1
|
Rossi S, Farina A, Malvaso A, Dinoto A, Fionda L, Cornacchini S, Florean I, Zuliani L, Garibaldi M, Lauletta A, Baccari F, Zenesini C, Rinaldi R, Mariotto S, Damato V, Diamanti L, Gastaldi M, Vogrig A, Marchioni E, Guarino M. Clinical Course of Neurologic Adverse Events Associated With Immune Checkpoint Inhibitors: Focus on Chronic Toxicities. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200314. [PMID: 39298719 DOI: 10.1212/nxi.0000000000200314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/22/2024]
Abstract
BACKGROUND AND OBJECTIVES The clinical course and the risk of chronicity of neurologic immune-related adverse events (n-irAEs) associated with immune checkpoint inhibitors (ICIs) are not well documented. This study aimed to characterize the clinical course of n-irAEs and assess the prevalence of chronic events. METHODS This nationwide, multicenter, retrospective study included patients with n-irAEs identified at 7 Italian hospitals. The clinical course of n-irAEs was categorized into fulminant (if resulted in death within 12 weeks), monophasic (if resolved within 12 weeks), and chronic (if persisted beyond 12 weeks). Chronic n-irAEs were further subdivided into active (if there was indirect evidence of ongoing inflammation [i.e., required ongoing immunosuppression, relapsed on steroid tapering, or exhibited neurologic progression]) and inactive (if patients had neurologic sequelae without ongoing inflammation). Comparisons between groups and time-to-death analyses were performed. RESULTS Sixty-six patients were included (median age: 69 years [IQR 62-75]; 53 [80%] men). n-irAEs involved the peripheral nervous system in 48 patients (73%), the central nervous system in 14 (21%), and both in 4 (6%). Twelve patients (18%) had a fulminant course, with the risk being significantly higher in those with concurrent myocarditis (OR 5.4; 95% CI [1.02-28.31]). Among 54 patients with a nonfulminant course, 23 (43%) had a monophasic n-irAE and 31 (57%) had a chronic n-irAE, of which 16 of 31 (52%) were chronic active (due to ongoing immunosuppression [69%], relapses at corticosteroid tapering [19%], or neurologic disease progression [12%]) and 15 of 31 (48%) were chronic inactive. In patients with chronic inactive n-irAEs, neurologic sequelae included cerebellar ataxia (33%), neuromuscular weakness (27%), visual loss (13%), sensory disturbances (13%), focal neurologic signs (7%), and cognitive impairment (7%). Compared with patients with monophasic events, those with chronic n-irAEs had a higher rate of severe neurologic disability at the last evaluation (p < 0.01), shorter survival (p < 0.01), and higher overall mortality (p < 0.01), primarily due to cancer progression. DISCUSSION More than half of the patients with n-irAEs who survived the acute phase developed a chronic condition. Patients with chronic n-irAEs were at higher risk of death, mainly due to cancer progression. Future studies are needed to further characterize chronic n-irAEs and identify optimal long-term management strategies.
Collapse
Affiliation(s)
- Simone Rossi
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Antonio Farina
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Antonio Malvaso
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Alessandro Dinoto
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Laura Fionda
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Sara Cornacchini
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Irene Florean
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Luigi Zuliani
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Matteo Garibaldi
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Antonio Lauletta
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Flavia Baccari
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Corrado Zenesini
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Rita Rinaldi
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Sara Mariotto
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Valentina Damato
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Luca Diamanti
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Matteo Gastaldi
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Alberto Vogrig
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Enrico Marchioni
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Maria Guarino
- From the IRCCS Istituto delle Scienze Neurologiche di Bologna (S.R., R.R., M. Guarino), Italy; Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A.F), Hospices Civils de Lyon, Neurological Hospital, Bron, MeLiS - UCBL-CNRS UMR 5284 - INSERM U1314, Universitè Claude Bernard Lyon 1, France; IRCCS Mondino Foundation (A.M., L.D., E.M.), Pavia; Neurology Unit (A.D., S.M.), Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Neuromuscular and Rare Disease Centre (L.F.), Neurology Unit, Sant'Andrea University Hospital, Rome, Italy; Department of Neurosciences Drugs and Child Health (S.C., V.D.), University of Florence; Clinical Neurology Unit (I.F., A.V.), Department of Medicine (DMED), University of Udine; Neurology Unit (L.Z.), AULSS8 Berica, San Bortolo Hospital, Vicenza; Department of Neuroscience (M. Garibaldi, A.L.), Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital; Epidemiology and Statistics Unit (F.B., C.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna; Department of Neurology 2, Careggi University Hospital, Florence, Italy; Neuroimmunology Laboratory (M.Gastaldi), IRCCS Mondino Foundation, Pavia, Italy; and Clinical Neurology (A.V.), Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| |
Collapse
|
2
|
Winklehner M, Wickel J, Gelpi E, Brämer D, Rauschenberger V, Günther A, Bauer J, Serra AS, Jauk P, Villmann C, Höftberger R, Geis C. Progressive Encephalomyelitis With Rigidity and Myoclonus With Glycine Receptor and GAD65 Antibodies: Case Report and Potential Mechanisms. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200298. [PMID: 39213470 PMCID: PMC11368231 DOI: 10.1212/nxi.0000000000200298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/28/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVES Progressive encephalomyelitis with rigidity and myoclonus (PERM) is a severe form of stiff-person spectrum disorder that can be associated with antibodies against surface antigens (glycine receptor (GlyR), dipeptidyl-peptidase-like-protein-6) and intracellular antigens (glutamate decarboxylase (GAD65), amphiphysin). METHODS We report clinico-pathologic findings of a PERM patient with coexisting GlyR and GAD65 antibodies. RESULTS A 75-year-old man presented with myoclonus and pain of the legs, subsequently developed severe motor symptoms, hyperekplexia, a pronounced startle reflex, hallucinations, dysautonomia, and died 10 months after onset despite extensive immunotherapy, symptomatic treatment, and continuous intensive care support. Immunotherapy comprised corticosteroids, IVIG, plasmapheresis, immunoadsorption, cyclophosphamide, and bortezomib. Intensive care treatment and permanent isoflurane sedation was required for more than 20 weeks. CNS tissue revealed neuronal loss, astrogliosis and microgliosis, representing a pallido-nigro-dentato-bulbar-spinal degeneration pattern, specifically along GlyR and GAD expression sites. Neurons showed pSTAT1, MHC class I, and GRP78 upregulation. Inflammation was moderate and characterized by CD8+ T cells and single CD20+/CD79a+ B/plasma cells. Focal tau-positive thread-like deposits were detected in gliotic brainstem areas. In the spinal cord, GlyR, glycine transporter-2, and GAD67 expression were strongly reduced. DISCUSSION A possible potentiating effect of pathogenic GlyR antibodies together with T cells directed against neurons may have led to the severe and progressive clinical course.
Collapse
Affiliation(s)
- Michael Winklehner
- From the Division of Neuropathology and Neurochemistry (M.W., E.G., R.H.), Department of Neurology, Medical University of Vienna; Department of Neurology (M.W.), Johannes Kepler University Linz, Kepler University Hospital, Linz, Austria; Section of Translational Neuroimmunology (J.W., D.B., A.G., C.G.), Department of Neurology, Jena University Hospital, Germany; Comprehensive Center for Clinical Neurosciences and Mental Health (E.G., R.H.), Medical University of Vienna, Austria; Institute of Clinical Neurobiology (V.R., C.V.), University Hospital, Julius-Maximilians-University of Würzburg, Germany; Department of Neuroimmunology (J.B.), Center for Brain Research; and Center for Medical Physics and Biomedical Engineering (A.S.S., P.J.), Medical University of Vienna, Austria
| | - Jonathan Wickel
- From the Division of Neuropathology and Neurochemistry (M.W., E.G., R.H.), Department of Neurology, Medical University of Vienna; Department of Neurology (M.W.), Johannes Kepler University Linz, Kepler University Hospital, Linz, Austria; Section of Translational Neuroimmunology (J.W., D.B., A.G., C.G.), Department of Neurology, Jena University Hospital, Germany; Comprehensive Center for Clinical Neurosciences and Mental Health (E.G., R.H.), Medical University of Vienna, Austria; Institute of Clinical Neurobiology (V.R., C.V.), University Hospital, Julius-Maximilians-University of Würzburg, Germany; Department of Neuroimmunology (J.B.), Center for Brain Research; and Center for Medical Physics and Biomedical Engineering (A.S.S., P.J.), Medical University of Vienna, Austria
| | - Ellen Gelpi
- From the Division of Neuropathology and Neurochemistry (M.W., E.G., R.H.), Department of Neurology, Medical University of Vienna; Department of Neurology (M.W.), Johannes Kepler University Linz, Kepler University Hospital, Linz, Austria; Section of Translational Neuroimmunology (J.W., D.B., A.G., C.G.), Department of Neurology, Jena University Hospital, Germany; Comprehensive Center for Clinical Neurosciences and Mental Health (E.G., R.H.), Medical University of Vienna, Austria; Institute of Clinical Neurobiology (V.R., C.V.), University Hospital, Julius-Maximilians-University of Würzburg, Germany; Department of Neuroimmunology (J.B.), Center for Brain Research; and Center for Medical Physics and Biomedical Engineering (A.S.S., P.J.), Medical University of Vienna, Austria
| | - Dirk Brämer
- From the Division of Neuropathology and Neurochemistry (M.W., E.G., R.H.), Department of Neurology, Medical University of Vienna; Department of Neurology (M.W.), Johannes Kepler University Linz, Kepler University Hospital, Linz, Austria; Section of Translational Neuroimmunology (J.W., D.B., A.G., C.G.), Department of Neurology, Jena University Hospital, Germany; Comprehensive Center for Clinical Neurosciences and Mental Health (E.G., R.H.), Medical University of Vienna, Austria; Institute of Clinical Neurobiology (V.R., C.V.), University Hospital, Julius-Maximilians-University of Würzburg, Germany; Department of Neuroimmunology (J.B.), Center for Brain Research; and Center for Medical Physics and Biomedical Engineering (A.S.S., P.J.), Medical University of Vienna, Austria
| | - Vera Rauschenberger
- From the Division of Neuropathology and Neurochemistry (M.W., E.G., R.H.), Department of Neurology, Medical University of Vienna; Department of Neurology (M.W.), Johannes Kepler University Linz, Kepler University Hospital, Linz, Austria; Section of Translational Neuroimmunology (J.W., D.B., A.G., C.G.), Department of Neurology, Jena University Hospital, Germany; Comprehensive Center for Clinical Neurosciences and Mental Health (E.G., R.H.), Medical University of Vienna, Austria; Institute of Clinical Neurobiology (V.R., C.V.), University Hospital, Julius-Maximilians-University of Würzburg, Germany; Department of Neuroimmunology (J.B.), Center for Brain Research; and Center for Medical Physics and Biomedical Engineering (A.S.S., P.J.), Medical University of Vienna, Austria
| | - Albrecht Günther
- From the Division of Neuropathology and Neurochemistry (M.W., E.G., R.H.), Department of Neurology, Medical University of Vienna; Department of Neurology (M.W.), Johannes Kepler University Linz, Kepler University Hospital, Linz, Austria; Section of Translational Neuroimmunology (J.W., D.B., A.G., C.G.), Department of Neurology, Jena University Hospital, Germany; Comprehensive Center for Clinical Neurosciences and Mental Health (E.G., R.H.), Medical University of Vienna, Austria; Institute of Clinical Neurobiology (V.R., C.V.), University Hospital, Julius-Maximilians-University of Würzburg, Germany; Department of Neuroimmunology (J.B.), Center for Brain Research; and Center for Medical Physics and Biomedical Engineering (A.S.S., P.J.), Medical University of Vienna, Austria
| | - Jan Bauer
- From the Division of Neuropathology and Neurochemistry (M.W., E.G., R.H.), Department of Neurology, Medical University of Vienna; Department of Neurology (M.W.), Johannes Kepler University Linz, Kepler University Hospital, Linz, Austria; Section of Translational Neuroimmunology (J.W., D.B., A.G., C.G.), Department of Neurology, Jena University Hospital, Germany; Comprehensive Center for Clinical Neurosciences and Mental Health (E.G., R.H.), Medical University of Vienna, Austria; Institute of Clinical Neurobiology (V.R., C.V.), University Hospital, Julius-Maximilians-University of Würzburg, Germany; Department of Neuroimmunology (J.B.), Center for Brain Research; and Center for Medical Physics and Biomedical Engineering (A.S.S., P.J.), Medical University of Vienna, Austria
| | - Anika Simonovska Serra
- From the Division of Neuropathology and Neurochemistry (M.W., E.G., R.H.), Department of Neurology, Medical University of Vienna; Department of Neurology (M.W.), Johannes Kepler University Linz, Kepler University Hospital, Linz, Austria; Section of Translational Neuroimmunology (J.W., D.B., A.G., C.G.), Department of Neurology, Jena University Hospital, Germany; Comprehensive Center for Clinical Neurosciences and Mental Health (E.G., R.H.), Medical University of Vienna, Austria; Institute of Clinical Neurobiology (V.R., C.V.), University Hospital, Julius-Maximilians-University of Würzburg, Germany; Department of Neuroimmunology (J.B.), Center for Brain Research; and Center for Medical Physics and Biomedical Engineering (A.S.S., P.J.), Medical University of Vienna, Austria
| | - Philipp Jauk
- From the Division of Neuropathology and Neurochemistry (M.W., E.G., R.H.), Department of Neurology, Medical University of Vienna; Department of Neurology (M.W.), Johannes Kepler University Linz, Kepler University Hospital, Linz, Austria; Section of Translational Neuroimmunology (J.W., D.B., A.G., C.G.), Department of Neurology, Jena University Hospital, Germany; Comprehensive Center for Clinical Neurosciences and Mental Health (E.G., R.H.), Medical University of Vienna, Austria; Institute of Clinical Neurobiology (V.R., C.V.), University Hospital, Julius-Maximilians-University of Würzburg, Germany; Department of Neuroimmunology (J.B.), Center for Brain Research; and Center for Medical Physics and Biomedical Engineering (A.S.S., P.J.), Medical University of Vienna, Austria
| | - Carmen Villmann
- From the Division of Neuropathology and Neurochemistry (M.W., E.G., R.H.), Department of Neurology, Medical University of Vienna; Department of Neurology (M.W.), Johannes Kepler University Linz, Kepler University Hospital, Linz, Austria; Section of Translational Neuroimmunology (J.W., D.B., A.G., C.G.), Department of Neurology, Jena University Hospital, Germany; Comprehensive Center for Clinical Neurosciences and Mental Health (E.G., R.H.), Medical University of Vienna, Austria; Institute of Clinical Neurobiology (V.R., C.V.), University Hospital, Julius-Maximilians-University of Würzburg, Germany; Department of Neuroimmunology (J.B.), Center for Brain Research; and Center for Medical Physics and Biomedical Engineering (A.S.S., P.J.), Medical University of Vienna, Austria
| | - Romana Höftberger
- From the Division of Neuropathology and Neurochemistry (M.W., E.G., R.H.), Department of Neurology, Medical University of Vienna; Department of Neurology (M.W.), Johannes Kepler University Linz, Kepler University Hospital, Linz, Austria; Section of Translational Neuroimmunology (J.W., D.B., A.G., C.G.), Department of Neurology, Jena University Hospital, Germany; Comprehensive Center for Clinical Neurosciences and Mental Health (E.G., R.H.), Medical University of Vienna, Austria; Institute of Clinical Neurobiology (V.R., C.V.), University Hospital, Julius-Maximilians-University of Würzburg, Germany; Department of Neuroimmunology (J.B.), Center for Brain Research; and Center for Medical Physics and Biomedical Engineering (A.S.S., P.J.), Medical University of Vienna, Austria
| | - Christian Geis
- From the Division of Neuropathology and Neurochemistry (M.W., E.G., R.H.), Department of Neurology, Medical University of Vienna; Department of Neurology (M.W.), Johannes Kepler University Linz, Kepler University Hospital, Linz, Austria; Section of Translational Neuroimmunology (J.W., D.B., A.G., C.G.), Department of Neurology, Jena University Hospital, Germany; Comprehensive Center for Clinical Neurosciences and Mental Health (E.G., R.H.), Medical University of Vienna, Austria; Institute of Clinical Neurobiology (V.R., C.V.), University Hospital, Julius-Maximilians-University of Würzburg, Germany; Department of Neuroimmunology (J.B.), Center for Brain Research; and Center for Medical Physics and Biomedical Engineering (A.S.S., P.J.), Medical University of Vienna, Austria
| |
Collapse
|
3
|
Nitsch S, Höftberger R. What we've learnt about autoimmune neurological diseases from neuropathology. Rev Neurol (Paris) 2024:S0035-3787(24)00593-9. [PMID: 39317583 DOI: 10.1016/j.neurol.2024.08.009] [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: 06/29/2024] [Revised: 08/15/2024] [Accepted: 08/28/2024] [Indexed: 09/26/2024]
Abstract
Antibody-associated autoimmune neurological diseases are a group of disorders with various immune effector mechanisms that result in significant differences in disease course and prognosis. Paraneoplastic or idiopathic autoimmune encephalitis associated with antibodies against intracellular antigens are mostly characterized by a T-cell-dominated inflammation with neuronal loss, astrogliosis, and microglial nodules. In anti-Yo paraneoplastic cerebellar degeneration CD8+/granzymeB+ T cells were demonstrated in close apposition to neurons along with a nuclear upregulation of the activator of transcription 1, suggesting an important role of interferon-gamma in disease pathogenesis. Early and late disease stages may show different lesion types. For example, tissue samples from patients with temporal lobe epilepsy associated with antiglutamic acid decarboxylase 65 antibodies in early disease stages show numerous infiltrating T cells targeting hippocampal neurons and high numbers of B cells and plasma cells, while in chronic stages inflammation gets less and is followed by hippocampal sclerosis. Similarly, antiglial fibrillary acidic protein meningoencephalomyelitis may show loss of astrocytes only in the very early lesions, whereas in subacute and chronic stages astrocytes can get replenished most likely due to their high regeneration potential. In contrast, neuropathology of autoimmune neurological diseases mediated by surface antibodies is mostly characterized by a dysfunction of neurons in the absence of immune-mediated neuronal damage. The interaction of surface antibodies with their target antigen and the resulting downstream mechanisms are variable and can range from an internalization of the receptor in well-preserved neurons in anti-N-methyl-D-aspartate receptor encephalitis to an irreversible internalization and blocking of the receptor that may be associated with an accumulation of phosphorylated tau in specific brain regions in anti-IgLON5 disease. Interestingly, anti-IgLON5 patients with short disease duration were shown to present prominent deposition of IgG4 in the neuropil and on neuronal membranes in the absence of neuronal tau deposits, suggesting that the immune mechanisms precede neurodegeneration. Knowledge about pathomechanisms and patterns of tissue damage in different disease stages of antibody-associated autoimmune diseases will help to identify novel biomarkers and can give important clues for possible therapeutic interventions.
Collapse
Affiliation(s)
- S Nitsch
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - R Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
4
|
Farina A, Villagrán-García M, Benaiteau M, Lamblin F, Fourier A, Honnorat J, Joubert B. Opsoclonus-Ataxia Syndrome in a Patient With Small-Cell Lung Cancer Treated With Immune Checkpoint Inhibitors. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200287. [PMID: 39013128 PMCID: PMC11262711 DOI: 10.1212/nxi.0000000000200287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/30/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVES To describe a case of post-immune checkpoint inhibitor (ICI) opsoclonus-myoclonus-ataxia syndrome (OMAS), with complete clinical remission after treatment. METHODS A 52-year-old man was admitted because of subacute-onset vertigo, dysarthria, vomiting, and weight loss. He was under atezolizumab (anti-PD-L1) monotherapy (23 cycles) for metastatic small-cell lung cancer, with excellent response. RESULTS On examination (1 month after symptom onset), the patient had opsoclonus, dysarthria, severe truncal and gait ataxia, and mild appendicular ataxia without myoclonus (SARA score 26/40). Brain MRI showed mild cerebellar atrophy, and CSF analysis disclosed pleocytosis and oligoclonal bands. Anti-SOX1 antibodies were detected in serum and CSF. Atezolizumab was stopped, and corticosteroids and monthly IV immunoglobulins were administered. Chemotherapy (carboplatin and etoposide) was also started because of cancer progression. Three months later, examination showed regression of the opsoclonus, truncal ataxia, and dysarthria and persistence of very mild gait ataxia (SARA score 3.5/40), which completely regressed at last examination (20 months after onset). DISCUSSION The clinical pattern and reversibility bring the present case close to a few patients with paraneoplastic OMAS described before the ICI era. More research is needed to clarify the pathogenesis and outcomes of OMAS in the context of ICI.
Collapse
Affiliation(s)
- Antonio Farina
- From the French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A. Farina, M.V.-G., M.B., J.H., B.J.), Hospices Civils de Lyon, Hôpital Neurologique, Bron; MeLiS-UCBL-CNRS UMR 5284. INSERM U1314, Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre; and Lyon Neuroscience Research Center (CRNL) (A. Fourier), Université de Lyon, CNRS, INSERM, France
| | - Macarena Villagrán-García
- From the French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A. Farina, M.V.-G., M.B., J.H., B.J.), Hospices Civils de Lyon, Hôpital Neurologique, Bron; MeLiS-UCBL-CNRS UMR 5284. INSERM U1314, Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre; and Lyon Neuroscience Research Center (CRNL) (A. Fourier), Université de Lyon, CNRS, INSERM, France
| | - Marie Benaiteau
- From the French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A. Farina, M.V.-G., M.B., J.H., B.J.), Hospices Civils de Lyon, Hôpital Neurologique, Bron; MeLiS-UCBL-CNRS UMR 5284. INSERM U1314, Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre; and Lyon Neuroscience Research Center (CRNL) (A. Fourier), Université de Lyon, CNRS, INSERM, France
| | - Florian Lamblin
- From the French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A. Farina, M.V.-G., M.B., J.H., B.J.), Hospices Civils de Lyon, Hôpital Neurologique, Bron; MeLiS-UCBL-CNRS UMR 5284. INSERM U1314, Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre; and Lyon Neuroscience Research Center (CRNL) (A. Fourier), Université de Lyon, CNRS, INSERM, France
| | - Anthony Fourier
- From the French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A. Farina, M.V.-G., M.B., J.H., B.J.), Hospices Civils de Lyon, Hôpital Neurologique, Bron; MeLiS-UCBL-CNRS UMR 5284. INSERM U1314, Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre; and Lyon Neuroscience Research Center (CRNL) (A. Fourier), Université de Lyon, CNRS, INSERM, France
| | - Jérôme Honnorat
- From the French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A. Farina, M.V.-G., M.B., J.H., B.J.), Hospices Civils de Lyon, Hôpital Neurologique, Bron; MeLiS-UCBL-CNRS UMR 5284. INSERM U1314, Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre; and Lyon Neuroscience Research Center (CRNL) (A. Fourier), Université de Lyon, CNRS, INSERM, France
| | - Bastien Joubert
- From the French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis (A. Farina, M.V.-G., M.B., J.H., B.J.), Hospices Civils de Lyon, Hôpital Neurologique, Bron; MeLiS-UCBL-CNRS UMR 5284. INSERM U1314, Université Claude Bernard Lyon 1; Department of Neurology (F.L.), University Hospital of La Réunion, Saint-Pierre; and Lyon Neuroscience Research Center (CRNL) (A. Fourier), Université de Lyon, CNRS, INSERM, France
| |
Collapse
|
5
|
Farina A, Villagrán-García M, Fourier A, Pinto AL, Chorfa F, Timestit N, Alberto T, Aupy J, Benaiteau M, Birzu C, Campetella L, Cotton F, Dalle S, Delaruelle CF, Dumez P, Germi R, Le Maréchal M, Maillet D, Marignier R, Pegat A, Psimaras D, Rafiq M, Picard G, Desestret V, Quadrio I, Honnorat J, Joubert B. Diagnostic and prognostic biomarkers in immune checkpoint inhibitor-related encephalitis: a retrospective cohort study. THE LANCET REGIONAL HEALTH. EUROPE 2024; 44:101011. [PMID: 39170102 PMCID: PMC11338149 DOI: 10.1016/j.lanepe.2024.101011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 07/06/2024] [Accepted: 07/11/2024] [Indexed: 08/23/2024]
Abstract
Background Immune checkpoint inhibitor-related encephalitis (ICI-encephalitis) is not well characterised and diagnostic and prognostic biomarkers are lacking. We aimed to comprehensively characterise ICI-encephalitis and identify diagnostic biomarkers and outcome predictors. Methods This retrospective observational study included all patients with ICI-encephalitis studied in the French Reference Centre on Paraneoplastic Neurological Syndromes (PNS) and Autoimmune Encephalitis (2015-2023). ICI encephalitis was considered definite in case of inflammatory findings at paraclinical tests and/or well-characterised neural antibodies. Predictors of immune-related adverse event (irAE) treatment response, defined as a Common Terminology Criteria for Adverse Events v5.0 grade < 3 at any time after therapeutic intervention, were assessed by logistic regression analysis, and predictors of mortality by Cox regression analysis. Neurofilament light chain (NfL) was measured by enzyme-linked immunosorbent assay. Findings Sixty-seven patients with definite encephalitis were identified (median age, 69 years; 66% male). A focal syndrome was observed in 43/67 patients (64%; limbic encephalitis, cerebellar ataxia, and/or brainstem encephalitis), while 24/67 (36%) had meningoencephalitis, a non-focal syndrome with altered mental status (22/24 patients, 92%) and pleocytosis (24/24 patients, 100%). Patients with focal encephalitis more frequently had abnormal brain MRI (26/42, 62% versus 8/24, 33%, p = 0.025), PNS-related antibodies (36/43, 84% versus 1/24, 4%, p < 0.001), and neuroendocrine cancers (22/43, 51% versus 1/24, 4%; p < 0.001) than patients with meningoencephalitis. Focal encephalitis patients had a lower rate of irAE treatment response (7/39, 18%) and higher mortality (27/43, 63%) compared to meningoencephalitis patients (12/22, 77% and 5/24, 21%, respectively, p < 0.001 each). PNS-related antibodies were associated with less irAE treatment response, independently of age, sex, and baseline severity (adjusted OR 0.05; 95%CI [0.01; 0.19]; p < 0.001) as well as higher mortality, independently of age and cancer type (adjusted HR 5.07; 95% CI [2.12; 12.12]; p < 0.001). Serum NfL discriminated patients with definite ICI-encephalitis (n = 27) from cancer-matched controls (n = 16; optimal cut-off >273.5 pg/mL, sensitivity 81%, specificity 88%, AUC 0.87, 95% CI [0.76; 0.98]) and irAE treatment responders (n = 10) from non-responders (n = 17, optimal cut-off >645 pg/mL, sensitivity 90%, specificity 65%; AUC 0.75, 95% CI [0.55; 0.94]). Interpretation ICI-encephalitis corresponds to a set of clinically-recognisable syndromes. Patients with focal encephalitis, PNS-related antibodies, and/or higher serum NfL have low irAE treatment response rates. Research is needed on the underlying immunopathogenesis to foster therapeutic innovations. Funding Agence Nationale de la Recherche.
Collapse
Affiliation(s)
- Antonio Farina
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Macarena Villagrán-García
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Anthony Fourier
- Lyon Neuroscience Research Center (CRNL), Université de Lyon, CNRS, INSERM, Lyon, France
| | - Anne-Laurie Pinto
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Fatima Chorfa
- Service de Biostatistique et Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France
| | - Noémie Timestit
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Tifanie Alberto
- Department of Neurology, CRC SEP, Centre Hospitalier of Lille, Lille, France
| | - Jérôme Aupy
- Department of Clinical Neurosciences, Centre Hospitalier of Bordeaux, Bordeaux, France
- CNRS, IMN, UMR 5293, University of Bordeaux, Bordeaux, France
| | - Marie Benaiteau
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Cristina Birzu
- AP-HP, Hospital Group Pitié-Salpêtrière, Neuro-oncology Department Paris, France
- Inserm U1127, CNRS, Paris Brain Institute, Institut du Cerveau (ICM), Paris, France
| | - Lucia Campetella
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - François Cotton
- Radiology Department, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Stéphane Dalle
- Deparment of Dermatology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
- ImmuCare, Institute of Cancerology, Hospices Civils de Lyon, Lyon 69002, France
| | - Clara Fontaine Delaruelle
- ImmuCare, Institute of Cancerology, Hospices Civils de Lyon, Lyon 69002, France
- Department of Pneumology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Pauline Dumez
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Rafaele Germi
- Virology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Marion Le Maréchal
- Infectious Disease Unit, Grenoble-Alpes University Hospital, Grenoble, France
| | - Denis Maillet
- ImmuCare, Institute of Cancerology, Hospices Civils de Lyon, Lyon 69002, France
- Department of Medical Oncology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Romain Marignier
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hospices Civils de Lyon, Lyon, France
| | - Antoine Pegat
- Service ENMG et Pathologies Neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
- Pathophysiology and Genetics of Neuron and Muscle, CNRS UMR 5261, INSERM U1315, INMG, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est, Lyon, France
| | - Dimitri Psimaras
- AP-HP, Hospital Group Pitié-Salpêtrière, Neuro-oncology Department Paris, France
- Inserm U1127, CNRS, Paris Brain Institute, Institut du Cerveau (ICM), Paris, France
| | - Marie Rafiq
- Department of Cognitive Neurology, Epilepsy and Movement Disorders, Toulouse Purpan University Hospital Center, Toulouse, France
| | - Géraldine Picard
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Virginie Desestret
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Isabelle Quadrio
- Lyon Neuroscience Research Center (CRNL), Université de Lyon, CNRS, INSERM, Lyon, France
| | - Jérôme Honnorat
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Bastien Joubert
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS-UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
- ImmuCare, Institute of Cancerology, Hospices Civils de Lyon, Lyon 69002, France
| |
Collapse
|
6
|
Zekeridou A. Paraneoplastic Neurologic Disorders. Continuum (Minneap Minn) 2024; 30:1021-1051. [PMID: 39088287 DOI: 10.1212/con.0000000000001449] [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: 08/03/2024]
Abstract
OBJECTIVE This article reviews the clinical presentations, neural antibody associations, and oncologic accompaniments of paraneoplastic neurologic syndromes and neurologic autoimmunity in the context of immune checkpoint inhibitor (ICI) cancer immunotherapy. LATEST DEVELOPMENTS Neural antibody discovery has improved the diagnosis of paraneoplastic neurologic syndromes. Neural antibodies also delineate the underlying disease pathophysiology and thus inform outcomes and treatments. Neural antibodies specific for extracellular proteins have pathogenic potential, whereas antibodies specific for intracellular targets are biomarkers of a cytotoxic T-cell immune response. A recent update in paraneoplastic neurologic syndrome criteria suggests high- and intermediate-risk phenotypes as well as neural antibodies to improve diagnostic accuracy in patients with paraneoplastic neurologic syndromes; a score was created based on this categorization. The introduction of ICI cancer immunotherapy has led to an increase in cancer-related neurologic autoimmunity with distinct clinical phenotypes. ESSENTIAL POINTS Paraneoplastic neurologic syndromes reflect an ongoing immunologic response to cancer mediated by effector T cells or antibodies. Paraneoplastic neurologic syndromes can present with manifestations at any level of the neuraxis, and neural antibodies aid diagnosis, focus cancer screening, and inform prognosis and therapy. In patients with high clinical suspicion of a paraneoplastic neurologic syndrome, cancer screening and treatment should be undertaken, regardless of the presence of a neural antibody. ICI therapy has led to immune-mediated neurologic complications. Recognition and treatment lead to improved outcomes.
Collapse
|
7
|
Thakolwiboon S, Linnoila J, Pittock SJ, Dubey D, Zekeridou A. Cerebellar leptomeningeal enhancement: An imaging finding of rapidly progressive Purkinje cell cytoplasmic autoantibody type 1 paraneoplastic cerebellar syndrome. J Neuroimmunol 2024; 387:578293. [PMID: 38266443 DOI: 10.1016/j.jneuroim.2024.578293] [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: 12/18/2023] [Revised: 01/14/2024] [Accepted: 01/17/2024] [Indexed: 01/26/2024]
Abstract
Purkinje cell cytoplasmic autoantibody type 1 (PCA1), also known as anti-Yo, is a 'high-risk' paraneoplastic antibody, associated with rapidly progressive cerebellar syndrome. In patients with this syndrome, various MRI abnormalities have been documented, including atrophy in the cerebellum and brainstem, T2 hyperintensity in the brainstem and spinal cord, and cranial nerve enhancement. This report introduces an imaging finding, cerebellar leptomeningeal enhancement, which was observed in all three cases at early stages. Despite neurological deterioration, all patients underwent immunotherapy, and subsequent follow-up MRI revealed resolution of the leptomeningeal enhancement, suggesting that this feature is distinct from meningeal carcinomatosis.
Collapse
Affiliation(s)
- Smathorn Thakolwiboon
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America; Department of Neurology, Mayo Clinic Health System Franciscan Health Care, La Crosse, WI, United States of America; Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States of America.
| | - Jenny Linnoila
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America.
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America; Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States of America; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America.
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America; Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States of America; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America.
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America; Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States of America; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America.
| |
Collapse
|
8
|
Farina A, Villagrán-García M, Vogrig A, Zekeridou A, Muñiz-Castrillo S, Velasco R, Guidon AC, Joubert B, Honnorat J. Neurological adverse events of immune checkpoint inhibitors and the development of paraneoplastic neurological syndromes. Lancet Neurol 2024; 23:81-94. [PMID: 38101905 DOI: 10.1016/s1474-4422(23)00369-1] [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: 03/02/2023] [Revised: 09/14/2023] [Accepted: 09/20/2023] [Indexed: 12/17/2023]
Abstract
Immune checkpoint inhibitors, a class of oncological treatments that enhance antitumour immunity, can trigger neurological adverse events closely resembling paraneoplastic neurological syndromes. Unlike other neurological adverse events caused by these drugs, post-immune checkpoint inhibitor paraneoplastic neurological syndromes predominantly affect the CNS and are associated with neural antibodies and cancer types commonly found also in spontaneous paraneoplastic neurological syndromes. Furthermore, post-immune checkpoint inhibitor paraneoplastic neurological syndromes have poorer neurological outcomes than other neurological adverse events of immune checkpoint inhibitors. Early diagnosis and initiation of immunosuppressive therapy are likely to be crucial in preventing the accumulation of neurological disability. Importantly, the neural antibodies found in patients with post-immune checkpoint inhibitor paraneoplastic neurological syndromes are sometimes detected before treatment, indicating that these antibodies might help to predict the development of neurological adverse events. Experimental and clinical evidence suggests that post-immune checkpoint inhibitor paraneoplastic neurological syndromes probably share immunological features with spontaneous paraneoplastic syndromes. Hence, the study of post-immune checkpoint inhibitor paraneoplastic neurological syndromes can help in deciphering the immunopathogenesis of paraneoplastic neurological syndromes and in identifying novel therapeutic targets.
Collapse
Affiliation(s)
- Antonio Farina
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France; Department of Neuroscience, Psychology, Pharmacology and Child Health, University of Florence, Florence, Italy
| | - Macarena Villagrán-García
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Alberto Vogrig
- Clinical Neurology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy; Department of Medicine (DAME), University of Udine Medical School, Udine, Italy
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Sergio Muñiz-Castrillo
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France; Stanford Center for Sleep Sciences and Medicine, Palo Alto, CA, USA
| | - Roser Velasco
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-Institut Català d Oncologia L'Hospitalet, Institut d'Investigació Biomèdica de Bellvitge, l'Hospitalet de Llobregat, Barcelona, Spain; Institute of Neurosciences and Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Amanda C Guidon
- Harvard Medical School, Boston, MA, USA; Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Bastien Joubert
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France; Department of Neurology, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Jérôme Honnorat
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France.
| |
Collapse
|
9
|
Abbatemarco JR, Vedeler CA, Greenlee JE. Paraneoplastic cerebellar and brainstem disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:173-191. [PMID: 38494276 DOI: 10.1016/b978-0-12-823912-4.00030-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic cerebellar and brainstem disorders are a heterogeneous group that requires prompt recognition and treatment to help prevent irreversible neurologic injury. Paraneoplastic cerebellar degeneration is best characterized by Yo antibodies in patients with breast or ovarian cancer. Tr (DNER) antibodies in patients with Hodgkin lymphoma can also present with a pure cerebellar syndrome and is one of the few paraneoplastic syndromes found with hematological malignancy. Opsoclonus-myoclonus-ataxia syndrome presents in both pediatric and adult patients with characteristic clinical findings. Other paraneoplastic brainstem syndromes are associated with Ma2 and Hu antibodies, which can cause widespread neurologic dysfunction. The differential for these disorders is broad and also includes pharmacological side effects, infection or postinfectious processes, and neurodegenerative diseases. Although these immune-mediated disorders have been known for many years, mechanisms of pathogenesis are still unclear, and optimal treatment has not been established.
Collapse
Affiliation(s)
- Justin R Abbatemarco
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, United States.
| | - Christian A Vedeler
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, University of Bergen, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - John E Greenlee
- Neurology Service, George E. Wahlen Veterans Affairs Health Care System, Salt Lake City, UT, United States; Department of Neurology, University of Utah, Salt Lake City, UT, United States
| |
Collapse
|
10
|
Quinot V, Höftberger R. Pathogenesis and immunopathology of paraneoplastic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:33-54. [PMID: 38494287 DOI: 10.1016/b978-0-12-823912-4.00027-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes (PNS) represent a rare group of immune-mediated complications associated with an underlying tumor. Ectopic protein expression in neoplastic cells or an aberrant immune regulation in the course of hematooncologic diseases or thymomas trigger an autoimmune response that may affect any part of the central and/or peripheral nervous system. Recent advances in drug therapies as well as novel animal models and neuropathologic studies have led to further insights on the immune pathomechanisms of PNS. Although the syndromes share common paths in pathogenesis, they may differ in the disease course, prognosis, and therapy targets, depending on the localization and type of antibody epitope. Neuropathologic hallmarks of PNS associated with antibodies directed against intracellular epitopes are characterized by T cell-dominated inflammation, reactive gliosis including microglial nodules, and neuronal degeneration. By contrast, the neuropathology of cell surface antibody-mediated PNS strongly depends on the targeted antigen and varies from B cell/plasma cell-dominated inflammation and well-preserved neurons together with a reduced expression of the target antigen in anti-NMDAR encephalitis to irreversible Purkinje cell loss in anti-P/Q-type VGCC antibody-associated paraneoplastic cerebellar degeneration. The understanding of different pathomechanisms in PNS is important because they strongly correspond with therapy response and prognosis, and should guide treatment decisions.
Collapse
Affiliation(s)
- Valérie Quinot
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
11
|
Manto M, Mitoma H. Recent Advances in Immune-Mediated Cerebellar Ataxias: Pathogenesis, Diagnostic Approaches, Therapies, and Future Challenges-Editorial. Brain Sci 2023; 13:1626. [PMID: 38137074 PMCID: PMC10741786 DOI: 10.3390/brainsci13121626] [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: 10/08/2023] [Accepted: 10/19/2023] [Indexed: 12/24/2023] Open
Abstract
The clinical category of immune-mediated cerebellar ataxias (IMCAs) has been established after 3 decades of clinical and experimental research. The cerebellum is particularly enriched in antigens (ion channels and related proteins, synaptic adhesion/organizing proteins, transmitter receptors, glial cells) and is vulnerable to immune attacks. IMCAs include various disorders, including gluten ataxia (GA), post-infectious cerebellitis (PIC), Miller Fisher syndrome (MFS), paraneoplastic cerebellar degeneration (PCD), opsoclonus myoclonus syndrome (OMS), and anti-GAD ataxia. Other disorders such as multiple sclerosis (MS), acute disseminated encephalomyelitis (ADEM), Behçet disease, and collagen vascular disorders may also present with cerebellar symptoms when lesions are localized to cerebellar pathways. The triggers of autoimmunity are established in GA (gluten sensitivity), PIC and MFS (infections), PCD (malignancy), and OMS (infections or malignant tumors). Patients whose clinical profiles do not match those of classic types of IMCAs are now included in the spectrum of primary autoimmune cerebellar ataxia (PACA). Recent remarkable progress has clarified various characteristics of these etiologies and therapeutic strategies in terms of immunotherapies. However, it still remains to be elucidated as to how immune tolerance is broken, leading to autoimmune insults of the cerebellum, and the consecutive sequence of events occurring during cerebellar damage caused by antibody- or cell-mediated mechanisms. Antibodies may specifically target the cerebellar circuitry and impair synaptic mechanisms (synaptopathies). The present Special Issue aims to illuminate what is solved and what is unsolved in clinical practice and the pathophysiology of IMCAs. Immune ataxias now represent a genuine category of immune insults to the central nervous system (CNS).
Collapse
Affiliation(s)
- Mario Manto
- Service de Neurologie, Médiathèque Jean Jacquy, CHU-Charleroi, 6000 Charleroi, Belgium
- Service des Neurosciences, Université de Mons, 7000 Mons, Belgium
| | - Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, Tokyo 160-8402, Japan;
| |
Collapse
|
12
|
Marsili L, Marcucci S, LaPorta J, Chirra M, Espay AJ, Colosimo C. Paraneoplastic Neurological Syndromes of the Central Nervous System: Pathophysiology, Diagnosis, and Treatment. Biomedicines 2023; 11:biomedicines11051406. [PMID: 37239077 DOI: 10.3390/biomedicines11051406] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/04/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023] Open
Abstract
Paraneoplastic neurological syndromes (PNS) include any symptomatic and non-metastatic neurological manifestations associated with a neoplasm. PNS associated with antibodies against intracellular antigens, known as "high-risk" antibodies, show frequent association with underlying cancer. PNS associated with antibodies against neural surface antigens, known as "intermediate- or low-risk" antibodies, are less frequently associated with cancer. In this narrative review, we will focus on PNS of the central nervous system (CNS). Clinicians should have a high index of suspicion with acute/subacute encephalopathies to achieve a prompt diagnosis and treatment. PNS of the CNS exhibit a range of overlapping "high-risk" clinical syndromes, including but not limited to latent and overt rapidly progressive cerebellar syndrome, opsoclonus-myoclonus-ataxia syndrome, paraneoplastic (and limbic) encephalitis/encephalomyelitis, and stiff-person spectrum disorders. Some of these phenotypes may also arise from recent anti-cancer treatments, namely immune-checkpoint inhibitors and CAR T-cell therapies, as a consequence of boosting of the immune system against cancer cells. Here, we highlight the clinical features of PNS of the CNS, their associated tumors and antibodies, and the diagnostic and therapeutic strategies. The potential and the advance of this review consists on a broad description on how the field of PNS of the CNS is constantly expanding with newly discovered antibodies and syndromes. Standardized diagnostic criteria and disease biomarkers are fundamental to quickly recognize PNS to allow prompt treatment initiation, thus improving the long-term outcome of these conditions.
Collapse
Affiliation(s)
- Luca Marsili
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Samuel Marcucci
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Joseph LaPorta
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Martina Chirra
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Alberto J Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Carlo Colosimo
- Department of Neurology, Santa Maria University Hospital, 05100 Terni, Italy
| |
Collapse
|
13
|
McLean RT, Buist E, St Clair D, Wei J. An examination of plasma autoantibodies against voltage gated calcium channels in schizophrenia. Brain Behav Immun Health 2023; 28:100603. [PMID: 36865984 PMCID: PMC9972490 DOI: 10.1016/j.bbih.2023.100603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/11/2023] [Indexed: 02/15/2023] Open
Abstract
Autoantibodies targeting the central nervous system have been shown to induce psychiatric symptoms resembling schizophrenia. Concurrently, genetic studies have characterised a number of risk variants associated with schizophrenia although their functional implications are largely unknown. Any biological effects of functional variants on protein function may potentially be replicated by the presence of autoantibodies against such proteins. Recent research has demonstrated that the R1346H variant in the CACNA1I gene coding for the Cav 3.3 protein results in a synaptic reduction of Cav3.3 voltage gated calcium channels and, consequently, sleep spindles, which have been shown to correlate with several symptom domains in patients with schizophrenia. The present study measured plasma levels of IgG against two peptides derived from CACNA1I and CACNA1C, respectively, in patients with schizophrenia and healthy controls. The results demonstrated that increased anti-CACNA1I IgG levels were associated with schizophrenia but not associated with any symptom domain related to the reduction of sleep spindles. In contrast to previously published work indicating that inflammation may be a marker for a depressive phenotype, plasma levels of IgG against either CACNA1I or CACNA1C peptides were not associated with depressive symptoms, suggesting that anti-Cav3.3 autoantibodies may function independently of pro-inflammatory processes.
Collapse
Affiliation(s)
- Ryan Thomas McLean
- Institute of Health Research and Innovation, University of the Highlands and Islands, Inverness, UK
| | - Elizabeth Buist
- Institute of Health Research and Innovation, University of the Highlands and Islands, Inverness, UK
- New Craigs Hospital, Inverness, UK
| | - David St Clair
- Department of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - Jun Wei
- Institute of Health Research and Innovation, University of the Highlands and Islands, Inverness, UK
- Corresponding author. Institute of Health Research and Innovation, University of the Highlands and Islands, Centre for Health Science, Old Perth Road, Inverness, IV2 3JH, UK.
| |
Collapse
|