1
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Tao T, Mo X, Zhao L. Identifying novel potential drug targets for endometriosis via plasma proteome screening. Front Endocrinol (Lausanne) 2024; 15:1416978. [PMID: 39036049 PMCID: PMC11257892 DOI: 10.3389/fendo.2024.1416978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 06/24/2024] [Indexed: 07/23/2024] Open
Abstract
Background Endometriosis (EM) is a chronic painful condition that predominantly affects women of reproductive age. Currently, surgery or medication can only provide limited symptom relief. This study used a comprehensive genetic analytical approach to explore potential drug targets for EM in the plasma proteome. Methods In this study, 2,923 plasma proteins were selected as exposure and EM as outcome for two-sample Mendelian randomization (MR) analyses. The plasma proteomic data were derived from the UK Biobank Pharmaceutical Proteomics Project (UKB-PPP), while the EM dataset from the FinnGen consortium R10 release data. Several sensitivity analyses were performed, including summary-data-based MR (SMR) analyses, heterogeneity in dependent instruments (HEIDI) test, reverse MR analyses, steiger detection test, and bayesian co-localization analyses. Furthermore, proteome-wide association study (PWAS) and single-cell transcriptomic analyses were also conducted to validate the findings. Results Six significant (p < 3.06 × 10-5) plasma protein-EM pairs were identified by MR analyses. These included EPHB4 (OR = 1.40, 95% CI: 1.20 - 1.63), FSHB (OR = 3.91, 95% CI: 3.13 - 4.87), RSPO3 (OR = 1.60, 95% CI: 1.38 - 1.86), SEZ6L2 (OR = 1.44, 95% CI: 1.23 - 1.68) and WASHC3 (OR = 2.00, 95% CI: 1.54 - 2.59) were identified as risk factors, whereas KDR (OR = 0.80, 95% CI: 0.75 - 0.90) was found to be a protective factor. All six plasma proteins passed the SMR test (P < 8.33 × 10-3), but only four plasma proteins passed the HEIDI heterogeneity test (PHEIDI > 0.05), namely FSHB, RSPO3, SEZ6L2 and EPHB4. These four proteins showed strong evidence of co-localization (PPH4 > 0.7). In particular, RSPO3 and EPHB4 were replicated in the validated PWAS. Single-cell analyses revealed high expression of SEZ6L2 and EPHB4 in stromal and epithelial cells within EM lesions, while RSPO3 exhibited elevated expression in stromal cells and fibroblasts. Conclusion Our study identified FSHB, RSPO3, SEZ6L2, and EPHB4 as potential drug targets for EM and highlighted the critical role of stromal and epithelial cells in disease development. These findings provide new insights into the diagnosis and treatment of EM.
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Affiliation(s)
- Tian Tao
- Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xiaoyu Mo
- Department of Gynaecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu, China
| | - Liangbin Zhao
- Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
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2
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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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3
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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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4
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Papi C, Milano C, Spatola M. Mechanisms of autoimmune encephalitis. Curr Opin Neurol 2024; 37:305-315. [PMID: 38667756 DOI: 10.1097/wco.0000000000001270] [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 provide an overview of the pathogenic mechanisms involved in autoimmune encephalitides mediated by antibodies against neuronal surface antigens, with a focus on NMDAR and LGI1 encephalitis. RECENT FINDINGS In antibody-mediated encephalitides, binding of IgG antibodies to neuronal surface antigens results in different pathogenic effects depending on the type of antibody, IgG subclass and epitope specificity. NMDAR IgG1 antibodies cause crosslinking and internalization of the target, synaptic and brain circuitry alterations, as well as alterations of NMDAR expressing oligodendrocytes, suggesting a link with white matter lesions observed in MRI studies. LGI1 IgG4 antibodies, instead, induce neuronal dysfunction by disrupting the interaction with cognate proteins and altering AMPAR-mediated signaling. In-vitro findings have been corroborated by memory and behavioral changes in animal models obtained by passive transfer of patients' antibodies or active immunization. These models have been fundamental to identify targets for innovative therapeutic strategies, aimed at counteracting or preventing antibody effects, such as the use of soluble ephrin-B2, NMDAR modulators (e.g., pregnenolone, SGE-301) or chimeric autoantibody receptor T cells (CAART) in models of NMDAR encephalitis. SUMMARY A deep understanding of the pathogenic mechanisms underlying antibody-mediated encephalitides is crucial for the development of new therapeutic approaches targeting brain autoimmunity.
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Affiliation(s)
- Claudia Papi
- Department of Neuroscience, Catholic University of the Sacred Heart, Rome, Italy
- Fundació Recerca Biomedica Clinic - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRBC-IDIBAPS), Barcelona, Spain
| | - Chiara Milano
- Fundació Recerca Biomedica Clinic - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRBC-IDIBAPS), Barcelona, Spain
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Marianna Spatola
- Fundació Recerca Biomedica Clinic - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRBC-IDIBAPS), Barcelona, Spain
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5
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Sanvito F, Pichiecchio A, Paoletti M, Rebella G, Resaz M, Benedetti L, Massa F, Morbelli S, Caverzasi E, Asteggiano C, Businaro P, Masciocchi S, Castellan L, Franciotta D, Gastaldi M, Roccatagliata L. Autoimmune encephalitis: what the radiologist needs to know. Neuroradiology 2024; 66:653-675. [PMID: 38507081 PMCID: PMC11031487 DOI: 10.1007/s00234-024-03318-x] [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: 11/15/2023] [Accepted: 02/20/2024] [Indexed: 03/22/2024]
Abstract
Autoimmune encephalitis is a relatively novel nosological entity characterized by an immune-mediated damage of the central nervous system. While originally described as a paraneoplastic inflammatory phenomenon affecting limbic structures, numerous instances of non-paraneoplastic pathogenesis, as well as extra-limbic involvement, have been characterized. Given the wide spectrum of insidious clinical presentations ranging from cognitive impairment to psychiatric symptoms or seizures, it is crucial to raise awareness about this disease category. In fact, an early diagnosis can be dramatically beneficial for the prognosis both to achieve an early therapeutic intervention and to detect a potential underlying malignancy. In this scenario, the radiologist can be the first to pose the hypothesis of autoimmune encephalitis and refer the patient to a comprehensive diagnostic work-up - including clinical, serological, and neurophysiological assessments.In this article, we illustrate the main radiological characteristics of autoimmune encephalitis and its subtypes, including the typical limbic presentation, the features of extra-limbic involvement, and also peculiar imaging findings. In addition, we review the most relevant alternative diagnoses that should be considered, ranging from other encephalitides to neoplasms, vascular conditions, and post-seizure alterations. Finally, we discuss the most appropriate imaging diagnostic work-up, also proposing a suggested MRI protocol.
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Affiliation(s)
- Francesco Sanvito
- Unit of Radiology, Department of Clinical, Surgical, Diagnostic, and Paediatric Sciences, University of Pavia, Viale Camillo Golgi, 19, 27100, Pavia, Italy.
- UCLA Brain Tumor Imaging Laboratory (BTIL), Center for Computer Vision and Imaging Biomarkers, University of California Los Angeles, Los Angeles, CA, USA.
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | - Anna Pichiecchio
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Matteo Paoletti
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Giacomo Rebella
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Martina Resaz
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Luana Benedetti
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Federico Massa
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Largo Daneo 3, 16132, Genoa, Italy
| | - Silvia Morbelli
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Via Antonio Pastore 1, 16132, Genoa, Italy
| | - Eduardo Caverzasi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Carlo Asteggiano
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Pietro Businaro
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Stefano Masciocchi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Lucio Castellan
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Diego Franciotta
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Luca Roccatagliata
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Via Antonio Pastore 1, 16132, Genoa, Italy
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Hahn C, Budhram A, Alikhani K, AlOhaly N, Beecher G, Blevins G, Brooks J, Carruthers R, Comtois J, Cowan J, de Robles P, Hébert J, Kapadia RK, Lapointe S, Mackie A, Mason W, McLane B, Muccilli A, Poliakov I, Smyth P, Williams KG, Uy C, McCombe JA. Canadian Consensus Guidelines for the Diagnosis and Treatment of Autoimmune Encephalitis in Adults. Can J Neurol Sci 2024:1-21. [PMID: 38312020 DOI: 10.1017/cjn.2024.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Abstract
Autoimmune encephalitis is increasingly recognized as a neurologic cause of acute mental status changes with similar prevalence to infectious encephalitis. Despite rising awareness, approaches to diagnosis remain inconsistent and evidence for optimal treatment is limited. The following Canadian guidelines represent a consensus and evidence (where available) based approach to both the diagnosis and treatment of adult patients with autoimmune encephalitis. The guidelines were developed using a modified RAND process and included input from specialists in autoimmune neurology, neuropsychiatry and infectious diseases. These guidelines are targeted at front line clinicians and were created to provide a pragmatic and practical approach to managing such patients in the acute setting.
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Affiliation(s)
- Christopher Hahn
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Adrian Budhram
- Clinical Neurological Sciences, London Health Sciences Centre, London, ON, Canada
- Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada
| | - Katayoun Alikhani
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Nasser AlOhaly
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Grayson Beecher
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - Gregg Blevins
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - John Brooks
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Robert Carruthers
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Jacynthe Comtois
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Juthaporn Cowan
- Division of Infectious Diseases, Department of Medicine Ottawa Hospital, Ottawa, ON, Canada
| | - Paula de Robles
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Julien Hébert
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Ronak K Kapadia
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Sarah Lapointe
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Aaron Mackie
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Warren Mason
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Brienne McLane
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | | | - Ilia Poliakov
- Division of Neurology, University of Saskatchewan College of Medicine, Saskatoon, SK, Canada
| | - Penelope Smyth
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | | | - Christopher Uy
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
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7
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Budhram A, Flanagan EP. Optimizing the diagnostic performance of neural antibody testing for paraneoplastic and autoimmune encephalitis in clinical practice. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:365-382. [PMID: 38494290 DOI: 10.1016/b978-0-12-823912-4.00002-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
The detection of neural antibodies in patients with paraneoplastic and autoimmune encephalitis has majorly advanced the diagnosis and management of neural antibody-associated diseases. Although testing for these antibodies has historically been restricted to specialized centers, assay commercialization has made this testing available to clinical chemistry laboratories worldwide. This improved test accessibility has led to reduced turnaround time and expedited diagnosis, which are beneficial to patient care. However, as the utilization of these assays has increased, so too has the need to evaluate how they perform in the clinical setting. In this chapter, we discuss assays for neural antibody detection that are in routine use, draw attention to their limitations and provide strategies to help clinicians and laboratorians overcome them, all with the aim of optimizing neural antibody testing for paraneoplastic and autoimmune encephalitis in clinical practice.
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Affiliation(s)
- Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, ON, Canada; Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada.
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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8
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Kadish R, Clardy SL. Epidemiology of paraneoplastic neurologic syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:57-77. [PMID: 38494297 DOI: 10.1016/b978-0-12-823912-4.00011-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes (PNS), initially depicted as seemingly cryptic remote manifestations of malignancy, were first described clinically in the early 20th century, with pathophysiologic correlates becoming better elucidated in the latter half of the century. There remain many questions not only about the pathophysiology but also regarding the epidemiology of these conditions. The continuous discovery of novel autoantigens and related neurologic disease has broadened the association in classical PNS to include conditions such as paraneoplastic cerebellar degeneration. It has also brought into focus several other neurologic syndromes with a putative neoplastic association. These conditions are overall rare, making it difficult to capture large numbers of patients to study, and raising the question of whether incidence is increasing over time or improved identification is driving the increased numbers of cases. With the rise and increasing use of immunotherapy for cancer treatment, the incidence of these conditions is additionally expected to rise and may present with various clinical symptoms. As we enter an era of clinical trial intervention in these conditions, much work is needed to capture more granular data on population groups defined by socioeconomic characteristics such as age, ethnicity, economic resources, and gender to optimize care and clinical trial planning.
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Affiliation(s)
- Robert Kadish
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Stacey L Clardy
- Department of Neurology, University of Utah, Salt Lake City, UT, United States; George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States.
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9
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Kudo A, Yaguchi H, Tanaka K, Kimura A, Yabe I. A retrospective study of autoimmune cerebellar ataxia over a 20-year period in a single institution. J Neurol 2024; 271:553-563. [PMID: 37610447 DOI: 10.1007/s00415-023-11946-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/08/2023] [Accepted: 08/14/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND It is important to differentiate autoimmune cerebellar ataxia (ACA) from neurodegenerative CA, but this is sometimes difficult. We performed a retrospective study in a single institution in Japan over a 20-year period to reveal the clinical features of ACA. METHODS Patients with CA as the primary neurological symptom were enrolled from those admitted to the Department of Neurology, Hokkaido University Hospital between April 2002 and March 2022. ACA was diagnosed retrospectively according to the following criteria: (1) CA being the predominant symptom; (2) identification of cancer within 2 years of onset; (3) improvement in cerebellar symptoms following immunotherapy; and (4) ruling out alternative causes of CA. Patients fulfilling criteria (1), (2), and (4) were classified as paraneoplastic cerebellar degeneration (PCD), while those fulfilling (1), (3), and (4) were classified as non-PCD and enrolled as patients with ACA. Neurodegenerative diseases, e.g., multiple system atrophy (MSA), were confirmed retrospectively based on generally used diagnostic criteria and enrolled. Furthermore, the ACA diagnostic criteria proposed by Dalmau and Graus were applied retrospectively to the ACA patients to examine the validity of the diagnoses. RESULTS Among the 243 patients with CA, 13 were enrolled as ACA; five were PCD and eight were non-PCD. Eight of these cases met the proposed diagnostic criteria by Dalmau and Graus. MSA was the most prevalent disease among CA patients, with 93 cases. The incidence of cerebellar atrophy was significantly lower in ACA (3/13) than in MSA (92/92). Cerebrospinal fluid (CSF) pleocytosis was significantly more frequent in ACA than in MSA (4/13 vs. 2/55, respectively). However, there was no significant difference in the presence of oligoclonal bands, increased protein in CSF, and laterality differences in ataxia. CONCLUSION ACA was present in ~ 5% of Japanese CA patients. The absence of cerebellar atrophy, despite the presence of CA, strongly supports ACA over MSA. While CSF pleocytosis was observed more often in ACA, the positivity rate was only ~ 30%. Since ACA is treatable, further studies are needed to identify additional clinical features and accurate diagnostic biomarkers.
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Affiliation(s)
- Akihiko Kudo
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15 W-7, Kita-Ku, Sapporo, Japan
| | - Hiroaki Yaguchi
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15 W-7, Kita-Ku, Sapporo, Japan.
| | - Keiko Tanaka
- Department of Animal Model Development, Brain Research Institute, Niigata University, Niigata, Japan
| | - Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Ichiro Yabe
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15 W-7, Kita-Ku, Sapporo, Japan.
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10
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Masciocchi S, Businaro P, Scaranzin S, Morandi C, Franciotta D, Gastaldi M. General features, pathogenesis, and laboratory diagnostics of autoimmune encephalitis. Crit Rev Clin Lab Sci 2024; 61:45-69. [PMID: 37777038 DOI: 10.1080/10408363.2023.2247482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/09/2023] [Indexed: 10/02/2023]
Abstract
Autoimmune encephalitis (AE) is a group of inflammatory conditions that can associate with the presence of antibodies directed to neuronal intracellular, or cell surface antigens. These disorders are increasingly recognized as an important differential diagnosis of infectious encephalitis and of other common neuropsychiatric conditions. Autoantibody diagnostics plays a pivotal role for accurate diagnosis of AE, which is of utmost importance for the prompt recognition and early treatment. Several AE subgroups can be identified, either according to the prominent clinical phenotype, presence of a concomitant tumor, or type of neuronal autoantibody, and recent diagnostic criteria have provided important insights into AE classification. Antibodies to neuronal intracellular antigens typically associate with paraneoplastic neurological syndromes and poor prognosis, whereas antibodies to synaptic/neuronal cell surface antigens characterize many AE subtypes that associate with tumors less frequently, and that are often immunotherapy-responsive. In addition to the general features of AE, we review current knowledge on the pathogenic mechanisms underlying these disorders, focusing mainly on the potential role of neuronal antibodies in the most frequent conditions, and highlight current theories and controversies. Then, we dissect the crucial aspects of the laboratory diagnostics of neuronal antibodies, which represents an actual challenge for both pathologists and neurologists. Indeed, this diagnostics entails technical difficulties, along with particularly interesting novel features and pitfalls. The novelties especially apply to the wide range of assays used, including specific tissue-based and cell-based assays. These assays can be developed in-house, usually in specialized laboratories, or are commercially available. They are widely used in clinical immunology and in clinical chemistry laboratories, with relevant differences in analytic performance. Indeed, several data indicate that in-house assays could perform better than commercial kits, notwithstanding that the former are based on non-standardized protocols. Moreover, they need expertise and laboratory facilities usually unavailable in clinical chemistry laboratories. Together with the data of the literature, we critically evaluate the analytical performance of the in-house vs commercial kit-based approach. Finally, we propose an algorithm aimed at integrating the present strategies of the laboratory diagnostics in AE for the best clinical management of patients with these disorders.
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Affiliation(s)
- Stefano Masciocchi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, Università degli Studi di Pavia, Pavia, Italy
| | - Pietro Businaro
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, Università degli Studi di Pavia, Pavia, Italy
| | - Silvia Scaranzin
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Chiara Morandi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Diego Franciotta
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Matteo Gastaldi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
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11
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Ryding M, Mikkelsen AW, Nissen MS, Nilsson AC, Blaabjerg M. Pathophysiological Effects of Autoantibodies in Autoimmune Encephalitides. Cells 2023; 13:15. [PMID: 38201219 PMCID: PMC10778077 DOI: 10.3390/cells13010015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
The heterogeneity of autoantibody targets in autoimmune encephalitides presents a challenge for understanding cellular and humoral pathophysiology, and the development of new treatment strategies. Thus, current treatment aims at autoantibody removal and immunosuppression, and is primarily based on data generated from other autoimmune neurological diseases and expert consensus. There are many subtypes of autoimmune encephalitides, which now entails both diseases with autoantibodies targeting extracellular antigens and classical paraneoplastic syndromes with autoantibodies targeting intracellular antigens. Here, we review the current knowledge of molecular and cellular effects of autoantibodies associated with autoimmune encephalitis, and evaluate the evidence behind the proposed pathophysiological mechanisms of autoantibodies in autoimmune encephalitis.
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Affiliation(s)
- Matias Ryding
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark;
- Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5000 Odense, Denmark
| | - Anne With Mikkelsen
- Department of Clinical Immunology, Odense University Hospital, 5000 Odense, Denmark;
| | | | - Anna Christine Nilsson
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark;
- Department of Clinical Immunology, Odense University Hospital, 5000 Odense, Denmark;
| | - Morten Blaabjerg
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark;
- Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5000 Odense, Denmark
- Department of Neurology, Odense University Hospital, 5000 Odense, Denmark;
- Brain Research—Inter Disciplinary Guided Excellence (BRIDGE), 5000 Odense, Denmark
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12
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Matsuyama Y, Satake M, Abe M, Yaguchi H, Yabe I. [A case of Seizure-related 6 homolog like 2 (Sez6l2) antibody-associated autoimmune cerebellar ataxia]. Rinsho Shinkeigaku 2023; 63:665-671. [PMID: 37779021 DOI: 10.5692/clinicalneurol.cn-001869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
A 35-year-old male patient had been repeatedly involved in car accidents since the age of 34 years, had difficulty in tidying his room, and developed speech and gait disorders. At the first examination, he had a hypophonia and poor gait, but he could talk and walk by himself. His Mini-Mental State Examination (MMSE) score was 23 and mild cognitive impairment was observed. Three months later, neurological findings showed subacute progression to loss of speech, and poor right dominant diadochokinesia and finger tapping, poor finger-nose test and heel-knee test, and loss of ability to stand and walk. Cerebellar atrophy was observed on head MRI, and the patient was positive for Seizure-related 6 homolog like 2 (Sez6l2) antibody, leading to a diagnosis of Sez6l2 antibody-associated autoimmune cerebellar ataxia. Immunotherapy halted the progression of symptoms, and the patient showed slight improvement. Sez6l2 antibody measurement and immunotherapy were considered necessary for subacute progressive cerebellar ataxia of unknown cause.
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Affiliation(s)
- Yumi Matsuyama
- Department of Neurology, Hamanomachi Hospital, National Public Service Mutual Aid Association
| | - Marie Satake
- Department of Neurology, Hamanomachi Hospital, National Public Service Mutual Aid Association
| | - Megumi Abe
- Department of Neurology, Hokkaido University
| | | | - Ichiro Yabe
- Department of Neurology, Hokkaido University
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13
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Yang B, Brown A, McKeon A, Ahlskog JE, Tipton P, Guo Y, Lucchinetti C, Pittock SJ, Zekeridou A. Tenascin-R Autoimmunity: Isolated Tremor Reversed with Immunotherapy. Ann Neurol 2023; 94:502-507. [PMID: 37370243 PMCID: PMC10527205 DOI: 10.1002/ana.26730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 05/10/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023]
Abstract
Autoimmune movement disorders are increasingly recognized, but isolated tremor is extremely rare. We describe a 70-year-old male with rapidly progressive, severe postural and intention tremor and weight loss. His cerebrospinal fluid was inflammatory and harbored a neural tissue-restricted antibody. The autoantigen was identified by immunoprecipitation and mass spectrometry and confirmed by antigen-specific assays to be specific for tenascin-R. He was investigated for cancer and diagnosed with follicular lymphoma that expressed tenascin-R suggesting a paraneoplastic origin; cancer treatment and immunotherapy led to complete recovery. With this individualized patient approach and antibody discovery, we expand the spectrum of antibodies accompanying autoimmune hyperkinetic movement disorders. ANN NEUROL 2023;94:502-507.
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Affiliation(s)
- Binxia Yang
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Andrew Brown
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Andrew McKeon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | - J Eric Ahlskog
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Philip Tipton
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Yong Guo
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | - Claudia Lucchinetti
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | - Sean J Pittock
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | - Anastasia Zekeridou
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
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14
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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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15
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Balint B. Relevance of Antibody Testing in Movement Disorders. Mov Disord Clin Pract 2023; 10:S32-S35. [PMID: 37637987 PMCID: PMC10448132 DOI: 10.1002/mdc3.13772] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 08/29/2023] Open
Affiliation(s)
- Bettina Balint
- Department of NeurologyUniversity Hospital Zurich, University of ZurichZurichSwitzerland
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16
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Abe M, Yaguchi H, Kudo A, Nagai A, Shirai S, Takahashi-Iwata I, Matsushima M, Nakamura N, Isahaya K, Yamano Y, Ashida S, Kasai T, Tanaka K, Watanabe M, Kondo T, Takahashi H, Hatakeyama S, Takekoshi A, Kimura A, Shimohata T, Yabe I. Sez6l2 autoimmunity in a large cohort study. J Neurol Neurosurg Psychiatry 2023; 94:667-668. [PMID: 37263766 DOI: 10.1136/jnnp-2022-330194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 05/04/2023] [Indexed: 06/03/2023]
Affiliation(s)
- Megumi Abe
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroaki Yaguchi
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Akihiko Kudo
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Azusa Nagai
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Shinichi Shirai
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Ikuko Takahashi-Iwata
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaaki Matsushima
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Naoko Nakamura
- Department of Neurology, Mie University Hospital, Tsu, Japan
| | - Kenji Isahaya
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yoshihisa Yamano
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Shinji Ashida
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takashi Kasai
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Keiko Tanaka
- Department of Animal Model Development, Brain Research Institute, Niigata University, Niigata, Japan
| | - Masashi Watanabe
- Department of Biochemistry, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takeshi Kondo
- Department of Biochemistry, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hidehisa Takahashi
- Department of Molecular Biology, Yokohama City University School of Medicine Graduate School of Medicine, Yokohama, Japan
| | - Shigetsugu Hatakeyama
- Department of Biochemistry, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Akira Takekoshi
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Ichiro Yabe
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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17
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Caza TN, Storey AJ, Hassen SI, Herzog C, Edmondson RD, Arthur JM, Kenan DJ, Larsen CP. Discovery of seven novel putative antigens in membranous nephropathy and membranous lupus nephritis identified by mass spectrometry. Kidney Int 2023; 103:593-606. [PMID: 36638888 PMCID: PMC9974866 DOI: 10.1016/j.kint.2023.01.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 12/28/2022] [Accepted: 01/04/2023] [Indexed: 01/12/2023]
Abstract
Multiple autoantigens have been identified in membranous nephropathy (MN) by tissue-based proteomics. However, antigenic targets of disease are unknown for over 10% of patients with MN and over half of those with membranous lupus nephritis (MLN). Here, we identified multiple new targets in PLA2R-/THSD7A-/EXT-/NELL1-quadruple negative MN biopsies through mass spectrometry of immune complexes recovered from biopsy tissue of patients with MN. Patients with MN negative for these four antigens were identified from Arkana Laboratories case archives. Protein G immunoprecipitation recovered immune complexes from frozen biopsy tissue from 142 quadruple-negative cases and 278 cases of known antigen type, followed by interrogation by mass spectrometry. Potential putative antigens were confirmed through paraffin immunofluorescence and co-localization with IgG within immune deposits. Consecutive series of 165 cases of PLA2R-negative MN and 142 MLN biopsies were screened to determine the frequency for each potential antigen. Seven putative antigens were discovered within immune complexes from biopsies of patients with MN including FCN3, CD206, EEA1, SEZ6L2, NPR3, MST1, and VASN. Peptides from these proteins were not enriched in the 278 cases of known antigen type. Between three to 30 unique peptides were detected for each new target. Frequencies of each biomarker, determined by staining consecutive case series, ranged from under 1 to 4.9%. NPR3 and CD206 were only positive in index cases. All cases showed co-localization of IgG within the immune deposits. Thus, seven putative antigens were newly identified in MN and MLN. Due to the number of antigens identified, it is becoming impractical to type PLA2R-negative MN or MLN cases through immunostaining alone. A multiplex approach is needed for subtyping of these diseases.
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Affiliation(s)
| | - Aaron J Storey
- Division of Nephrology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | | | - Christian Herzog
- Division of Nephrology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Rick D Edmondson
- Division of Nephrology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - John M Arthur
- Division of Nephrology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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18
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Gaig C, Graus F. Motor symptoms in nonparaneoplastic CNS disorders associated with neural antibodies. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:277-294. [PMID: 37620074 DOI: 10.1016/b978-0-323-98817-9.00004-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Motor symptoms are common, and sometimes predominant, in almost all nonparaneoplastic CNS disorders associated with neural antibodies. These CNS disorders can be classified into five groups: (1) Autoimmune encephalitis with antibodies against synaptic receptors, (2) cerebellar ataxias associated with neuronal antibodies that mostly target intracellular antigens. (3) Stiff-person syndrome and progressive encephalomyelitis with rigidity and myoclonus which have antibodies against glutamic acid decarboxylase and glycine receptor, respectively. Both diseases have in common the presence of predominant muscle stiffness and rigidity. (4) Three diseases associated with glial antibodies. Two present motor symptoms mainly due to the involvement of the spinal cord: neuromyelitis optica spectrum disorders with aquaporin-4 antibodies and myelin oligodendrocyte glycoprotein antibody-associated disease. The third disorder is the meningoencephalitis associated with glial fibrillar acidic protein antibodies which frequently also presents a myelopathy. (5) Two antibody-related diseases which are characterized by prominent sleep dysfunction: anti-IgLON5 disease, a disorder that frequently presents a variety of movement disorders, and Morvan syndrome associated with contactin-associated protein-like 2 antibodies and clinical manifestations of peripheral nerve hyperexcitability. In this chapter, we describe the main clinical features of these five groups with particular emphasis on the presence, frequency, and types of motor symptoms.
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Affiliation(s)
- Carles Gaig
- Neurology Service, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Francesc Graus
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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19
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Kather A, Holtbernd F, Brunkhorst R, Hasan D, Markewitz R, Wandinger KP, Wiesmann M, Schulz JB, Tauber SC. Anti-SEZ6L2 antibodies in paraneoplastic cerebellar syndrome: case report and review of the literature. Neurol Res Pract 2022; 4:54. [PMID: 36310162 PMCID: PMC9620611 DOI: 10.1186/s42466-022-00218-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/01/2022] [Indexed: 12/03/2022] Open
Abstract
Seizure Related 6 Homolog Like 2 (SEZ6L2) protein has been shown to have implications in neuronal and especially motor function development. In oncology, overexpression of SEZ6L2 serves as a negative prognostic marker in several tumor entities. Recently, few cases of anti-SEZ6L2 antibody mediated cerebellar syndromes were reported. In this article, we present a case of a 70-year-old woman with subacute onset of gait disturbance, dysarthria and limb ataxia. Serum anti-SEZ6L2 antibodies were markedly increased, and further diagnostic workup revealed left sided breast cancer. Neurological symptoms and SEZ6L2 titer significantly improved after curative tumor therapy. This is a very rare and educationally important report of anti-SEZ6L2 autoimmune cerebellar syndrome with a paraneoplastic etiology. Additionally, we performed a review of the current literature for SEZ6L2, focusing on comparing the published cases on autoimmune cerebellar syndrome.
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20
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Reis Carneiro D, Maresch Â, Cunha R, Morgadinho A. Sez6l2-associated encephalitis in a patient with small-cell lung cancer. Neurol Sci 2022; 43:6131-6133. [DOI: 10.1007/s10072-022-06244-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 06/21/2022] [Indexed: 11/30/2022]
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21
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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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22
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Lancaster E. Autoantibody Encephalitis: Presentation, Diagnosis, and Management. J Clin Neurol 2022; 18:373-390. [PMID: 35796263 PMCID: PMC9262450 DOI: 10.3988/jcn.2022.18.4.373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/22/2022] [Accepted: 04/22/2022] [Indexed: 02/07/2023] Open
Abstract
Autoantibody encephalitis causes distinct clinical syndromes involving alterations in mentation, abnormal movements, seizures, psychiatric symptoms, sleep disruption, spasms, and neuromyotonia. The diagnoses can be confirmed by specific antibody tests, although some antibodies may be better detected in spinal fluid and others in serum. Each disorder conveys a risk of certain tumors which may inform diagnosis and be important for treatment. Autoantibodies to receptors and other neuronal membrane proteins are generally thought to be pathogenic and result in loss of function of the targets, so understanding the pharmacology of the receptors may inform our understanding of the syndromes. Patients may be profoundly ill but the syndromes usually respond to immune therapy, although there are differences in the types of immune therapy that are thought to be most effective for the various disorders.
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Affiliation(s)
- Eric Lancaster
- Department of Neurology, The University of Pennsylvania, Philadelphia, PA, USA.
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Abstract
PURPOSE OF REVIEW Autoimmune encephalitis (AE) refers to immune-mediated neurological syndromes often characterised by the detection of pathogenic autoantibodies in serum and/or cerebrospinal fluid which target extracellular epitopes of neuroglial antigens. There is increasing evidence these autoantibodies directly modulate function of their antigens in vivo. Early treatment with immunotherapy improves outcomes. Yet, these patients commonly exhibit chronic disability. Importantly, optimal therapeutic strategies at onset and during escalation remain poorly understood. In this review of a rapidly emerging field, we evaluate recent studies on larger cohorts, registries, and meta-analyses to highlight existing evidence for contemporary therapeutic approaches in AE. RECENT FINDINGS We highlight acute and long-term treatments used in specific AE syndromes, exemplify how understanding disease pathogenesis can inform precision therapy and outline challenges of defining disability outcomes in AE. SUMMARY Early first-line immunotherapies, including corticosteroids and plasma exchange, improve outcomes, with emerging evidence showing second-line immunotherapies (especially rituximab) reduce relapse rates. Optimal timing of immunotherapy escalation remains unclear. Routine reporting of outcome measures which incorporate cognitive impairment, fatigue, pain, and mental health will permit more accurate quantification of residual disability and comprehensive comparisons between international multicentre cohorts, and enable future meta-analyses with the aim of developing evidence-based therapeutic guidelines.
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Affiliation(s)
- Benjamin P Trewin
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead; Sydney Medical School and Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Isaak Freeman
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Sudarshini Ramanathan
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead; Sydney Medical School and Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Neurology, Concord Hospital, Sydney, Australia
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
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24
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Mehdiyeva A, Hietaharju A, Sipilä J. SEZ6L2 Antibody-Associated Cerebellar Ataxia Responsive to Sequential Immunotherapy. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2022; 9:9/2/e1131. [PMID: 35031588 PMCID: PMC8759717 DOI: 10.1212/nxi.0000000000001131] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 11/24/2021] [Indexed: 11/17/2022]
Abstract
Objectives Seizure-related 6 homolog like 2 (SEZ6L2) antibody–associated ataxia is an extremely rare disease. Six patients have been reported and none of them improved significantly with immunotherapy. Herein, we present the case of a patient with cerebellar ataxia and SEZ6L2 antibodies who benefited from immunotherapy, which dramatically altered the course of her disease. Methods We present a case report of a 73-year-old woman with progressive balance problems. Her condition had rapidly deteriorated in the 2 weeks before the admission to our hospital leading to repeated falls and eventually left her bed-ridden. Results She presented with severe trunk ataxia, bidirectional nystagmus, dysarthric speech, and persistent nausea. With the exception of cerebellar atrophy, extensive imaging studies revealed no pathology. SEZ6L2 antibodies were found in both CSF and serum. Over a period of 9 months, our patient received immunotherapy consisting of steroid pulse therapy, IV immunoglobulin infusions, rituximab, and cyclophosphamide. Consequently, her condition improved markedly, and she was discharged home from the neurologic rehabilitation unit. Discussion Our case report shows that intense sequential immunotherapy may considerably improve level of functioning in some patients with SEZ6L2 antibody–associated cerebellar ataxia. Classification of Evidence This provides Class IV evidence. It is a single observational study without controls.
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Affiliation(s)
- Ayla Mehdiyeva
- From the Department of Neurology (A.M., J.S.), North Karelia Central Hospital, Joensuu; Department of Neurology (A.M.), University of Eastern Finland, Kuopio, Finland; Department of Neurology (A.H.), Tampere University Hospital; Clinical Neurosciences (J.S.), University of Turku, Turku, Finland.
| | - Aki Hietaharju
- From the Department of Neurology (A.M., J.S.), North Karelia Central Hospital, Joensuu; Department of Neurology (A.M.), University of Eastern Finland, Kuopio, Finland; Department of Neurology (A.H.), Tampere University Hospital; Clinical Neurosciences (J.S.), University of Turku, Turku, Finland
| | - Jussi Sipilä
- From the Department of Neurology (A.M., J.S.), North Karelia Central Hospital, Joensuu; Department of Neurology (A.M.), University of Eastern Finland, Kuopio, Finland; Department of Neurology (A.H.), Tampere University Hospital; Clinical Neurosciences (J.S.), University of Turku, Turku, Finland
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25
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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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26
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Liu M, Ren H, Fan S, Zhang W, Xu Y, Zhao W, Guan H. Neurological Autoimmunity Associated With Homer-3 Antibody: A Case Series From China. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/6/e1077. [PMID: 34580182 PMCID: PMC8477375 DOI: 10.1212/nxi.0000000000001077] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/06/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE To present 6 new cases with Homer-3 antibodies that expand their clinical spectra and to evaluate the effect of immunotherapy. METHODS Patients with suspected autoimmune cerebellar disorder were tested for rare autoimmune cerebellar ataxia (ACA) antibodies (anti-Tr(DNER)/Zic4/ITPR1/Homer-3/NCDN/PKCγ/PCA-2/AP3B2/mGluR1/ATP1A3 antibodies) using both cell-based and tissue-based assays. Patients with positive serum or CSF results who were diagnosed with ACA were registered and followed up. This study reports and analyzes cases with Homer-3 antibodies. RESULTS Of the serum and CSF samples of 750 patients tested, 6 were positive for Homer-3 antibodies. All manifested subacute or insidious-onset cerebellar ataxia. Furthermore, 2 patients each exhibited encephalopathy, myeloradiculopathy, REM sleep behavior disorder, and autonomic dysfunction. Brain magnetic resonance images were normal (n = 1) or revealed cerebellar atrophy (n = 1), cerebellum and pons atrophy with the hot cross bun sign (n = 2), and bilateral cerebral abnormalities (n = 2). Definite leukocytosis was identified in the CSF of 2 patients, protein concentration elevation was observed in the CSF of 1 patient, and oligoclonal bands were present in 2 patients. All patients received immunotherapy, including corticosteroid, IV immunoglobulin, plasma exchange, and mycophenolate mofetil, after which the residual disability was still severe (modified Rankin Scale score ≥3 at the last follow-up in 4 patients and final Scale for the Assessment and Rating of Ataxia scores of 12-29), although 4 patients partially improved and 1 patient stabilized. The remaining 1 patient continued to deteriorate after repeated immunotherapy. Two patients relapsed. DISCUSSION Disorders associated with Homer-3 antibody can mimic multiple system atrophy with cerebellar features in both clinical and radiologic aspects. Accurate identification of autoimmune-mediated cases is critical. Timely, comprehensive immunotherapy is warranted, given the possibility of long-term clinical benefit.
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Affiliation(s)
- Mange Liu
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China
| | - Haitao Ren
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China
| | - Siyuan Fan
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China
| | - Weihe Zhang
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China
| | - Yao Xu
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China
| | - Weili Zhao
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China
| | - Hongzhi Guan
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China.
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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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28
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Nissen MS, Ørvik MS, Nilsson AC, Ryding M, Lydolph M, Blaabjerg M. NMDA-receptor encephalitis in Denmark from 2009 to 2019: a national cohort study. J Neurol 2021; 269:1618-1630. [PMID: 34351472 DOI: 10.1007/s00415-021-10738-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/30/2021] [Accepted: 07/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND To describe the national Danish N-methyl-D-aspartate receptor encephalitis (NMDARE) cohort. METHODS All NMDAR immunoglobulin G (IgG) positive cases in Denmark from 2009 to 2019 were included. Medical information was assessed retrospectively for clinical phenotype, workup, treatment and outcome. RESULTS Seventy-seven patients were NMDAR IgG positive in serum/CSF. Fifty-five fulfilled the criteria of NMDARE, 18 did not and 4 had missing data. Incidence was 0.17/100,000 persons per year in 2018, and incidence rates increased since 2009. Of the 55 NMDARE patients (median age 27; 60% female), 9 had post-herpes simplex (HSE) NMDARE and 7 had a tumor (four teratomas). MRI was normal in 51% of patients. Brain FDG PET was performed in 17 patients, and was abnormal in 47% of patients with a normal MRI. First-line therapy was administered to 91%, and 24% required second-line therapy. Maintenance therapy during recovery was given 84% of patients, with no effect on relapse-risk. ICU admission occurred in 29%. Poor outcome (mRS > 2) was reported in 27% and dependent on age and etiology. Patients > 45 years had a poorer outcome (71% vs 8%, p < 0.0001), more frequently post-HSE NMDARE (47% vs 3%, p < 0.0001) and underlying malignancies (18% vs 0%). CONCLUSION The incidence of NMDARE in Denmark is currently 0.17/100,000 persons per year, and has increased since 2009. NMDARE patients in Denmark display a higher median age, lower female:male ratio, a less frequent tumor association and need for ICU admission. Maintenance therapy did not reduce relapse rate. Poor outcome was seen with higher age, likely related to underlying etiology.
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Affiliation(s)
- Mette Scheller Nissen
- Department of Neurology, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- Brain Research-Inter Disciplinary Guided Excellence (BRIDGE), Odense, Denmark.
| | | | - Anna Christine Nilsson
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - Matias Ryding
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Brain Research-Inter Disciplinary Guided Excellence (BRIDGE), Odense, Denmark
| | - Magnus Lydolph
- Danish National Biobank, Statens Serum Institut, Copenhagen, Denmark
| | - Morten Blaabjerg
- Department of Neurology, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- Brain Research-Inter Disciplinary Guided Excellence (BRIDGE), Odense, Denmark.
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark.
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29
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Guasp M, Landa J, Martinez-Hernandez E, Sabater L, Iizuka T, Simabukuro M, Nakamura M, Kinoshita M, Kurihara M, Kaida K, Bruna J, Kapetanovic S, Sánchez P, Ruiz-García R, Naranjo L, Planagumà J, Muñoz-Lopetegi A, Bataller L, Saiz A, Dalmau J, Graus F. Thymoma and Autoimmune Encephalitis: Clinical Manifestations and Antibodies. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/5/e1053. [PMID: 34301822 PMCID: PMC8312280 DOI: 10.1212/nxi.0000000000001053] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 05/05/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To report the clinical, neuroimaging, and antibody associations in patients with autoimmune encephalitis (AE) and thymoma. METHODS A retrospective cohort study of 43 patients was conducted. Antibody determination and immunoprecipitation to characterize novel antigens were performed using reported techniques. RESULTS Patients' median age was 52 years (range: 23-88 years). Forty (93%) had neuronal surface antibodies: gamma-aminobutyric acid receptor A (GABAAR) (15), amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) (13), contactin-associated protein-like 2 (CASPR2) (4), leucine-rich, glioma inactivated 1 (LGI1) (3), glycine receptor (GlyR) (3), and unknown antigens (2). Concurrent antibodies against intracellular antigens occurred in 13 (30%; 9 anti-collapsin response mediator protein 5 [CRMP5]) and were more frequent in anti-AMPAR encephalitis (54% vs 20%; p = 0.037). The most common clinical presentation was encephalitis with multiple T2/fluid-attenuated inversion recovery hyperintense lesions in 23 (53%) patients (15 GABAAR, 5 AMPAR, and 1 unknown neuropil antibody), followed by encephalitis with peripheral nerve hyperexcitability in 7 (16%; 4 CASPR2, 2 LGI1, and 1 unknown antibody), limbic encephalitis in 6 (14%; 4 AMPAR, 1 LGI1, and 1 antibody negative), progressive encephalomyelitis with rigidity and myoclonus in 4 (9%; 3 GlyR and 1 AMPAR antibodies), and encephalitis with normal MRI in 3 (7%; AMPAR antibodies). Anti-GABAAR encephalitis was more prevalent in Japanese patients compared with Caucasians and other ethnicities (61% vs 16%; p = 0.003). In anti-AMPAR encephalitis, 3/4 patients with poor and 0/6 with good outcome had concurrent CRMP5 antibodies (p = 0.033). Immunoprecipitation studies identified metabotropic glutamate receptor 3 antibodies that were additionally found in 5 patients (3 with and 2 without encephalitis). CONCLUSIONS AE in patients with thymoma include several clinical-radiologic syndromes that vary according to the associated antibodies. Anti-GABAAR encephalitis was the most frequent AE and occurred more frequently in Japanese patients.
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Affiliation(s)
- Mar Guasp
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Jon Landa
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Eugenia Martinez-Hernandez
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Lidia Sabater
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Takahiro Iizuka
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Mateus Simabukuro
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Masataka Nakamura
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Makoto Kinoshita
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Masanori Kurihara
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Kenichi Kaida
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Jordi Bruna
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Solange Kapetanovic
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Pedro Sánchez
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Raquel Ruiz-García
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Laura Naranjo
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Jesús Planagumà
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Amaia Muñoz-Lopetegi
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Luis Bataller
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Albert Saiz
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Josep Dalmau
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Francesc Graus
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.L., E.M.-H., L.S., J.P., A.M.-L., A.S., J.D., F.G.), Hospital Clínic, Universitat de Barcelona; Neurology Department (M.G., E.M.-H., A.M.-L., A.S., J.D.), Institute of Neuroscience, Hospital Clínic, Barcelona; Centro de Investigación Biomédica en Red (M.G., E.M.-H., L.S., J.D.), Enfermedades Raras (CIBERER), Spain; Department of Neurology (T.I.), Kitasato University School of Medicine, Sagamihara, Japan; Neurology Division (M.S.), University of São Paulo, School of Medicine, Brazil; Department of Neurology (M.N.), Kansai Medical University, Hirakata; Department of Neurology (M. Kinoshita), Osaka University Graduate School of Medicine; Department of Neurology (M. Kurihara), Graduate School of Medicine, University of Tokyo; Department of Neurology (K.K.), Saitama Medical Center, Saitama Medical University, Kawagoe, Japan; Neuro-Oncology Unit (J.B.), Hospital Universitari de Bellvitge-ICO L'Hospitalet, Spain; Department of Neurology (S.K.), Hospital de Basurto, Bilbao; Hospital Universitario de La Princesa (P.S.), Instituto de Investigación Sanitaria La Princesa, Madrid; Immunology Department (R.R.-G., L.N.), Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Neurology Department (L.B.), Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institute for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain.
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Landa J, Guasp M, Míguez-Cabello F, Guimarães J, Mishima T, Oda F, Zipp F, Krajinovic V, Fuhr P, Honnorat J, Titulaer M, Simabukuro M, Planagumà J, Martínez-Hernández E, Armangué T, Saiz A, Gasull X, Soto D, Graus F, Sabater L, Dalmau J. Encephalitis with Autoantibodies against the Glutamate Kainate Receptors GluK2. Ann Neurol 2021; 90:101-117. [PMID: 33949707 DOI: 10.1002/ana.26098] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/03/2021] [Accepted: 05/03/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The objective of this study was to report the identification of antibodies against the glutamate kainate receptor subunit 2 (GluK2-abs) in patients with autoimmune encephalitis, and describe the clinical-immunological features and antibody effects. METHODS Two sera from 8 patients with similar rat brain immunostaining were used to precipitate the antigen from neuronal cultures. A cell-based assay (CBA) with GluK2-expressing HEK293 cells was used to assess 596 patients with different neurological disorders, and 23 healthy controls. GluK2-ab effects were determined by confocal microscopy in cultured neurons and electrophysiology in GluK2-expressing HEK293 cells. RESULTS Patients' antibodies precipitated GluK2. GluK2 antibody-specificity was confirmed by CBA, immunoprecipitation, GluK2-immunoabsorption, and GluK2 knockout brain immunohistochemistry. In 2 of 8 samples, antibodies reacted with additional GluK2 epitopes present in GluK1 or GluK3; in both, the reactivity was abrogated after GluK2 immuno-absorption. Six of 8 patients developed acute encephalitis and clinical or magnetic resonance imaging (MRI) features of predominant cerebellar involvement (4 presenting as cerebellitis, which in 2 patients caused obstructive hydrocephalus), and 2 patients had other syndromes (1 with cerebellar symptoms). One of the samples showed mild reactivity with non-kainate receptors (alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors [AMPAR] and N-methyl-D-aspartate receptors [NMDAR]) leading to identify 6 additional cases with GluK2-abs among patients with anti-AMPAR (5/71) or anti-NMDAR encephalitis (1/73). GluK2-abs internalized GluK2 in HEK293 cells and neurons; these antibody-effects were reversible in neurons. A significant reduction of GluK2-mediated currents was observed in cells treated with patients' GluK2 serum following the time frame of antibody-mediated GluK2 internalization. INTERPRETATION GluK2-abs associate with an encephalitis with prominent clinicoradiological cerebellar involvement. The antibody effects are predominantly mediated by internalization of GluK2. ANN NEUROL 2021;90:107-123.
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Affiliation(s)
- Jon Landa
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Mar Guasp
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Service of Neurology, Hospital Clinic, Barcelona, Spain
| | - Federico Míguez-Cabello
- Neurophysiology Laboratory, Department of Biomedicine, School of Medicine, Neuroscience Institute, University of Barcelona, Barcelona, Spain
| | - Joana Guimarães
- Neurology Department, Centro Hospitalar Universitário São João, Clinical Neurosciences and Mental Health Department, Faculty of Medicine, Porto, Portugal
| | | | - Fumiko Oda
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Frauke Zipp
- Neurology Department, Focus Program Translational Neurosciences (FTN) and Immunotherapy (FZI), Rhine Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Vladimir Krajinovic
- University Hospital for Infectious Diseases "Dr. Fran Mihaljevic", Zagreb, Croatia
| | - Peter Fuhr
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Jerome Honnorat
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, University Claude Bernard, Villeurbanne, France
| | - Maarten Titulaer
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Mateus Simabukuro
- Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Jesus Planagumà
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Eugenia Martínez-Hernández
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Service of Neurology, Hospital Clinic, Barcelona, Spain
| | - Thais Armangué
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Neuroimmunology Unit, Neurology Service, Sant Joan de Déu Children's Hospital, University of Barcelona, Barcelona, Spain
| | - Albert Saiz
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Service of Neurology, Hospital Clinic, Barcelona, Spain
| | - Xavier Gasull
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Neurophysiology Laboratory, Department of Biomedicine, School of Medicine, Neuroscience Institute, University of Barcelona, Barcelona, Spain
| | - David Soto
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Neurophysiology Laboratory, Department of Biomedicine, School of Medicine, Neuroscience Institute, University of Barcelona, Barcelona, Spain
| | - Francesc Graus
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Lidia Sabater
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Josep Dalmau
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Service of Neurology, Hospital Clinic, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Madrid, Spain
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Catalan Institute for Research and Advanced Studies (ICREA), Barcelona, Spain
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Ruiz-García R, Muñoz-Sánchez G, Naranjo L, Guasp M, Sabater L, Saiz A, Dalmau J, Graus F, Martinez-Hernandez E. Limitations of a Commercial Assay as Diagnostic Test of Autoimmune Encephalitis. Front Immunol 2021; 12:691536. [PMID: 34267758 PMCID: PMC8276168 DOI: 10.3389/fimmu.2021.691536] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/15/2021] [Indexed: 12/24/2022] Open
Abstract
Detection of neuronal surface antibodies (NSAb) is important for the diagnosis of autoimmune encephalitis (AE). Although most clinical laboratories use a commercial diagnostic kit (Euroimmun, Lübeck, Germany) based on indirect immunofluorescence on transfected cells (IIFA), clinical experience suggests diagnostic limitations. Here, we assessed the performance of the commercial IIFA in serum and CSF samples of patients with suspected AE previously examined by rat brain immunohistochemistry (Cohort A). Of 6213 samples, 404 (6.5%) showed brain immunostaining suggestive of NSAb: 163 (40%) were positive by commercial IIFA and 241 (60%) were negative. When these 241 samples were re-assessed with in-house IIFA, 42 (18%) were positive: 21 (9%) had NSAb against antigens not included in the commercial IIFA and the other 21 (9%) had NSAb against antigens included in the commercial kit (false negative results). False negative results occurred more frequently with CSF (29% vs 10% in serum) and predominantly affected GABABR (39%), LGI1 (17%) and AMPAR (11%) antibodies. Results were reproduced in a separate cohort (B) of 54 AE patients with LGI1, GABABR or AMPAR antibodies in CSF which were missed in 30% by commercial IIFA. Patients with discordant GABABR antibody results (positive in-house but negative commercial IIFA) were less likely to develop full-blown clinical syndrome; no significant clinical differences were noted for the other antibodies. Overall, NSAb testing by commercial IIFA led to false negative results in a substantial number of patients, mainly those affected by anti-LG1, GABABR or AMPAR encephalitis. If these disorders are suspected and commercial IIFA is negative, more comprehensive antibody studies are recommended.
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Affiliation(s)
- Raquel Ruiz-García
- Immunology Department, Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona, Spain
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Laura Naranjo
- Immunology Department, Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona, Spain
| | - Mar Guasp
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Neurology Department, Hospital Clinic, and University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Raras (CIBERER), Madrid, Spain
| | - Lidia Sabater
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Albert Saiz
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Neurology Department, Hospital Clinic, and University of Barcelona, Barcelona, Spain
| | - Josep Dalmau
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Neurology Department, Hospital Clinic, and University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Raras (CIBERER), Madrid, Spain
- Neurology Department, University of Pennsylvania, Philadelphia, PA, United States
- Catalan Institution of Research and Advanced Studies (ICREA), Barcelona, Spain
| | - Francesc Graus
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Eugenia Martinez-Hernandez
- Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Neurology Department, Hospital Clinic, and University of Barcelona, Barcelona, Spain
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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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