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Saiz A, Graus F. Neuronal antibodies in nonparaneoplastic autoimmune cerebellar ataxias. Curr Opin Neurol 2024; 37:322-328. [PMID: 38483149 DOI: 10.1097/wco.0000000000001260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2024]
Abstract
PURPOSE OF REVIEW To describe relevant advances in nonparaneoplastic autoimmune cerebellar ataxias (ACA) with neuronal antibodies. RECENT FINDINGS Apart from metabotropic glutamate receptor 1(mGluR1) antibodies, in recent years, the number of neuronal antibodies against surface antigens in ACA has increased with the description of glutamate kainate receptor subunit 2 (GluK2) antibodies in young patients with cerebellitis. Around 20% of patients with contactin-associated protein-like 2 (CASPR2) encephalitis also present prominent cerebellar ataxia. However, isolate cerebellar ataxia is unusual (<4%). Outcome in patients with neuronal antibodies against surface antigens remains suboptimal despite the cerebellar ataxia probably is antibody-mediated.Concerning neuronal antibodies against intracellular antigens, up to 25% of patients with glutamic acid decarboxylase (GAD) antibodies present transient episodes of vertigo or diplopia that antedate the development of the ACA. There is in-vitro evidence that septin-5 is partially exposed to the membrane and the antibodies may interfere with septin-5 function. The clinical significance of the remaining antibodies against intracellular antigens remains unclear. SUMMARY The number of antibodies against surface antigens is increasing in ACA, but the response to the immunotherapy remains suboptimal. More studies are needed to clarify the role of most of the antibodies against intracellular antigens described in these patients.
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Affiliation(s)
- Albert Saiz
- Service of Neurology, Hospital Clinic
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Francesc Graus
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Segal Y, Zekeridou A. Interest of rare autoantibodies in autoimmune encephalitis and paraneoplastic neurological syndromes: the utility (or futility) of rare antibody discovery. Curr Opin Neurol 2024; 37:295-304. [PMID: 38533672 DOI: 10.1097/wco.0000000000001261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
PURPOSE OF REVIEW The increasing recognition and diagnosis of autoimmune encephalitis (AE) and paraneoplastic neurological syndromes (PNS) is partly due to neural autoantibody testing and discovery. The past two decades witnessed an exponential growth in the number of identified neural antibodies. This review aims to summarize recent rare antibody discoveries in the context of central nervous system (CNS) autoimmunity and evaluate the ongoing debate about their utility. RECENT FINDINGS In the last 5 years alone 15 novel neural autoantibody specificities were identified. These include rare neural antibody biomarkers of autoimmune encephalitis, cerebellar ataxia or other movement disorders, including multifocal presentations. SUMMARY Although the clinical applications of these rare antibody discoveries may be limited by the low number of positive cases, they still provide important diagnostic, prognostic, and therapeutic insights.
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Affiliation(s)
- Yahel Segal
- Department of Laboratory Medicine and Pathology
| | - Anastasia Zekeridou
- Department of Laboratory Medicine and Pathology
- Department of Neurology
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
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Nijim W, Morgan J, Montalvo M, McKeon A, McLeod C. Case Presentation of Autoimmune Septin-5 Cerebellar Ataxia. Mov Disord Clin Pract 2024; 11:734-737. [PMID: 38561872 PMCID: PMC11145106 DOI: 10.1002/mdc3.14028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 01/28/2024] [Accepted: 03/03/2024] [Indexed: 04/04/2024] Open
Affiliation(s)
| | - John Morgan
- Neurology DepartmentMedical College of GeorgiaAugustaGAUSA
| | - Mayra Montalvo
- Neurology DepartmentFixel Institute for Neurological Diseases/University of FloridaGainesvilleFLUSA
| | | | - Colin McLeod
- Neurology DepartmentMedical College of GeorgiaAugustaGAUSA
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Gilligan M, McGuigan C, McKeon A. Autoimmune central nervous system disorders: Antibody testing and its clinical utility. Clin Biochem 2024; 126:110746. [PMID: 38462203 PMCID: PMC11016295 DOI: 10.1016/j.clinbiochem.2024.110746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/16/2024] [Accepted: 03/05/2024] [Indexed: 03/12/2024]
Abstract
A rapidly expanding repertoire of neural antibody biomarkers exists for autoimmune central nervous system (CNS) disorders. Following clinical recognition of an autoimmune CNS disorder, the detection of a neural antibody facilitates diagnosis and informs prognosis and management. This review considers the phenotypes, diagnostic assay methodologies, and clinical utility of neural antibodies in autoimmune CNS disorders. Autoimmune CNS disorders may present with a diverse range of clinical features. Clinical phenotype should inform the neural antibodies selected for testing via the use of phenotype-specific panels. Both serum and cerebrospinal fluid (CSF) are preferred in the vast majority of cases but for some analytes either CSF (e.g. N-methyl-D-aspartate receptor [NMDA-R] IgG) or serum (e.g. aquaporin-4 [AQP4] IgG) specimens may be preferred. Screening using 2 methods is recommended for most analytes, particularly paraneoplastic antibodies. We utilize murine tissue-based indirect immunofluorescence assay (TIFA) with subsequent confirmatory protein-specific testing. The cellular location of the target antigen informs choice of confirmatory diagnostic assay (e.g. blot for intracellular antigens such as Hu; cell-based assay for cell surface targets such as leucine-rich glioma inactivated 1 [LGI1]). Titers of positive results have limited diagnostic utility with the exception of glutamic acid decarboxylase (GAD) 65 IgG autoimmunity, which is associated with neurological disease at higher values. While novel antibodies are typically discovered using established techniques such as TIFA and immunoprecipitation-mass spectrometry, more recent high-throughput molecular technologies (such as protein microarray and phage-display immunoprecipitation sequencing) may expedite the process of antibody discovery. Individual neural antibodies inform the clinician regarding the clinical associations, oncological risk stratification and tumor histology, the likely prognosis, and immunotherapy choice. In the era of neural antibody biomarkers for autoimmune CNS disorders, access to appropriate laboratory assays for neural antibodies is of critical importance in the diagnosis and management of these disorders.
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Affiliation(s)
- Michael Gilligan
- Departments of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Neurology, St Vincent's University Hospital, Dublin, Ireland
| | | | - Andrew McKeon
- Departments of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Neurology, Mayo Clinic, Rochester, MN, USA.
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Guo L, Ren H, Fan S, Chao X, Liu M, Guan H, Wang J. Autoantibodies against eukaryotic translation elongation factor 1 delta in two patients with autoimmune cerebellar ataxia. Front Immunol 2024; 14:1289175. [PMID: 38332912 PMCID: PMC10850295 DOI: 10.3389/fimmu.2023.1289175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 12/26/2023] [Indexed: 02/10/2024] Open
Abstract
Background Autoantibodies are useful biomarkers for the early detection and diagnosis of autoimmune cerebellar ataxia (ACA). Objective To identify novel autoantibody candidates in ACA patients. Methods Patients with cerebellar ataxia of unknown cause were recruited from July 2018 to February 2023. Anti-neural autoantibodies in patient samples were detected by tissue-based indirect immunofluorescence assay (TBA) on rat cerebellum sections. TBA-positive samples were further screened for well-established anti-neural autoantibodies using commercial kits. Tissue-immunoprecipitation (TIP) and subsequent mass spectrometric (MS) analysis were used to explore the target antigens of autoantibodies in samples that were TBA-positive but negative for known autoantibodies. The specific binding between autoantibodies and the identified target antigen was confirmed by neutralization experiments, recombinant cell-based indirect immunofluorescence assay (CBA), and western blotting experiments. Results The eukaryotic translation elongation factor 1 delta (EEF1D) protein was identified as a target antigen of autoantibodies in samples from a 43-year-old female ACA patient, while the specific binding of autoantibodies and EEF1D was confirmed by subsequent experiments. A second anti-EEF1D autoantibody-positive ACA patient, a 59-year-old female, was detected in simultaneous screening. The main clinical manifestations in each of the two patients were cerebellar syndrome, such as unsteady walking and limb ataxia. Both patients received immunotherapy, including corticosteroids, intravenous immunoglobulin, and mycophenolate mofetil. Their outcomes provided evidence to support the effectiveness of immunotherapy, but the cerebellar atrophy that occurred before treatment may be irreversible. Conclusion In the current study, we identified anti-EEF1D autoantibody as a novel autoantibody candidate in ACA. Its pathological roles and diagnostic value need to be further verified in larger-scale studies.
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Affiliation(s)
- Liyuan Guo
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xingchen Chao
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Mange Liu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Wang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
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Takekoshi A, Kimura A, Yoshikura N, Yamakawa I, Urushitani M, Nakamura K, Yoshida K, Shimohata T. Clinical Features and Neuroimaging Findings of Neuropil Antibody-Positive Idiopathic Sporadic Ataxia of Unknown Etiology. CEREBELLUM (LONDON, ENGLAND) 2023; 22:915-924. [PMID: 36057079 DOI: 10.1007/s12311-022-01468-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 06/15/2023]
Abstract
Idiopathic sporadic ataxia (ISA) is the clinical term for nonfamilial ataxia with adult-onset and a slowly progressive course. However, immune-mediated cerebellar ataxia cannot be completely excluded from ISA. The current study investigated the neuropil antibodies against cell-surface antigens and clarified the clinical features and neuroimaging findings of patients with these antibodies. Using tissue-based immunofluorescence assays (TBAs), we examined antibodies against the cerebellum in serum samples from 67 patients who met the ISA diagnostic criteria, including 30 patients with multiple system atrophy with predominant cerebellar features (MSA-C) and 20 patients with hereditary ataxia (HA), and 18 healthy control subjects. According to the TBA results, we divided subjects into three groups: subjects positive for neuropil antibodies, subjects positive for intracellular antibodies only, and subjects negative for antibodies. We compared clinical features and neuroimaging findings in ISA patients among these three groups. The prevalence of neuropil antibodies in ISA (17.9%) was significantly higher than that in MSA-C (3.3%), HA (0%), or healthy subjects (0%). The neuropil antibody-positive ISA patients showed pure cerebellar ataxia more frequently than the other ISA patients. Two neuropil antibody-positive patients showed significant improvement of cerebellar ataxia after immunotherapy. We detected neuropil antibodies in 17.9% of ISA patients. Characteristic clinical features of neuropil antibody-positive ISA patients were pure cerebellar ataxia. Some cases of neuropil antibody-positive ISA responded to immunotherapy.
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Affiliation(s)
- Akira Takekoshi
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Nobuaki Yoshikura
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Isamu Yamakawa
- Department of Neurology, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Japan
| | - Makoto Urushitani
- Department of Neurology, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Japan
| | - Katsuya Nakamura
- Department of Neurology (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Japan
| | - Kunihiro Yoshida
- Department of Brain Disease Research, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan.
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7
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McKeon A, Lesnick C, Vorasoot N, Buckley MW, Dasari S, Flanagan EP, Gilligan M, Lafrance-Corey R, Miske R, Pittock SJ, Scharf M, Yang B, Zekeridou A, Dubey D, Mills J. Utility of Protein Microarrays for Detection of Classified and Novel Antibodies in Autoimmune Neurologic Disease. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200145. [PMID: 37550073 PMCID: PMC10406426 DOI: 10.1212/nxi.0000000000200145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/01/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Neural antibodies are detected by tissue-based indirect immunofluorescence assay (IFA) in Mayo Clinic's Neuroimmunology Laboratory practice, but the process of characterizing and validating novel antibodies is lengthy. We report our assessment of human protein arrays. METHODS Assessment of arrays (81% human proteome coverage) was undertaken using diverse known positive samples (17 serum and 14 CSF). Samples from patients with novel neural antibodies were reflexed from IFA to arrays. Confirmatory assays were cell-based (CBA) or line blot. Epitope mapping was undertaken using phage display immunoprecipitation sequencing (PhiPSeq). RESULTS Control positive samples known to be reactive with linear epitopes of intracellular antigens (e.g., ANNA-1 [anti-Hu]) were readily identified by arrays in 20 of 21 samples. By contrast, 10 positive controls known to be enriched with antibodies against cell surface protein conformational epitopes (e.g., GluN1 subunit of NMDA-R) were indistinguishable from background signal. Three antibodies, previously characterized by other investigators (but unclassified in our laboratory), were unmasked in 4 patients using arrays (July-December 2022): Neurexin-3α, 1 patient; regulator of gene protein signaling (RGS)8, 1 patient; and seizure-related homolog like 2 (SEZ6L2), 2 patients. All were accompanied by previously reported phenotypes (encephalitis, 1; cerebellar ataxia, 3). Patient 1 had subacute onset of seizures and encephalopathy. Neurexin-3α ranked high in CSF (second ranked neural protein) but low in serum (660th overall). Neurexin-3α CBA was positive in both samples. Patient 2 presented with rapidly progressive cerebellar ataxia. RGS8 ranked the highest neural protein in available CSF sample by array (third overall). RGS8-specific line blot was positive. Patients 3 and 4 had rapidly progressive cerebellar ataxia. SEZ6L2 was the highest ranked neural antigen by arrays in all samples (CSF, 1, serum, 2; Patient 3, ranked 9th overall in CSF, 11th in serum; Patient 4, 6th overall in serum]). By PhIPSeq, diverse neurexin-3α epitopes (including cell surface) were detected in CSF from patient 1, but no SEZ6L2 peptides were detected for serum or CSF samples from Patient 3. DISCUSSION Individualized autoimmune neurologic diagnoses may be accelerated using protein arrays. They are optimal for detection of intracellular antigen-reactive antibodies, though certain cell surface-directed antibodies (neurexin-3α and SEZ6L2) may also be detected.
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Affiliation(s)
- Andrew McKeon
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany.
| | - Connie Lesnick
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Nisa Vorasoot
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Monica W Buckley
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Surendra Dasari
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Eoin P Flanagan
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Michael Gilligan
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Reghann Lafrance-Corey
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Ramona Miske
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Sean J Pittock
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Madeleine Scharf
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Binxia Yang
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Anastasia Zekeridou
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - Divyanshu Dubey
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
| | - John Mills
- From the Departments of Laboratory Medicine and Pathology and Neurology (A.M., E.P.F., S.J.P., B.Y., A.Z., D.D.); Department of Laboratory Medicine and Pathology (C.L., N.V., M.G., R.L.-C., J.M.); Khon Kaen University (N.V.), Thailand; University of Virginia (M.W.B.); Division of Biomedical Statistics and Informatics (S.D.), Mayo Clinic, Rochester, MN; The Institute for Experimental Immunology (R.M., M.S.), affiliated to Euroimmun AG, Lubeck, Germany
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Wischmann J, Borowski K, Havla J, Thaler FS, Winkler T, Jung T, Straube A, Masouris I. Case report: Anti septin-5-encephalitis as a treatable cause of cerebellar ataxia and psychiatric symptoms. Front Neurol 2023; 14:1220295. [PMID: 37435157 PMCID: PMC10331165 DOI: 10.3389/fneur.2023.1220295] [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: 05/10/2023] [Accepted: 06/08/2023] [Indexed: 07/13/2023] Open
Abstract
Objectives Anti-septin-5 encephalitis is a rare disease with only few published cases, mainly based on retrospective CSF and serum analyses. Predominant symptoms are cerebellar ataxia and oculomotor abnormalities. Due to the rareness of the disease, treatment recommendations are scarce. Herein, we prospectively describe the clinical course of a female patient with anti-septin-5 encephalitis. Methods We describe diagnostic workup, treatment and follow-up of a 54-year-old patient presenting with vertigo, unsteady gait, lack of drive and behavioral changes. Results Clinical examination revealed severe cerebellar ataxia, saccadic smooth pursuit, upbeat-nystagmus, and dysarthria. Additionally, the patient presented with a depressive syndrome. MRI of the brain and spinal cord were normal. CSF analysis showed lymphocytic pleocytosis (11 cells/μl). Extensive antibody testing revealed anti septin-5 IgG in both CSF and serum without coexisting anti-neuronal antibodies. PET/CT detected no signs of malignancy. Corticosteroids, plasma exchange, and rituximab led to transient clinical improvement followed by relapse. Re-applied treatment with plasma exchange followed by bortezomib resulted in moderate but sustained clinical improvement. Discussion Anti septin-5 encephalitis represents a rare but treatable and therefore relevant differential diagnosis in patients with cerebellar ataxia. Psychiatric symptoms can be observed in anti septin-5 encephalitis. Immunosuppressive treatment including bortezomib is moderately effective.
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Affiliation(s)
- Johannes Wischmann
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Kathrin Borowski
- Clinical Immunological Laboratory Prof. Dr. med. Winfried Stöcker, Luebeck, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, University Hospital, Ludwig-Maximilians-Universität Munich, Munich, Germany
- Biomedical Center, Medical Faculty, Ludwig-Maximilians-Universität Munich, Munich, Germany
| | - Franziska S. Thaler
- Institute of Clinical Neuroimmunology, University Hospital, Ludwig-Maximilians-Universität Munich, Munich, Germany
- Biomedical Center, Medical Faculty, Ludwig-Maximilians-Universität Munich, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Tobias Winkler
- Department of Neurology, kbo-Inn-Salzach-Klinikum, Wasserburg am Inn, Germany
| | - Tobias Jung
- Department of Neurology, kbo-Inn-Salzach-Klinikum, Wasserburg am Inn, Germany
| | - Andreas Straube
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Ilias Masouris
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
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9
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Miske R, Scharf M, Borowski K, Rieckhoff N, Teegen B, Denno Y, Probst C, Guthke K, Didrihsone I, Wildemann B, Ruprecht K, Komorowski L, Jarius S. Septin-3 autoimmunity in patients with paraneoplastic cerebellar ataxia. J Neuroinflammation 2023; 20:88. [PMID: 36997937 PMCID: PMC10061979 DOI: 10.1186/s12974-023-02718-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/03/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Septins are cytoskeletal proteins with filament forming capabilities, which have multiple roles during cell division, cellular polarization, morphogenesis, and membrane trafficking. Autoantibodies against septin-5 are associated with non-paraneoplastic cerebellar ataxia, and autoantibodies against septin-7 with encephalopathy with prominent neuropsychiatric features. Here, we report on newly identified autoantibodies against septin-3 in patients with paraneoplastic cerebellar ataxia. We also propose a strategy for anti-septin autoantibody determination. METHODS Sera from three patients producing similar immunofluorescence staining patterns on cerebellar and hippocampal sections were subjected to immunoprecipitation followed by mass spectrometry. The identified candidate antigens, all of which were septins, were expressed recombinantly in HEK293 cells either individually, as complexes, or combinations missing individual septins, for use in recombinant cell-based indirect immunofluorescence assays (RC-IIFA). Specificity for septin-3 was further confirmed by tissue IIFA neutralization experiments. Finally, tumor tissue sections were analyzed immunohistochemically for septin-3 expression. RESULTS Immunoprecipitation with rat cerebellum lysate revealed septin-3, -5, -6, -7, and -11 as candidate target antigens. Sera of all three patients reacted with recombinant cells co-expressing septin-3/5/6/7/11, while none of 149 healthy control sera was similarly reactive. In RC-IIFAs the patient sera recognized only cells expressing septin-3, individually and in complexes. Incubation of patient sera with five different septin combinations, each missing one of the five septins, confirmed the autoantibodies' specificity for septin-3. The tissue IIFA reactivity of patient serum was abolished by pre-incubation with HEK293 cell lysates overexpressing the septin-3/5/6/7/11 complex or septin-3 alone, but not with HEK293 cell lysates overexpressing septin-5 as control. All three patients had cancers (2 × melanoma, 1 × small cell lung cancer), presented with progressive cerebellar syndromes, and responded poorly to immunotherapy. Expression of septin-3 was demonstrated in resected tumor tissue available from one patient. CONCLUSIONS Septin-3 is a novel autoantibody target in patients with paraneoplastic cerebellar syndromes. Based on our findings, RC-IIFA with HEK293 cells expressing the septin-3/5/6/7/11 complex may serve as a screening tool to investigate anti-septin autoantibodies in serological samples with a characteristic staining pattern on neuronal tissue sections. Autoantibodies against individual septins can then be confirmed by RC-IIFA expressing single septins.
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Affiliation(s)
- Ramona Miske
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Madeleine Scharf
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany.
| | - Kathrin Borowski
- Clinical Immunological Laboratory Prof. Dr. med. Winfried Stöcker, Lübeck, Germany
| | - Nicole Rieckhoff
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Bianca Teegen
- Clinical Immunological Laboratory Prof. Dr. med. Winfried Stöcker, Lübeck, Germany
| | - Yvonne Denno
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Christian Probst
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Kersten Guthke
- Department of Neurology, Städtisches Klinikum Görlitz, Görlitz, Germany
| | - Ieva Didrihsone
- Department of Neurology, Hermann-Josef-Krankenhaus, Erkelenz, Germany
| | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lars Komorowski
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany.
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10
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Mastrianni JA, Seibert K. Challenging Cases of Neurocognitive Disorders. Semin Neurol 2022; 42:742-751. [PMID: 36623535 DOI: 10.1055/s-0042-1760378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Dementia is broadly defined by DSM-V as cognitive decline from a previous level that impacts the patient's functioning at work or play. This broad definition does not provide information about the underlying disease process, an aspect of clinical care that is of increasing importance, as therapeutic development inches closer to effective disease-modifying treatments. The most common neurodegenerative dementias include Alzheimer's disease, dementia with Lewy bodies, frontotemporal dementia, and Parkinson's disease dementia. Although rare, the prion diseases constitute an important group of dementias that should be routinely considered in the evaluation. Over the last two decades, advances in neuroimaging, biomarker development, and neurogenetics have not only led to a better understanding of the biology of these diseases, but they have improved our awareness of less common clinical subtypes of dementia. As such, to best define the disease process, the evaluation of a patient with cognitive decline requires attention to a myriad of disease aspects, such as the primary symptom at onset (memory, language, visual perception, praxis, etc.), the age at onset (younger or older than 65 years), the rate of disease progression (weeks to months or years), the cognitive and behavioral profile (neuropsychological assessment), and involvement of physical findings. We present here three cases that highlight the decision-making process in the evaluation of patients with atypical presentations of dementia.
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Affiliation(s)
- James A Mastrianni
- Department of Neurology, Center for Comprehensive Care and Research on Memory Disorders, University of Chicago, Chicago, Illinois
| | - Kaitlin Seibert
- Department of Neurology, Center for Comprehensive Care and Research on Memory Disorders, University of Chicago, Chicago, Illinois
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11
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Rare Etiologies in Immune-Mediated Cerebellar Ataxias: Diagnostic Challenges. Brain Sci 2022; 12:brainsci12091165. [PMID: 36138901 PMCID: PMC9496914 DOI: 10.3390/brainsci12091165] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/06/2022] [Accepted: 08/26/2022] [Indexed: 12/03/2022] Open
Abstract
The cerebellum is particularly enriched in antigens and represents a vulnerable target to immune attacks. Immune-mediated cerebellar ataxias (IMCAs) have diverse etiologies, such as gluten ataxia (GA), post-infectious cerebellitis (PIC), Miller Fisher syndrome (MFS), paraneoplastic cerebellar degeneration (PCD), opsoclonus myoclonus syndrome (OMS), and anti-GAD ataxia. Apart from these well-established entities, cerebellar ataxia (CA) occurs also in association with autoimmunity against ion channels and related proteins, synaptic adhesion/organizing proteins, transmitter receptors, glial cells, as well as the brainstem antigens. Most of these conditions manifest diverse neurological clinical features, with CAs being one of the main clinical phenotypes. The term primary autoimmune cerebellar ataxia (PACA) refers to ataxic conditions suspected to be autoimmune even in the absence of specific well-characterized pathogenic antibody markers. We review advances in the field of IMCAs and propose a clinical approach for the understanding and diagnosis of IMCAs, focusing on rare etiologies which are likely underdiagnosed. The frontiers of PACA are discussed. The identification of rare immune ataxias is of importance since they are potentially treatable and may lead to a severe clinical syndrome in absence of early therapy.
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12
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Muñiz-Castrillo S, Vogrig A, Ciano-Petersen NL, Villagrán-García M, Joubert B, Honnorat J. Novelties in Autoimmune and Paraneoplastic Cerebellar Ataxias: Twenty Years of Progresses. CEREBELLUM (LONDON, ENGLAND) 2022; 21:573-591. [PMID: 35020135 DOI: 10.1007/s12311-021-01363-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/23/2021] [Indexed: 06/14/2023]
Abstract
Major advances in our knowledge concerning autoimmune and paraneoplastic cerebellar ataxias have occurred in the last 20 years. The discovery of several neural antibodies represents an undeniable contribution to this field, especially those serving as good biomarkers of paraneoplastic neurological syndromes and those showing direct pathogenic effects. Yet, many patients still lack detectable or known antibodies, and also many antibodies have only been reported in few patients, which makes it difficult to define in detail their clinical value. Nevertheless, a notable progress has additionally been made in the clinical characterization of patients with the main neural antibodies, which, although typically present with a subacute pancerebellar syndrome, may also show either hyperacute or chronic onsets that complicate the differential diagnoses. However, prodromal and transient features could be useful clues for an early recognition, and extracerebellar involvement may also be highly indicative of the associated antibody. Moreover, important advances in our understanding of the pathogenesis of cerebellar ataxias include the description of antibody effects, especially those targeting cell-surface antigens, and first attempts to isolate antigen-specific T-cells. Furthermore, genetic predisposition seems relevant, although differently involved according to cancer association, with particular HLA observed in non-paraneoplastic cases and genetic abnormalities in the tumor cells in paraneoplastic ones. Finally, immune checkpoint inhibitors used as cancer immunotherapy may rarely induce cerebellar ataxias, but even this undesirable effect may in turn serve to shed some light on their physiopathology. Herein, we review the principal novelties of the last 20 years regarding autoimmune and paraneoplastic cerebellar ataxias.
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Affiliation(s)
- Sergio Muñiz-Castrillo
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France
- SynatAc Team, Institut NeuroMyoGène, INSERM U1217, CNRS, UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Alberto Vogrig
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France
- SynatAc Team, Institut NeuroMyoGène, INSERM U1217, CNRS, UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Nicolás Lundahl Ciano-Petersen
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France
- SynatAc Team, Institut NeuroMyoGène, INSERM U1217, CNRS, UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Macarena Villagrán-García
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France
- SynatAc Team, Institut NeuroMyoGène, INSERM U1217, CNRS, UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Bastien Joubert
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France
- SynatAc Team, Institut NeuroMyoGène, INSERM U1217, CNRS, UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Jérôme Honnorat
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France.
- SynatAc Team, Institut NeuroMyoGène, INSERM U1217, CNRS, UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France.
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13
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Damato V, Papi C, Spagni G, Evoli A, Silvestri G, Masi G, Sabatelli E, Campetella L, McKeon A, Andreetta F, Riso V, Monte G, Luigetti M, Primiano G, Calabresi P, Iorio R. Clinical features and outcome of patients with autoimmune cerebellar ataxia evaluated with the Scale for the Assessment and Rating of Ataxia. Eur J Neurol 2022; 29:564-572. [PMID: 34710286 PMCID: PMC9564532 DOI: 10.1111/ene.15161] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/08/2021] [Accepted: 10/21/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE This study was undertaken to assess the long-term outcome of patients with paraneoplastic and non paraneoplastic autoimmune cerebellar ataxia (ACA) using the Scale for the Assessment and Rating of Ataxia (SARA). METHODS Patients with subacute cerebellar ataxia admitted to our institution between September 2012 and April 2020 were prospectively recruited. Serum and/or cerebrospinal fluid was tested for neural autoantibodies by indirect immunofluorescence on mouse brain, cell-based assays, and radioimmunoassay. SARA and modified Rankin Scale (mRS) score were employed to assess patients' outcome. RESULTS Fifty-five patients were recruited, of whom 23 (42%) met the criteria for cerebellar ataxia of autoimmune etiology. Neural autoantibodies were detected in 22 of 23 patients (Yo-immunoglobulin G [IgG], n = 6; glutamic acid decarboxylase 65-IgG, n = 3; metabotropic glutamate receptor 1-IgG, n = 2; voltage-gated calcium channel P/Q type-IgG, n = 2; Hu-IgG, n = 1; glial fibrillary acidic protein-IgG, n = 1; IgG-binding unclassified antigens, n = 7). Thirteen patients were diagnosed with paraneoplastic cerebellar syndrome (PCS) and 10 with idiopathic ACA. All patients received immunotherapy. Median SARA score was higher in the PCS group at all time points (p = 0.0002), while it decreased significantly within the ACA group (p = 0.049) after immunotherapy. Patients with good outcome (mRS ≤ 2) had less neurological disability (SARA < 15) at disease nadir (p = 0.039) and presented less frequently with paraneoplastic neurological syndrome (p = 0.0028). The univariate linear regression model revealed a good correlation between mRS and SARA score both at disease onset (p < 0.0001) and at last follow-up (p < 0.0001). SARA score < 11 identified patients with good outcome. CONCLUSIONS Patients with idiopathic ACA significantly improved after immunotherapy. SARA score accurately reflects patients' clinical status and may be a suitable outcome measure for patients with ACA.
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Affiliation(s)
- Valentina Damato
- UOC Neurologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS. Rome, Italy,Dipartimento di Neuroscienze. Università Cattolica del Sacro Cuore. Rome, Italy
| | - Claudia Papi
- Dipartimento di Neuroscienze. Università Cattolica del Sacro Cuore. Rome, Italy
| | - Gregorio Spagni
- Dipartimento di Neuroscienze. Università Cattolica del Sacro Cuore. Rome, Italy
| | - Amelia Evoli
- UOC Neurologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS. Rome, Italy,Dipartimento di Neuroscienze. Università Cattolica del Sacro Cuore. Rome, Italy
| | - Gabriella Silvestri
- UOC Neurologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS. Rome, Italy,Dipartimento di Neuroscienze. Università Cattolica del Sacro Cuore. Rome, Italy
| | - Gianvito Masi
- Dipartimento di Neuroscienze. Università Cattolica del Sacro Cuore. Rome, Italy
| | - Eleonora Sabatelli
- Dipartimento di Neuroscienze. Università Cattolica del Sacro Cuore. Rome, Italy
| | - Lucia Campetella
- Dipartimento di Neuroscienze. Università Cattolica del Sacro Cuore. Rome, Italy
| | - Andrew McKeon
- Departments of Neurology and Laboratory Medicine and Pathology Mayo Clinic, Rochester, Minnesota, USA
| | - Francesca Andreetta
- Neurology Unit IV, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Vittorio Riso
- Dipartimento di Neuroscienze. Università Cattolica del Sacro Cuore. Rome, Italy
| | - Gabriele Monte
- Dipartimento di Neuroscienze. Università Cattolica del Sacro Cuore. Rome, Italy
| | - Marco Luigetti
- UOC Neurologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS. Rome, Italy,Dipartimento di Neuroscienze. Università Cattolica del Sacro Cuore. Rome, Italy
| | - Guido Primiano
- UOC Neurologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS. Rome, Italy,Dipartimento di Neuroscienze. Università Cattolica del Sacro Cuore. Rome, Italy
| | - Paolo Calabresi
- UOC Neurologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS. Rome, Italy,Dipartimento di Neuroscienze. Università Cattolica del Sacro Cuore. Rome, Italy
| | - Raffaele Iorio
- UOC Neurologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS. Rome, Italy,Dipartimento di Neuroscienze. Università Cattolica del Sacro Cuore. Rome, Italy
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14
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Abstract
The realization that autoantibodies can contribute to dysfunction of the brain has brought about a paradigm shift in neurological diseases over the past decade, offering up important novel diagnostic and therapeutic opportunities. Detection of specific autoantibodies to neuronal or glial targets has resulted in a better understanding of central nervous system autoimmunity and in the reclassification of some diseases previously thought to result from infectious, 'idiopathic' or psychogenic causes. The most prominent examples, such as aquaporin 4 autoantibodies in neuromyelitis optica or NMDAR autoantibodies in encephalitis, have stimulated an entire field of clinical and experimental studies on disease mechanisms and immunological abnormalities. Also, these findings inspired the search for additional autoantibodies, which has been very successful to date and has not yet reached its peak. This Review summarizes this rapid development at a point in time where preclinical studies have started delivering fundamental new data for mechanistic understanding, where new technologies are being introduced into this field, and - most importantly - where the first specifically tailored immunotherapeutic approaches are emerging.
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Affiliation(s)
- Harald Prüss
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany.
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
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15
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Update on Paraneoplastic Cerebellar Degeneration. Brain Sci 2021; 11:brainsci11111414. [PMID: 34827413 PMCID: PMC8615604 DOI: 10.3390/brainsci11111414] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 12/16/2022] Open
Abstract
Purpose of review: To provide an update on paraneoplastic cerebellar degeneration (PCD), the involved antibodies and tumors, as well as management strategies. Recent findings: PCD represents the second most common presentation of the recently established class of immune mediated cerebellar ataxias (IMCAs). Although rare in general, PCD is one of the most frequent paraneoplastic presentations and characterized clinically by a rapidly progressive cerebellar syndrome. In recent years, several antibodies have been described in association with the clinical syndrome related to PCD; their clinical significance, however, has yet to be determined. The 2021 updated diagnostic criteria for paraneoplastic neurologic symptoms help to establish the diagnosis of PCD, direct cancer screening, and to evaluate the presence of these newly identified antibodies. Recognition of the clinical syndrome and prompt identification of a specific antibody are essential for early detection of an underlying malignancy and initiation of an appropriate treatment, which represents the best opportunity to modulate the course of the disease. As clinical symptoms can precede tumor diagnosis by years, co-occurrence of specific symptoms and antibodies should prompt continuous surveillance of the patient. Summary: We provide an in-depth overview on PCD, summarize recent findings related to PCD, and highlight the transformed diagnostic approach.
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16
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Garza M, Piquet AL. Update in Autoimmune Movement Disorders: Newly Described Antigen Targets in Autoimmune and Paraneoplastic Cerebellar Ataxia. Front Neurol 2021; 12:683048. [PMID: 34489848 PMCID: PMC8416494 DOI: 10.3389/fneur.2021.683048] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/28/2021] [Indexed: 12/29/2022] Open
Abstract
Movement disorders are a common feature of many antibody-associated neurological disorders. In fact, cerebellar ataxia is one of the most common manifestations of autoimmune neurological diseases. Some of the first autoantibodies identified against antigen targets include anti-neuronal nuclear antibody type 1 (ANNA-1 or anti-Hu) and Purkinje cell cytoplasmic antibody (PCA-1) also known as anti-Yo have been identified in paraneoplastic cerebellar degeneration. Historically these antibodies have been associated with an underlying malignancy; however, recently discovered antibodies can occur in the absence of cancer as well, resulting in the clinical syndrome of autoimmune cerebellar ataxia. The pace of discovery of new antibodies associated with autoimmune or paraneoplastic cerebellar ataxia has increased rapidly over the last few years, and pathogenesis and potential treatment options remains to be explored. Here we will review the literature on recently discovered antibodies associated with autoimmune and paraneoplastic cerebellar ataxia including adaptor protein-3B2 (AP3B2); inositol 1,4,5-trisphophate receptor type 1 (ITPR1); tripartite motif-containing (TRIM) proteins 9, 67, and 46; neurochondrin; neuronal intermediate filament light chain (NIF); septin 5; metabotropic glutamate receptor 2 (mGluR2); seizure-related 6 homolog like 2 (SEZ6L2) and homer-3 antibodies. We will review their clinical characteristics, imaging and CSF findings and treatment response. In addition, we will discuss two clinical case examples of autoimmune cerebellar ataxia.
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Affiliation(s)
- Madeline Garza
- Department of Neurology, University of Colorado, Aurora, CO, United States
| | - Amanda L Piquet
- Department of Neurology, University of Colorado, Aurora, CO, United States
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17
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Herrero San Martin A, Amarante Cuadrado C, Gonzalez Arbizu M, Rábano-Suárez P, Ostos-Moliz F, Naranjo L, Sabater L, Martinez Hernandez E, Ruiz Garcia R, Toledo Alfocea D. Autoimmune Septin-5 Disease Presenting as Spinocerebellar Ataxia and Nystagmus. Neurology 2021; 97:291-292. [PMID: 34031206 DOI: 10.1212/wnl.0000000000012240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Alejandro Herrero San Martin
- From the Department of Neurology (A.H.S.M., C.A.C., M.G.A., P.R.-S., F.O.M., D.T.A.) and Multidisciplinary Sleep Unit (A.H.S.M.), Hospital Universitario, "12 de Octubre"; Group of Neurodegenerative Diseases (A.H.S.M.), Instituto de Investigación, Hospital 12 de Octubre (I+12); Biomedical Research Networking Center in Neurodegenerative Diseases (CIBERNED) (A.H.S.M.), Madrid; Immunology Department (L.N., R.R.G.), Biomedical Diagnostic Centre, Hospital Clinic de Barcelona; Neuroimmunology Program (L.S., E.M.H., R.R.G.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona; and Neurology Service (E.M.H.), Hospital Clinic, University of Barcelona, Spain.
| | - Carla Amarante Cuadrado
- From the Department of Neurology (A.H.S.M., C.A.C., M.G.A., P.R.-S., F.O.M., D.T.A.) and Multidisciplinary Sleep Unit (A.H.S.M.), Hospital Universitario, "12 de Octubre"; Group of Neurodegenerative Diseases (A.H.S.M.), Instituto de Investigación, Hospital 12 de Octubre (I+12); Biomedical Research Networking Center in Neurodegenerative Diseases (CIBERNED) (A.H.S.M.), Madrid; Immunology Department (L.N., R.R.G.), Biomedical Diagnostic Centre, Hospital Clinic de Barcelona; Neuroimmunology Program (L.S., E.M.H., R.R.G.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona; and Neurology Service (E.M.H.), Hospital Clinic, University of Barcelona, Spain
| | - Maialen Gonzalez Arbizu
- From the Department of Neurology (A.H.S.M., C.A.C., M.G.A., P.R.-S., F.O.M., D.T.A.) and Multidisciplinary Sleep Unit (A.H.S.M.), Hospital Universitario, "12 de Octubre"; Group of Neurodegenerative Diseases (A.H.S.M.), Instituto de Investigación, Hospital 12 de Octubre (I+12); Biomedical Research Networking Center in Neurodegenerative Diseases (CIBERNED) (A.H.S.M.), Madrid; Immunology Department (L.N., R.R.G.), Biomedical Diagnostic Centre, Hospital Clinic de Barcelona; Neuroimmunology Program (L.S., E.M.H., R.R.G.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona; and Neurology Service (E.M.H.), Hospital Clinic, University of Barcelona, Spain
| | - Pablo Rábano-Suárez
- From the Department of Neurology (A.H.S.M., C.A.C., M.G.A., P.R.-S., F.O.M., D.T.A.) and Multidisciplinary Sleep Unit (A.H.S.M.), Hospital Universitario, "12 de Octubre"; Group of Neurodegenerative Diseases (A.H.S.M.), Instituto de Investigación, Hospital 12 de Octubre (I+12); Biomedical Research Networking Center in Neurodegenerative Diseases (CIBERNED) (A.H.S.M.), Madrid; Immunology Department (L.N., R.R.G.), Biomedical Diagnostic Centre, Hospital Clinic de Barcelona; Neuroimmunology Program (L.S., E.M.H., R.R.G.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona; and Neurology Service (E.M.H.), Hospital Clinic, University of Barcelona, Spain
| | - Fernando Ostos-Moliz
- From the Department of Neurology (A.H.S.M., C.A.C., M.G.A., P.R.-S., F.O.M., D.T.A.) and Multidisciplinary Sleep Unit (A.H.S.M.), Hospital Universitario, "12 de Octubre"; Group of Neurodegenerative Diseases (A.H.S.M.), Instituto de Investigación, Hospital 12 de Octubre (I+12); Biomedical Research Networking Center in Neurodegenerative Diseases (CIBERNED) (A.H.S.M.), Madrid; Immunology Department (L.N., R.R.G.), Biomedical Diagnostic Centre, Hospital Clinic de Barcelona; Neuroimmunology Program (L.S., E.M.H., R.R.G.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona; and Neurology Service (E.M.H.), Hospital Clinic, University of Barcelona, Spain
| | - Laura Naranjo
- From the Department of Neurology (A.H.S.M., C.A.C., M.G.A., P.R.-S., F.O.M., D.T.A.) and Multidisciplinary Sleep Unit (A.H.S.M.), Hospital Universitario, "12 de Octubre"; Group of Neurodegenerative Diseases (A.H.S.M.), Instituto de Investigación, Hospital 12 de Octubre (I+12); Biomedical Research Networking Center in Neurodegenerative Diseases (CIBERNED) (A.H.S.M.), Madrid; Immunology Department (L.N., R.R.G.), Biomedical Diagnostic Centre, Hospital Clinic de Barcelona; Neuroimmunology Program (L.S., E.M.H., R.R.G.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona; and Neurology Service (E.M.H.), Hospital Clinic, University of Barcelona, Spain
| | - Lidia Sabater
- From the Department of Neurology (A.H.S.M., C.A.C., M.G.A., P.R.-S., F.O.M., D.T.A.) and Multidisciplinary Sleep Unit (A.H.S.M.), Hospital Universitario, "12 de Octubre"; Group of Neurodegenerative Diseases (A.H.S.M.), Instituto de Investigación, Hospital 12 de Octubre (I+12); Biomedical Research Networking Center in Neurodegenerative Diseases (CIBERNED) (A.H.S.M.), Madrid; Immunology Department (L.N., R.R.G.), Biomedical Diagnostic Centre, Hospital Clinic de Barcelona; Neuroimmunology Program (L.S., E.M.H., R.R.G.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona; and Neurology Service (E.M.H.), Hospital Clinic, University of Barcelona, Spain
| | - Eugenia Martinez Hernandez
- From the Department of Neurology (A.H.S.M., C.A.C., M.G.A., P.R.-S., F.O.M., D.T.A.) and Multidisciplinary Sleep Unit (A.H.S.M.), Hospital Universitario, "12 de Octubre"; Group of Neurodegenerative Diseases (A.H.S.M.), Instituto de Investigación, Hospital 12 de Octubre (I+12); Biomedical Research Networking Center in Neurodegenerative Diseases (CIBERNED) (A.H.S.M.), Madrid; Immunology Department (L.N., R.R.G.), Biomedical Diagnostic Centre, Hospital Clinic de Barcelona; Neuroimmunology Program (L.S., E.M.H., R.R.G.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona; and Neurology Service (E.M.H.), Hospital Clinic, University of Barcelona, Spain
| | - Raquel Ruiz Garcia
- From the Department of Neurology (A.H.S.M., C.A.C., M.G.A., P.R.-S., F.O.M., D.T.A.) and Multidisciplinary Sleep Unit (A.H.S.M.), Hospital Universitario, "12 de Octubre"; Group of Neurodegenerative Diseases (A.H.S.M.), Instituto de Investigación, Hospital 12 de Octubre (I+12); Biomedical Research Networking Center in Neurodegenerative Diseases (CIBERNED) (A.H.S.M.), Madrid; Immunology Department (L.N., R.R.G.), Biomedical Diagnostic Centre, Hospital Clinic de Barcelona; Neuroimmunology Program (L.S., E.M.H., R.R.G.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona; and Neurology Service (E.M.H.), Hospital Clinic, University of Barcelona, Spain
| | - Daniel Toledo Alfocea
- From the Department of Neurology (A.H.S.M., C.A.C., M.G.A., P.R.-S., F.O.M., D.T.A.) and Multidisciplinary Sleep Unit (A.H.S.M.), Hospital Universitario, "12 de Octubre"; Group of Neurodegenerative Diseases (A.H.S.M.), Instituto de Investigación, Hospital 12 de Octubre (I+12); Biomedical Research Networking Center in Neurodegenerative Diseases (CIBERNED) (A.H.S.M.), Madrid; Immunology Department (L.N., R.R.G.), Biomedical Diagnostic Centre, Hospital Clinic de Barcelona; Neuroimmunology Program (L.S., E.M.H., R.R.G.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona; and Neurology Service (E.M.H.), Hospital Clinic, University of Barcelona, Spain
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18
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Abstract
PURPOSE OF REVIEW The rapid developments in neuroimmunology reflect also on the field of movement disorders, where there is an ever expanding spectrum of new antibodies. This review focuses on the new neuronal antibodies, their clinical spectrum and recent pathophysiological insights. It gives an update on previous work about neuronal antibody-related movement disorders. RECENT FINDINGS Phosphodiesterase 10A antibodies are a new marker of paraneoplastic chorea. Seizure-related 6 homolog like 2 antibodies are a differential diagnosis in atypical parkinsonism with cerebellar ataxia and cognitive impairment. mGluR5-antibodies cause various hyperkinetic movement disorders with Ophelia syndrome. Most new antibodies were described in the context of cerebellar ataxia: Kelch-like protein 11 antibodies are a comparatively frequent marker of paraneoplastic cerebellar ataxia with germ cell tumours. Nonparaneoplastic cerebellar ataxia occurs with Septin-5 and neurochondrin antibodies. Studies into the mechanisms of neuronal surface antibodies have shown that there is much pathophysiological heterogeneity, ranging from immediate antagonistic effect to induction of neurodegeneration after weeks. SUMMARY The new markers of autoimmune movement disorders are key to identify those patients that may benefit from immunotherapy, and tumour therapy, where appropriate. Insights into the underlying pathophysiology might guide treatment decisions and help tailoring more targeted approaches in the future.
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19
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Balint B, Bhatia KP, Dalmau J. "Antibody of Unknown Significance" (AUS): The Issue of Interpreting Antibody Test Results. Mov Disord 2021; 36:1543-1547. [PMID: 33955060 DOI: 10.1002/mds.28597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/30/2021] [Accepted: 03/05/2021] [Indexed: 11/11/2022] Open
Affiliation(s)
- Bettina Balint
- Department of Neurology, University Hospital, Heidelberg, Germany.,Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
| | - Kailash P Bhatia
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
| | - Josep Dalmau
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.,Service of Neurology, Hospital Clinic de Barcelona, Barcelona, Spain.,Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Centro de Investigación Biomédica en Red de Enfermedades Raras, Barcelona, Spain.,Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
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20
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Dubey D, Kryzer T, Guo Y, Clarkson B, Cheville JC, Costello BA, Leibovich BC, Algeciras-Schimnich A, Lucchinnetti C, Hammami MB, Knight AM, Howe C, Lennon VA, McKeon A, Pittock SJ. Leucine Zipper 4 Autoantibody: A Novel Germ Cell Tumor and Paraneoplastic Biomarker. Ann Neurol 2021; 89:1001-1010. [PMID: 33583072 DOI: 10.1002/ana.26050] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study was undertaken to describe a novel biomarker of germ cell tumor and associated paraneoplastic neurological syndrome (PNS). METHODS Archival sera from patients with germ cell tumor-associated PNS were evaluated. We identified a common autoantigen in a human testicular cancer cell line (TCam-2) by Western blot and mass spectrometry. Its identity was confirmed by recombinant-protein Western blot, enzyme-linked immunosorbent assay (ELISA), and cell-based assay. Autoantibody specificity was confirmed by analyzing assorted control sera/cerebrospinal fluid. RESULTS Leucine zipper 4 (LUZP4)-immunoglobulin G (IgG) was detected in 28 patients' sera, 26 of whom (93%) were men. The median age at neurological symptom onset was 45 years (range = 28-84). Median titer (ELISA) was 1:300 (1:50 to >1:6,400, normal value < 1:50). Coexistent kelchlike protein 11-IgG was identified in 18 cases (64%). The most common presenting phenotype was rhombencephalitis (17/28, 61%). Other presentations included limbic encephalitis (n = 5, 18%), seizures and/or encephalitis (n = 2, 7%), and motor neuronopathy/polyradiculopathy (n = 4, 14%). The most common malignancy among cancer-evaluated PNS patients was seminoma (21/27, 78%). Nine of the 21 seminomas detected by whole-body fluorodeoxyglucose positron emission tomography scan (43%) were extratesticular. Both female patients had ovarian teratoma. Regressed testicular germ cell tumors were found in 4 patients. Exposure of T-cell-dendritic-cell cocultures from chronic immunosuppression-naïve LUZP4-IgG-seropositive patients to recombinant LUZP4 protein evoked a marked increase in CD69 expression on both CD4+ and CD8+ T cells when compared to vehicle-exposed and healthy control cultures. INTERPRETATION LUZP4-IgG represents a novel serological biomarker of PNS and has high predictive value for germ cell tumors. The demonstrated antigen-specific T-cell responses support a CD8+ T-cell-mediated cytotoxic paraneoplastic and antitumor potential. ANN NEUROL 2021;89:1001-1010.
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Affiliation(s)
- Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, NY.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, NY.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, NY
| | - Thomas Kryzer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, NY.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, NY
| | - Yong Guo
- Department of Neurology, Mayo Clinic, Rochester, NY.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, NY
| | - Benjamin Clarkson
- Department of Neurology, Mayo Clinic, Rochester, NY.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, NY
| | - John C Cheville
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, NY
| | | | | | | | - Claudia Lucchinnetti
- Department of Neurology, Mayo Clinic, Rochester, NY.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, NY
| | - M Bakri Hammami
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, NY
| | - Andrew M Knight
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, NY
| | - Charles Howe
- Department of Neurology, Mayo Clinic, Rochester, NY.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, NY
| | - Vanda A Lennon
- Department of Neurology, Mayo Clinic, Rochester, NY.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, NY.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, NY.,Department of Immunology, Mayo Clinic, Rochester, NY
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, NY.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, NY.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, NY
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, NY.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, NY.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, NY
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21
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Paraneoplastic Progressive Downbeat Nystagmus, Ataxia and Sensorineural Hearing Loss due to the ANTI-Kelch-11 Protein Antibody. J Neuroophthalmol 2021; 41:261-265. [PMID: 33630775 DOI: 10.1097/wno.0000000000001194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
ABSTRACT A 45-year-old man with a history of testicular seminoma treated 8 years earlier presented with chronic progressive truncal and limb ataxia, progressive sensorineural hearing loss, and episodic vertigo. Eye movement and neuro-otology examinations showed localizing abnormalities to the bilateral cerebellar flocculus, vermis, and bilateral cerebellar hemispheres. Audiometric testing showed bilateral symmetric sensorineural hearing loss. There was a normal MRI of the brain. Cerebrospinal fluid (CSF) showed modest lymphocytic pleocytosis, and there was an elevated serum choriogonadotrophic hormone. An abdominal CT scan showed a solitary, large retroperitoneal lymph node, and histopathologic examination of the node biopsy showed granulomatous inflammation without microorganisms; eventually, immunohistochemical markers confirmed the diagnosis of metastatic seminoma. Although normal neuroimaging and inflammatory CSF reaction suggested a paraneoplastic etiology, the initial paraneoplastic antibody testing was negative. Subsequent investigation identified a positive kelch-11 protein antibody, thus confirming the paraneoplastic connection between the metastatic seminoma and the subacute neurologic-cochleovestibular syndrome.
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22
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McKeon A, Shelly S, Zivelonghi C, Basal E, Dubey D, Flanagan E, Madhavan AA, Mariotto S, Toledano M, Tracy JA, Zekeridou A, Pittock SJ. Neuronal intermediate filament IgGs in CSF: Autoimmune Axonopathy Biomarkers. Ann Clin Transl Neurol 2020; 8:425-439. [PMID: 33369283 PMCID: PMC7886032 DOI: 10.1002/acn3.51284] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/26/2020] [Accepted: 12/06/2020] [Indexed: 12/03/2022] Open
Abstract
Objectives To describe CSF‐defined neuronal intermediate filament (NIF) autoimmunity. Methods NIF‐IgG CSF‐positive patients (41, 0.03% of 118599 tested, 1996–2019) were included (serum was neither sensitive nor specific). Criteria‐based patient NIF‐IgG staining of brain and myenteric NIFs was detected by indirect immunofluorescence assay (IFA); NIF‐specificity was confirmed by cell‐based assays (CBAs, alpha internexin, neurofilament light [NF‐L]), heavy‐[NF‐H] chain). Results Sixty‐one percent of 41 patients were men, median age, 61 years (range, 21–88). Syndromes were encephalopathy predominant (23), cerebellar ataxia predominant (11), or myeloradiculoneuropathies (7). MRI abnormalities (T2 hyperintensities of brain, spinal cord white matter tracts. and peripheral nerve axons) and neurophysiologic testing (EEG, EMG, evoked potentials) co‐localized with clinical neurological phenotypes (multifocal in 29%). Thirty patients (73%) had ≥ 1 immunological perturbation: cancer (paraneoplastic), 22; systemic infection (parainfectious [including ehrlichosis, 3] or HIV), 7; checkpoint‐inhibitor cancer immunotherapy, 4; other, 5. Cancers were as follows: neuroendocrine‐lineage carcinomas, 12 (small cell, 6; Merkel cell, 5; pancreatic, 1 [11/12 had NF‐L‐IgG detected, versus 8/29 others, P = 0.0005]) and other, 11. Onset was predominantly subacute (92%) and accompanied by inflammatory CSF (75%), and immunotherapy response (77%). In contrast, CSF controls (15684 total) demonstrated NIF‐IgG negativity (100% of test validation controls), and low frequencies of autoimmune diagnoses (20% of consecutively referred clinical specimens) and neuroendocrine‐lineage carcinoma diagnosis (3.1% vs. 30% of NIF cases), P < 0.0001. Median NF‐L protein concentration was higher in 8 NF‐L‐IgG‐positive patients (median, 6718 ng/L) than 16 controls. Interpretation Neurological autoimmunity, defined by CSF‐detected NIF‐IgGs, represents a continuum of treatable axonopathies, sometimes paraneoplastic or parainfectious.
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Affiliation(s)
- Andrew McKeon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shahar Shelly
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Cecilia Zivelonghi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Neurology Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Eati Basal
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Divyanshu Dubey
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eoin Flanagan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ajay A Madhavan
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara Mariotto
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Michel Toledano
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Anastasia Zekeridou
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean J Pittock
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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23
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Yshii L, Bost C, Liblau R. Immunological Bases of Paraneoplastic Cerebellar Degeneration and Therapeutic Implications. Front Immunol 2020; 11:991. [PMID: 32655545 PMCID: PMC7326021 DOI: 10.3389/fimmu.2020.00991] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 04/27/2020] [Indexed: 12/14/2022] Open
Abstract
Paraneoplastic cerebellar degeneration (PCD) is a rare immune-mediated disease that develops mostly in the setting of neoplasia and offers a unique prospect to explore the interplay between tumor immunity and autoimmunity. In PCD, the deleterious adaptive immune response targets self-antigens aberrantly expressed by tumor cells, mostly gynecological cancers, and physiologically expressed by the Purkinje neurons of the cerebellum. Highly specific anti-neuronal antibodies in the serum and cerebrospinal fluid represent key diagnostic biomarkers of PCD. Some anti-neuronal antibodies such as anti-Yo autoantibodies (recognizing the CDR2/CDR2L proteins) are only associated with PCD. Other anti-neuronal antibodies, such as anti-Hu, anti-Ri, and anti-Ma2, are detected in patients with PCD or other types of paraneoplastic neurological manifestations. Importantly, these autoantibodies cannot transfer disease and evidence for a pathogenic role of autoreactive T cells is accumulating. However, the precise mechanisms responsible for disruption of self-tolerance to neuronal self-antigens in the cancer setting and the pathways involved in pathogenesis within the cerebellum remain to be fully deciphered. Although the occurrence of PCD is rare, the risk for such severe complication may increase with wider use of cancer immunotherapy, notably immune checkpoint blockade. Here, we review recent literature pertaining to the pathophysiology of PCD and propose an immune scheme underlying this disabling disease. Additionally, based on observations from patients' samples and on the pre-clinical model we recently developed, we discuss potential therapeutic strategies that could blunt this cerebellum-specific autoimmune disease.
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Affiliation(s)
- Lidia Yshii
- INSERM U1043, CNRS UMR 5282, Université Toulouse III, Center for Pathophysiology Toulouse Purpan, Toulouse, France
| | - Chloé Bost
- INSERM U1043, CNRS UMR 5282, Université Toulouse III, Center for Pathophysiology Toulouse Purpan, Toulouse, France.,Department of Immunology, Purpan University Hospital Toulouse, Toulouse, France
| | - Roland Liblau
- INSERM U1043, CNRS UMR 5282, Université Toulouse III, Center for Pathophysiology Toulouse Purpan, Toulouse, France.,Department of Immunology, Purpan University Hospital Toulouse, Toulouse, France
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24
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Abstract
PURPOSE OF REVIEW The current review develops the clinical presentations of nonparaneoplastic autoimmune cerebellar ataxia (ACA) and analyzes the association with autoantibodies. RECENT FINDINGS Emerging evidence suggests that autoimmunity is involved in a significant proportion of sporadic ataxia cases. Moreover, numerous autoantibodies have recently been described in association with sporadic cerebellar ataxia, improving diagnosis and patient categorization. SUMMARY Nonparaneoplastic ACA encompasses postinfectious acute cerebellar ataxia, opsoclonus-myoclonus-ataxia syndrome, and pure cerebellar ataxia with or without autoantibodies. There is still confusion about how to diagnose and classify the patients, and retrospective data suggest that these very rare entities are in fact largely underrecognized. Numerous autoantibodies have been found associated with sporadic ataxia, improving diagnosis accuracy, and patient categorization. However, although anti-glutamate decarboxylase isotype 65 (GAD65), anti-contactin-associated protein 2 (CASPR2), and anti metabotropic glutamate receptor (mGluR1) antibodies are well recognized biomarkers, many other autoantibodies have been described in very small numbers of patients and their specificity is unknown. Efficient biomarkers for ACA are still lacking and in many cases the diagnosis has to rely on a body of converging evidence.
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25
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Shelly S, Kryzer TJ, Komorowski L, Miske R, Anderson MD, Flanagan EP, Hinson SR, Lennon VA, Pittock SJ, McKeon A. Neurochondrin neurological autoimmunity. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:6/6/e612. [PMID: 31511329 PMCID: PMC6745726 DOI: 10.1212/nxi.0000000000000612] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/30/2019] [Indexed: 11/19/2022]
Abstract
Objectives To describe the neurologic spectrum and treatment outcomes for neurochondrin-IgG positive cases identified serologically in the Mayo Clinic Neuroimmunology Laboratory. Methods Archived serum and CSF specimens previously scored positive for IgGs that stained mouse hippocampal tissue in a nonuniform synaptic pattern by immunofluorescence assay (89 among 616,025 screened, 1993–2019) were reevaluated. Antibody characterization experiments revealed specificity for neurochondrin, confirmed by recombinant protein assays. Results IgG in serum (9) or CSF (4) from 8 patients yielded identical neuron-restricted CNS patterns, most pronounced in hippocampus (stratum lucidum in particular), cerebellum (Purkinje cells and molecular layer), and amygdala. All were neurochondrin-IgG positive. Five were women; median symptom onset age was 43 years (range, 30–69). Of 7 with clinical data, 6 presented with rapidly progressive cerebellar ataxia, brainstem signs, or both; 1 had isolated unexplained psychosis 1 year prior. Five of 6 had cerebellar signs, 4 with additional brainstem symptoms or signs (eye movement abnormalities, 3; dysphagia, 2; nausea and vomiting, 1). One patient with brainstem signs (vocal cord paralysis and VII nerve palsy) had accompanying myelopathy (longitudinally extensive abnormality on MRI; aquaporin-4-IgG and myelin oligodendrocyte glycoprotein-IgG negative). The 7th patient had small fiber neuropathy only. Just 1 of 7 had contemporaneous cancer (uterine). Six patients with ataxia or brainstem signs received immunotherapy, but just 1 remained ambulatory. At last follow-up, 5 had MRI evidence of severe cerebellar atrophy. Conclusion In our series, neurochondrin autoimmunity was usually accompanied by a nonparaneoplastic rapidly progressive rhombencephalitis with poor neurologic outcomes. Other phenotypes and occasional paraneoplastic causes may occur.
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Affiliation(s)
- Shahar Shelly
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Thomas J Kryzer
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Lars Komorowski
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Ramona Miske
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Mark D Anderson
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Eoin P Flanagan
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Shannon R Hinson
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Vanda A Lennon
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Sean J Pittock
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Andrew McKeon
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS.
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26
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Honorat JA, Lopez-Chiriboga AS, Kryzer TJ, Komorowski L, Scharf M, Hinson SR, Lennon VA, Pittock SJ, Klein CJ, McKeon A. Autoimmune gait disturbance accompanying adaptor protein-3B2-IgG. Neurology 2019; 93:e954-e963. [PMID: 31371564 PMCID: PMC6745733 DOI: 10.1212/wnl.0000000000008061] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 04/08/2019] [Indexed: 01/03/2023] Open
Abstract
Objective To describe phenotypes, treatment response, and outcomes of autoimmunity targeting a synaptic vesicle coat protein, the neuronal (B2) form of adaptor protein–3 (AP3). Methods Archived serum and CSF specimens (from 616,025 screened) harboring unclassified synaptic antibodies mimicking amphiphysin–immunoglobulin G (IgG) on tissue-based indirect immunofluorescence assay (IFA) were re-evaluated for novel IgG staining patterns. Autoantigens were identified by western blot and mass spectrometry. Recombinant western blot and cell-binding assay (CBA) were used to confirm antigen specificity. Clinical data were obtained retrospectively. Results Serum (10) and CSF (6) specimens of 10 patients produced identical IFA staining patterns throughout mouse nervous system tissues, most prominently in cerebellum (Purkinje neuronal perikarya, granular layer synapses, and dentate regions), spinal cord gray matter, dorsal root ganglia, and sympathetic ganglia. The antigen revealed by mass spectrometry analysis and confirmed by recombinant assays (western blot and CBA) was AP3B2 in all. Of 10 seropositive patients, 6 were women; median symptom onset age was 42 years (range 24–58). Clinical information was available for 9 patients, all with subacute onset and rapidly progressive gait ataxia. Neurologic manifestations were myeloneuropathy (3), peripheral sensory neuropathy (2), cerebellar ataxia (2), and spinocerebellar ataxia (2). Five patients received immunotherapy; none improved, but they did not worsen over the follow-up period (median 36 months; range 3–94). Two patients (both with cancer) died. One of 50 control sera was positive by western blot only (but not by IFA or CBA). Conclusion AP3B2 (previously named β-neuronal adaptin-like protein) autoimmunity appears rare, is accompanied by ataxia (sensory or cerebellar), and is potentially treatable.
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Affiliation(s)
- Josephe A Honorat
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany
| | - A Sebastian Lopez-Chiriboga
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany
| | - Thomas J Kryzer
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany
| | - Lars Komorowski
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany
| | - Madeleine Scharf
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany
| | - Shannon R Hinson
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany
| | - Vanda A Lennon
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany
| | - Sean J Pittock
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany
| | - Christopher J Klein
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany
| | - Andrew McKeon
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany.
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Falk J, Boubakar L, Castellani V. Septin functions during neuro-development, a yeast perspective. Curr Opin Neurobiol 2019; 57:102-109. [DOI: 10.1016/j.conb.2019.01.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 01/09/2019] [Accepted: 01/13/2019] [Indexed: 12/24/2022]
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Autoimmune Septin-5 Cerebellar Ataxia. NEUROLOGY - NEUROIMMUNOLOGY NEUROINFLAMMATION 2019; 6:e534. [PMID: 30588485 PMCID: PMC6292488 DOI: 10.1212/nxi.0000000000000534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Prüss H. Further reducing terra incognita on the map of synaptic autoimmunity. NEUROLOGY - NEUROIMMUNOLOGY NEUROINFLAMMATION 2018; 5:e489. [PMID: 30175163 PMCID: PMC6117184 DOI: 10.1212/nxi.0000000000000489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Harald Prüss
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Germany, and Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Germany
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