, Taizhou Hospital of Zhejiang Province, Zhejiang, China
| | - Jie Chang
- Department of Neurology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Bo Tang
- Department of Neurology, Affiliated Hangzhou First People’s Hospital School of Medicine, Westlake University, Hangzhou, Zhejiang, China
| | - Congying Xu
- Department of Neurology, The Second Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Yi Lu
- Department of Neurology, The First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui, China
| | - Jian Zhou
- Department of Pediatrics, The First People’s Hospital of Yongkang, Yongkang, China
| | - Xiangyong Kong
- Department of Neurology, Yongkang Traditional Chinese Medicine Hospital, Zhejiang, China
| | - Xiaoying Zhu
- Department of Neurology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sheng Chen
- Department of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qinming Zhou
- Department of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huanyu Meng
- Department of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Dai Y, Zheng Y, Zhu J, Ding J, Qiu K, Tang B. DPPX antibody-mediated autoimmune encephalitis:the first case with breast cancer and review of the literature. Heliyon 2024; 10:e27413. [PMID: 38449607 PMCID: PMC10915555 DOI: 10.1016/j.heliyon.2024.e27413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/21/2024] [Accepted: 02/28/2024] [Indexed: 03/08/2024] Open
Abstract
Dipeptidyl-peptidase-like protein 6 (DPPX) antibody-mediated encephalitis is a rare type of autoimmune encephalitis (AE), which mainly manifests as diarrhea accompanied by weight loss, cognitive decline, epileptic seizures, and even psychiatric symptoms. Remarkably, it is also reported to be associated with tumors, predominantly B-cell lymphoma. Overall, the AE remains uncharacterized clinically and its long-term prognosis remains elusive. Herein, we report the first case of DPPX antibody-mediated AE secondary to breast cancer. Importantly, it substantially improves after aggressive immunotherapy. Our case highlights DPPX antibody-mediated AE as a paraneoplastic syndrome and discusses the pearls in its diagnosis and management.
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Affiliation(s)
- Yijie Dai
- Zhejiang Chinese Medical University, China
| | - Yang Zheng
- The First Affiliated Hospital of Zhejiang Chinese Medical University, China
| | | | - Jiao Ding
- Third People's Hospital of Hangzhou, China
| | - Kefan Qiu
- Zhejiang Chinese Medical University, China
| | - Bo Tang
- Hangzhou First People's Hospital, China
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3
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Budhram A, Sechi E. Antibodies to neural cell surface and synaptic proteins in paraneoplastic neurologic syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:347-364. [PMID: 38494289 DOI: 10.1016/b978-0-12-823912-4.00006-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Among patients with paraneoplastic neurologic syndromes (PNS), emphasis has historically been placed on neural antibodies against intracellular proteins that have a strong association with malignancy. Because of the intracellular location of their antigenic targets, these antibodies are typically considered to be non-pathogenic surrogate markers of immune cell-mediated neural injury. Unfortunately, patients with these antibodies often have suboptimal response to immunotherapy and poor prognosis. Over the last two decades, however, dramatic advancements have been made in the discovery and clinical characterization of neural antibodies against extracellular targets. These antibodies are generally considered to be pathogenic, given their potential to directly alter antigen structure or function, and patients with these antibodies often respond favorably to prompt immunotherapy. These antibodies also associate with tumors and may thus occur as PNS, albeit more variably than neural antibodies against intracellular targets. The updated 2021 PNS diagnostic criteria, which classifies antibodies as high-risk, intermediate-risk, or lower-risk for an associated cancer, better clarifies how neural antibodies against extracellular targets relate to PNS. Using this recently created framework, the clinical presentations, ancillary test findings, oncologic associations, and treatment responses of syndromes associated with these antibodies are discussed.
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Affiliation(s)
- Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, ON, Canada; Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada.
| | - Elia Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
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Bjerknes TL, Steihaug OM, Haugen M, Hjelland IE, Vedeler CA. Case report: Pain in anti-DPPX encephalitis. Front Neurol 2022; 13:1091688. [PMID: 36588910 PMCID: PMC9794743 DOI: 10.3389/fneur.2022.1091688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022] Open
Abstract
Encephalitis due to antibodies targeting dipeptidyl-peptidase-like protein 6 (DPPX), a potassium channel subunit, is rare. The illness is typically characterized by a triad of weight loss, CNS hyperexcitability and cognitive symptoms, but recent reports suggest that the clinical picture may be more heterogeneous. Here, we describe the case of a 63-year-old female who was admitted to the hospital with severe extremity pain, which had been preceded by diarrhea and weight loss. She later developed cognitive changes, and her general condition rapidly deteriorated. Extensive workup did not reveal gastrointestinal illness or underlying malignancies. MRI of the brain was normal. Analyses of blood and cerebrospinal fluid showed normal cell counts but high titres of DPPX antibodies in blood and cerebrospinal fluid. The patient was treated with intravenous methylprednisolone followed by rituximab. At 1-year follow-up, she was without pain and had completely recovered. In this case, DPPX-associated autoimmune encephalitis was dominated by severe extremity pain, illustrating that sensory symptoms may be one of the main complaints in these patients. It is important for clinicians to be aware of the heterogeneous clinical picture in this serious condition, since correct diagnosis and treatment with immunosuppressants are associated with favorable prognosis.
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Affiliation(s)
- Tale L. Bjerknes
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway,*Correspondence: Tale L. Bjerknes
| | | | - Mette Haugen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Ina Elen Hjelland
- Department of Neurophysiology, Haukeland University Hospital, Bergen, Norway
| | - Christian Alexander Vedeler
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Zhang S, Mao C, Li X, Miao W, Teng J. Advances in Potential Cerebrospinal Fluid Biomarkers for Autoimmune Encephalitis: A Review. Front Neurol 2022; 13:746653. [PMID: 35937071 PMCID: PMC9355282 DOI: 10.3389/fneur.2022.746653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 06/20/2022] [Indexed: 12/24/2022] Open
Abstract
Autoimmune encephalitis (AE) is a severe inflammatory disease of the brain. Patients with AE demonstrate amnesia, seizures, and psychosis. Recent studies have identified numerous associated autoantibodies (e.g., against NMDA receptors (NMDARs), LGI1, etc.) involved in the pathogenesis of AE, and the levels of diagnosis and treatment are thus improved dramatically. However, there are drawbacks of clinical diagnosis and treatment based solely on antibody levels, and thus the application of additional biomarkers is urgently needed. Considering the important role of immune mechanisms in AE development, we summarize the relevant research progress in identifying cerebrospinal fluid (CSF) biomarkers with a focus on cytokines/chemokines, demyelination, and nerve damage.
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Rare antibody-mediated and seronegative autoimmune encephalitis: An update. Autoimmun Rev 2022; 21:103118. [PMID: 35595048 DOI: 10.1016/j.autrev.2022.103118] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 05/15/2022] [Indexed: 01/14/2023]
Abstract
Paralleling advances with respect to more common antibody-mediated encephalitides, such as anti-N-methyl-D-aspartate receptor (NMDAR) and anti-leucine-rich glioma-inactivated 1 (LGI1) Ab-mediated encephalitis, the discovery and characterisation of novel antibody-mediated encephalitides accelerated over the past decade, adding further depth etiologically to the spectrum of antibody-mediated encephalitis. Herein, we review the major mechanistic, clinical features and management considerations with respect to anti-γ-aminobutyric acid B (GABAB)-, anti-α-amino-3-hydroxy-5-methyl-4-isoxazolepropinoic receptor- (AMPAR), anti-GABAA-, anti-dipeptidyl-peptidase-like protein-6 (DPPX) Ab-mediated encephalitides, delineate rarer subtypes and summarise findings to date regarding seronegative autoimmune encephalitis.
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7
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Xiao J, Fu PC, Li ZJ. Clinical and imaging analysis to evaluate the response of patients with anti-DPPX encephalitis to immunotherapy. BMC Neurol 2022; 22:129. [PMID: 35382765 PMCID: PMC8981927 DOI: 10.1186/s12883-022-02649-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/20/2022] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND To report the main spectrum and new clinical and imaging characteristics of dipeptidyl-peptidase-like protein 6 (DPPX) antibody-associated encephalitis, and to evaluate the effect of immunotherapy. METHODS A retrospective analysis of nine patients with anti-DPPX encephalitis was performed, and all previously reported cases in the literature were reviewed. A cell-based indirect immunofluorescence assay using human embryonic kidney 293 cells transfected with DPPX was used. RESULTS Nine patients were identified (median age, 51 years; range, 14-65 years) with prodromal fever, diarrhea, or weight loss, followed by rapid progressive encephalopathy characterized by cognitive disorder. One patient who received methylprednisolone therapy and a trial of tacrolimus showed substantial improvement and had no relapse by the 6-month follow-up. Our comprehensive literature review demonstrated that 53 cases were reported, of which more than half had prodromal weight loss (52.8%) and gastrointestinal disorders (58.5%). Cognitive disorders (74.6%) and brainstem/spinal cord disorders (75.5%) were the most common major symptoms. A greater proportion of Chinese patients than non-Chinese patients had abnormalities on brain magnetic resonance imaging specific for encephalitis (70.0% vs. 23.3%, P < 0.001). Our study is the first to report three patients with anti-DPPX encephalitis who had sleep disorders with rapid eye movement sleep behavior disorder, limb paralysis (two), severe pleocytosis, elevated protein levels (two) in the cerebrospinal fluid, and increased T2/FLAIR signal abnormalities in the bilateral hippocampus, temporal lobe, amygdala, basal ganglia, thalamus, centrum semiovale, and frontal and parietal lobes in seven patients (77.8%). CONCLUSION Our study expands the clinical and imaging phenotypes of anti-DPPX encephalitis. Further studies elucidating the entire clinical spectrum of anti-DPPX encephalitis, its pathogenic mechanisms, and prognosis under long-term immunosuppressive therapy are warranted.
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Affiliation(s)
- Jun Xiao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 People’s Republic of China
| | - Pei-cai Fu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 People’s Republic of China
| | - Zhi-jun Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 People’s Republic of China
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8
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Dean EA, Sola CL. Psychiatric Sequelae of Anti-Dipeptidyl Peptidase-Like Protein-6 Encephalitis: A Case Report and Review of the Literature. J Acad Consult Liaison Psychiatry 2021; 62:449-455. [PMID: 34210404 DOI: 10.1016/j.jaclp.2021.01.003] [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] [Received: 01/15/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Erin A Dean
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH.
| | - Christopher L Sola
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH
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9
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Deuel LM, Yu CH, Vaughan CL, Piquet AL. Oro-Bucco-Lingual Dyskinesia, Weight Loss, and Cognitive Decline in Anti-DPPX Antibody-Mediated Encephalitis. Mov Disord Clin Pract 2020; 7:S80-S82. [PMID: 33015231 DOI: 10.1002/mdc3.13058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/06/2020] [Accepted: 05/07/2020] [Indexed: 11/06/2022] Open
Affiliation(s)
- Lisa M Deuel
- Department of Neurology University of Vermont Medical Center SA, Burlington Vermont USA
| | - Cherry H Yu
- Department of Neurology University of Vermont Medical Center SA, Burlington Vermont USA
| | - Christina L Vaughan
- Department of Neurology University of Vermont Medical Center SA, Burlington Vermont USA
| | - Amanda L Piquet
- Department of Neurology University of Vermont Medical Center SA, Burlington Vermont USA
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10
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Blinder T, Lewerenz J. Cerebrospinal Fluid Findings in Patients With Autoimmune Encephalitis-A Systematic Analysis. Front Neurol 2019; 10:804. [PMID: 31404257 PMCID: PMC6670288 DOI: 10.3389/fneur.2019.00804] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 07/11/2019] [Indexed: 01/15/2023] Open
Abstract
Autoimmune encephalitides (AIE) comprise a group of inflammatory diseases of the central nervous system (CNS), which can be further characterized by the presence of different antineuronal antibodies. Recently, a clinical approach for diagnostic criteria for the suspected diagnosis of AIE as well as definitive AIE were proposed. These are intended to guide physicians when to order the antineuronal antibody testing and/or facilitate early diagnosis even prior to the availability of the specific disease-confirming test results to facilitate prompt treatment. These diagnostic criteria also include the results of basic cerebrospinal fluid (CSF) analysis. However, the different antibody-defined AIE subtypes might be highly distinct with regard to their immune pathophysiology, e.g., the pre-dominance of specific IgG subclasses, IgG1, or IgG4, or frequency of paraneoplastic compared to idiopathic origin. Thus, it is conceivable that the results of basic CSF analysis might also be very different. However, this has not been explored systematically. Here, we systematically reviewed the literature about the 10 most important AIE subtypes, AIE with antibodies against NMDA, AMPA, glycine, GABAA, and GABAB receptors as well as DPPX, CASPR2, LGI1, IgLON5, or glutamate decarboxylase (GAD), with respect to the reported basic CSF findings comprising CSF leukocyte count, total protein, and the presence of oligoclonal bands (OCB) restricted to the CSF as a sensitive measure for intrathecal IgG synthesis. Our results indicate that these basic CSF findings are profoundly different among the 10 different AIE subtypes. Whereas, AIEs with antibodies against NMDA, GABAB, and AMPA receptors as well as DPPX show rather frequent inflammatory CSF changes, in AIEs with either CASPR2, LGI1, GABAA, or glycine receptor antibodies CSF findings were mostly normal. Two subtypes, AIEs defined by either GAD, or IgLON5 antibodies, did not fit into this general pattern. In AIE with GAD antibodies, positive OCBs in the absence of other changes were typical, while the CSF in IgLON5 antibody-positive AIE was characterized by elevated protein.
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Affiliation(s)
| | - Jan Lewerenz
- Department of Neurology, Ulm University, Ulm, Germany
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