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Mahadeen AZ, Carlson AK, Cohen JA, Galioto R, Abbatemarco JR, Kunchok A. Review of the Longitudinal Management of Autoimmune Encephalitis, Potential Biomarkers, and Novel Therapeutics. Neurol Clin Pract 2024; 14:e200306. [PMID: 38831758 PMCID: PMC11145747 DOI: 10.1212/cpj.0000000000200306] [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: 03/25/2023] [Accepted: 02/08/2024] [Indexed: 06/05/2024]
Abstract
Purpose of Review Increasing awareness and earlier diagnosis of autoimmune encephalitis (AE) have led to a greater number of patients being cared for longitudinally by neurologists. Although many neurologists are now familiar with the general approach to diagnosis and acute immunosuppression, this review aims to provide neurologists with guidance related to management beyond the acute phase of disease, including long-term immunosuppression, monitoring, potential biomarkers of disease activity, outcome measures, and symptom management. Recent Findings Observational studies in AE have demonstrated that early diagnosis and treatment is associated with improved neurologic outcomes, particularly in AE with antibodies targeting neuronal cell surface/synaptic proteins. The literature regarding long-term management is evolving. In addition to traditional immunosuppressive approaches, there is emerging use of novel immunosuppressive therapies (ISTs) in case series, and several randomized controlled trials are planned. Novel biomarkers of disease activity and methods to measure outcomes and response to treatment are being explored. Furthermore, it is increasingly recognized that many individuals have chronic symptoms affecting quality of life including seizures, cognitive impairment, fatigue, sleep disorders, and mood disorders, and there are emerging data supporting the use of patient centered outcome measures and multidisciplinary symptom-based care. Summary This review aims to summarize recent literature and offer a practical approach to long-term management of adult patients with AE through a multidisciplinary approach. We summarize current knowledge on ISTs, potential biomarkers of disease activity, outcome measures, and long-term sequelae. Further research is needed to answer questions regarding optimal IST, biomarker validity, and sequelae of disease.
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Affiliation(s)
- Ahmad Z Mahadeen
- Department of Neurology (AZM), University of Mississippi Medical Center, Jackson; and Cleveland Clinic Mellen Center (AKC, JAC, RG, JRA, AK), OH
| | - Alise K Carlson
- Department of Neurology (AZM), University of Mississippi Medical Center, Jackson; and Cleveland Clinic Mellen Center (AKC, JAC, RG, JRA, AK), OH
| | - Jeffrey A Cohen
- Department of Neurology (AZM), University of Mississippi Medical Center, Jackson; and Cleveland Clinic Mellen Center (AKC, JAC, RG, JRA, AK), OH
| | - Rachel Galioto
- Department of Neurology (AZM), University of Mississippi Medical Center, Jackson; and Cleveland Clinic Mellen Center (AKC, JAC, RG, JRA, AK), OH
| | - Justin R Abbatemarco
- Department of Neurology (AZM), University of Mississippi Medical Center, Jackson; and Cleveland Clinic Mellen Center (AKC, JAC, RG, JRA, AK), OH
| | - Amy Kunchok
- Department of Neurology (AZM), University of Mississippi Medical Center, Jackson; and Cleveland Clinic Mellen Center (AKC, JAC, RG, JRA, AK), OH
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Alsalek S, Schwarzmann KB, Budhathoki S, Hernandez-Lopez V, Smith JB, Li BH, Langer-Gould A. Racial and Ethnic Disparities in the Incidence of Anti-NMDA Receptor Encephalitis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200255. [PMID: 38728608 PMCID: PMC11089538 DOI: 10.1212/nxi.0000000000200255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/14/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVES To estimate the incidence of anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis. METHODS We conducted a retrospective cohort study of >10 million person-years of observation from members of Kaiser Permanente Southern California, 2011-2022. The electronic health record of individuals with text-string mention of NMDA and encephalitis were reviewed to identify persons who met diagnostic criteria for anti-NMDAR encephalitis. Age-standardized and sex-standardized incidences stratified by race and ethnicity were estimated according to the 2020 US Census population. RESULTS We identified 70 patients who met diagnostic criteria for anti-NMDAR encephalitis. The median age at onset was 23.7 years (IQR = 14.2-31.0 years), and 45 (64%) were female patients. The age-standardized and sex-standardized incidence of anti-NMDAR encephalitis per 1 million person-years was significantly higher in Black (2.94, 95% CI 1.27-4.61), Hispanic (2.17, 95% CI 1.51-2.83), and Asian/Pacific Island persons (2.02, 95% CI 0.77-3.28) compared with White persons (0.40, 95% CI 0.08-0.72). Ovarian teratomas were found in 58.3% of Black female individuals and 10%-28.6% in other groups. DISCUSSION Anti-NMDA receptor encephalitis disproportionately affected Black, Hispanic, or Asian/Pacific Island persons. Ovarian teratomas were a particularly common trigger in Black female individuals. Future research should seek to identify environmental and biological risk factors that disproportionately affect minoritized individuals residing in the United States.
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Affiliation(s)
- Samir Alsalek
- From the Kaiser Permanente Bernard J. Tyson School of Medicine (S.A., K.B.S., S.B., V.H.-L.); Department of Research and Evaluation (J.B.S., B.H.L.); Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group; and Department of Clinical Science (A.L.-G.), Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Kathryn B Schwarzmann
- From the Kaiser Permanente Bernard J. Tyson School of Medicine (S.A., K.B.S., S.B., V.H.-L.); Department of Research and Evaluation (J.B.S., B.H.L.); Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group; and Department of Clinical Science (A.L.-G.), Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Sakar Budhathoki
- From the Kaiser Permanente Bernard J. Tyson School of Medicine (S.A., K.B.S., S.B., V.H.-L.); Department of Research and Evaluation (J.B.S., B.H.L.); Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group; and Department of Clinical Science (A.L.-G.), Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Viridiana Hernandez-Lopez
- From the Kaiser Permanente Bernard J. Tyson School of Medicine (S.A., K.B.S., S.B., V.H.-L.); Department of Research and Evaluation (J.B.S., B.H.L.); Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group; and Department of Clinical Science (A.L.-G.), Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Jessica B Smith
- From the Kaiser Permanente Bernard J. Tyson School of Medicine (S.A., K.B.S., S.B., V.H.-L.); Department of Research and Evaluation (J.B.S., B.H.L.); Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group; and Department of Clinical Science (A.L.-G.), Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Bonnie H Li
- From the Kaiser Permanente Bernard J. Tyson School of Medicine (S.A., K.B.S., S.B., V.H.-L.); Department of Research and Evaluation (J.B.S., B.H.L.); Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group; and Department of Clinical Science (A.L.-G.), Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Annette Langer-Gould
- From the Kaiser Permanente Bernard J. Tyson School of Medicine (S.A., K.B.S., S.B., V.H.-L.); Department of Research and Evaluation (J.B.S., B.H.L.); Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group; and Department of Clinical Science (A.L.-G.), Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
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Wei M, Bannout F, Dastjerdi M, Phan C, Batarseh S, Guo X, Baker N. Immunotherapy in a case of low titre GAD65 antibody-associated spectrum neurological disorders. BMJ Case Rep 2024; 17:e260503. [PMID: 38871638 DOI: 10.1136/bcr-2024-260503] [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: 06/15/2024] Open
Abstract
We present a rare case of low titre GAD65 antibody-associated autoimmune encephalitis and status epilepticus in a young woman. She initially presented with left arm dystonic movements, contractures and status epilepticus. Due to the concern of autoimmune encephalitis and seizures, the patient received intravenous immunoglobulin empirically. After the detection of low serum GAD65 antibodies, the patient underwent immunomodulation therapy with significant improvement. This case demonstrated that in autoimmune encephalitis, it is important to monitor serum GAD65 antibodies levels and consider immunotherapy, despite mildly elevated serum levels. The patient's history of left arm dystonic movements without impaired awareness may have been due to limb dystonia, a presenting symptom of stiff person syndrome (SPS), despite SPS more commonly affecting axial muscles. This case further demonstrates that GAD65 antibody-related syndromes can manifest with different neurological phenotypes including co-occurrence of epilepsy with possible focal SPS despite low GAD65 antibodies titres.
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Affiliation(s)
- Miao Wei
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Firas Bannout
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Mohammad Dastjerdi
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Cattien Phan
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Sanad Batarseh
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Xiaofan Guo
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Nancy Baker
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
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Binks SNM, Al-Diwani A, Handel AE, Bajorek T, Manohar S, Husain M, Irani SR, Koychev I. LGI1-antibody encephalitis: how to approach this highly treatable dementia mimic in memory and mental health services. Br J Psychiatry 2024; 224:252-257. [PMID: 38699852 PMCID: PMC7615977 DOI: 10.1192/bjp.2024.72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Leucine-rich glioma-inactivated 1-antibody-encephalitis is a treatable and potentially reversible cause of cognitive and psychiatric presentations, and may mimic cognitive decline, rapidly progressive dementia and complex psychosis in older patients. This aetiology is of immediate relevance given the alternative treatment pathway required, compared with other conditions presenting with cognitive deficits.
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Affiliation(s)
- Sophie N M Binks
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Adam Al-Diwani
- University Department of Psychiatry, University of Oxford, UK
- Department of Psychological Medicine, John Radcliffe Hospital, Oxford University Hospital NHS Foundation Trust, Oxford, UK
- Oxford Community Psychological Medicine Service, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Adam E Handel
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospital NHS Foundation Trust, Oxford, UK
- Department of Psychological Medicine, John Radcliffe Hospital, Oxford University Hospital NHS Foundation Trust, Oxford, UK
- Oxford Community Psychological Medicine Service, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Tomasz Bajorek
- Department of Psychological Medicine, John Radcliffe Hospital, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Sanjay Manohar
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospital NHS Foundation Trust, Oxford, UK
- Department of Experimental Psychology, University of Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Masud Husain
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospital NHS Foundation Trust, Oxford, UK
- Department of Experimental Psychology, University of Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Ivan Koychev
- University Department of Psychiatry, University of Oxford, UK; and Department of Psychological Medicine, John Radcliffe Hospital, Oxford University Hospital NHS Foundation Trust, Oxford, UK
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Crowe EP, Diaz-Arias LA, Habis R, Vozniak SO, Geocadin RG, Venkatesan A, Tobian AAR, Probasco JC, Bloch EM. Suspected autoimmune encephalitis: A retrospective study of patients referred for therapeutic plasma exchange. J Clin Apher 2024; 39:e22112. [PMID: 38634442 DOI: 10.1002/jca.22112] [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: 01/17/2024] [Revised: 02/16/2024] [Accepted: 02/22/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Autoimmune encephalitis (AE) comprises a heterogeneous group of autoantibody-mediated disorders targeting the brain parenchyma. Therapeutic plasma exchange (TPE), one of several first-line therapies for AE, is often initiated when AE is suspected, albeit prior to an established diagnosis. We sought to characterize the role of TPE in the treatment of suspected AE. METHODS A single-center, retrospective analysis was performed of adults (≥18 years) who underwent at least one TPE procedure for "suspected AE." The following parameters were extracted and evaluated descriptively: clinicopathologic characteristics, treatment course, TPE-related adverse events, outcomes (e.g., modified Rankin scale [mRS]), and diagnosis once investigation was complete. RESULTS A total of 37 patients (median age 56 years, range 28-77 years, 62.2% male) were evaluated. Autoimmune antibody testing was positive in serum for 43.2% (n = 16) and cerebrospinal fluid for 29.7% (n = 11). Patients underwent a median of five TPE procedures (range 3-16), with 97.3% (n = 36) via a central line and 21.6% (n = 8) requiring at least one unit of plasma as replacement fluid. Fifteen patients (40.5%) experienced at least one TPE-related adverse event. Compared with mRS at admission, the mRS at discharge was improved in 21.6% (n = 8), unchanged in 59.5% (n = 22), or worse in 18.9% (n = 7). Final diagnosis of AE was determined to be definite in 48.6% (n = 18), probable in 8.1% (n = 3) and possible in 27.0% (n = 10). Six (16.2%) patients were ultimately determined to have an alternate etiology. CONCLUSION Empiric TPE for suspected AE is generally well-tolerated. However, its efficacy remains uncertain in the absence of controlled trials, particularly in the setting of seronegative disease.
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Affiliation(s)
- Elizabeth P Crowe
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Luisa A Diaz-Arias
- Johns Hopkins Encephalitis Center, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ralph Habis
- Johns Hopkins Encephalitis Center, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sonja O Vozniak
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Romergryko G Geocadin
- Johns Hopkins Encephalitis Center, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Arun Venkatesan
- Johns Hopkins Encephalitis Center, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - John C Probasco
- Johns Hopkins Encephalitis Center, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Evan M Bloch
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Lopes S, Francisco L, Moreira S, Varanda S, Araújo JM. Anti-CASPR2 Antibody-Associated Syndrome Presenting With Episodic Ataxia. Cureus 2024; 16:e59821. [PMID: 38846209 PMCID: PMC11156247 DOI: 10.7759/cureus.59821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2024] [Indexed: 06/09/2024] Open
Abstract
The anti-CASPR2 antibody-associated syndrome is a rare immune-mediated disorder. Most case reports describe neurologic symptoms that include encephalic signs, peripheral nerve hyperexcitability, dysautonomia, or neuropathic pain. We report the case of a 70-year-old man, admitted to the emergency department with complaints of slurred speech and imbalance. Neurological examination was relevant for dysarthria, hyperreflexia, and pancerebellar syndrome. Cranial CT and basic laboratory tests were normal and he spontaneously recovered after 14 hours. Over the next four months, the patient experienced three similar episodes in relation to stressful events (emotional and organic disturbances like prolonged fasting and vaccination). A contrast-enhanced MRI was performed, along with extensive laboratory testing, analysis of cerebrospinal fluid (CSF), paraneoplastic investigation, and next-generation sequencing panel for episodic ataxias. The results revealed oligoclonal bands in the CSF and positive anti-CASPR2 antibodies both in serum and CSF. Three-day-IV- methylprednisolone pulse followed by plasmapheresis and monthly intravenous immunoglobulins was performed with good response. In conclusion, the neurological manifestations that led to the diagnosis of anti-CASPR2 antibody-associated syndrome were intermittent self-limiting episodes of ataxia, often triggered by concurrent stress-inducing factors. This case supports the aim of other authors to add paroxysmal cerebellar ataxia to the spectrum of the anti-CASPR2 antibody syndrome.
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Affiliation(s)
- Sofia Lopes
- Neurology Department, Unidade Local de Saúde de Braga, Braga, PRT
| | - Leonor Francisco
- Neurology Department, Unidade Local de Saúde Alto Minho, Viana do Castelo, PRT
| | - Stefanie Moreira
- Neurology Department, Unidade Local de Saúde de Braga, Braga, PRT
| | - Sara Varanda
- Neurology Department, Unidade Local de Saúde de Braga, Braga, PRT
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Campetella L, Farina A, Villagrán-García M, Villard M, Benaiteau M, Timestit N, Vogrig A, Picard G, Rogemond V, Psimaras D, Rafiq M, Chanson E, Marchal C, Goncalves D, Joubert B, Honnorat J, Muñiz-Castrillo S. Predictors and Clinical Characteristics of Relapses in LGI1-Antibody Encephalitis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200228. [PMID: 38603771 PMCID: PMC11010249 DOI: 10.1212/nxi.0000000000200228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/29/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND AND OBJECTIVES Relapses occur in 15%-25% of patients with leucine-rich glioma-inactivated 1 antibody (LGI1-Ab) autoimmune encephalitis and may cause additional disability. In this study, we clinically characterized the relapses and identified factors predicting their occurrence. METHODS This is a retrospective chart review of patients with LGI1-Ab encephalitis diagnosed at our center between 2005 and 2022. Relapse was defined as worsening of previous or appearance of new symptoms after at least 3 months of clinical stabilization. RESULTS Among 210 patients, 30 (14%) experienced a total of 33 relapses. The median time to first relapse was 23.9 months (range: 4.9-110.1, interquartile range [IQR]: 17.8). The CSF was inflammatory in 11/25 (44%) relapses, while LGI1-Abs were found in the serum in 16/24 (67%) and in the CSF in 12/26 (46%); brain MRI was abnormal in 16/26 (62%) relapses. Compared with the initial episode, relapses manifested less frequently with 3 or more symptoms (4/30 patients, 13% vs 28/30, 93%; p < 0.001) and had lower maximal modified Rankin scale (mRS) score (median 3, range: 2-5, IQR: 1 vs 3, range: 2-5, IQR: 0; p = 0.001). The median mRS at last follow-up after relapse (2, range: 0-4, IQR: 2) was significantly higher than after the initial episode (1, range: 0-4, IQR: 1; p = 0.005). Relapsing patients did not differ in their initial clinical and diagnostic features from 85 patients without relapse. Nevertheless, residual cognitive dysfunction after the initial episode (hazard ratio:13.8, 95% confidence interval [1.5; 129.5]; p = 0.022) and no administration of corticosteroids at the initial episode (hazard ratio: 4.8, 95% confidence interval [1.1; 21.1]; p = 0.036) were significantly associated with an increased risk of relapse. DISCUSSION Relapses may occur years after the initial encephalitis episode and are usually milder but cause additional disability. Corticosteroid treatment reduces the risk of future relapses, while patients with residual cognitive dysfunction after the initial episode have an increased relapse risk.
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Affiliation(s)
- Lucia Campetella
- From the French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (L.C., A.F., M.V.-G., M.V., M.B., A.V., G.P., V.R., B.J., J.H., S.M.-C.), Hospices Civils de Lyon; MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314 (L.C., A.F., M.V.-G., M.B., A.V., B.J., J.H., S.M.-C.), Université Claude Bernard Lyon 1, France; Department of Neuroscience (A.F.), Psychology, Pharmacology and Child Health, University of Florence, Italy; Department of Biostatistics (N.T.), Hospices Civils de Lyon, France; Clinical Neurology (A.V.), Santa Maria Della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine, Italy; Neurology Department 2-Mazarin (D.P.), Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, APHP; Brain and Spinal Cord Institute (D.P.), INSERM U1127/CNRS UMR 7255, Université Pierre-et-Marie-Curie, Universités Sorbonnes, Paris; Neurology Department (M.R.), Hôpital Pierre Paul Riquet, CHU de Toulouse; Neurology Department (E.C.), Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand; Neurology Department (C.M.), Centre Hospitalier Universitaire de Bordeaux; Immunology Department (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; and Stanford Center for Sleep Sciences and Medicine (S.M.-C.), Stanford University, Palo Alto, CA
| | - Antonio Farina
- From the French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (L.C., A.F., M.V.-G., M.V., M.B., A.V., G.P., V.R., B.J., J.H., S.M.-C.), Hospices Civils de Lyon; MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314 (L.C., A.F., M.V.-G., M.B., A.V., B.J., J.H., S.M.-C.), Université Claude Bernard Lyon 1, France; Department of Neuroscience (A.F.), Psychology, Pharmacology and Child Health, University of Florence, Italy; Department of Biostatistics (N.T.), Hospices Civils de Lyon, France; Clinical Neurology (A.V.), Santa Maria Della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine, Italy; Neurology Department 2-Mazarin (D.P.), Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, APHP; Brain and Spinal Cord Institute (D.P.), INSERM U1127/CNRS UMR 7255, Université Pierre-et-Marie-Curie, Universités Sorbonnes, Paris; Neurology Department (M.R.), Hôpital Pierre Paul Riquet, CHU de Toulouse; Neurology Department (E.C.), Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand; Neurology Department (C.M.), Centre Hospitalier Universitaire de Bordeaux; Immunology Department (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; and Stanford Center for Sleep Sciences and Medicine (S.M.-C.), Stanford University, Palo Alto, CA
| | - Macarena Villagrán-García
- From the French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (L.C., A.F., M.V.-G., M.V., M.B., A.V., G.P., V.R., B.J., J.H., S.M.-C.), Hospices Civils de Lyon; MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314 (L.C., A.F., M.V.-G., M.B., A.V., B.J., J.H., S.M.-C.), Université Claude Bernard Lyon 1, France; Department of Neuroscience (A.F.), Psychology, Pharmacology and Child Health, University of Florence, Italy; Department of Biostatistics (N.T.), Hospices Civils de Lyon, France; Clinical Neurology (A.V.), Santa Maria Della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine, Italy; Neurology Department 2-Mazarin (D.P.), Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, APHP; Brain and Spinal Cord Institute (D.P.), INSERM U1127/CNRS UMR 7255, Université Pierre-et-Marie-Curie, Universités Sorbonnes, Paris; Neurology Department (M.R.), Hôpital Pierre Paul Riquet, CHU de Toulouse; Neurology Department (E.C.), Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand; Neurology Department (C.M.), Centre Hospitalier Universitaire de Bordeaux; Immunology Department (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; and Stanford Center for Sleep Sciences and Medicine (S.M.-C.), Stanford University, Palo Alto, CA
| | - Marine Villard
- From the French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (L.C., A.F., M.V.-G., M.V., M.B., A.V., G.P., V.R., B.J., J.H., S.M.-C.), Hospices Civils de Lyon; MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314 (L.C., A.F., M.V.-G., M.B., A.V., B.J., J.H., S.M.-C.), Université Claude Bernard Lyon 1, France; Department of Neuroscience (A.F.), Psychology, Pharmacology and Child Health, University of Florence, Italy; Department of Biostatistics (N.T.), Hospices Civils de Lyon, France; Clinical Neurology (A.V.), Santa Maria Della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine, Italy; Neurology Department 2-Mazarin (D.P.), Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, APHP; Brain and Spinal Cord Institute (D.P.), INSERM U1127/CNRS UMR 7255, Université Pierre-et-Marie-Curie, Universités Sorbonnes, Paris; Neurology Department (M.R.), Hôpital Pierre Paul Riquet, CHU de Toulouse; Neurology Department (E.C.), Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand; Neurology Department (C.M.), Centre Hospitalier Universitaire de Bordeaux; Immunology Department (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; and Stanford Center for Sleep Sciences and Medicine (S.M.-C.), Stanford University, Palo Alto, CA
| | - Marie Benaiteau
- From the French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (L.C., A.F., M.V.-G., M.V., M.B., A.V., G.P., V.R., B.J., J.H., S.M.-C.), Hospices Civils de Lyon; MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314 (L.C., A.F., M.V.-G., M.B., A.V., B.J., J.H., S.M.-C.), Université Claude Bernard Lyon 1, France; Department of Neuroscience (A.F.), Psychology, Pharmacology and Child Health, University of Florence, Italy; Department of Biostatistics (N.T.), Hospices Civils de Lyon, France; Clinical Neurology (A.V.), Santa Maria Della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine, Italy; Neurology Department 2-Mazarin (D.P.), Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, APHP; Brain and Spinal Cord Institute (D.P.), INSERM U1127/CNRS UMR 7255, Université Pierre-et-Marie-Curie, Universités Sorbonnes, Paris; Neurology Department (M.R.), Hôpital Pierre Paul Riquet, CHU de Toulouse; Neurology Department (E.C.), Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand; Neurology Department (C.M.), Centre Hospitalier Universitaire de Bordeaux; Immunology Department (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; and Stanford Center for Sleep Sciences and Medicine (S.M.-C.), Stanford University, Palo Alto, CA
| | - Noémie Timestit
- From the French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (L.C., A.F., M.V.-G., M.V., M.B., A.V., G.P., V.R., B.J., J.H., S.M.-C.), Hospices Civils de Lyon; MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314 (L.C., A.F., M.V.-G., M.B., A.V., B.J., J.H., S.M.-C.), Université Claude Bernard Lyon 1, France; Department of Neuroscience (A.F.), Psychology, Pharmacology and Child Health, University of Florence, Italy; Department of Biostatistics (N.T.), Hospices Civils de Lyon, France; Clinical Neurology (A.V.), Santa Maria Della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine, Italy; Neurology Department 2-Mazarin (D.P.), Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, APHP; Brain and Spinal Cord Institute (D.P.), INSERM U1127/CNRS UMR 7255, Université Pierre-et-Marie-Curie, Universités Sorbonnes, Paris; Neurology Department (M.R.), Hôpital Pierre Paul Riquet, CHU de Toulouse; Neurology Department (E.C.), Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand; Neurology Department (C.M.), Centre Hospitalier Universitaire de Bordeaux; Immunology Department (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; and Stanford Center for Sleep Sciences and Medicine (S.M.-C.), Stanford University, Palo Alto, CA
| | - Alberto Vogrig
- From the French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (L.C., A.F., M.V.-G., M.V., M.B., A.V., G.P., V.R., B.J., J.H., S.M.-C.), Hospices Civils de Lyon; MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314 (L.C., A.F., M.V.-G., M.B., A.V., B.J., J.H., S.M.-C.), Université Claude Bernard Lyon 1, France; Department of Neuroscience (A.F.), Psychology, Pharmacology and Child Health, University of Florence, Italy; Department of Biostatistics (N.T.), Hospices Civils de Lyon, France; Clinical Neurology (A.V.), Santa Maria Della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine, Italy; Neurology Department 2-Mazarin (D.P.), Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, APHP; Brain and Spinal Cord Institute (D.P.), INSERM U1127/CNRS UMR 7255, Université Pierre-et-Marie-Curie, Universités Sorbonnes, Paris; Neurology Department (M.R.), Hôpital Pierre Paul Riquet, CHU de Toulouse; Neurology Department (E.C.), Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand; Neurology Department (C.M.), Centre Hospitalier Universitaire de Bordeaux; Immunology Department (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; and Stanford Center for Sleep Sciences and Medicine (S.M.-C.), Stanford University, Palo Alto, CA
| | - Géraldine Picard
- From the French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (L.C., A.F., M.V.-G., M.V., M.B., A.V., G.P., V.R., B.J., J.H., S.M.-C.), Hospices Civils de Lyon; MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314 (L.C., A.F., M.V.-G., M.B., A.V., B.J., J.H., S.M.-C.), Université Claude Bernard Lyon 1, France; Department of Neuroscience (A.F.), Psychology, Pharmacology and Child Health, University of Florence, Italy; Department of Biostatistics (N.T.), Hospices Civils de Lyon, France; Clinical Neurology (A.V.), Santa Maria Della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine, Italy; Neurology Department 2-Mazarin (D.P.), Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, APHP; Brain and Spinal Cord Institute (D.P.), INSERM U1127/CNRS UMR 7255, Université Pierre-et-Marie-Curie, Universités Sorbonnes, Paris; Neurology Department (M.R.), Hôpital Pierre Paul Riquet, CHU de Toulouse; Neurology Department (E.C.), Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand; Neurology Department (C.M.), Centre Hospitalier Universitaire de Bordeaux; Immunology Department (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; and Stanford Center for Sleep Sciences and Medicine (S.M.-C.), Stanford University, Palo Alto, CA
| | - Véronique Rogemond
- From the French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (L.C., A.F., M.V.-G., M.V., M.B., A.V., G.P., V.R., B.J., J.H., S.M.-C.), Hospices Civils de Lyon; MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314 (L.C., A.F., M.V.-G., M.B., A.V., B.J., J.H., S.M.-C.), Université Claude Bernard Lyon 1, France; Department of Neuroscience (A.F.), Psychology, Pharmacology and Child Health, University of Florence, Italy; Department of Biostatistics (N.T.), Hospices Civils de Lyon, France; Clinical Neurology (A.V.), Santa Maria Della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine, Italy; Neurology Department 2-Mazarin (D.P.), Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, APHP; Brain and Spinal Cord Institute (D.P.), INSERM U1127/CNRS UMR 7255, Université Pierre-et-Marie-Curie, Universités Sorbonnes, Paris; Neurology Department (M.R.), Hôpital Pierre Paul Riquet, CHU de Toulouse; Neurology Department (E.C.), Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand; Neurology Department (C.M.), Centre Hospitalier Universitaire de Bordeaux; Immunology Department (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; and Stanford Center for Sleep Sciences and Medicine (S.M.-C.), Stanford University, Palo Alto, CA
| | - Dimitri Psimaras
- From the French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (L.C., A.F., M.V.-G., M.V., M.B., A.V., G.P., V.R., B.J., J.H., S.M.-C.), Hospices Civils de Lyon; MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314 (L.C., A.F., M.V.-G., M.B., A.V., B.J., J.H., S.M.-C.), Université Claude Bernard Lyon 1, France; Department of Neuroscience (A.F.), Psychology, Pharmacology and Child Health, University of Florence, Italy; Department of Biostatistics (N.T.), Hospices Civils de Lyon, France; Clinical Neurology (A.V.), Santa Maria Della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine, Italy; Neurology Department 2-Mazarin (D.P.), Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, APHP; Brain and Spinal Cord Institute (D.P.), INSERM U1127/CNRS UMR 7255, Université Pierre-et-Marie-Curie, Universités Sorbonnes, Paris; Neurology Department (M.R.), Hôpital Pierre Paul Riquet, CHU de Toulouse; Neurology Department (E.C.), Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand; Neurology Department (C.M.), Centre Hospitalier Universitaire de Bordeaux; Immunology Department (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; and Stanford Center for Sleep Sciences and Medicine (S.M.-C.), Stanford University, Palo Alto, CA
| | - Marie Rafiq
- From the French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (L.C., A.F., M.V.-G., M.V., M.B., A.V., G.P., V.R., B.J., J.H., S.M.-C.), Hospices Civils de Lyon; MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314 (L.C., A.F., M.V.-G., M.B., A.V., B.J., J.H., S.M.-C.), Université Claude Bernard Lyon 1, France; Department of Neuroscience (A.F.), Psychology, Pharmacology and Child Health, University of Florence, Italy; Department of Biostatistics (N.T.), Hospices Civils de Lyon, France; Clinical Neurology (A.V.), Santa Maria Della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine, Italy; Neurology Department 2-Mazarin (D.P.), Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, APHP; Brain and Spinal Cord Institute (D.P.), INSERM U1127/CNRS UMR 7255, Université Pierre-et-Marie-Curie, Universités Sorbonnes, Paris; Neurology Department (M.R.), Hôpital Pierre Paul Riquet, CHU de Toulouse; Neurology Department (E.C.), Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand; Neurology Department (C.M.), Centre Hospitalier Universitaire de Bordeaux; Immunology Department (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; and Stanford Center for Sleep Sciences and Medicine (S.M.-C.), Stanford University, Palo Alto, CA
| | - Eve Chanson
- From the French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (L.C., A.F., M.V.-G., M.V., M.B., A.V., G.P., V.R., B.J., J.H., S.M.-C.), Hospices Civils de Lyon; MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314 (L.C., A.F., M.V.-G., M.B., A.V., B.J., J.H., S.M.-C.), Université Claude Bernard Lyon 1, France; Department of Neuroscience (A.F.), Psychology, Pharmacology and Child Health, University of Florence, Italy; Department of Biostatistics (N.T.), Hospices Civils de Lyon, France; Clinical Neurology (A.V.), Santa Maria Della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine, Italy; Neurology Department 2-Mazarin (D.P.), Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, APHP; Brain and Spinal Cord Institute (D.P.), INSERM U1127/CNRS UMR 7255, Université Pierre-et-Marie-Curie, Universités Sorbonnes, Paris; Neurology Department (M.R.), Hôpital Pierre Paul Riquet, CHU de Toulouse; Neurology Department (E.C.), Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand; Neurology Department (C.M.), Centre Hospitalier Universitaire de Bordeaux; Immunology Department (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; and Stanford Center for Sleep Sciences and Medicine (S.M.-C.), Stanford University, Palo Alto, CA
| | - Cecile Marchal
- From the French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (L.C., A.F., M.V.-G., M.V., M.B., A.V., G.P., V.R., B.J., J.H., S.M.-C.), Hospices Civils de Lyon; MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314 (L.C., A.F., M.V.-G., M.B., A.V., B.J., J.H., S.M.-C.), Université Claude Bernard Lyon 1, France; Department of Neuroscience (A.F.), Psychology, Pharmacology and Child Health, University of Florence, Italy; Department of Biostatistics (N.T.), Hospices Civils de Lyon, France; Clinical Neurology (A.V.), Santa Maria Della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine, Italy; Neurology Department 2-Mazarin (D.P.), Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, APHP; Brain and Spinal Cord Institute (D.P.), INSERM U1127/CNRS UMR 7255, Université Pierre-et-Marie-Curie, Universités Sorbonnes, Paris; Neurology Department (M.R.), Hôpital Pierre Paul Riquet, CHU de Toulouse; Neurology Department (E.C.), Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand; Neurology Department (C.M.), Centre Hospitalier Universitaire de Bordeaux; Immunology Department (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; and Stanford Center for Sleep Sciences and Medicine (S.M.-C.), Stanford University, Palo Alto, CA
| | - David Goncalves
- From the French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (L.C., A.F., M.V.-G., M.V., M.B., A.V., G.P., V.R., B.J., J.H., S.M.-C.), Hospices Civils de Lyon; MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314 (L.C., A.F., M.V.-G., M.B., A.V., B.J., J.H., S.M.-C.), Université Claude Bernard Lyon 1, France; Department of Neuroscience (A.F.), Psychology, Pharmacology and Child Health, University of Florence, Italy; Department of Biostatistics (N.T.), Hospices Civils de Lyon, France; Clinical Neurology (A.V.), Santa Maria Della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine, Italy; Neurology Department 2-Mazarin (D.P.), Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, APHP; Brain and Spinal Cord Institute (D.P.), INSERM U1127/CNRS UMR 7255, Université Pierre-et-Marie-Curie, Universités Sorbonnes, Paris; Neurology Department (M.R.), Hôpital Pierre Paul Riquet, CHU de Toulouse; Neurology Department (E.C.), Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand; Neurology Department (C.M.), Centre Hospitalier Universitaire de Bordeaux; Immunology Department (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; and Stanford Center for Sleep Sciences and Medicine (S.M.-C.), Stanford University, Palo Alto, CA
| | - Bastien Joubert
- From the French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (L.C., A.F., M.V.-G., M.V., M.B., A.V., G.P., V.R., B.J., J.H., S.M.-C.), Hospices Civils de Lyon; MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314 (L.C., A.F., M.V.-G., M.B., A.V., B.J., J.H., S.M.-C.), Université Claude Bernard Lyon 1, France; Department of Neuroscience (A.F.), Psychology, Pharmacology and Child Health, University of Florence, Italy; Department of Biostatistics (N.T.), Hospices Civils de Lyon, France; Clinical Neurology (A.V.), Santa Maria Della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine, Italy; Neurology Department 2-Mazarin (D.P.), Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, APHP; Brain and Spinal Cord Institute (D.P.), INSERM U1127/CNRS UMR 7255, Université Pierre-et-Marie-Curie, Universités Sorbonnes, Paris; Neurology Department (M.R.), Hôpital Pierre Paul Riquet, CHU de Toulouse; Neurology Department (E.C.), Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand; Neurology Department (C.M.), Centre Hospitalier Universitaire de Bordeaux; Immunology Department (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; and Stanford Center for Sleep Sciences and Medicine (S.M.-C.), Stanford University, Palo Alto, CA
| | - Jérôme Honnorat
- From the French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (L.C., A.F., M.V.-G., M.V., M.B., A.V., G.P., V.R., B.J., J.H., S.M.-C.), Hospices Civils de Lyon; MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314 (L.C., A.F., M.V.-G., M.B., A.V., B.J., J.H., S.M.-C.), Université Claude Bernard Lyon 1, France; Department of Neuroscience (A.F.), Psychology, Pharmacology and Child Health, University of Florence, Italy; Department of Biostatistics (N.T.), Hospices Civils de Lyon, France; Clinical Neurology (A.V.), Santa Maria Della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine, Italy; Neurology Department 2-Mazarin (D.P.), Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, APHP; Brain and Spinal Cord Institute (D.P.), INSERM U1127/CNRS UMR 7255, Université Pierre-et-Marie-Curie, Universités Sorbonnes, Paris; Neurology Department (M.R.), Hôpital Pierre Paul Riquet, CHU de Toulouse; Neurology Department (E.C.), Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand; Neurology Department (C.M.), Centre Hospitalier Universitaire de Bordeaux; Immunology Department (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; and Stanford Center for Sleep Sciences and Medicine (S.M.-C.), Stanford University, Palo Alto, CA
| | - Sergio Muñiz-Castrillo
- From the French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (L.C., A.F., M.V.-G., M.V., M.B., A.V., G.P., V.R., B.J., J.H., S.M.-C.), Hospices Civils de Lyon; MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314 (L.C., A.F., M.V.-G., M.B., A.V., B.J., J.H., S.M.-C.), Université Claude Bernard Lyon 1, France; Department of Neuroscience (A.F.), Psychology, Pharmacology and Child Health, University of Florence, Italy; Department of Biostatistics (N.T.), Hospices Civils de Lyon, France; Clinical Neurology (A.V.), Santa Maria Della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine, Italy; Neurology Department 2-Mazarin (D.P.), Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, APHP; Brain and Spinal Cord Institute (D.P.), INSERM U1127/CNRS UMR 7255, Université Pierre-et-Marie-Curie, Universités Sorbonnes, Paris; Neurology Department (M.R.), Hôpital Pierre Paul Riquet, CHU de Toulouse; Neurology Department (E.C.), Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand; Neurology Department (C.M.), Centre Hospitalier Universitaire de Bordeaux; Immunology Department (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; and Stanford Center for Sleep Sciences and Medicine (S.M.-C.), Stanford University, Palo Alto, CA
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Han B, Dai Y, Peng J, Yuan T, Yin Q, Yang L. Study on clinical features and factors related to long-term outcomes of antibody-negative autoimmune encephalitis. Ann Clin Transl Neurol 2024; 11:1325-1337. [PMID: 38644648 DOI: 10.1002/acn3.52049] [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: 11/29/2023] [Revised: 03/04/2024] [Accepted: 03/13/2024] [Indexed: 04/23/2024] Open
Abstract
OBJECTIVE To delineate the clinical characteristics of antibody-negative autoimmune encephalitis (AE) and to investigate factors associated with long-term outcomes among antibody-negative AE. METHODS Patients diagnosed with antibody-negative AE were recruited from January 2016 to December 2022 at the Second Xiangya Hospital of Central South University. The study assessed the long-term outcomes of antibody-negative AE using the modified Rankin scale (mRS) and the Clinical Assessment Scale in Autoimmune Encephalitis (CASE). Predictors influencing long-term outcomes were subsequently analyzed. External validation of RAPID scores (refractory status epilepticus [RSE], age of onset ≥60 years, ANPRA [antibody-negative probable autoimmune encephalitis], infratentorial involvement, and delay of immunotherapy ≥1 month) was performed. RESULTS In total, 100 (47 females and 53 males) antibody-negative AE patients were enrolled in this study, with approximately 49 (49%) experiencing unfavorable long-term outcomes (mRS scores ≥3). Antibody-negative AE was subcategorized into ANPRA, autoimmune limbic encephalitis (LE), and acute disseminated encephalomyelitis (ADEM). Psychiatric symptoms were prevalent in LE and ANPRA subtypes, while weakness and gait instability/dystonia were predominant in the ADEM subtype. Higher peak CASE scores (odds ratio [OR] 1.846, 95% confidence interval [CI]: 1.163-2.930, p = 0.009) and initiating immunotherapy within 30 days (OR 0.210, 95% CI: 0.046-0.948, p = 0.042) were correlated with long-term outcomes. Receiver operating characteristic (ROC) analysis returned that the RAPID scores cutoff of 1.5 best discriminated the group with poor long-term outcomes (sensitivity 85.7%, specificity 56.9%). INTERPRETATION The ANPRA subtype exhibited poorer long-term outcomes compared to LE and ADEM subtypes, and early immunotherapy was crucial for improving long-term outcomes in antibody-negative AE. The use of RAPID scoring could aid in guiding clinical decision making.
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Affiliation(s)
- Binhong Han
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yuwei Dai
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jian Peng
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Tianxiang Yuan
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qing Yin
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Li Yang
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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Lamblin F, Kerstens J, Muñiz-Castrillo S, Vogrig A, Goncalves D, Rogemond V, Picard G, Villard M, Pinto AL, Van Coevorden-Hameete MH, De Bruijn MA, De Vries JM, Schreurs M, Tyvaert L, Hopes L, Aupy J, Marchal C, Psimaras D, Kremer L, Bourg V, Antoine JCG, Wang A, Kahane P, Demeret S, Ahle G, Sempere VP, Timestit N, Nourredine M, Maureille A, Benaiteau M, Joubert B, Mignot E, Titulaer MJ, Honnorat J. Comparative Study of Paraneoplastic and Nonparaneoplastic Autoimmune Encephalitis With GABA BR Antibodies. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200229. [PMID: 38657198 PMCID: PMC11087025 DOI: 10.1212/nxi.0000000000200229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/29/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND AND OBJECTIVES While patients with paraneoplastic autoimmune encephalitis (AE) with gamma-aminobutyric-acid B receptor antibodies (GABABR-AE) have poor functional outcomes and high mortality, the prognosis of nonparaneoplastic cases has not been well studied. METHODS Patients with GABABR-AE from the French and the Dutch Paraneoplastic Neurologic Syndromes Reference Centers databases were retrospectively included and their data collected; the neurologic outcomes of paraneoplastic and nonparaneoplastic cases were compared. Immunoglobulin G (IgG) isotyping and human leukocyte antigen (HLA) genotyping were performed in patients with available samples. RESULTS A total of 111 patients (44/111 [40%] women) were enrolled, including 84 of 111 (76%) paraneoplastic and 18 of 111 (16%) nonparaneoplastic cases (cancer status was undetermined for 9 patients). Patients presented with seizures (88/111 [79%]), cognitive impairment (54/111 [49%]), and/or behavioral disorders (34/111 [31%]), and 54 of 111 (50%) were admitted in intensive care unit (ICU). Nonparaneoplastic patients were significantly younger (median age 54 years [range 19-88] vs 67 years [range 50-85] for paraneoplastic cases, p < 0.001) and showed a different demographic distribution. Nonparaneoplastic patients more often had CSF pleocytosis (17/17 [100%] vs 58/78 [74%], p = 0.02), were almost never associated with KTCD16-abs (1/16 [6%] vs 61/70 [87%], p < 0.001), and were more frequently treated with second-line immunotherapy (11/18 [61%] vs 18/82 [22%], p = 0.003). However, no difference of IgG subclass or HLA association was observed, although sample size was small (10 and 26 patients, respectively). After treatment, neurologic outcome was favorable (mRS ≤2) for 13 of 16 (81%) nonparaneoplastic and 37 of 84 (48%) paraneoplastic cases (p = 0.03), while 3 of 18 (17%) and 42 of 83 (51%) patients had died at last follow-up (p = 0.008), respectively. Neurologic outcome no longer differed after adjustment for confounding factors but seemed to be negatively associated with increased age and ICU admission. A better survival was associated with nonparaneoplastic cases, a younger age, and the use of immunosuppressive drugs. DISCUSSION Nonparaneoplastic GABABR-AE involved younger patients without associated KCTD16-abs and carried better neurologic and vital prognoses than paraneoplastic GABABR-AE, which might be due to a more intensive treatment strategy. A better understanding of immunologic mechanisms underlying both forms is needed.
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Affiliation(s)
- Florian Lamblin
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Jeroen Kerstens
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Sergio Muñiz-Castrillo
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Alberto Vogrig
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - David Goncalves
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Veronique Rogemond
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Geraldine Picard
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Marine Villard
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Anne-Laurie Pinto
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Marleen H Van Coevorden-Hameete
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Marienke A De Bruijn
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Juna M De Vries
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Marco Schreurs
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Louise Tyvaert
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Lucie Hopes
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Jerome Aupy
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Cecile Marchal
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Dimitri Psimaras
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Laurent Kremer
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Veronique Bourg
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Jean-Christophe G Antoine
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Adrien Wang
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Philippe Kahane
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Sophie Demeret
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Guido Ahle
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Vicente Peris Sempere
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Noemie Timestit
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Mikail Nourredine
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Aurelien Maureille
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Marie Benaiteau
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Bastien Joubert
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Emmanuel Mignot
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Maarten J Titulaer
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
| | - Jerome Honnorat
- From the French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Hospices Civils de Lyon; Institut MeLiS INSERM U1314/CNRS UMR 5284 (F.L., V.R., G.P., M.V., A.-L.P., M.B., B.J., J.H.), Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre (La Réunion), France; Department of Neurology (J.K., M.H.V.C.-H., M.A.D.B., J.M.V., M.J.T.), Erasmus Medical Center, Rotterdam, The Netherlands; Stanford Center for Sleep Sciences and Medicine (S.M.-C., V.P.S., E.M.), Stanford University, Palo Alto, CA; Clinical Neurology (A.V.), Department of Neurosciences, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC); Department of Medicine (DAME) (A.V.), University of Udine Medical School, Italy; Department of Immunology (D.G.), Hôpital Lyon Sud, Hospices Civils de Lyon, France; Department of Immunology (M.S.), Laboratory Medical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Neurology (L.T., L.H.), University Hospital of Nancy; Department of Clinical Neurosciences (J.A., C.M.), University Hospital of Bordeaux, Bordeaux, France; Department of Neuro-Oncology (D.P.), Pitié Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (L.K.), University Hospital of Strasbourg; Department of Neurology (V.B.), Côte d'Azur University, Nice; Department of Neurology (J.-C.G.A.), University Hospital of Saint-Etienne; Stroke Center Neurology Division (A.W.), Hopital Foch, Suresnes; University Grenoble Alpes (P.K.), Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences; Neurological Intensive Care Unit (S.D.), Pitié-Salpêtrière Hospital, AP-HP, Paris; Department of Neurology (G.A.), Hôpitaux Civils de Colmar; Department of Public Health (N.T., M.N.), Hospices Civils de Lyon; and Department of Medicine (A.M.), Centre Leon Berard, UNICANCER, Lyon, France
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Ünlü S, Sánchez Navarro BG, Cakan E, Berchtold D, Meleka Hanna R, Vural S, Vural A, Meisel A, Fichtner ML. Exploring the depths of IgG4: insights into autoimmunity and novel treatments. Front Immunol 2024; 15:1346671. [PMID: 38698867 PMCID: PMC11063302 DOI: 10.3389/fimmu.2024.1346671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/29/2024] [Indexed: 05/05/2024] Open
Abstract
IgG4 subclass antibodies represent the rarest subclass of IgG antibodies, comprising only 3-5% of antibodies circulating in the bloodstream. These antibodies possess unique structural features, notably their ability to undergo a process known as fragment-antigen binding (Fab)-arm exchange, wherein they exchange half-molecules with other IgG4 antibodies. Functionally, IgG4 antibodies primarily block and exert immunomodulatory effects, particularly in the context of IgE isotype-mediated hypersensitivity reactions. In the context of disease, IgG4 antibodies are prominently observed in various autoimmune diseases combined under the term IgG4 autoimmune diseases (IgG4-AID). These diseases include myasthenia gravis (MG) with autoantibodies against muscle-specific tyrosine kinase (MuSK), nodo-paranodopathies with autoantibodies against paranodal and nodal proteins, pemphigus vulgaris and foliaceus with antibodies against desmoglein and encephalitis with antibodies against LGI1/CASPR2. Additionally, IgG4 antibodies are a prominent feature in the rare entity of IgG4 related disease (IgG4-RD). Intriguingly, both IgG4-AID and IgG4-RD demonstrate a remarkable responsiveness to anti-CD20-mediated B cell depletion therapy (BCDT), suggesting shared underlying immunopathologies. This review aims to provide a comprehensive exploration of B cells, antibody subclasses, and their general properties before examining the distinctive characteristics of IgG4 subclass antibodies in the context of health, IgG4-AID and IgG4-RD. Furthermore, we will examine potential therapeutic strategies for these conditions, with a special focus on leveraging insights gained from anti-CD20-mediated BCDT. Through this analysis, we aim to enhance our understanding of the pathogenesis of IgG4-mediated diseases and identify promising possibilities for targeted therapeutic intervention.
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Affiliation(s)
- Selen Ünlü
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Koç University School of Medicine, Istanbul, Türkiye
| | - Blanca G. Sánchez Navarro
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Elif Cakan
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, Cambridge, MA, United States
| | - Daniel Berchtold
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Rafael Meleka Hanna
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Secil Vural
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Department of Dermatology and Venereology, Koç University School of Medicine, İstanbul, Türkiye
| | - Atay Vural
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Department of Neurology, Koç University School of Medicine, İstanbul, Türkiye
| | - Andreas Meisel
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Miriam L. Fichtner
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
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11
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Coleman B, Sawhney K, LaPenna P. A Case of Anti-Leucine-Rich Glioma-Inactivated Protein 1 (Anti-LGI1) Limbic Encephalitis With New-Onset Panic Attacks. Cureus 2024; 16:e58406. [PMID: 38756253 PMCID: PMC11097232 DOI: 10.7759/cureus.58406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 04/14/2024] [Indexed: 05/18/2024] Open
Abstract
Anti-leucine-rich glioma-inactivated protein 1 (anti-LGI1) limbic encephalitis is a rare autoimmune neurologic disorder with antibodies against LGI1. It was first recognized as a disease in 2010 and represents the second most common cause of autoimmune encephalitis. Clinically, it is characterized by subacute changes in cognition, memory, and behavior, associated with hyponatremia and faciobrachial dystonic seizures (FBDS). This report discusses a unique onset of anti-LGI1 limbic encephalitis where an elderly female presented with symptoms of new-onset panic attacks and rhythmic facial movements for one week. She was then admitted to neurology for further serum, cerebrospinal fluid(CSF), and lab testing. She was eventually found to be positive for antibodies against LGI1 voltage-gated potassium channels, which confirmed the diagnosis of limbic encephalitis. The quick recognition of symptoms and escalation of management allowed the patient to experience drastic improvements after the initiation of steroids, immunotherapy, and lacosamide. Since anti-LGI1 limbic encephalitis is underdiagnosed, it can lead to irreversible long-term cognitive sequelae (i.e., memory deficits). Thus, awareness of the typically associated findings of FBDS, cognitive disturbances, psychiatric changes, and hyponatremia can aid in early diagnosis and prompt treatment with immunotherapy, allowing for more favorable outcomes.
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Affiliation(s)
- Bre'Ana Coleman
- Neurology, Edward Via College of Osteopathic Medicine, Spartanburg, USA
| | | | - Paul LaPenna
- Neurology, Bon Secours St. Francis Downtown, Greenville, USA
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12
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Shang H, Shen X, Yu X, Zhang J, Jia Y, Gao F. B-cell targeted therapies in autoimmune encephalitis: mechanisms, clinical applications, and therapeutic potential. Front Immunol 2024; 15:1368275. [PMID: 38562943 PMCID: PMC10982343 DOI: 10.3389/fimmu.2024.1368275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/04/2024] [Indexed: 04/04/2024] Open
Abstract
Autoimmune encephalitis (AE) broadly refers to inflammation of the brain parenchyma mediated by autoimmune mechanisms. In most patients with AE, autoantibodies against neuronal cell surface antigens are produced by B-cells and induce neuronal dysfunction through various mechanisms, ultimately leading to disease progression. In recent years, B-cell targeted therapies, including monoclonal antibody (mAb) therapy and chimeric antigen receptor T-cell (CAR-T) therapy, have been widely used in autoimmune diseases. These therapies decrease autoantibody levels in patients and have shown favorable results. This review summarizes the mechanisms underlying these two B-cell targeted therapies and discusses their clinical applications and therapeutic potential in AE. Our research provides clinicians with more treatment options for AE patients whose conventional treatments are not effective.
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Affiliation(s)
- Haodong Shang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, Henan, China
- BGI College, Zhengzhou University, Zhengzhou, Henan, China
| | - Xinru Shen
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, Henan, China
- BGI College, Zhengzhou University, Zhengzhou, Henan, China
| | - Xiaoxiao Yu
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, Henan, China
- BGI College, Zhengzhou University, Zhengzhou, Henan, China
| | - Jing Zhang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, Henan, China
- BGI College, Zhengzhou University, Zhengzhou, Henan, China
| | - Yongliang Jia
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, Henan, China
- BGI College, Zhengzhou University, Zhengzhou, Henan, China
| | - Feng Gao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, Henan, China
- BGI College, Zhengzhou University, Zhengzhou, Henan, China
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13
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Liu M, Ren H, Wang L, Fan S, Bai L, Guan H. Prognostic and relapsing factors of primary autoimmune cerebellar ataxia: a prospective cohort study. J Neurol 2024; 271:1072-1079. [PMID: 38141127 DOI: 10.1007/s00415-023-12128-9] [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: 10/12/2023] [Revised: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE The objective of this study was to investigate the factors influencing relapse and prognosis in patients with primary autoimmune cerebellar ataxia (PACA), an area previously not well understood. METHODS This prospective cohort study included patients who satisfied the modified diagnostic criteria of PACA. A modified Rankin scale score ≤ 2 at the last follow-up was defined as a favorable prognosis. Cox and Logistic regression were utilized to identify relapsing and prognostic factors, respectively. RESULTS A total of 68 patients were included and 35.3% were male. The median onset age was 42.9 years (IQR 22.1-54.0). Neuronal autoantibodies were detected in 33 (50.8%) patients. Of the 65 patients who received first-line immunotherapy, 55 (84.6%) were responsive and 10 (15.4%) were not. Responsiveness to first-line immunotherapy emerged as an independent factor for favorable prognosis (HR 16.762; 95% CI 2.877-97.655; p = 0.002), as did the absence of peripheral neuropathy/radiculopathy (HR 14.286; 95% CI 2.41-83.333; p = 0.003). Relapses occurred in 19 (27.9%) patients. Onset age ≤ 43 years (HR 5.245; 95% CI 1.499-18.35; p = 0.009), presence of peripheral neuropathy/radiculopathy (HR 4.280; 95% CI 1.622-11.298; p = 0.003) and elevated cerebrospinal fluid (CSF) protein concentration (HR 3.443; 95% CI 1.083-10.951; p = 0.036) were statistically significant relapsing factors. CONCLUSION This study identified younger onset age, presence of peripheral neuropathy/radiculopathy and elevated CSF protein concentration as relapsing factors, and absence of peripheral neuropathy/radiculopathy and responsiveness to first-line immunotherapy as independent factors for favorable prognosis in PACA patients. These findings may guide individualized treatment strategies and potentially improve patient outcomes.
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Affiliation(s)
- Mange Liu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Wang
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin Bai
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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14
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Lin Z, Zhou F, Ni L, Dong S, Fu G, Zhao J. Case report: Successful treatment of an anti-D2R and DPPX antibody-associated autoimmune encephalitis patient with high-dose methylprednisolone and intravenous immunoglobulin. Front Immunol 2024; 15:1338714. [PMID: 38469308 PMCID: PMC10925708 DOI: 10.3389/fimmu.2024.1338714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/02/2024] [Indexed: 03/13/2024] Open
Abstract
Background Autoimmune encephalitis is a neurological condition caused by abnormal immune responses, manifesting as cognitive impairments, behavioral abnormalities, and seizures. Its diagnosis depends on the detecting neuronal surface antibodies in serum or cerebrospinal fluid. Despite recent advances in understanding, clinical recognition remains challenging, especially with rare antibodies such as anti-dopamine D2 receptor (D2R) and anti-dipeptidyl-peptidase-like protein 6 (DPPX) antibodies. Delayed diagnosis can lead to severe complications. This case presentation emphasizes the diagnostic intricacies and effective treatment of the anti-D2R and DPPX antibody-associated autoimmune encephalitis. Case description The patient presented with a 3-day history of fatigue and limb soreness followed by a 3-h episode of confusion and limb convulsions. Upon admission to our facility, the initial diagnosis included status epilepticus, aspiration pneumonia, metabolic acidosis, respiratory alkalosis, and suspected encephalitis. Despite receiving antiepileptic, anti-infection, and antivirus therapy, the patient's condition deteriorated. Both computed tomography (CT) scan and magnetic resonance imaging (MRI) of the brain showed no significant abnormalities. No pathogen was identified in the cerebrospinal fluid (CSF). However, further CSF and serum examination revealed positive results of anti-D2R and anti-DPPX antibodies, confirming a diagnosis of anti-D2R and DPPX antibody-associated autoimmune encephalitis. The patient underwent a comprehensive treatment regimen, including high-dose methylprednisolone pulse therapy combined with intravenous immunoglobulin (IVIG), antiviral and anti-infection treatments, and antiepileptic medications. Significant clinical improvement was observed, and by the 18th day of admission, the patient was stable and coherent. Conclusions The current patient represents the first reported case of double-positive autoimmune encephalitis for anti-D2R and DPPX antibodies, with epilepsy as a prominent feature. High-dose methylprednisolone pulse therapy combined with IVIG has shown significant safety and efficacy in treating anti-D2R and DPPX antibody-positive autoimmune encephalitis-associated epilepsy.
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Affiliation(s)
- Zhangliang Lin
- Neurology Department, Shaoxing No.2 Hospital Meical Community General Hospital, Shaoxing, China
| | - Feng Zhou
- Neurology Department, Shaoxing No.2 Hospital Meical Community General Hospital, Shaoxing, China
| | - Lili Ni
- Neurology Department, Shaoxing No.2 Hospital Meical Community General Hospital, Shaoxing, China
| | - Shiye Dong
- Department of Medicine, Shanghai Biotecan Pharmaceuticals Co., Ltd., Shanghai Zhangjiang Institute of Medical Innovation, Shanghai, China
| | - Guoping Fu
- Neurology Department, Shaoxing No.2 Hospital Meical Community General Hospital, Shaoxing, China
| | - Jiangman Zhao
- Department of Medicine, Shanghai Biotecan Pharmaceuticals Co., Ltd., Shanghai Zhangjiang Institute of Medical Innovation, Shanghai, China
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15
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Voit A, Graziano A, Schomer A, Theodore D. Ovarian teratoma-associated anti-NMDA receptor encephalitis with severe features. BMJ Case Rep 2024; 17:e258038. [PMID: 38355204 PMCID: PMC10868323 DOI: 10.1136/bcr-2023-258038] [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: 02/16/2024] Open
Abstract
Anti-N-methyl-D-aspartame receptor (NMDAR) encephalitis is an uncommon clinical entity for the general intensivist or neurologist. Diagnosis can be made by the presence of cerebrospinal fluid IgG antibody against the GluNR1 and GluNR2 subunits of the NMDAR. We present a case of anti-NMDAR encephalitis in a young woman with an ovarian teratoma treated with surgical resection and multiple immunomodulatory therapies.
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Affiliation(s)
- Antanina Voit
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ashley Graziano
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Andrew Schomer
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Danny Theodore
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
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16
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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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17
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Kvam KA, Stahl JP, Chow FC, Soldatos A, Tattevin P, Sejvar J, Mailles A. Outcome and Sequelae of Autoimmune Encephalitis. J Clin Neurol 2024; 20:3-22. [PMID: 38179628 PMCID: PMC10782092 DOI: 10.3988/jcn.2023.0242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 01/06/2024] Open
Abstract
Autoimmune etiologies are a common cause for encephalitis. The clinical syndromes consistent with autoimmune encephalitis are both distinct and increasingly recognized, but less is known about persisting sequelae or outcomes. We searched PubMed for reports on outcomes after autoimmune encephalitis. Studies assessing validated, quantitative outcomes were included. We performed a narrative review of the published literature of outcomes after autoimmune encephalitis. We found 146 studies that produced outcomes data. The mortality rates were 6%-19% and the relapse risks were 10%-62%. Most patients achieved a good outcome based on a score on the modified Rankin Scale (mRS) of ≤2. Forty-nine studies evaluated outcomes beyond mRS; these studies investigated cognitive outcome, psychiatric sequelae, neurological deficits, global function, and quality-of-life/patient-reported outcomes using various tools at varying time points after the index hospital discharge. These more-detailed assessments revealed that most patients had persistent impairments, with frequent deficits in cognitive function, especially memory and attention. Depression and anxiety were also common. Many of these sequelae continued to improve over months or even years after the acute illness. While we found that lasting impairments were common among survivors of autoimmune encephalitis, additional research is needed to better understand the nature and impact of these sequelae. Standardized evaluation protocols are needed to improve the ability to compare outcomes across studies, guide rehabilitation strategies, and inform outcomes of interest in treatment trials as the field advances.
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Affiliation(s)
- Kathryn A Kvam
- Department of Neurology & Neurological Sciences, Center for Academic Medicine, Stanford University, Stanford, CA, USA.
| | | | - Felicia C Chow
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, CA, USA
| | - Ariane Soldatos
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - James Sejvar
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alexandra Mailles
- Department of Infectious Diseases, Santé publique France, Saint-Maurice, France
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18
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Pecuh I, Slobodan J, McCombe JA, Morneau-Jacob FD, Smyth P, Wilbur C. Rituximab for Pediatric Central Nervous System Inflammatory Disorders in Alberta, Canada. Can J Neurol Sci 2024; 51:50-56. [PMID: 36710585 DOI: 10.1017/cjn.2023.16] [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: 01/31/2023]
Abstract
BACKGROUND Early and effective treatment of central nervous system (CNS) inflammatory disorders is vital to reduce neurologic morbidity and improve long-term outcomes in affected children. Rituximab is a B-cell-depleting monoclonal antibody whose off-label use for these disorders is funded in the province of Alberta, Canada, by the Short-Term Exceptional Drug Therapy (STEDT) program. This study describes the use of rituximab for pediatric CNS inflammatory disorders in Alberta. METHODS Rituximab applications for CNS inflammatory indications in patients <18 years of age were identified from the STEDT database between January 1, 2012, and December 31, 2019. Patient information was linked to other provincial datasets including the Discharge Abstract Database, Pharmaceutical Information Network, and Provincial Laboratory data. Analysis was descriptive. RESULTS Fifty-one unique rituximab applications were identified, of which 50 were approved. New applications increased from one in 2012 to a high of 12 in 2018. The most common indication was autoimmune encephalitis without a specified antibody (n = 16, 31%). Most children were approved for a two-dose (n = 33, 66%) or four-dose (n = 16, 32%) induction regimen. Physician-reported outcomes were available for 24 patients, of whom 14 (58%) were felt to have fully met outcome targets. CONCLUSION The use of rituximab for pediatric CNS inflammatory disorders has increased, particularly for the indication of autoimmune encephalitis. This study identified significant heterogeneity in dosing practices and laboratory monitoring. Standardized protocols for the use of rituximab in these disorders and more robust outcome reporting will help better define the safety and efficacy of rituximab in this population.
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Affiliation(s)
- Ihor Pecuh
- Alberta Health Services, Edmonton, Canada
| | | | - Jennifer A McCombe
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | | | - Penelope Smyth
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Colin Wilbur
- Division of Neurology, Department of Pediatrics, University of Alberta, Edmonton, Canada
- Women and Children's Health Research Institute, Edmonton, Canada
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19
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Iorio R, Lennon VA. Paraneoplastic autoimmune neurologic disorders associated with thymoma. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:385-396. [PMID: 38494291 DOI: 10.1016/b978-0-12-823912-4.00008-6] [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
Thymoma is often associated with paraneoplastic neurologic diseases. Neural autoantibody testing is an important tool aiding diagnosis of thymoma and its autoimmune neurologic complications. Autoantibodies specific for muscle striational antigens and ion channels of the ligand-gated nicotinic acetylcholine receptor superfamily are the most prevalent biomarkers. The autoimmune neurologic disorders associating most commonly with thymoma are myasthenia gravis (MG), peripheral nerve hyperexcitability (neuromyotonia and Morvan syndrome), dysautonomia, and encephalitis. Patients presenting with these neurologic disorders should be screened for thymoma at diagnosis. Although they can cause profound disability, they usually respond to immunotherapy and treatment of the thymoma. Worsening of the neurologic disorder following surgical removal of a thymoma may herald tumor recurrence. Prompt recognition of paraneoplastic neurologic disorders is critical for patient management. A multidisciplinary approach is required for optimal management of neurologic autoimmunity associated with thymoma.
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Affiliation(s)
- Raffaele Iorio
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Vanda A Lennon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Immunology, Mayo Clinic, Rochester, MN, United States
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20
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Budhram A, Sechi E. Antibodies to neural cell surface and synaptic proteins in paraneoplastic neurologic syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:347-364. [PMID: 38494289 DOI: 10.1016/b978-0-12-823912-4.00006-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Among patients with paraneoplastic neurologic syndromes (PNS), emphasis has historically been placed on neural antibodies against intracellular proteins that have a strong association with malignancy. Because of the intracellular location of their antigenic targets, these antibodies are typically considered to be non-pathogenic surrogate markers of immune cell-mediated neural injury. Unfortunately, patients with these antibodies often have suboptimal response to immunotherapy and poor prognosis. Over the last two decades, however, dramatic advancements have been made in the discovery and clinical characterization of neural antibodies against extracellular targets. These antibodies are generally considered to be pathogenic, given their potential to directly alter antigen structure or function, and patients with these antibodies often respond favorably to prompt immunotherapy. These antibodies also associate with tumors and may thus occur as PNS, albeit more variably than neural antibodies against intracellular targets. The updated 2021 PNS diagnostic criteria, which classifies antibodies as high-risk, intermediate-risk, or lower-risk for an associated cancer, better clarifies how neural antibodies against extracellular targets relate to PNS. Using this recently created framework, the clinical presentations, ancillary test findings, oncologic associations, and treatment responses of syndromes associated with these antibodies are discussed.
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Affiliation(s)
- Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, ON, Canada; Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada.
| | - Elia Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
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21
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Kerstens J, Titulaer MJ. Overview of treatment strategies in paraneoplastic neurological syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:97-112. [PMID: 38494299 DOI: 10.1016/b978-0-12-823912-4.00015-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Treatment strategies in paraneoplastic neurological syndromes rely on the three pillars of tumor treatment, immunotherapy, and symptomatic treatment, the first one being by far the most important in the majority of patients and syndromes. Classically, antibodies against extracellular antigens are directly pathogenic, and patients with these syndromes are more responsive to immunomodulatory or immunosuppressive treatments than the ones with antibodies against intracellular targets. This chapter first discusses some general principles of tumor treatment and immunotherapy, followed by a closer look at specific treatment options for different clinical syndromes, focusing on symptomatic treatments.
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Affiliation(s)
- Jeroen Kerstens
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Maarten J Titulaer
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands.
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22
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Eisenhut K, Faber J, Engels D, Gerhards R, Lewerenz J, Doppler K, Sommer C, Markewitz R, Falk KK, Rössling R, Pruess H, Finke C, Wickel J, Geis C, Ratuszny D, Pfeffer LK, Bittner S, Piepgras J, Kraft A, Klausewitz J, Nuscher B, Kümpfel T, Thaler FS. Early Neuroaxonal Damage in Neurologic Disorders Associated With GAD65 Antibodies. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200176. [PMID: 37914416 PMCID: PMC10624332 DOI: 10.1212/nxi.0000000000200176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/20/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Neurodegeneration is considered a relevant pathophysiologic feature in neurologic disorders associated with antibodies against glutamic acid decarboxylase 65 (GAD65). In this study, we investigate surrogates of neuroaxonal damage in relation to disease duration and clinical presentation. METHODS In a multicentric cohort of 50 patients, we measured serum neurofilament light chain (sNfL) in relation to disease duration and disease phenotypes, applied automated MRI volumetry, and analyzed clinical characteristics. RESULTS In patients with neurologic disorders associated with GAD65 antibodies, we detected elevated sNfL levels early in the disease course. By contrast, this elevation of sNfL levels was less pronounced in patients with long-standing disease. Increased sNfL levels were observed in patients presenting with cerebellar ataxia and limbic encephalitis, but not in those with stiff person syndrome. Using MRI volumetry, we identified atrophy predominantly of the cerebellar cortex, cerebellar superior posterior lobe, and cerebral cortex with similar atrophy patterns throughout all clinical phenotypes. DISCUSSION Together, our data provide evidence for early neuroaxonal damage and support the need for timely therapeutic interventions in GAD65 antibody-associated neurologic disorders.
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Affiliation(s)
- Katharina Eisenhut
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Jennifer Faber
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Daniel Engels
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Ramona Gerhards
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Jan Lewerenz
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Kathrin Doppler
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Claudia Sommer
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Robert Markewitz
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Kim K Falk
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Rosa Rössling
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Harald Pruess
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Carsten Finke
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Jonathan Wickel
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Christian Geis
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Dominica Ratuszny
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Lena K Pfeffer
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Stefan Bittner
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Johannes Piepgras
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Andrea Kraft
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Jaqueline Klausewitz
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Brigitte Nuscher
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Tania Kümpfel
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys
| | - Franziska S Thaler
- From the Institute of Clinical Neuroimmunology (K.E.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Sy; German Center for Neurodegenerative Diseases (DZNE) (J.F.); Department of Neurology, University Hospital Bonn, Germany; Institute of Clinical Neuroimmunology (D.E., R.G., T.K.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Department of Neurology (J.L.), Ulm University; Department of Neurology (K.D., C.S.), University Hospital Würzburg; Institute of Clinical Chemistry (R.M.), University Hospital Schleswig-Holstein, Lübeck; Institute of Clinical Chemistry (K.K.F.), University Hospital Schleswig-Holstein, Kiel; Department of Neurology and Experimental Neurology (R.R., H.P.), Charité - Universitätsmedizin Berlin; German Center for Neurodegenerative Diseases (DZNE) Berlin; Department of Neurology and Experimental Neurology (C.F.), Charité - Universitätsmedizin Berlin; Section of Translational Neuroimmunology (J.W., C.G.), Department of Neurology, Jena University Hospital; Department of Neurology (D.R.), Hannover Medical School; Institute of Neuroimmunology and Multiple Sclerosis (L.K.P.), Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf; Department of Neurology (S.B., J.P.), University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (A.K.), Martha-Maria Hospital Halle; Department of Neurology (J.K.), University Hospital Bochum; German Center for Neurodegenerative Diseases (DZNE) (B.N.), Munich; Metabolic Biochemistry, Faculty of Medicine, Biomedical Center (BMC), Ludwig-Maximilians-Universität München; and Institute of Clinical Neuroimmunology (F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried, Germany; Munich Cluster for Sys.
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23
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Asbeutah S, Alhashime K, Alhamer M. A Case Report and Literature Review on Positivity for Multiple Antibodies: Autoimmune Encephalitis in Focus. Cureus 2023; 15:e50393. [PMID: 38213350 PMCID: PMC10783615 DOI: 10.7759/cureus.50393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/13/2024] Open
Abstract
Autoimmune encephalitis (AE) is a group of neuropsychiatric disorders caused by antibodies that target the neuronal surface, synaptic, or intracellular antigens, impairing brain function. Although AE can affect people of different age groups, the occurrence of AE within specific age brackets depends on the specific type of AE and the antibodies produced. While AE is frequently considered a paraneoplastic syndrome linked to cancer, it is essential to acknowledge that the intensity of this association can vary depending on the specific antibody, leading to diverse relationships with paraneoplastic syndromes. Numerous cases have been recorded where AE manifests without an underlying malignancy. The diagnostic criteria for AE are characterized by a subacute deterioration of cognition, altered mental status, or psychiatric symptoms. Immunotherapy is recommended as a treatment for the condition, and the prognosis varies depending on the subtype. In this case, we present the case of an elderly woman who showed acute mental status changes, psychiatric symptoms, EEG alterations, and positive antibody results in both serum and CSF. Our case breaks new ground as the first documented instance of a female with positive serum anti-LGI 1, anti-AMPAR2, anti-Ri, and anti-CENP-A/B antibodies.
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Affiliation(s)
| | | | - Maryam Alhamer
- Internal Medicine, Kuwait Board of Internal Medicine, Kuwait City, KWT
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24
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Yang JH, Liu EN, Nguyen L, Dunn-Pirio A, Graves JS. Survival Analysis of Immunotherapy Effects on Relapse Rate in Pediatric and Adult Autoimmune Encephalitis. Neurology 2023; 101:e2300-e2313. [PMID: 37827848 PMCID: PMC10727225 DOI: 10.1212/wnl.0000000000207746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/01/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Prior observational studies for autoimmune encephalitis (AE) have mostly focused on outcomes after acute immunotherapies with better outcomes associated with earlier immunotherapy use. However, the impact of long-term immunotherapy and its association with clinical relapse is not well known. METHODS We conducted a retrospective study of consecutive patients meeting published clinical criteria for AE evaluated at UC San Diego and Rady Children's Hospital from January 2007 to November 2021. Survival analysis and Cox multivariable regression models were used to evaluate relapse risk using rituximab exposure as a time-dependent variable. Pooled and age-stratified analyses were performed. RESULTS A total of 204 pediatric and 380 adult participants were screened of which 30 pediatric and 75 adult participants were included. The most common antibody subtype in both cohorts was anti-NMDA receptor (76% in pediatric, 34% in adult). Relapses occurred in 31% of pediatric antibody-positive, 40% of adult antibody-positive, and 20% of adult antibody-negative cases. Times to first relapse (TTFR) were 10.6 ± 7.4 months (pediatric antibody-positive), 13.1 ± 24.5 months (adult antibody-positive), and 6.9 ± 3.8 months (adult antibody-negative). Rituximab was the most common second-line immunotherapy used. Combining pediatric and adult data, rituximab use was associated with a 71% lower hazard for time to first relapse (hazard ratio [HR] 0.29, 95% CI 0.09-0.85) and 51% lower hazard for recurring relapses (HR 0.49, 95% CI 0.9-1.26). The HR for TTFR with rituximab use in children was 0.30 (95% CI 0.05-1.69), 0.29 (95% CI 0.07-1.29) in adults, 0.32 in non-NMDA antibody-positive encephalitis (95% CI 0.07-1.39), and 0.42 (95% CI 0.07-2.67) for anti-NMDAR. DISCUSSION Relapses are common in pediatric and adult patients with AE, although less frequently in anti-NMDARE. Using a rigorous survival model, we demonstrate a substantial benefit of rituximab use for reducing relapse rates in AE, especially for the adult population. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that rituximab is associated with a lower hazard to relapse in patients with AE.
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Affiliation(s)
- Jennifer H Yang
- From the Department of Neurosciences (J.H.Y., L.N., A.D.-P., J.S.G.), University of California, San Diego; Rady Children's Hospital San Diego (J.H.Y., L.N., J.S.G.); and School of Medicine (E.N.L.), University of California, San Diego.
| | - Emilie N Liu
- From the Department of Neurosciences (J.H.Y., L.N., A.D.-P., J.S.G.), University of California, San Diego; Rady Children's Hospital San Diego (J.H.Y., L.N., J.S.G.); and School of Medicine (E.N.L.), University of California, San Diego
| | - Linda Nguyen
- From the Department of Neurosciences (J.H.Y., L.N., A.D.-P., J.S.G.), University of California, San Diego; Rady Children's Hospital San Diego (J.H.Y., L.N., J.S.G.); and School of Medicine (E.N.L.), University of California, San Diego
| | - Anastasie Dunn-Pirio
- From the Department of Neurosciences (J.H.Y., L.N., A.D.-P., J.S.G.), University of California, San Diego; Rady Children's Hospital San Diego (J.H.Y., L.N., J.S.G.); and School of Medicine (E.N.L.), University of California, San Diego
| | - Jennifer S Graves
- From the Department of Neurosciences (J.H.Y., L.N., A.D.-P., J.S.G.), University of California, San Diego; Rady Children's Hospital San Diego (J.H.Y., L.N., J.S.G.); and School of Medicine (E.N.L.), University of California, San Diego
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25
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Srivastava IN, Van Haren KP. Immunotherapy in Autoimmune Encephalitis: So Many Options, So Few Guidelines. Neurology 2023; 101:985-986. [PMID: 37879941 DOI: 10.1212/wnl.0000000000208026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/27/2023] [Indexed: 10/27/2023] Open
Affiliation(s)
- Isha N Srivastava
- From the Department of Neurology, School of Medicine, Stanford University, Palo Alto, CA.
| | - Keith P Van Haren
- From the Department of Neurology, School of Medicine, Stanford University, Palo Alto, CA
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26
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Mojžišová H, Krýsl D, Hanzalová J, Dargvainiene J, Wandinger KP, Leypoldt F, Elišák M, Marusič P. Antibody-Negative Autoimmune Encephalitis: A Single-Center Retrospective Analysis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200170. [PMID: 37879962 PMCID: PMC10605954 DOI: 10.1212/nxi.0000000000200170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/29/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Autoimmune encephalitis (AE) refers to a heterogenous group of inflammatory CNS diseases. Subgroups with specified neural autoantibodies are more homogeneous in presentation, trigger factors, outcome, and response to therapy. However, a considerable fraction of patients has AE features but does not harbor detectable autoantibodies and is referred to as antibody-negative AE. Our aim was to describe clinical features, trigger factors, treatments, and outcome of a cohort of comprehensively tested antibody-negative AE patients. METHODS This retrospective monocentric study recruited adult patients whose serum and/or CSF was sent to our tertiary center for neural antibody testing between 2011 and 2020, who entered the diagnostic algorithm as possible antibody-negative AE and had the following: (1) probable antibody-negative AE, definite antibody-negative acute disseminated encephalomyelitis (ADEM), or definite autoimmune limbic encephalitis (LE) according to diagnostic criteria; (2) available data on MRI of the brain, CSF, and EEG; and (3) stored serum and/or CSF samples. These samples were reanalyzed using a comprehensive combination of cell-based and tissue-based assays. RESULTS Of 2,250 patients tested, 33 (1.5%) were classified as possible antibody-negative AE. Of these, 5 were found to have antibodies by comprehensive testing, 5 fulfilled the criteria of probable AE (3F:2M, median age 67, range 42-67), 4 of definite autoimmune LE (2F:2M, median age 45.5, range 27-60 years), one of definite antibody-negative ADEM, 2 of Hashimoto encephalopathy, one had no samples available for additional testing, and 15 had no further categorization. Of 10 probable/definite AE/LE/ADEM, one had a malignancy and none of them received an alternative diagnosis until the end of follow-up (median 18 months). In total, 80% (8/10) of patients received immunotherapy including corticosteroids, and 6/10 (60%) patients received rituximab, azathioprine, cyclophosphamide, plasma exchange, or IV immunoglobulins. Five (50%) patients improved, one (10%) stabilized, one (10%) worsened, and 3 (30%) died. All deaths were considered to be related to encephalitis. We did not observe differences of immunotherapy-treated patients in likelihood of improvement with or without nonsteroidal immunotherapy (with 2/6, without 1/2). DISCUSSION Antibody-negative AE should be diagnosed only after comprehensive testing. Diagnostic effort is important because many patients benefit from immunotherapy and some have malignancies.
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Affiliation(s)
- Hana Mojžišová
- From the Departments of Neurology (H.M., D.K., M.E., P.M.) and Immunology (J.H.), Second Faculty of Medicine Charles University and Motol University Hospital, Prague, Czech Republic; Institute of Clinical Chemistry (J.D., K.-P.W., F.L.), University Hospital Schleswig-Holstein, Kiel/Lübeck; and Neuroimmunology (F.L.), Department of Neurology, University Hospital Schleswig-Holstein Kiel, Germany.
| | - David Krýsl
- From the Departments of Neurology (H.M., D.K., M.E., P.M.) and Immunology (J.H.), Second Faculty of Medicine Charles University and Motol University Hospital, Prague, Czech Republic; Institute of Clinical Chemistry (J.D., K.-P.W., F.L.), University Hospital Schleswig-Holstein, Kiel/Lübeck; and Neuroimmunology (F.L.), Department of Neurology, University Hospital Schleswig-Holstein Kiel, Germany
| | - Jitka Hanzalová
- From the Departments of Neurology (H.M., D.K., M.E., P.M.) and Immunology (J.H.), Second Faculty of Medicine Charles University and Motol University Hospital, Prague, Czech Republic; Institute of Clinical Chemistry (J.D., K.-P.W., F.L.), University Hospital Schleswig-Holstein, Kiel/Lübeck; and Neuroimmunology (F.L.), Department of Neurology, University Hospital Schleswig-Holstein Kiel, Germany
| | - Justina Dargvainiene
- From the Departments of Neurology (H.M., D.K., M.E., P.M.) and Immunology (J.H.), Second Faculty of Medicine Charles University and Motol University Hospital, Prague, Czech Republic; Institute of Clinical Chemistry (J.D., K.-P.W., F.L.), University Hospital Schleswig-Holstein, Kiel/Lübeck; and Neuroimmunology (F.L.), Department of Neurology, University Hospital Schleswig-Holstein Kiel, Germany
| | - Klaus-Peter Wandinger
- From the Departments of Neurology (H.M., D.K., M.E., P.M.) and Immunology (J.H.), Second Faculty of Medicine Charles University and Motol University Hospital, Prague, Czech Republic; Institute of Clinical Chemistry (J.D., K.-P.W., F.L.), University Hospital Schleswig-Holstein, Kiel/Lübeck; and Neuroimmunology (F.L.), Department of Neurology, University Hospital Schleswig-Holstein Kiel, Germany
| | - Frank Leypoldt
- From the Departments of Neurology (H.M., D.K., M.E., P.M.) and Immunology (J.H.), Second Faculty of Medicine Charles University and Motol University Hospital, Prague, Czech Republic; Institute of Clinical Chemistry (J.D., K.-P.W., F.L.), University Hospital Schleswig-Holstein, Kiel/Lübeck; and Neuroimmunology (F.L.), Department of Neurology, University Hospital Schleswig-Holstein Kiel, Germany
| | - Martin Elišák
- From the Departments of Neurology (H.M., D.K., M.E., P.M.) and Immunology (J.H.), Second Faculty of Medicine Charles University and Motol University Hospital, Prague, Czech Republic; Institute of Clinical Chemistry (J.D., K.-P.W., F.L.), University Hospital Schleswig-Holstein, Kiel/Lübeck; and Neuroimmunology (F.L.), Department of Neurology, University Hospital Schleswig-Holstein Kiel, Germany
| | - Petr Marusič
- From the Departments of Neurology (H.M., D.K., M.E., P.M.) and Immunology (J.H.), Second Faculty of Medicine Charles University and Motol University Hospital, Prague, Czech Republic; Institute of Clinical Chemistry (J.D., K.-P.W., F.L.), University Hospital Schleswig-Holstein, Kiel/Lübeck; and Neuroimmunology (F.L.), Department of Neurology, University Hospital Schleswig-Holstein Kiel, Germany
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Ceanga M, Rahmati V, Haselmann H, Schmidl L, Hunter D, Brauer AK, Liebscher S, Kreye J, Prüss H, Groc L, Hallermann S, Dalmau J, Ori A, Heckmann M, Geis C. Human NMDAR autoantibodies disrupt excitatory-inhibitory balance, leading to hippocampal network hypersynchrony. Cell Rep 2023; 42:113166. [PMID: 37768823 DOI: 10.1016/j.celrep.2023.113166] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/30/2023] [Accepted: 09/07/2023] [Indexed: 09/30/2023] Open
Abstract
Anti-NMDA receptor autoantibodies (NMDAR-Abs) in patients with NMDAR encephalitis cause severe disease symptoms resembling psychosis and cause cognitive dysfunction. After passive transfer of patients' cerebrospinal fluid or human monoclonal anti-GluN1-autoantibodies in mice, we find a disrupted excitatory-inhibitory balance resulting from CA1 neuronal hypoexcitability, reduced AMPA receptor (AMPAR) signaling, and faster synaptic inhibition in acute hippocampal slices. Functional alterations are also reflected in widespread remodeling of the hippocampal proteome, including changes in glutamatergic and GABAergic neurotransmission. NMDAR-Abs amplify network γ oscillations and disrupt θ-γ coupling. A data-informed network model reveals that lower AMPAR strength and faster GABAA receptor current kinetics chiefly account for these abnormal oscillations. As predicted in silico and evidenced ex vivo, positive allosteric modulation of AMPARs alleviates aberrant γ activity, reinforcing the causative effects of the excitatory-inhibitory imbalance. Collectively, NMDAR-Ab-induced aberrant synaptic, cellular, and network dynamics provide conceptual insights into NMDAR-Ab-mediated pathomechanisms and reveal promising therapeutic targets that merit future in vivo validation.
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Affiliation(s)
- Mihai Ceanga
- Section of Translational Neuroimmunology, Department of Neurology, Jena University Hospital, 07747 Jena, Germany
| | - Vahid Rahmati
- Section of Translational Neuroimmunology, Department of Neurology, Jena University Hospital, 07747 Jena, Germany
| | - Holger Haselmann
- Section of Translational Neuroimmunology, Department of Neurology, Jena University Hospital, 07747 Jena, Germany
| | - Lars Schmidl
- Section of Translational Neuroimmunology, Department of Neurology, Jena University Hospital, 07747 Jena, Germany
| | - Daniel Hunter
- Université de Bordeaux, CNRS, Interdisciplinary Institute for Neuroscience, UMR 5297, 33000 Bordeaux, France
| | - Anna-Katherina Brauer
- Institute of Clinical Neuroimmunology, Klinikum der Universität München, Ludwig Maximilians University Munich, Martinsried, Germany; Biomedical Center, Ludwig Maximilians University Munich, Martinsried, Germany
| | - Sabine Liebscher
- Institute of Clinical Neuroimmunology, Klinikum der Universität München, Ludwig Maximilians University Munich, Martinsried, Germany; Biomedical Center, Ludwig Maximilians University Munich, Martinsried, Germany; Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Jakob Kreye
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Department of Pediatric Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
| | - Laurent Groc
- Université de Bordeaux, CNRS, Interdisciplinary Institute for Neuroscience, UMR 5297, 33000 Bordeaux, France
| | - Stefan Hallermann
- Carl Ludwig Institute for Physiology, Faculty of Medicine, Leipzig University, 04103 Leipzig, Germany
| | - Josep Dalmau
- Catalan Institution for Research and Advanced Studies (ICREA) and IDIBAPS-Hospital Clinic, University of Barcelona, 08036 Barcelona, Spain
| | - Alessandro Ori
- Leibniz Institute on Aging - Fritz Lipmann Institute (FLI), 07745 Jena, Germany
| | - Manfred Heckmann
- Department of Neurophysiology, Institute of Physiology, University of Würzburg, 97070 Würzburg, Germany
| | - Christian Geis
- Section of Translational Neuroimmunology, Department of Neurology, Jena University Hospital, 07747 Jena, Germany.
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28
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Bertram D, Tsaktanis T, Berthele A, Korn T. The role of intrathecal free light chains kappa for the detection of autoimmune encephalitis in subacute onset neuropsychiatric syndromes. Sci Rep 2023; 13:17224. [PMID: 37821561 PMCID: PMC10567819 DOI: 10.1038/s41598-023-44427-6] [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: 07/28/2023] [Accepted: 10/08/2023] [Indexed: 10/13/2023] Open
Abstract
Intrathecal synthesis of free light chains kappa (FLCK) is increasingly recognized as a marker of inflammatory CNS pathologies. Here, we tested the performance of FLCK in differentiating autoimmune encephalitis (AIE) from non-inflammatory etiologies in subacute onset neuropsychiatric syndromes. Patients undergoing diagnostic work-up for suspected autoimmune encephalitis at our department between 2015 and 2020 were retrospectively assessed for definitive diagnosis, available CSF and blood samples, as well as complete clinical records. Intrathecal FLCK was measured along with established CSF markers of CNS inflammation. The study cohort consisted of 19 patients with antibody-mediated AIE (AIE+), 18 patients with suspected AIE but without detectable autoantibodies (AIE-), 10 patients with infectious (viral) encephalitis (INE), and 15 patients with degenerative encephalopathies (DGE). 25 age- and sex-matched patients with non-inflammatory neurological diseases (NIND) were used as a control group. All AIE+ patients exhibited intrathecal synthesis of FLCK compared to only 39% of AIE- patients and 81% of patients in the INE group. No intrathecal synthesis of FLCK was found in DGE and NIND patients. While intrathecal FLCK was equally specific for an inflammatory etiology as oligoclonal bands (OCB) in the cerebrospinal fluid (CSF), the sensitivity of intrathecal FLCK for any inflammatory intrathecal process was higher than that of OCB (83% vs. 38%). Intrathecal FLCK synthesis was found to discriminate AIE+ from non-inflammatory encephalopathies and AIE- when the CSF cell count was normal [receiver operating characteristic (ROC) analysis area under the curve (AUC): 0.867, p = 0.002], while it failed to differentiate between AIE+ and INE in the presence of CSF pleocytosis (AUC: 0.561, p = 0.607). In conclusion, in the absence of CSF pleocytosis, intrathecal FLCK discriminated AIE+ from competing diagnoses in our cohort of subacute onset neuropsychiatric syndromes. In addition to established markers of CSF inflammation, intrathecal FLCK might support clinical decision-making and contribute to selecting patients for (repeated) antibody testing.
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Affiliation(s)
- Dominic Bertram
- Department of Neurology, Technical University of Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany
| | - Thanos Tsaktanis
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Achim Berthele
- Department of Neurology, Technical University of Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany
| | - Thomas Korn
- Department of Neurology, Technical University of Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany.
- Institute for Experimental Neuroimmunology, Technical University of Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany.
- Munich Cluster for Systems Neurology (SyNergy), Feodor-Lynen-Str. 17, 81377, Munich, Germany.
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29
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Stevens-Jones O, Mojzisova H, Elisak M, Constantinescu R, Hanzalova J, Axelsson M, Krysl D. Paraneoplastic or not? Sirtuin 2 in anti-N-methyl-d-aspartate receptor encephalitis. Eur J Neurol 2023; 30:3228-3235. [PMID: 37483157 DOI: 10.1111/ene.15987] [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: 05/22/2023] [Revised: 06/27/2023] [Accepted: 07/17/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND AND PURPOSE N-methyl-d-aspartate receptor (NMDAR) and leucine-rich glioma-inactivated protein 1 (LGI1) encephalitis are important types of autoimmune encephalitis (AE) with significant morbidity. In this study, we used a proteomic approach in search of novel clinically relevant biomarkers in these types of encephalitides. METHODS Swedish and Czech tertiary neuroimmunology centers collaborated in this retrospective exploratory study. Fifty-eight cerebrospinal fluid (CSF) samples of 28 patients with AE (14 definite NMDAR, 14 with definite LGI1 encephalitis) and 30 controls were included. CSF samples were analyzed using proximity extension assay technology (Olink Target 96 Inflammation panel). For each CSF sample, 92 proteins were measured. Clinical variables were retrospectively collected, and correlations with protein levels were statistically analyzed. RESULTS Patients and controls differed significantly in the following 18 biomarkers: TNFRSF9, TNFRSF12, TNFRSF14, TNFβ, TNFα, IL7, IL10, IL12B, IFNγ, CD5, CD6, CASP8, MMP1, CXCL8, CXCL10, CXCL11, IL20RA, and sirtuin 2 (SIRT2). In LGI1 encephalitis, no clinically useful association was found between biomarkers and clinical variables. In the NMDAR encephalitis group, SIRT2, TNFβ, and CD5 were significantly associated with ovarian teratoma. For SIRT2, this was true even for the first patients' CSF sample (SIRT2 without vs. with tumor, mean ± SD = 2.2 ± 0.29 vs. 2.88 ± 0.48; p = 0.007, 95% confidence interval = -1.15 to -0.22; r statistic in point-biserial correlation (rpb) = 0.66, p = 0.011). SIRT2 was positively correlated with age (rpb = 0.39, p = 0.018) and total hospital days (r = 0.55, p = <0.001). CONCLUSIONS SIRT2 should be investigated as a biomarker of paraneoplastic etiology in NMDAR encephalitis.
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Affiliation(s)
- Oskar Stevens-Jones
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Neuroscience and Physiology, Sahlgrenska Akademin, Gothenburg University, Gothenburg, Sweden
| | - Hana Mojzisova
- Department of Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Martin Elisak
- Department of Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Radu Constantinescu
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Neuroscience and Physiology, Sahlgrenska Akademin, Gothenburg University, Gothenburg, Sweden
| | - Jitka Hanzalova
- Department of Immunology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Markus Axelsson
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Neuroscience and Physiology, Sahlgrenska Akademin, Gothenburg University, Gothenburg, Sweden
| | - David Krysl
- Institute of Neuroscience and Physiology, Sahlgrenska Akademin, Gothenburg University, Gothenburg, Sweden
- Department of Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
- Department of Clinical Neurophysiology, Sahlgrenska University Hospital, Gothenburg, Sweden
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30
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Vlad B, Wang Y, Newsome SD, Balint B. Stiff Person Spectrum Disorders-An Update and Outlook on Clinical, Pathophysiological and Treatment Perspectives. Biomedicines 2023; 11:2500. [PMID: 37760941 PMCID: PMC10525659 DOI: 10.3390/biomedicines11092500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Stiff person spectrum disorders (SPSD) are paradigm autoimmune movement disorders characterized by stiffness, spasms and hyperekplexia. Though rare, SPSD represent a not-to-miss diagnosis because of the associated disease burden and treatment implications. After decades as an enigmatic orphan disease, major advances in our understanding of the evolving spectrum of diseases have been made along with the identification of multiple associated autoantibodies. However, the most important recent developments relate to the recognition of a wider affection, beyond the classic core motor symptoms, and to further insights into immunomodulatory and symptomatic therapies. In this review, we summarize the recent literature on the clinical and paraclinical spectrum, current pathophysiological understanding, as well as current and possibly future therapeutic strategies.
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Affiliation(s)
- Benjamin Vlad
- Department of Neurology, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Yujie Wang
- Department of Neurology, University of Washington, Seattle, WA 98195, USA
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Scott D. Newsome
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Bettina Balint
- Department of Neurology, University Hospital Zurich, 8091 Zurich, Switzerland;
- Faculty of Medicine, University of Zurich, 8091 Zurich, Switzerland
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31
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Xue H, Jiang Y, Qin L, Wang X, Zhang M, Dai S, Teng Y, Xu J, Li W. Ofatumumab, a Fully Human Anti-CD20 Monoclonal Antibody, in the Treatment of Severe Refractory Anti-N-methyl-D-Aspartate Receptor Encephalitis: Two Case Reports. Ann Indian Acad Neurol 2023; 26:774-777. [PMID: 38022469 PMCID: PMC10666899 DOI: 10.4103/aian.aian_236_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 04/12/2023] [Accepted: 05/10/2023] [Indexed: 12/01/2023] Open
Abstract
Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is a type of autoimmune encephalitis (AE) characterized by antibodies against NMDA receptor. As the most common AE, anti-NMDAR encephalitis affects 54% ~ 80% of patients with AE. It is associated with a high percentage of severe illness. It typically manifests as behavioral and psychiatric disturbance, epilepsy, cognitive decline, decreased level of consciousness, involuntary movements, autonomic dysfunction, central hypoventilation, etc. We report two refractory anti-NMDAR encephalitis. One of them describes a case of anti-NMDA encephalitis coexisting with MOG antibodies. The two patients were administered first-line therapy with glucocorticoids and intravenous immunoglobulin but did not improve clinically. Therefore, the patient was switched to the fully human anti-CD20 monoclonal antibody, ofatumumab. Their consciousness, behavioral and psychiatric disturbance, and capacity to conduct daily tasks improved markedly after sequential therapy with ofatumumab, as demonstrated by the modified Rankin scale (mRS) score. For the first time, we report a successful approach to the treatment of refractory anti-NMDAR encephalitis using the fully human anti-CD20 monoclonal antibody ofatumumab, which serves as an important reference for the treatment of AE.
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Affiliation(s)
- Hongfei Xue
- Department of Neurology, People's Hospital of Zhengzhou University, Zhengzhou, Henan Province China
| | - Yushu Jiang
- Department of Neurology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Lingzhi Qin
- Department of Neurology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Xiaojuan Wang
- Department of Neurology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Milan Zhang
- Department of Neurology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Shuhua Dai
- Department of Neurology, People's Hospital of Xinxiang Medical University, Zhengzhou, China
| | - Yongshi Teng
- Department of Neurology, People's Hospital of Zhengzhou University, Zhengzhou, Henan Province China
| | - Jiajia Xu
- Department of Neurology, People's Hospital of Henan University, Zhengzhou, China
| | - Wei Li
- Department of Neurology, Henan Provincial People's Hospital, Zhengzhou, China
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32
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Varley JA, Strippel C, Handel A, Irani SR. Autoimmune encephalitis: recent clinical and biological advances. J Neurol 2023; 270:4118-4131. [PMID: 37115360 PMCID: PMC10345035 DOI: 10.1007/s00415-023-11685-3] [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: 03/03/2023] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 04/29/2023]
Abstract
In 2015, we wrote a review in The Journal of Neurology summarizing the field of autoantibody-associated neurological diseases. Now, in 2023, we present an update of the subject which reflects the rapid expansion and refinement of associated clinical phenotypes, further autoantibody discoveries, and a more detailed understanding of immunological and neurobiological pathophysiological pathways which mediate these diseases. Increasing awareness around distinctive aspects of their clinical phenotypes has been a key driver in providing clinicians with a better understanding as to how these diseases are best recognized. In clinical practice, this recognition supports the administration of often effective immunotherapies, making these diseases 'not to miss' conditions. In parallel, there is a need to accurately assess patient responses to these drugs, another area of growing interest. Feeding into clinical care are the basic biological underpinnings of the diseases, which offer clear pathways to improved therapies toward enhanced patient outcomes. In this update, we aim to integrate the clinical diagnostic pathway with advances in patient management and biology to provide a cohesive view on how to care for these patients in 2023, and the future.
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Affiliation(s)
- James A Varley
- Department of Brain Sciences, Charing Cross Hospital, Imperial College London, Fulham Palace Road, London, W6 8RF, UK
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Oxford, OX3 9DS, UK
| | - Christine Strippel
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Oxford, OX3 9DS, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
| | - Adam Handel
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Oxford, OX3 9DS, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Oxford, OX3 9DS, UK.
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK.
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Vakrakou AG, Karachaliou E, Chroni E, Zouvelou V, Tzanetakos D, Salakou S, Papadopoulou M, Tzartos S, Voumvourakis K, Kilidireas C, Giannopoulos S, Tsivgoulis G, Tzartos J. Immunotherapies in MuSK-positive Myasthenia Gravis; an IgG4 antibody-mediated disease. Front Immunol 2023; 14:1212757. [PMID: 37564637 PMCID: PMC10410455 DOI: 10.3389/fimmu.2023.1212757] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/05/2023] [Indexed: 08/12/2023] Open
Abstract
Muscle-specific kinase (MuSK) Myasthenia Gravis (MG) represents a prototypical antibody-mediated disease characterized by predominantly focal muscle weakness (neck, facial, and bulbar muscles) and fatigability. The pathogenic antibodies mostly belong to the immunoglobulin subclass (Ig)G4, a feature which attributes them their specific properties and pathogenic profile. On the other hand, acetylcholine receptor (AChR) MG, the most prevalent form of MG, is characterized by immunoglobulin (Ig)G1 and IgG3 antibodies to the AChR. IgG4 class autoantibodies are impotent to fix complement and only weakly bind Fc-receptors expressed on immune cells and exert their pathogenicity via interfering with the interaction between their targets and binding partners (e.g. between MuSK and LRP4). Cardinal differences between AChR and MuSK-MG are the thymus involvement (not prominent in MuSK-MG), the distinct HLA alleles, and core immunopathological patterns of pathology in neuromuscular junction, structure, and function. In MuSK-MG, classical treatment options are usually less effective (e.g. IVIG) with the need for prolonged and high doses of steroids difficult to be tapered to control symptoms. Exceptional clinical response to plasmapheresis and rituximab has been particularly observed in these patients. Reduction of antibody titers follows the clinical efficacy of anti-CD20 therapies, a feature implying the role of short-lived plasma cells (SLPB) in autoantibody production. Novel therapeutic monoclonal against B cells at different stages of their maturation (like plasmablasts), or against molecules involved in B cell activation, represent promising therapeutic targets. A revolution in autoantibody-mediated diseases is pharmacological interference with the neonatal Fc receptor, leading to a rapid reduction of circulating IgGs (including autoantibodies), an approach already suitable for AChR-MG and promising for MuSK-MG. New precision medicine approaches involve Chimeric autoantibody receptor T (CAAR-T) cells that are engineered to target antigen-specific B cells in MuSK-MG and represent a milestone in the development of targeted immunotherapies. This review aims to provide a detailed update on the pathomechanisms involved in MuSK-MG (cellular and humoral aberrations), fostering the understanding of the latest indications regarding the efficacy of different treatment strategies.
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Affiliation(s)
- Aigli G. Vakrakou
- First Department of Neurology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Karachaliou
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Elisabeth Chroni
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece
| | - Vasiliki Zouvelou
- First Department of Neurology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Tzanetakos
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Stavroula Salakou
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marianna Papadopoulou
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Physiotherapy, University of West Attica, Athens, Greece
| | - Socrates Tzartos
- Tzartos NeuroDiagnostics, Athens, Greece
- Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece
- Department of Pharmacy, University of Patras, Patras, Greece
| | - Konstantinos Voumvourakis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Constantinos Kilidireas
- First Department of Neurology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, Henry Dunant Hospital Center, Athens, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, United States
| | - John Tzartos
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Venkatesan A, Habis R, Geocadin RG. Approach to acute encephalitis in the intensive care unit. Curr Opin Crit Care 2023; 29:89-98. [PMID: 36794940 DOI: 10.1097/mcc.0000000000001028] [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: 02/17/2023]
Abstract
PURPOSE OF REVIEW Recent years have seen a dramatic increase in the identification of autoimmune encephalitis (AE) and the emergence of new causes of infectious encephalitis (IE). However, management of these patients remains challenging, with many requiring care in intensive care units. Here, we describe recent advances in the diagnosis and management of acute encephalitis. RECENT FINDINGS Advances in the identification of clinical presentations, neuroimaging biomarkers, and electroencephalogram patterns have enabled more rapid diagnosis of encephalitis. Newer modalities such as meningitis/encephalitis multiplex PCR panels, metagenomic next-generation sequencing, and phage display-based assays are being evaluated in an effort to improve detection of autoantibodies and pathogens. Specific advances in the treatment of AE include establishment of a systematic approach to first-line therapies and the development of newer second-line modalities. The role of immunomodulation and its applications in IE are actively being investigated. In the ICU, particular attention to status epilepticus, cerebral edema, and dysautonomia may improve outcomes. SUMMARY Substantial diagnostic delays still occur, with many cases left without an identified etiology. Antiviral therapies remain scarce, and optimal treatment regimens for AE still need to be clarified. Nevertheless, our understanding of diagnostic and therapeutic approaches to encephalitis is rapidly evolving.
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Affiliation(s)
| | - Ralph Habis
- Johns Hopkins Encephalitis Center, Department of Neurology
| | - Romergryko G Geocadin
- Johns Hopkins Encephalitis Center, Department of Neurology
- Departments of Neurosurgery and Anaesthesia/Critical Care, Johns Hopkins University School of Medicine, Maryland, USA
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Feng J, Li J, Xie Y, Lü Y, Bi F, Zhou J. Clinical features of 28 cases of anti -leucine -rich glioma -inactivated protein 1 encephalitis and anti -contactin -associated protein -like 2 encephalitis. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2023; 48:386-396. [PMID: 37164922 PMCID: PMC10930077 DOI: 10.11817/j.issn.1672-7347.2023.220548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Indexed: 05/12/2023]
Abstract
OBJECTIVES Autoimmune encephalitis arising from autoantibodies against leucine-rich glioma-inactivated protein 1 (LGI1) and contactin-associated protein-like 2 (CASPR2) are rare and with high clinical heterogeneity. They are easily misdiagnosed and missing diagnosed. This study aims to explore the clinical characteristics, auxiliary examinations, therapies and prognosis of anti-LGI1 and anti-CASPR2 encephalitis. METHODS Seventeen anti-LGI1 and 11 anti-CASPR2 encephalitis patients who were admitted to the Department of Neurology, Xiangya Hospital, Central South University between January 2018 and January 2021 were collected and retrospectively analyzed. Autoimmune encephalitis related antibodies and paraneoplastic antibodies were screened in all patients. The clinical manifestations, results of laboratory tests, imaging features, treatments and outcomes of 2 encephalitis groups were analyzed and compared. RESULTS In the anti-LGI1 encephalitis group, the age of 17 patients was 28-83 (53.18±19.08) years old, and the ratio of male to female was 9꞉8. There were 10 patients with cognitive impairment, 7 seizures, 4 faciobrachial dystonic seizures, and 1 psychiatric disturbance. Hyponatremia was observed in 7 patients. Eight patients had increased slow waves and 5 had epileptic discharge in electroencephalogram (EEG). Brain magnetic resonance (MRI) showed T2-weighted imaging (T2WI) and fluid attenuated inversion recovery (FLAIR) hyperintense signal in the temporal lobe, hippocampus and basal ganglia in 13 patients. In the anti-CASPR2 group, the age of 11 patients was 17-68 (47.18±16.20) years old, and the ratio of male to female was 5꞉6, with 7 limbic encephalitis, 1 Morvan syndrome, and 3 acquired neuromyotonia (NMT). Three patients had increased slow waves and 2 had epileptic discharge in EEG. Brain MRI showed T2WI and FLAIR hyperintense signal in the temporal lobe, hippocampus in 2 patients. Steroids, intravenous immunoglobin, and plasma exchange were administrated in 16 anti-LGI1 encephalitis and 8 anti-CASPR2 encephalitis patients with good therapeutic responses. Among them, 1 patient with anti-LGI1 encephalitis and 3 with anti-CASPR2 encephalitis were administrated with mycophenolate mofetil for immune maintenance therapy. No recurrences were observed in all patients with immunotherapy except for 2 patients who lost of follow-up. There were significant differences in cognitive impairment, hyponatremia, and brain MRI abnormalities between anti-LGI1 and anti-CASPR2 encephalitis patients (all P<0.05). CONCLUSIONS Limbic encephalitis is a common syndrome in both anti-LGI1 and anti-CASPR2 encephalitis patients. Anti-CASPR2 encephalitis has a wider clinical spectrum than anti-LGI1 encephalitis, presenting as NMT and Morvan syndrome, which has a closer relationship with tumors. Both of these 2 antibodies associated disorders are sensitive to immunotherapy and have a good prognosis.
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Affiliation(s)
- Jie Feng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha 410008, China.
| | - Jingwen Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Yuanyuan Xie
- Department of Neurology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Yefan Lü
- Department of Neurology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Fangfang Bi
- Department of Neurology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Jinxia Zhou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha 410008, China.
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Zhou Q, Yin D, Ma J, Chen S. The therapeutic effect of ofatumumab in autoimmune encephalitis: A case series. J Neuroimmunol 2023; 377:578062. [PMID: 36898305 DOI: 10.1016/j.jneuroim.2023.578062] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/16/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023]
Abstract
The management of autoimmune encephalitis (AE) with immunotherapy is non-standardized, especially in refractory AE. Ofatumumab (OFA), an anti-CD20 antibody, has not been reported in the treatment of AE. This study presented three AE cases that received the OFA treatment. OFA was administered subcutaneously at a dose of 20 mg two or three times within three weeks. There were some mild adverse effects, including low-grade fever and dizziness. They had favorable responses (reduced antibody titer and clinical symptom improvement). Their symptoms were stable and even improved during a three-month follow-up. Thus, OFA injection is demonstrated to be safe and effective in treating AE. This is the first report about OFA treatment in AE, depicting its potential as a therapeutic option.
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Affiliation(s)
- Qinming Zhou
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dou Yin
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianfang Ma
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Sheng Chen
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Co-innovation Center of Neuroregeneration, Nantong University, Nantong, China.
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Khambholja K, Gehani M. Use of Structured Template and Reporting Tool for Real-World Evidence for Critical Appraisal of the Quality of Reporting of Real-World Evidence Studies: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:427-434. [PMID: 36210293 DOI: 10.1016/j.jval.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Real-world evidence (RWE) studies are increasingly being used to support healthcare decisions. Various frameworks, tools, and checklists exist for ensuring quality of real-world data, designing robust studies, and assessing potential for bias. In January 2021, Structured Template and Reporting Tool for RWE (STaRT-RWE) was released to further reduce ambiguity, assumptions, and misinterpretation while planning, implementing, and reporting RWE studies of the safety and effectiveness of treatments. The objective of this study was to identify gaps in the reporting quality of published RWE studies by using this template for critical appraisal. METHODS Two reviewers conducted a keyword search on PubMed for free-full-text research articles using real-world data, RWE design, and safety with or without effectiveness outcomes of a medicinal product or intervention in humans of any age or gender, published in English between January 13, 2021, and January 13, 2022. Assessment of risk of bias was done using Assessment of Real-World Observational Studies critical appraisal tool. Deficiencies in methods and findings as per STaRT-RWE template were reported as frequencies. RESULTS A total of 54 of 2374 retrieved studies were included in the review. Based on the STaRT-RWE template, the studies inadequately reported empirically defined covariates, power and sample size calculation, attrition, sensitivity analyses, index date (day 0) defining criterion, predefined covariates, outcome, metadata about data source and software, objective, inclusion and exclusion criteria, analysis specifications, and follow-up. CONCLUSIONS The use of STaRT-RWE template along with its tables, design diagram, and library of published studies has a potential of improving robustness of RWE studies.
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Affiliation(s)
- Kapil Khambholja
- Department of Medical Writing and Real World Evidence, Genpro Research Inc, Waltham, MA, USA.
| | - Manish Gehani
- Department of Medical Writing and Real World Evidence, Genpro Research Pvt Ltd, Thiruvananthapuram, India
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Ramanathan S, Brilot F, Irani SR, Dale RC. Origins and immunopathogenesis of autoimmune central nervous system disorders. Nat Rev Neurol 2023; 19:172-190. [PMID: 36788293 DOI: 10.1038/s41582-023-00776-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 02/16/2023]
Abstract
The field of autoimmune neurology is rapidly evolving, and recent discoveries have advanced our understanding of disease aetiologies. In this article, we review the key pathogenic mechanisms underlying the development of CNS autoimmunity. First, we review non-modifiable risk factors, such as age, sex and ethnicity, as well as genetic factors such as monogenic variants, common variants in vulnerability genes and emerging HLA associations. Second, we highlight how interactions between environmental factors and epigenetics can modify disease onset and severity. Third, we review possible disease mechanisms underlying triggers that are associated with the loss of immune tolerance with consequent recognition of self-antigens; these triggers include infections, tumours and immune-checkpoint inhibitor therapies. Fourth, we outline how advances in our understanding of the anatomy of lymphatic drainage and neuroimmune interfaces are challenging long-held notions of CNS immune privilege, with direct relevance to CNS autoimmunity, and how disruption of B cell and T cell tolerance and the passage of immune cells between the peripheral and intrathecal compartments have key roles in initiating disease activity. Last, we consider novel therapeutic approaches based on our knowledge of the immunopathogenesis of autoimmune CNS disorders.
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Affiliation(s)
- Sudarshini Ramanathan
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead, Sydney, New South Wales, Australia
- Sydney Medical School, Faculty of Medicine and Health and Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Concord Hospital, Sydney, New South Wales, Australia
| | - Fabienne Brilot
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead, Sydney, New South Wales, Australia
- School of Medical Science, Faculty of Medicine and Health and Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Russell C Dale
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead, Sydney, New South Wales, Australia.
- Sydney Medical School, Faculty of Medicine and Health and Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia.
- TY Nelson Department of Paediatric Neurology, Children's Hospital Westmead, Sydney, New South Wales, Australia.
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Biljecki M, Eisenhut K, Beltrán E, Winklmeier S, Mader S, Thaller A, Eichhorn P, Steininger P, Flierl-Hecht A, Lewerenz J, Kümpfel T, Kerschensteiner M, Meinl E, Thaler FS. Antibodies Against Glutamic Acid Decarboxylase 65 Are Locally Produced in the CSF and Arise During Affinity Maturation. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:10/3/e200090. [PMID: 36823135 PMCID: PMC9969496 DOI: 10.1212/nxi.0000000000200090] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 12/12/2022] [Indexed: 02/25/2023]
Abstract
BACKGROUND AND OBJECTIVES Antibodies (Abs) against the cytoplasmic protein glutamic acid decarboxylase 65 (GAD65) are detected in patients with neurologic syndromes together referred to as GAD65-Ab spectrum disorders. The response of some of these patients to plasma exchange or immunoglobulins indicates that GAD65-Abs could contribute to disease pathogenesis at least at some stages of disease. However, the involvement of GAD65-reactive B cells in the CNS is incompletely understood. METHODS We studied 7 patients with high levels of GAD65-Abs and generated monoclonal Abs (mAbs) derived from single cells in the CSF. Sequence characteristics, reactivity to GAD65, and the role of somatic hypermutations of the mAbs were analyzed. RESULTS Twelve CSF-derived mAbs were generated originating from 3 patients with short disease duration, and 7/12 of these mAbs (58%) were GAD65 reactive in at least 1 detection assay. Four of 12 (33%) were definitely positive in all 3 detection assays. The intrathecal anti-GAD65 response was polyclonal. GAD65-Abs were mostly of the IgG1 subtype and had undergone affinity maturation. Reversion of 2 GAD65-reactive mAbs to their corresponding germline-encoded unmutated common ancestors abolished GAD65 reactivity. DISCUSSION GAD65-specific B cells are present in the CNS and represent a sizable fraction of CSF B cells early in the disease course. The anti-GAD65 response in the CSF is polyclonal and shows evidence of antigen-driven affinity maturation required for GAD65 recognition. Our data support the hypothesis that the accumulation of GAD65-specific B cells and plasma cells in the CSF is an important feature of early disease stages.
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Affiliation(s)
- Michelle Biljecki
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Katharina Eisenhut
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Eduardo Beltrán
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Stephan Winklmeier
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Simone Mader
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Anna Thaller
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Peter Eichhorn
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Philipp Steininger
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Andrea Flierl-Hecht
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Jan Lewerenz
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Tania Kümpfel
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Martin Kerschensteiner
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Edgar Meinl
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Franziska S Thaler
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany.
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Gövert F, Abrante L, Becktepe J, Balint B, Ganos C, Hofstadt-van Oy U, Krogias C, Varley J, Irani SR, Paneva S, Titulaer MJ, de Vries JM, Boon AJW, Schreurs MWJ, Joubert B, Honnorat J, Vogrig A, Ariño H, Sabater L, Dalmau J, Scotton S, Jacob S, Melzer N, Bien CG, Geis C, Lewerenz J, Prüss H, Wandinger KP, Deuschl G, Leypoldt F. Distinct movement disorders in contactin-associated-protein-like-2 antibody-associated autoimmune encephalitis. Brain 2023; 146:657-667. [PMID: 35875984 DOI: 10.1093/brain/awac276] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 06/02/2022] [Accepted: 06/22/2022] [Indexed: 11/14/2022] Open
Abstract
Autoimmune encephalitis can be classified into antibody-defined subtypes, which can manifest with immunotherapy-responsive movement disorders sometimes mimicking non-inflammatory aetiologies. In the elderly, anti-LGI1 and contactin associated protein like 2 (CASPR2) antibody-associated diseases compose a relevant fraction of autoimmune encephalitis. Patients with LGI1 autoantibodies are known to present with limbic encephalitis and additionally faciobrachial dystonic seizures may occur. However, the clinical spectrum of CASPR2 autoantibody-associated disorders is more diverse including limbic encephalitis, Morvan's syndrome, peripheral nerve hyperexcitability syndrome, ataxia, pain and sleep disorders. Reports on unusual, sometimes isolated and immunotherapy-responsive movement disorders in CASPR2 autoantibody-associated syndromes have caused substantial concern regarding necessity of autoantibody testing in patients with movement disorders. Therefore, we aimed to systematically assess their prevalence and manifestation in patients with CASPR2 autoimmunity. This international, retrospective cohort study included patients with CASPR2 autoimmunity from participating expert centres in Europe. Patients with ataxia and/or movement disorders were analysed in detail using questionnaires and video recordings. We recruited a comparator group with anti-LGI1 encephalitis from the GENERATE network. Characteristics were compared according to serostatus. We identified 164 patients with CASPR2 autoantibodies. Of these, 149 (90.8%) had only CASPR2 and 15 (9.1%) both CASPR2 and LGI1 autoantibodies. Compared to 105 patients with LGI1 encephalitis, patients with CASPR2 autoantibodies more often had movement disorders and/or ataxia (35.6 versus 3.8%; P < 0.001). This was evident in all subgroups: ataxia 22.6 versus 0.0%, myoclonus 14.6 versus 0.0%, tremor 11.0 versus 1.9%, or combinations thereof 9.8 versus 0.0% (all P < 0.001). The small group of patients double-positive for LGI1/CASPR2 autoantibodies (15/164) significantly more frequently had myoclonus, tremor, 'mixed movement disorders', Morvan's syndrome and underlying tumours. We observed distinct movement disorders in CASPR2 autoimmunity (14.6%): episodic ataxia (6.7%), paroxysmal orthostatic segmental myoclonus of the legs (3.7%) and continuous segmental spinal myoclonus (4.3%). These occurred together with further associated symptoms or signs suggestive of CASPR2 autoimmunity. However, 2/164 patients (1.2%) had isolated segmental spinal myoclonus. Movement disorders and ataxia are highly prevalent in CASPR2 autoimmunity. Paroxysmal orthostatic segmental myoclonus of the legs is a novel albeit rare manifestation. Further distinct movement disorders include isolated and combined segmental spinal myoclonus and autoimmune episodic ataxia.
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Affiliation(s)
- Felix Gövert
- Department of Neurology, Christian-Albrecht University of Kiel and University Medical Center Schleswig-Holstein, 24105 Kiel, Germany
| | - Ligia Abrante
- Neuroimmunology, Institute of Clinical Chemistry, Christian-Albrecht University of Kiel and University Medical Center Schleswig-Holstein, 24105 Kiel, Germany
| | - Jos Becktepe
- Department of Neurology, Christian-Albrecht University of Kiel and University Medical Center Schleswig-Holstein, 24105 Kiel, Germany
| | - Bettina Balint
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK.,Department of Neurology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Christos Ganos
- Department of Neurology, Charité University Medicine Berlin, 10117 Berlin, Germany
| | | | - Christos Krogias
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, 44791 Bochum, Germany
| | - James Varley
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Sofija Paneva
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Maarten J Titulaer
- Department of Neurology, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Juna M de Vries
- Department of Neurology, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Agnita J W Boon
- Department of Neurology, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Marco W J Schreurs
- Department of Neurology, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Bastien Joubert
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Hôpital Neurologique, 69677 Bron, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon-Université Claude Bernard Lyon 1, Lyon, France
| | - Jerome Honnorat
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Hôpital Neurologique, 69677 Bron, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon-Université Claude Bernard Lyon 1, Lyon, France
| | - Alberto Vogrig
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Hôpital Neurologique, 69677 Bron, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon-Université Claude Bernard Lyon 1, Lyon, France
| | - Helena Ariño
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS); Service of Neurology, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain
| | - Lidia Sabater
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS); Service of Neurology, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain
| | - Josep Dalmau
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS); Service of Neurology, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain.,Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104, USA.,Catalan Institution for Research and Advanced Studies (ICREA), 08010 Barcelona, Spain
| | - Sangeeta Scotton
- Department of Neurology, University Hospitals Birmingham, Birmingham B15 2TH, UK
| | - Saiju Jacob
- Department of Neurology, University Hospitals Birmingham, Birmingham B15 2TH, UK
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, University of Münster, 48149 Münster, Germany.,Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Christian G Bien
- Department of Epileptology (Krankenhaus Mara), Bielefeld University, Medical School, Campus Bielefeld-Bethel, 33617 Bielefeld, Germany
| | - Christian Geis
- Department of Neurology, University of Jena, 07747 Jena, Germany
| | - Jan Lewerenz
- Department of Neurology, Ulm University, 89081 Ulm, Germany
| | - Harald Prüss
- German Center for Neurodegenerative Diseases (DZNE) Berlin and Department of Neurology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Klaus-Peter Wandinger
- Neuroimmunology, Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein, 23538 Lübeck, Germany.,Department of Neurology, University of Luebeck and University Medical Center Schleswig-Holstein, 23538 Lübeck, Germany
| | - Günther Deuschl
- Department of Neurology, Christian-Albrecht University of Kiel and University Medical Center Schleswig-Holstein, 24105 Kiel, Germany
| | - Frank Leypoldt
- Department of Neurology, Christian-Albrecht University of Kiel and University Medical Center Schleswig-Holstein, 24105 Kiel, Germany.,Neuroimmunology, Institute of Clinical Chemistry, Christian-Albrecht University of Kiel and University Medical Center Schleswig-Holstein, 24105 Kiel, Germany
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Brämer D, Geis C, Günther A. [Autoimmune encephalitis-Challenges and management in intensive medical care]. DER NERVENARZT 2023; 94:113-119. [PMID: 36651935 DOI: 10.1007/s00115-022-01423-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 01/19/2023]
Abstract
Despite relevant improvements in the diagnostics and treatment of autoimmune encephalitis (AE), severely affected patients still need treatment on the intensive care unit (ICU). Such complex disease states are sometimes difficult to bring under control and ICU complications have a negative influence on the outcome of treatment. A rapid diagnosis and timely initiation of immunotherapy are crucial to minimize ICU treatment and to avoid potentially severe complications. This article outlines the ICU treatment of autoimmune encephalitis and describes the most common challenges and complications of (neuro)intensive medical care and their management.
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Affiliation(s)
- Dirk Brämer
- Klinik für Neurologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - Christian Geis
- Klinik für Neurologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - Albrecht Günther
- Klinik für Neurologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland.
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Nguyen L, Wang C. Anti-NMDA Receptor Autoimmune Encephalitis: Diagnosis and Management Strategies. Int J Gen Med 2023; 16:7-21. [PMID: 36628299 PMCID: PMC9826635 DOI: 10.2147/ijgm.s397429] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 12/20/2022] [Indexed: 01/05/2023] Open
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is the most recognized form of autoimmune encephalitis. It is characterized by a constellation of neurologic and psychiatric features along with positive NMDAR antibody, which is more sensitive and specific in CSF than serum. All patients should be screened at least once for neoplasm, with ovarian teratoma being found in most tumor-related cases. In the acute phase, first-line immunotherapy, often a combination of high-dose steroids, immunoglobulins, and/or plasma exchange, is strongly recommended. When first-line therapy fails, escalation to second-line immunotherapy, particularly rituximab, can further improve outcomes and prevent relapses. In refractory cases, additional complementary immunotherapies, such as cyclophosphamide, bortezomib and/or tocilizumab may be considered. Relapses occur in 10-30% of cases, mostly within the first two years from onset. Individuals should be followed up to determine if chronic maintenance therapy is required.
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Affiliation(s)
- Linda Nguyen
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA,Correspondence: Linda Nguyen, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA, Tel +1-214-645-0136, Fax +1-214-645-8238, Email
| | - Cynthia Wang
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Muacevic A, Adler JR, McFarlane SI. Autoimmune Encephalitis With Autoimmune Diabetes: A Case of Horror Autotoxicus. Cureus 2023; 15:e34268. [PMID: 36855486 PMCID: PMC9968443 DOI: 10.7759/cureus.34268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2023] [Indexed: 01/28/2023] Open
Abstract
Diagnosing autoimmune encephalitis relies on clinical, radiological, and serological studies. Several autoantibodies have been implicated and recognized, with dozens of potential targets identified in the past 20 years. Despite that progress, some patients with encephalitis present a diagnostic dilemma with a seronegative status. The presence of other autoimmune diseases in a patient with encephalitis should provide a clue to the autoimmune nature of a developing neurological syndrome (cognitive, psychiatric, behavioral, and catatonia). In this report, we describe the case of a young man with type 1 diabetes mellitus who was diagnosed with seronegative autoimmune encephalitis after presenting with catatonia. We describe the lengthy clinical course, the various therapeutic trials, and his clinical outcome and response to B-cell depleting agent. This study also discusses the potential pathophysiologic pathways, providing a rationale for the diagnostic workup and therapeutic options for autoimmune encephalopathy in this case presentation.
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Binks S, Lamquet S, Crawford AH, Meurs A, Irani SR, Pakozdy A. Parallel roles of neuroinflammation in feline and human epilepsies. Vet J 2022; 290:105912. [PMID: 36209994 PMCID: PMC10912827 DOI: 10.1016/j.tvjl.2022.105912] [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: 01/22/2022] [Revised: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
Autoimmune encephalitis refers to a group of disorders characterised by a non-infectious encephalitis, often with prominent seizures and surface neuronal autoantibodies. AE is an important cause of new-onset refractory status epilepticus in humans and is frequently responsive to immunotherapies including corticosteroids, plasma exchange, intravenous immunoglobulin G and rituximab. Recent research suggests that parallel autoantibodies can be detected in non-human mammalian species. The best documented example is leucine-rich glioma-inactivated 1 (LGI1)-antibodies in domestic cats with limbic encephalitis (LE). In this review, we discuss the role of neuroinflammation and autoantibodies in human and feline epilepsy and LE.
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Affiliation(s)
- Sophie Binks
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, OX3 9DU, UK; Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals Foundation Trust, Oxford OX3 9DU, UK.
| | - Simon Lamquet
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Abbe H Crawford
- Clinical Science and Services, The Royal Veterinary College, Hertfordshire AL9 7TA, UK
| | - Alfred Meurs
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, OX3 9DU, UK; Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals Foundation Trust, Oxford OX3 9DU, UK
| | - Akos Pakozdy
- University Clinic for Small Animals, University of Veterinary Medicine Vienna, Austria
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Liu H, Dong Z, Zhang M, Pang R, Xu J, He P, Mei W, Zhang S, You G, Li W. Case report: Complex paraneoplastic syndromes in thymoma with nephrotic syndrome, cutaneous amyloidosis, myasthenia gravis, and Morvan’s syndrome. Front Oncol 2022; 12:1002808. [DOI: 10.3389/fonc.2022.1002808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/02/2022] [Indexed: 11/22/2022] Open
Abstract
BackgroundApart from myasthenia gravis (MG), thymoma is associated with a wide spectrum of autoimmune paraneoplastic syndromes (PNSs). Here, we report on a rare case presenting with four different PNSs, namely, MG, membranous nephropathy, cutaneous amyloidosis, and Morvan’s syndrome associated with thymoma.Case presentationA middle-aged man was frequently hospitalized because of nephrotic syndrome (stage I membranous nephropathy), cutaneous amyloidosis, and MG with acetylcholine receptor (AChR) antibody and titin antibody positivity. Chest CT showed a thymic mass in the left anterior mediastinum, and he received intravenous immunoglobulin (IVIG), methylprednisolone pulse therapy, thoracoscopic thymoma resection, and radiotherapy. Postoperative pathological examination revealed a type B2 thymoma. During the perioperative stage, his electrocardiogram (ECG) showed myocardial infarction-like ECG changes; however, his levels of cardiac enzymes and troponin were normal, and he had no symptoms of precardiac discomfort. Six months after thymectomy, his nephrotic syndrome and MG symptoms were relieved; however, he presented with typical manifestations of Morvan’s syndrome, including neuromyotonia, severe insomnia, abnormal ECG activity, and antibodies against leucine-rich glioma-inactivated 1 (LGI1) and γ-amino-butyric acid-B receptor (GABABR). His symptoms did not improve after repeated IVIG and steroid therapies. Finally, he received low-dose rituximab, and his symptoms gradually resolved.ConclusionThis case serves to remind us that apart from MG, thymoma is also associated with other autoimmune PNSs such as membranous nephropathy, cutaneous amyloidosis, and Morvan’s syndrome. Autoimmune PNSs can present concurrently with or after surgical or medical therapy for thymoma. For Morvan’s syndrome post-thymectomy with LGI1 antibody positivity, B-cell depletion therapy such as intravenous rituximab is an effective treatment.
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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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Du Y, Zhao C, Liu J, Li C, Yan Q, Li L, Hao Y, Yao D, Si H, Zhao Y, Zhang W. Simplified regimen of combined low-dose rituximab for autoimmune encephalitis with neuronal surface antibodies. J Neuroinflammation 2022; 19:259. [PMID: 36273158 PMCID: PMC9587594 DOI: 10.1186/s12974-022-02622-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/13/2022] [Indexed: 11/25/2022] Open
Abstract
Background Autoimmune encephalitis (AE) with neuronal surface antibodies (NSAbs) presents pathogenesis mediated by B cell-secreting antibodies. Rituximab is a second-line choice for the treatment for AE with NSAbs, which can cause B cell depletion via targeting CD20. However, the optimal protocol and dosage of rituximab combined with first-line therapy for NSAbs-associated AE remains unclear so far. In this study, we explored the efficacy and safety of low-dose rituximab combined with first-line treatment for NSAbs-associated AE. Methods Fifty-nine AE patients with NSAbs were enrolled, and retrospectively divided into common first-line therapy (41 patients) and combined low-dose rituximab (100 mg induction weekly with 3 circles, followed by 100 mg reinfusion every 6 months) with first-line therapy (18 patients). Outcome measures included changes in the Clinical Assessment Scale for Autoimmune Encephalitis (CASE) score (primary endpoint), changes in the modified Rankin Scale (mRS), the Mini-mental State Examination (MMSE), the patient and caregiver Neuropsychiatric Inventory (NPI) score at each visit (baseline, discharge, 6 months, 12 months and last follow-up) between two groups (secondary endpoint), as well as oral prednisone dosage, relapse and adverse effects during follow-up. Results Compared with traditional first-line therapy group, for primary outcome, CASE scores at last follow-up were significantly improved in combined rituximab group, as well as markedly improving changes of CASE scores between baseline and each visit. While changes of mRS, MMSE and NPI scores, as secondary endpoint, were all markedly accelerating improvement between baseline and each visit, as well as both oral prednisone dosage and relapse were also greatly reduced during follow-up. Meanwhile, longitudinal analysis in combination of rituximab cohort also revealed persistently marked amelioration in a series of scales from baseline even more than 1 year. Moreover, analysis in rituximab subgroup showed no difference in any clinical outcomes between combination with single first-line and with repeated first-line treatment (≥ 2 times), while compared to delayed combination with rituximab (> 3 months), early initiation of combination (≤ 3 months) might achieve better improvements in CASE and MMSE assessment even 1 year later. No rituximab-correlated serious adverse events have been reported in our patients. Conclusions Our simplified regimen of combined low-dose rituximab firstly showed significantly accelerating short-term recovery and long-term improvement for AE with NSAbs, in parallel with markedly reduced prednisone dosage and clinical relapses. Moreover, opportunity of protocol showed earlier initiation (≤ 3 months) with better long-term improvement. Supplementary Information The online version contains supplementary material available at 10.1186/s12974-022-02622-8.
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Affiliation(s)
- Ying Du
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an City, 710038, Shaanxi Province, China
| | - Chao Zhao
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an City, 710038, Shaanxi Province, China
| | - Juntong Liu
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an City, 710038, Shaanxi Province, China
| | - Chuan Li
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an City, 710038, Shaanxi Province, China
| | - Qi Yan
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an City, 710038, Shaanxi Province, China
| | - Lin Li
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an City, 710038, Shaanxi Province, China
| | - Yunfeng Hao
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an City, 710038, Shaanxi Province, China
| | - Dan Yao
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an City, 710038, Shaanxi Province, China
| | - Huaxing Si
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an City, 710038, Shaanxi Province, China
| | - Yingjun Zhao
- Fujian Provincial Key Laboratory of Neurodegenerative Disease and Aging Research, Institute of Neuroscience, School of Medicine, Xiamen University, Xiamen, 361005, China.
| | - Wei Zhang
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an City, 710038, Shaanxi Province, China.
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Bai L, Ren H, Liang M, Lu Q, Lin N, Liu M, Fan S, Cui R, Guan H. Neurological disorders associated with glutamic acid decarboxylase 65 antibodies: Clinical spectrum and prognosis of a cohort from China. Front Neurol 2022; 13:990553. [PMID: 36277926 PMCID: PMC9581312 DOI: 10.3389/fneur.2022.990553] [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: 07/10/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
Objective To describe clinical phenotypes and prognosis of neurological autoimmunity related to glutamic acid decarboxylase 65 (GAD65) antibodies in China. Method In this retrospective observational study from Peking Union Medical College Hospital, we identified patients with neurological disorders related to GAD65 antibodies (cell-based assay) from May 2015 to September 2021. Clinical manifestations, immunotherapy responsiveness, and outcomes were collected after obtaining informed consent from all patients. Results Fifty-five patients were included: 40 (72.73%) were women and initial neurological symptoms developed at 42(34-55) years of age. The median time to the nadir of the disease was 5 months (range from 1 day to 48 months). The clinical syndromes included limbic encephalitis (LE) or epilepsy (Ep) (n = 34, 61.82%), stiff-person syndromes (SPS) (n = 18, 32.73%), autoimmune cerebellar ataxia (ACA) (n = 11, 20%), and overlap syndrome in eight (14.55%) patients. Thirty-two (58.2%) patients had comorbidities of other autoimmune diseases, including Hashimoto thyroiditis (n = 17, 53.13%), T1DM (n = 11, 34.78%), vitiligo (n = 6, 18.75%), and others (n=5, 15.63%). Two (3.64%) patients had tumors, including thymoma and small cell lung cancer. Fifty-one (92.7%) patients received first-line immunotherapy (glucocorticoids and/or IV immunoglobulin), and 4 (7.3%) received second-line immunotherapy (rituximab). Long-term immunotherapy (mycophenolate mofetil) was administered to 23 (41.8%) patients. At the median time of 15 months (IQR 6–33.75 month, range 3–96 month) of follow-up, the patients' median modified Rankin Score (mRS) had declined from 2 to 1. Thirty-eight (70.4%) patients experienced clinical improvement (mRS declined ≥1), 47 (87%) had favorable clinical outcomes (mRS ≤2), and nine were symptom-free (16.7%). The sustained response to immunotherapy ranged from 7/15 (63.63%) in ACA patients and 22/34 (64.7%) in LE/Ep patients to 14/17 (82.35%) in SPS patients. Conclusions LE/Ep was the most common neurological phenotype of GAD65 antibody neurological autoimmunity in our cohort. Most patients had comorbidities of other autoimmune diseases, but underlying tumors were rare. Most patients responded to immunotherapy. However, the long-term prognosis varied among different clinical phenotypes.
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Affiliation(s)
- Lin Bai
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Menglin Liang
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Qiang Lu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Nan Lin
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Mange Liu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ruixue Cui
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Hongzhi Guan
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Chen TX, Fan YT, Peng BW. Distinct mechanisms underlying therapeutic potentials of CD20 in neurological and neuromuscular disease. Pharmacol Ther 2022; 238:108180. [DOI: 10.1016/j.pharmthera.2022.108180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/16/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
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Cornacchini S, Farina A, Contento M, Berti V, Biggi M, Barilaro A, Massacesi L, Damato V, Rosati E. Long-term-video monitoring EEG and 18F-FDG-PET are useful tools to detect residual disease activity in anti-LGI1-Abs encephalitis: A case report. Front Neurol 2022; 13:949240. [PMID: 36051221 PMCID: PMC9425832 DOI: 10.3389/fneur.2022.949240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/27/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe use of CD20-depleting monoclonal antibodies has shown to improve the long-term outcome of patients with anti-leucine-rich glioma-inactivated protein 1 antibodies (anti-LGI1-Abs) encephalitis after first-line immunotherapy, but currently predictive markers of treatment response and disease activity are lacking.Case presentationA 75-year-old man presented cognitive impairment and faciobrachial dystonic seizures (FBDS), with mild abnormalities at electroencephalography (EEG), normal brain magnetic resonance and cerebrospinal fluid (CSF) analysis. Anti-LGI1-Abs were detected in serum and CSF, and corticosteroids and intravenous immunoglobulins were administered. Despite partial cognitive improvement, 18F-fluoridesoxyglucose-positron emission tomography (18F-FDG-PET) showed the persistence of temporo-mesial hypermetabolism, and FBDS were still detected by long-term monitoring video EEG (LTMV EEG). Rituximab was therefore administered with FBDS disappearance, further cognitive improvement, and resolution of 18F-FDG-PET temporo-mesial hypermetabolism.ConclusionsOur experience supports the use of 18F-FDG-PET and LTMVEEG as useful tools to measure disease activity, evaluate treatment response and guide therapeutic decisions in the long-term management of anti-LGI1-antibody encephalitis.
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Affiliation(s)
- Sara Cornacchini
- Department of Neurosciences Drugs and Child Health, University of Florence, Florence, Italy
- Department of Neurology 2, Careggi University Hospital, Florence, Italy
| | - Antonio Farina
- Department of Neurosciences Drugs and Child Health, University of Florence, Florence, Italy
| | - Margherita Contento
- Department of Neurosciences Drugs and Child Health, University of Florence, Florence, Italy
- Department of Neurology, Pordenone Hospital, Pordenone, Italy
| | - Valentina Berti
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, Florence, Italy
- Nuclear Medicine, Careggi University Hospital, Florence, Italy
| | - Martina Biggi
- Department of Neurosciences Drugs and Child Health, University of Florence, Florence, Italy
- Department of Neurology 2, Careggi University Hospital, Florence, Italy
| | | | - Luca Massacesi
- Department of Neurosciences Drugs and Child Health, University of Florence, Florence, Italy
- Department of Neurology 2, Careggi University Hospital, Florence, Italy
| | - Valentina Damato
- Department of Neurosciences Drugs and Child Health, University of Florence, Florence, Italy
- Department of Neurology 2, Careggi University Hospital, Florence, Italy
- *Correspondence: Valentina Damato
| | - Eleonora Rosati
- Department of Neurology 2, Careggi University Hospital, Florence, Italy
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