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Almeida FC, Pereira AI, Mendes-Pinto C, Lopes J, Moura J, Sousa JM, Videira G, Samões R, Oliveira TG. MR Imaging Findings in Anti-Leucine-Rich Glioma Inactivated Protein 1 Encephalitis: A Systematic Review and Meta-analysis. AJNR Am J Neuroradiol 2024; 45:977-986. [PMID: 38871367 DOI: 10.3174/ajnr.a8256] [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: 11/14/2023] [Accepted: 02/14/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Antibodies against leucine-rich glioma inactivated protein 1 (LGI1) constitute a common form of autoimmune encephalitis. On MR imaging, it may show T2 FLAIR hyperintensities of the medial temporal lobe (T2 FLAIR-MTL), involve the basal ganglia, or be unremarkable. PURPOSE We performed a systematic review and meta-analysis to obtain prevalence estimates of abnormal findings on MR imaging in anti-LGI1 encephalitis. A human brain map of the LGI1 microarray gene expression was derived from the Allen Human Brain Atlas. DATA SOURCES PubMed and Web of Science were searched with the terms "LGI1" and "encephalitis" from inception to April 7, 2022. STUDY SELECTION Thirty-one research publications, encompassing case series and retrospective cohort and case-control studies, with >10 patients with anti-LGI1 encephalitis and MR imaging data were included. DATA ANALYSIS Pooled prevalence estimates were calculated using Freeman-Tukey double-arcsine transformation. Meta-analysis used DerSimonian and Laird random effects models. DATA SYNTHESIS Of 1318 patients in 30 studies, T2 FLAIR-MTL hyperintensities were present in 54% (95% CI, 0.48-0.60; I2 = 76%). Of 394 patients in 13 studies, 27% showed bilateral (95% CI, 0.19-0.36; I2 = 71%) and 24% unilateral T2 FLAIR-MTL abnormalities (95% CI, 0.17-0.32; I2 = 61%). Of 612 patients in 15 studies, basal ganglia abnormalities were present in 10% (95% CI, 0.06-0.15; I2 = 67%). LGI1 expression was highest in the amygdala, hippocampus, and caudate nucleus. LIMITATIONS Only part of the spectrum of MR imaging abnormalities in anti-LGI1 encephalitis could be included in a meta-analysis. MR imaging findings were not the main outcomes in most studies, limiting available information. I2 values ranged from 62% to 76%, representing moderate-to-large heterogeneity. CONCLUSIONS T2 FLAIR-MTL hyperintensities were present in around one-half of patients with anti-LGI1. The prevalence of unilateral and bilateral presentations was similar, suggesting unilaterality should raise the suspicion of this disease in the appropriate clinical context. Around 10% of patients showed basal ganglia abnormalities, indicating that special attention should be given to this region. LGI1 regional expression coincided with the most frequently reported abnormal findings on MR imaging. Regional specificity might be partially determined by expression levels of the target protein.
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Affiliation(s)
- Francisco C Almeida
- From the Department of Neuroradiology (F.C.A., A.I.P., C.M.-P.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Life and Health Sciences Research Institute (F.C.A., T.G.O.), School of Medicine, University of Minho, Braga, Portugal
- Life and Health Sciences Research Institute/3B's-PT Government Associate Laboratory (F.C.A., T.G.O.), Braga/Guimarães, Portugal
| | - Ana I Pereira
- From the Department of Neuroradiology (F.C.A., A.I.P., C.M.-P.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Catarina Mendes-Pinto
- From the Department of Neuroradiology (F.C.A., A.I.P., C.M.-P.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Joana Lopes
- Department of Neurology (J.L., J.M., G.V., R.S.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - João Moura
- Department of Neurology (J.L., J.M., G.V., R.S.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - José Maria Sousa
- Department of Neuroradiology (J.M.S.), Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Gonçalo Videira
- Department of Neurology (J.L., J.M., G.V., R.S.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Raquel Samões
- Department of Neurology (J.L., J.M., G.V., R.S.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Unit for Multidisciplinary Research in Biomedicine (R.S.), Instituto de Ciências Biomédicas de Abel Salazar da Universidade do Porto, Porto, Portugal
| | - Tiago Gil Oliveira
- Life and Health Sciences Research Institute (F.C.A., T.G.O.), School of Medicine, University of Minho, Braga, Portugal
- Life and Health Sciences Research Institute/3B's-PT Government Associate Laboratory (F.C.A., T.G.O.), Braga/Guimarães, Portugal
- Department of Neuroradiology (T.G.O.), Hospital de Braga, Braga, Portugal
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Viezens I, Knierim E, Deubzer HE, Hauptmann K, Fassbender J, Morales-Gonzalez S, Kaindl AM, Schuelke M, Nikolaus M. Expression of mGluR5 in Pediatric Hodgkin and Non-Hodgkin lymphoma-A Comparative Analysis of Immunohistochemical and Clinical Findings Regarding the Association between Tumor and Paraneoplastic Neurological Disease. Cancers (Basel) 2024; 16:2452. [PMID: 39001514 PMCID: PMC11240514 DOI: 10.3390/cancers16132452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 06/27/2024] [Accepted: 07/02/2024] [Indexed: 07/16/2024] Open
Abstract
Autoantibodies targeting the neuronal antigen metabotropic glutamate receptor 5 (mGluR5) have been identified in patients with Ophelia syndrome, which describes a co-occurrence of paraneoplastic limbic encephalitis and Hodgkin lymphoma (HL). Little data exist regarding frequency and function of mGluR5 in HL and its potential role in causing seropositive paraneoplastic disease. We studied a representative cohort of pediatric HL and NHL patients (n = 57) using immunohistochemistry and fluorescence staining to investigate mGluR5 expression. All lymphoma tissues displayed positive mGluR5 staining, with focus on Hodgkin-Reed-Sternberg (H-RS) cells. We did not detect any mGluR5 staining in tumor-free lymph nodes, which is consistent with the absence of GRM5 transcripts in RNA-sequencing data from non-malignant B and T cells. The frequent presence in pediatric lymphoma falls in line with reports of mGluR5 expression and associated tumor progression in other malignancies. We tested for correlation with clinical features, focusing on disease progression and neurological symptoms. Low mGluR5 expression in H-RS cells correlated with young patient age (<15 years) and positive histology for EBV infection. Paraneoplastic or neurological symptoms were found exclusively in HL patients. While an impact of mGluR5 on HL severity remains possible, a prognostic value of mGluR5 expression levels requires further investigation.
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Affiliation(s)
- Ingeborg Viezens
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (I.V.); (E.K.); (J.F.); (S.M.-G.); (M.S.)
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Ellen Knierim
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (I.V.); (E.K.); (J.F.); (S.M.-G.); (M.S.)
- DRK Kliniken Westend, Klinik für Kinder- und Jugendmedizin, 14050 Berlin, Germany
| | - Hedwig E. Deubzer
- Department of Pediatric Oncology/Hematology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany;
- Experimental and Clinical Research Center (ECRC), Charité and Max-Delbrück-Center of Molecular Medicine, Helmholtz Association, 13125 Berlin, Germany
| | - Kathrin Hauptmann
- Institute of Pathology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Jessica Fassbender
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (I.V.); (E.K.); (J.F.); (S.M.-G.); (M.S.)
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Susanne Morales-Gonzalez
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (I.V.); (E.K.); (J.F.); (S.M.-G.); (M.S.)
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Angela M. Kaindl
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany;
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Institute for Cell and Neurobiology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Markus Schuelke
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (I.V.); (E.K.); (J.F.); (S.M.-G.); (M.S.)
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany;
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Marc Nikolaus
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (I.V.); (E.K.); (J.F.); (S.M.-G.); (M.S.)
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany;
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
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Salles PA, Trujillo-Godoy O, Lozano-Iraguen P, Chaná-Cuevas P. mGlur5 Encephalitis Causing Myoclonus-Ataxia Syndrome and Psychosis: A Case Report. Mov Disord Clin Pract 2024. [PMID: 38923251 DOI: 10.1002/mdc3.14136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 03/29/2024] [Accepted: 05/24/2024] [Indexed: 06/28/2024] Open
Affiliation(s)
- Philippe A Salles
- Center for Movement Disorders CETRAM, Santiago, Chile
- Neuroscience Institute, Davila Clinic, Santiago, Chile
- Movement Disorders Section, Neurology Department, Alemana Clinic, Santiago, Chile
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Feng SY, Su LC, Liu XY, Qin Z, Fu L, Huang AF, Xu WD. Prediction model for developing neuropsychiatric systemic lupus erythematosus in lupus patients. Clin Rheumatol 2024; 43:1881-1896. [PMID: 38676758 DOI: 10.1007/s10067-024-06970-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 03/15/2024] [Accepted: 04/09/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE This study aimed to construct a predictive model for assessing the risk of development of neuropsychiatric systemic lupus erythematosus (NPSLE) among patients with SLE based on clinical, laboratory, and meteorological data. METHODS A total of 2232 SLE patients were included and were randomly assigned into training and validation sets. Variables such as clinical and laboratory data and local meteorological data were screened by univariate and least absolute shrinkage and selection operator (LASSO) logistic regression modelling. After 10-fold cross-validation, the predictive model was built by multivariate logistic regression, and a nomogram was constructed to visualize the risk of NPSLE. The efficacy and accuracy of the model were assessed by receiver operating characteristic (ROC) curve and calibration curve analysis. Net clinical benefit was assessed by decision curve analysis. RESULTS Variables that were included in the predictive model were anti-dsDNA, anti-SSA, lymphocyte count, hematocrit, erythrocyte sedimentation rate, pre-albumin, retinol binding protein, creatine kinase isoenzyme MB, Nterminal brain natriuretic peptide precursor, creatinine, indirect bilirubin, fibrinogen, hypersensitive C-reactive protein, CO, and mild contamination. The nomogram showed a broad prediction spectrum; the area under the curve (AUC) was 0.895 (0.858-0.931) for the training set and 0.849 (0.783-0.916) for the validation set. CONCLUSION The model exhibits good predictive performance and will confer clinical benefit in NPSLE risk calculation. Key Points • Clinical, laboratory, and meteorological data were incorporated into a predictive model for neuropsychiatric systemic lupus erythematosus (NPSLE) in SLE patients. • Anti-dsDNA, anti-SSA, LYM, HCT, ESR, hsCRP, IBIL, PA, RBP, CO, Fib, NT-proBNP, Crea, CO, and mild contamination are predictors of the development of NPSLE and may have potential for research. • The nomogram has good predictive performance and clinical value and can be used to guide clinical diagnosis and treatment.
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Affiliation(s)
- Si-Yu Feng
- Department of Evidence-Based Medicine, School of Public Health, Southwest Medical University, Luzhou, Sichuan, China
| | - Lin-Chong Su
- Hubei Provincial Key Laboratory of Occurrence and Intervention of Rheumatic diseases, Affiliated Minda Hospital of Hubei Institute for Nationalities, Enshi, Hubei, China
- Department of Rheumatology and Immunology, Affiliated Minda Hospital of Hubei Institute for Nationalities, Enshi, Hubei, China
| | - Xiao-Yan Liu
- Department of Evidence-Based Medicine, School of Public Health, Southwest Medical University, Luzhou, Sichuan, China
| | - Zhen Qin
- Department of Rheumatology and Immunology, the Affiliated Hospital, Southwest Medical University, Luzhou, Sichuan, China
| | - Lu Fu
- Laboratory Animal Center, Southwest Medical University, Luzhou, Sichuan, China
| | - An-Fang Huang
- Department of Rheumatology and Immunology, the Affiliated Hospital, Southwest Medical University, Luzhou, Sichuan, China
| | - Wang-Dong Xu
- Department of Evidence-Based Medicine, School of Public Health, Southwest Medical University, Luzhou, Sichuan, China.
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5
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Papi C, Milano C, Spatola M. Mechanisms of autoimmune encephalitis. Curr Opin Neurol 2024; 37:305-315. [PMID: 38667756 DOI: 10.1097/wco.0000000000001270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2024]
Abstract
PURPOSE OF REVIEW To provide an overview of the pathogenic mechanisms involved in autoimmune encephalitides mediated by antibodies against neuronal surface antigens, with a focus on NMDAR and LGI1 encephalitis. RECENT FINDINGS In antibody-mediated encephalitides, binding of IgG antibodies to neuronal surface antigens results in different pathogenic effects depending on the type of antibody, IgG subclass and epitope specificity. NMDAR IgG1 antibodies cause crosslinking and internalization of the target, synaptic and brain circuitry alterations, as well as alterations of NMDAR expressing oligodendrocytes, suggesting a link with white matter lesions observed in MRI studies. LGI1 IgG4 antibodies, instead, induce neuronal dysfunction by disrupting the interaction with cognate proteins and altering AMPAR-mediated signaling. In-vitro findings have been corroborated by memory and behavioral changes in animal models obtained by passive transfer of patients' antibodies or active immunization. These models have been fundamental to identify targets for innovative therapeutic strategies, aimed at counteracting or preventing antibody effects, such as the use of soluble ephrin-B2, NMDAR modulators (e.g., pregnenolone, SGE-301) or chimeric autoantibody receptor T cells (CAART) in models of NMDAR encephalitis. SUMMARY A deep understanding of the pathogenic mechanisms underlying antibody-mediated encephalitides is crucial for the development of new therapeutic approaches targeting brain autoimmunity.
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Affiliation(s)
- Claudia Papi
- Department of Neuroscience, Catholic University of the Sacred Heart, Rome, Italy
- Fundació Recerca Biomedica Clinic - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRBC-IDIBAPS), Barcelona, Spain
| | - Chiara Milano
- Fundació Recerca Biomedica Clinic - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRBC-IDIBAPS), Barcelona, Spain
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Marianna Spatola
- Fundació Recerca Biomedica Clinic - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRBC-IDIBAPS), Barcelona, Spain
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Smith KM, Budhram A, Geis C, McKeon A, Steriade C, Stredny CM, Titulaer MJ, Britton JW. Autoimmune-associated seizure disorders. Epileptic Disord 2024. [PMID: 38818801 DOI: 10.1002/epd2.20231] [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: 01/24/2024] [Revised: 03/28/2024] [Accepted: 04/13/2024] [Indexed: 06/01/2024]
Abstract
With the discovery of an expanding number of neural autoantibodies, autoimmune etiologies of seizures have been increasingly recognized. Clinical phenotypes have been identified in association with specific underlying antibodies, allowing an earlier diagnosis. These phenotypes include faciobrachial dystonic seizures with LGI1 encephalitis, neuropsychiatric presentations associated with movement disorders and seizures in NMDA-receptor encephalitis, and chronic temporal lobe epilepsy in GAD65 neurologic autoimmunity. Prompt recognition of these disorders is important, as some of them are highly responsive to immunotherapy. The response to immunotherapy is highest in patients with encephalitis secondary to antibodies targeting cell surface synaptic antigens. However, the response is less effective in conditions involving antibodies binding intracellular antigens or in Rasmussen syndrome, which are predominantly mediated by cytotoxic T-cell processes that are associated with irreversible cellular destruction. Autoimmune encephalitides also may have a paraneoplastic etiology, further emphasizing the importance of recognizing these disorders. Finally, autoimmune processes and responses to novel immunotherapies have been reported in new-onset refractory status epilepticus (NORSE) and febrile infection-related epilepsy syndrome (FIRES), warranting their inclusion in any current review of autoimmune-associated seizure disorders.
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Affiliation(s)
- Kelsey M Smith
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Adrian Budhram
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Christian Geis
- Department of Neurology and Section Translational Neuroimmunology, Jena University Hospital, Jena, Germany
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Claude Steriade
- Department of Neurology, New York University Langone Health, New York, New York, USA
| | - Coral M Stredny
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Maarten J Titulaer
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
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7
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Sanvito F, Pichiecchio A, Paoletti M, Rebella G, Resaz M, Benedetti L, Massa F, Morbelli S, Caverzasi E, Asteggiano C, Businaro P, Masciocchi S, Castellan L, Franciotta D, Gastaldi M, Roccatagliata L. Autoimmune encephalitis: what the radiologist needs to know. Neuroradiology 2024; 66:653-675. [PMID: 38507081 PMCID: PMC11031487 DOI: 10.1007/s00234-024-03318-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/20/2024] [Indexed: 03/22/2024]
Abstract
Autoimmune encephalitis is a relatively novel nosological entity characterized by an immune-mediated damage of the central nervous system. While originally described as a paraneoplastic inflammatory phenomenon affecting limbic structures, numerous instances of non-paraneoplastic pathogenesis, as well as extra-limbic involvement, have been characterized. Given the wide spectrum of insidious clinical presentations ranging from cognitive impairment to psychiatric symptoms or seizures, it is crucial to raise awareness about this disease category. In fact, an early diagnosis can be dramatically beneficial for the prognosis both to achieve an early therapeutic intervention and to detect a potential underlying malignancy. In this scenario, the radiologist can be the first to pose the hypothesis of autoimmune encephalitis and refer the patient to a comprehensive diagnostic work-up - including clinical, serological, and neurophysiological assessments.In this article, we illustrate the main radiological characteristics of autoimmune encephalitis and its subtypes, including the typical limbic presentation, the features of extra-limbic involvement, and also peculiar imaging findings. In addition, we review the most relevant alternative diagnoses that should be considered, ranging from other encephalitides to neoplasms, vascular conditions, and post-seizure alterations. Finally, we discuss the most appropriate imaging diagnostic work-up, also proposing a suggested MRI protocol.
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Affiliation(s)
- Francesco Sanvito
- Unit of Radiology, Department of Clinical, Surgical, Diagnostic, and Paediatric Sciences, University of Pavia, Viale Camillo Golgi, 19, 27100, Pavia, Italy.
- UCLA Brain Tumor Imaging Laboratory (BTIL), Center for Computer Vision and Imaging Biomarkers, University of California Los Angeles, Los Angeles, CA, USA.
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | - Anna Pichiecchio
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Matteo Paoletti
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Giacomo Rebella
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Martina Resaz
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Luana Benedetti
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Federico Massa
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Largo Daneo 3, 16132, Genoa, Italy
| | - Silvia Morbelli
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Via Antonio Pastore 1, 16132, Genoa, Italy
| | - Eduardo Caverzasi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Carlo Asteggiano
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Pietro Businaro
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Stefano Masciocchi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Lucio Castellan
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Diego Franciotta
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Luca Roccatagliata
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Via Antonio Pastore 1, 16132, Genoa, Italy
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Pedrosa DA, Ferreira JHF, Gleizer R, Carra RB, de Carvalho RM, Endmayr V, Hoftberger R, Dutra LA. Encephalitis associated with anti-mGluR5 antibodies. Pract Neurol 2024:pn-2024-004089. [PMID: 38423754 DOI: 10.1136/pn-2024-004089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2024] [Indexed: 03/02/2024]
Abstract
A 30-year-old woman had 5 days of visual hallucinations, nystagmus, memory impairment and mutism. On examination, she was disorientated with reduced attention span, gaze-evoked nystagmus, paratonia and abnormal frontal reflexes. Cerebrospinal fluid (CSF) showed 80 cells, protein 0.41 g/L and glucose 3.2 mmol/L (plasma glucose 5.0 mmol/L). MR scan of the brain showed involvement of limbic and extra-limbic regions and brainstem. Commercial cell-based assays were negative, but tissue-based assays showed neuropil staining, and cell-based assays for anti-metabotropic glutamate receptor 5 (mGluR5) antibodies were positive in serum and CSF. Six months later, she was diagnosed with Hodgkin's lymphoma. This case emphasises the broader clinical spectrum of anti-mGluR5 encephalitis, challenging its initial characterisation as Ophelia syndrome. It underscores the significance of interpreting commercial cell-based assays and advocates for tissue-based assay testing followed by cell-based assay testing in serum and CSF for diagnosing rare autoimmune encephalitis.
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Affiliation(s)
| | | | - Rene Gleizer
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | - Verena Endmayr
- Department of Neurology, Medical University of Vienna, Wien, Austria
| | - Romana Hoftberger
- Department of Neurology, Medical University of Vienna, Wien, Austria
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Chen X, Chen Y, Di L, Liu N, Liu T, Cai Y, Di W. Cerebellar encephalitis associated with anti-mGluR1 antibodies: a case report and comprehensive literature review. Front Neurol 2024; 15:1333658. [PMID: 38410193 PMCID: PMC10894994 DOI: 10.3389/fneur.2024.1333658] [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: 11/05/2023] [Accepted: 02/02/2024] [Indexed: 02/28/2024] Open
Abstract
Anti-metabotropic glutamate receptor 1 encephalitis is an uncommon autoimmune condition characterized by a subacute onset of cerebellar syndrome. Frequently, it also manifests as sleep disorders and cognitive or behavioral changes. While immunotherapy is the primary treatment approach, the disease remains poorly understood. Herein, we present a case of anti-metabotropic glutamate receptor 1 encephalitis, highlighting its primary cerebellar syndrome manifestation. The first magnetic resonance imaging scan showed no obvious abnormality. Lumbar puncture showed increased cerebrospinal fluid pressure, increased white blood cell count and protein level. The next-generation sequencing of cerebrospinal fluid showed Epstein-Barr virus infection, and the patient was diagnosed with viral cerebellar encephalitis. However, antiviral therapy was ineffective. Finally, anti-metabotropic glutamate receptor 1 was measured at 1:1,000, and the patient was definitely diagnosed with anti-metabotropic glutamate receptor 1 encephalitis. Therefore, clinicians should pay attention to such diseases to avoid misdiagnosis.
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Affiliation(s)
- Xue Chen
- Department of Neurology, Affiliated Hospital of Hebei University, Baoding, China
| | - Yanan Chen
- Department of Neurology, Affiliated Hospital of Hebei University, Baoding, China
| | - Lu Di
- Hospital of Stomatology Hebei Medical University, Shijiazhuang, China
| | - Na Liu
- Department of Neurology, Affiliated Hospital of Hebei University, Baoding, China
| | - Ting Liu
- Department of Neurology, Affiliated Hospital of Hebei University, Baoding, China
| | - Yun Cai
- Department of Neurology, Affiliated Hospital of Hebei University, Baoding, China
| | - Weiying Di
- Department of Neurology, Affiliated Hospital of Hebei University, Baoding, China
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10
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Shi K, Zhao H, Li Y, Li X, Chen W. Anti-metabolic glutamate receptor 5 encephalitis with gangliocytoma: a case and review of the literature. BMC Neurol 2024; 24:27. [PMID: 38218780 PMCID: PMC10787404 DOI: 10.1186/s12883-024-03528-z] [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: 08/04/2023] [Accepted: 01/04/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND There are very limited reports on anti-metabolic glutamate receptor5 (mGluR5) encephalitis, especially lacking of pediatric research. The disease was mostly accompanied by tumors, mainly Hodgkin's lymphoma. No reports of other tumors, such as gangliocytoma have been reported to associate with anti-mGluR5 encephalitis so far. CASE PRESENTATION AND LITERATURE REVIEWS We reported a case of a 12-year-old boy with anti-mGluR5 encephalitis complicated with gangliocytoma. The patient suffered from mental disorders including auditory hallucination, and sleep disorders. His cranial magnetic resonance imaging (MRI) showed an abnormality in the right insular lobe. Autoimmune encephalitis antibodies testing was positive for mGluR5 IgG antibody both in cerebrospinal fluid and serum (1:3.2, 1:100 respectively). Abdominal CT indicated a mass in left retroperitoneal confirmed with gangliocytoma via pathology. The patient underwent resection of gangliocytoma. After first-line immunotherapy (glucocorticoid, gamma globulin), his condition was improved. Furthermore, we provide a summary of 6 pediatric cases of Anti-mGluR5 encephalitis. Most of them complicated with Hodgkin's lymphoma, except the case currently reported comorbid with gangliocytoma. The curative effect is satisfactory. CONCLUSIONS We report the first patient with anti-mGlur5 encephalitis complicated with gangliocytoma. It suggests that in addition to paying attention to the common lymphoma associated with anti-mGlur5 encephalitis, we should also screen the possibility of other tumors for early detection of the cause, active treatment and prevention of recurrence.
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Affiliation(s)
- Kaili Shi
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou, 510623, China
| | - Huimin Zhao
- Department of Pediatrics, People's Hospital of Pidu, Sichuan, 611730, China
| | - Ying Li
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou, 510623, China
| | - Xiaojing Li
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou, 510623, China.
| | - Wenxiong Chen
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou, 510623, China.
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11
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Briani C, Visentin A. Hematologic malignancies and hematopoietic stem cell transplantation. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:419-429. [PMID: 38494294 DOI: 10.1016/b978-0-12-823912-4.00016-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes are rarely associated with hematologic malignancies. In their rarity, lymphomas are the diseases with more frequent paraneoplastic neurologic syndrome. High-risk antibodies are absent in most lymphoma-associated paraneoplastic neurologic syndromes, with the exception of antibodies to Tr/DNER in paraneoplastic cerebellar degeneration, mGluR5 in limbic encephalitis, and mGluR1 in some cerebellar ataxias. Peripheral nervous system paraneoplastic neurologic syndromes are rare and heterogeneous, with a prevalence of demyelinating polyradiculoneuropathy in non-Hodgkin lymphoma. Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, skin changes (POEMS) is a rare, paraneoplastic syndrome due to an underlying plasma cell disorder. The diagnosis is based on defined criteria, and vascular endothelial growth factor (VEGF), not an antibody, is considered a reliable diagnostic marker that also mirrors therapy response. As with the paraneoplastic neurologic syndromes in solid tumors, therapies rely on cancer treatment associated with immunomodulatory treatment with better response in PNS with antibodies to surface antigens. The best outcome is generally present in Ophelia syndrome/limbic encephalitis with anti-mGluR5 antibodies, with frequent complete recovery. Besides patients with isolated osteosclerotic lesions (where radiotherapy is indicated), hematopoietic stem-cell transplantation is the therapy of choice in patients with POEMS syndrome. In the paraneoplastic neurologic syndromes secondary to immune checkpoint inhibitors, discontinuation of the drug together with immunomodulatory treatment is recommended.
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Affiliation(s)
- Chiara Briani
- Department of Neurosciences, Neurology Unit, University of Padova, Padova, Italy.
| | - Andrea Visentin
- Department of Medicine, Hematology Unit, University of Padova, Padova, Italy
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12
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Graus F. Clinical approach to diagnosis of paraneoplastic neurologic syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:79-96. [PMID: 38494298 DOI: 10.1016/b978-0-12-823912-4.00007-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
The correct diagnosis of a paraneoplastic neurologic syndrome (PNS) first requires the identification of the syndrome as one of those defined as high-risk (previously called classical) or intermediate-risk for cancer in the 2021 PNS diagnostic criteria. Testing for neuronal antibodies should be restricted to these syndromes as indiscriminate request decreases the diagnostic value of the antibodies. Identifying onconeural (high-risk for cancer) or intermediate-risk for cancer antibodies supports the paraneoplastic diagnosis and mandates the search for an underlying cancer. Tumor screening must follow the published guidelines. Repeated screening is indicated in neurologic syndromes with onconeural antibodies and patients with high-risk for cancer neurologic syndromes unless they present neuronal antibodies which are not associated with cancer. Neuronal antibodies should be screened by immunohistochemistry and confirmed by immunoblot (intracellular antigens) or cell-based assay (CBA) (surface antigens). Positive results only by immunoblot or CBA should be taken with caution. Although the 2021 diagnostic criteria for PNS do not capture all PNS, as they do not allow to diagnose definite PNS neurologic syndromes without neuronal antibodies, the updated criteria represent a step forward to differentiate true PNS from neurologic syndromes that coincide in time with cancer diagnosis without having a pathogenic link.
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Affiliation(s)
- Francesc Graus
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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13
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Kadish R, Clardy SL. Epidemiology of paraneoplastic neurologic syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:57-77. [PMID: 38494297 DOI: 10.1016/b978-0-12-823912-4.00011-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes (PNS), initially depicted as seemingly cryptic remote manifestations of malignancy, were first described clinically in the early 20th century, with pathophysiologic correlates becoming better elucidated in the latter half of the century. There remain many questions not only about the pathophysiology but also regarding the epidemiology of these conditions. The continuous discovery of novel autoantigens and related neurologic disease has broadened the association in classical PNS to include conditions such as paraneoplastic cerebellar degeneration. It has also brought into focus several other neurologic syndromes with a putative neoplastic association. These conditions are overall rare, making it difficult to capture large numbers of patients to study, and raising the question of whether incidence is increasing over time or improved identification is driving the increased numbers of cases. With the rise and increasing use of immunotherapy for cancer treatment, the incidence of these conditions is additionally expected to rise and may present with various clinical symptoms. As we enter an era of clinical trial intervention in these conditions, much work is needed to capture more granular data on population groups defined by socioeconomic characteristics such as age, ethnicity, economic resources, and gender to optimize care and clinical trial planning.
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Affiliation(s)
- Robert Kadish
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Stacey L Clardy
- Department of Neurology, University of Utah, Salt Lake City, UT, United States; George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States.
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14
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Jean MJ, Samkoff L, Mohile N. Management of Paraneoplastic Syndromes in the Era of Immune Checkpoint Inhibitors. Curr Treat Options Oncol 2024; 25:42-65. [PMID: 38198120 DOI: 10.1007/s11864-023-01157-1] [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] [Accepted: 11/22/2023] [Indexed: 01/11/2024]
Abstract
OPINION STATEMENT Our understanding of paraneoplastic neurologic syndromes (PNS) has blossomed over the past few decades. Clinicians have access to more robust diagnostic criteria and have a heightened index of suspicion for these disorders. Nonetheless, treatment, which typically includes immunosuppression, and response to treatment, varies. Due to persistent difficulty in making a definitive diagnosis, we favor empiric treatment when a possible diagnosis of PNS is suspected, and other alternative causes have substantially been excluded (e.g., infections, toxic-metabolic derangements, metastasis, or leptomeningeal disease). Treatment of the underlying cancer, if identified, is the first therapeutic step and can prevent disease worsening and in rare cases, can reverse neurologic symptoms. In addition to anti-cancer treatment, first line immunotherapies, which include corticosteroids, intravenous immunoglobulins (IVIG), or plasma exchange (PLEX) are typically used. If partial or no benefit is seen, second line immunotherapeutic agents such as rituximab are considered. Additionally, the severity of the initial presentation and possible risk for relapse influences the use of the latter agents. Symptomatic management is also an important component in our practice and will depend on the syndrome being treated. One of the more novel entities we are facing currently is the management of immune checkpoint (ICI)-induced PNS. In those cases, current American Society of Clinical Oncology (ASCO) guidelines are followed.
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Affiliation(s)
- Maxime Junior Jean
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Lawrence Samkoff
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Nimish Mohile
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA.
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15
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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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16
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Casagrande S, Zuliani L, Grisold W. Paraneoplastic encephalitis. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:131-149. [PMID: 38494274 DOI: 10.1016/b978-0-12-823912-4.00019-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
The first reports of encephalitis associated with cancer date to the 1960s and were characterized by clinical and pathologic involvement of limbic areas. This specific association was called limbic encephalitis (LE). The subsequent discovery of several "onconeural" antibodies (Abs), i.e., Abs targeting an antigen shared by neurons and tumor cells, supported the hypothesis of an autoimmune paraneoplastic etiology of LE and other forms of rapidly progressive encephalopathy. Over the past 20 years, similar clinical pictures with different clinical courses have been described in association with novel Abs-binding neuronal membrane proteins and proved to be pathogenic. The most well-known encephalitis in this group was described in 2007 as an association of a complex neuro-psychiatric syndrome, N-methyl-d-aspartate (NMDA) receptor-Abs, and ovarian teratoma in young women. Later on, nonparaneoplastic cases of NMDA receptor encephalitis were also described. Since then, the historical concept of LE and Ab associated encephalitis has changed. Some of these occur in fact more commonly in the absence of a malignancy (e.g., anti-LG1 Abs). Lastly, seronegative cases were also described. The term paraneoplastic encephalitis nowadays encompasses different syndromes that may be triggered by occult tumors.
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Affiliation(s)
- Silvia Casagrande
- Neurology Unit, Rovereto Hospital, Trento, Italy; Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy.
| | - Luigi Zuliani
- Department of Neurology, San Bortolo Hospital, Azienda ULSS8 Berica, Vicenza, Italy
| | - Wolfgang Grisold
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
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17
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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.
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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.
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18
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Masciocchi S, Businaro P, Scaranzin S, Morandi C, Franciotta D, Gastaldi M. General features, pathogenesis, and laboratory diagnostics of autoimmune encephalitis. Crit Rev Clin Lab Sci 2024; 61:45-69. [PMID: 37777038 DOI: 10.1080/10408363.2023.2247482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/09/2023] [Indexed: 10/02/2023]
Abstract
Autoimmune encephalitis (AE) is a group of inflammatory conditions that can associate with the presence of antibodies directed to neuronal intracellular, or cell surface antigens. These disorders are increasingly recognized as an important differential diagnosis of infectious encephalitis and of other common neuropsychiatric conditions. Autoantibody diagnostics plays a pivotal role for accurate diagnosis of AE, which is of utmost importance for the prompt recognition and early treatment. Several AE subgroups can be identified, either according to the prominent clinical phenotype, presence of a concomitant tumor, or type of neuronal autoantibody, and recent diagnostic criteria have provided important insights into AE classification. Antibodies to neuronal intracellular antigens typically associate with paraneoplastic neurological syndromes and poor prognosis, whereas antibodies to synaptic/neuronal cell surface antigens characterize many AE subtypes that associate with tumors less frequently, and that are often immunotherapy-responsive. In addition to the general features of AE, we review current knowledge on the pathogenic mechanisms underlying these disorders, focusing mainly on the potential role of neuronal antibodies in the most frequent conditions, and highlight current theories and controversies. Then, we dissect the crucial aspects of the laboratory diagnostics of neuronal antibodies, which represents an actual challenge for both pathologists and neurologists. Indeed, this diagnostics entails technical difficulties, along with particularly interesting novel features and pitfalls. The novelties especially apply to the wide range of assays used, including specific tissue-based and cell-based assays. These assays can be developed in-house, usually in specialized laboratories, or are commercially available. They are widely used in clinical immunology and in clinical chemistry laboratories, with relevant differences in analytic performance. Indeed, several data indicate that in-house assays could perform better than commercial kits, notwithstanding that the former are based on non-standardized protocols. Moreover, they need expertise and laboratory facilities usually unavailable in clinical chemistry laboratories. Together with the data of the literature, we critically evaluate the analytical performance of the in-house vs commercial kit-based approach. Finally, we propose an algorithm aimed at integrating the present strategies of the laboratory diagnostics in AE for the best clinical management of patients with these disorders.
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Affiliation(s)
- Stefano Masciocchi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, Università degli Studi di Pavia, Pavia, Italy
| | - Pietro Businaro
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, Università degli Studi di Pavia, Pavia, Italy
| | - Silvia Scaranzin
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Chiara Morandi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Diego Franciotta
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Matteo Gastaldi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
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19
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Ryding M, Mikkelsen AW, Nissen MS, Nilsson AC, Blaabjerg M. Pathophysiological Effects of Autoantibodies in Autoimmune Encephalitides. Cells 2023; 13:15. [PMID: 38201219 PMCID: PMC10778077 DOI: 10.3390/cells13010015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
The heterogeneity of autoantibody targets in autoimmune encephalitides presents a challenge for understanding cellular and humoral pathophysiology, and the development of new treatment strategies. Thus, current treatment aims at autoantibody removal and immunosuppression, and is primarily based on data generated from other autoimmune neurological diseases and expert consensus. There are many subtypes of autoimmune encephalitides, which now entails both diseases with autoantibodies targeting extracellular antigens and classical paraneoplastic syndromes with autoantibodies targeting intracellular antigens. Here, we review the current knowledge of molecular and cellular effects of autoantibodies associated with autoimmune encephalitis, and evaluate the evidence behind the proposed pathophysiological mechanisms of autoantibodies in autoimmune encephalitis.
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Affiliation(s)
- Matias Ryding
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark;
- Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5000 Odense, Denmark
| | - Anne With Mikkelsen
- Department of Clinical Immunology, Odense University Hospital, 5000 Odense, Denmark;
| | | | - Anna Christine Nilsson
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark;
- Department of Clinical Immunology, Odense University Hospital, 5000 Odense, Denmark;
| | - Morten Blaabjerg
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark;
- Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5000 Odense, Denmark
- Department of Neurology, Odense University Hospital, 5000 Odense, Denmark;
- Brain Research—Inter Disciplinary Guided Excellence (BRIDGE), 5000 Odense, Denmark
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20
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Yang X, Liu Q, Lai MF, Ma XH, Hao XT, Xu JJ, Guo WJ. Case report: Orthostatic leg tremor as the initial manifestation in a patient with metabotropic glutamate receptor-5 encephalitis without cortical dysfunction: complexities in identification and treatment. Front Neurol 2023; 14:1288075. [PMID: 38162450 PMCID: PMC10755007 DOI: 10.3389/fneur.2023.1288075] [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: 09/28/2023] [Accepted: 11/20/2023] [Indexed: 01/03/2024] Open
Abstract
Objective Metabotropic glutamate receptor 5 (mGluR5) encephalitis is such a rare type of autoimmune encephalitis that its diagnosis remains a challenge. Case report A 19-year-old female patient initially presented with anxiety and orthostatic leg tremors without cortical dysfunction. We found that this patient was positive for mGluR5 antibodies in both serum (1:1,000) and cerebrospinal fluid (1:32). After comprehensive intervention, the patient showed complete recovery at the 18-month follow-up. Discussion This report expands our knowledge of the possible presentations of mGluR5 encephalitis for early diagnosis, which makes it possible to prevent serious consequences and improve the prognosis.
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Affiliation(s)
- Xia Yang
- Mental Health Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Qiong Liu
- Mental Health Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Ming-feng Lai
- Mental Health Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xiao-hong Ma
- Mental Health Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- Psychiatric Laboratory and Mental Health Center, The State Key Laboratory of Biotherapy, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xiao-ting Hao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jia-jun Xu
- Mental Health Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Wan-jun Guo
- Affiliated Mental Health Center and Hangzhou Seventh People's Hospital, Zhejiang University School of Medicine, Hangzhou Seventh People's Hospital, Hangzhou, Zhejiang, China
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21
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Sanpei Y, Miura M, Funasaka H, Hanazono A, Kamada S, Sugawara M. Case Report: Anti-mGluR5 antibody-negative Ophelia syndrome with failed lymph node biopsy due to steroid therapy. Front Immunol 2023; 14:1188154. [PMID: 38162652 PMCID: PMC10755457 DOI: 10.3389/fimmu.2023.1188154] [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: 03/17/2023] [Accepted: 11/24/2023] [Indexed: 01/03/2024] Open
Abstract
Ophelia syndrome is paraneoplastic limbic encephalitis (PLE) with Hodgkin lymphoma. Some Ophelia syndrome patients have been reported as testing positive for anti-metabotropic glutamate receptor 5 (mGluR5) antibodies. However, we experienced a case of anti-mGluR5 antibody-negative Ophelia syndrome. The type of onset, neurological symptoms, and imaging as well as electroencephalographic findings were like previous reports except for a normal cell count in cerebrospinal fluid (CSF). Unfortunately, a lymph node biopsy failed and could not diagnose the patient before death because steroid treatment for limbic encephalitis had shrunk lymph nodes. We believe it is essential to accumulate cases of this syndrome and clarify the association between PLE and Hodgkin lymphoma so chemotherapy can be initiated even if malignant lymphoma cannot be pathologically proven or when antibodies cannot be measured or are negative.
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Affiliation(s)
- Yui Sanpei
- Department of Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Masahito Miura
- Department of Molecular and Tumour Pathology, Akita University Graduate School of Medicine, Akita, Japan
| | - Homare Funasaka
- Department of Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Akira Hanazono
- Department of Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Sachiko Kamada
- Department of Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Masashiro Sugawara
- Department of Neurology, Akita University Graduate School of Medicine, Akita, Japan
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22
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Li EC, Lai QL, Cai MT, Fang GL, Shen CH, Ding MP, Zhang YX. Anti-adenylate kinase 5 encephalitis: Clinical characteristics, diagnosis, and management of this rare entity. J Transl Autoimmun 2023; 7:100218. [PMID: 37859804 PMCID: PMC10582738 DOI: 10.1016/j.jtauto.2023.100218] [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: 06/06/2023] [Revised: 09/08/2023] [Accepted: 10/06/2023] [Indexed: 10/21/2023] Open
Abstract
The spectrum and understanding of antibody-positive autoimmune encephalitis (AE) have expanded over the past few decades. In 2007, a rare subtype of AE known as anti-adenylate kinase 5 (AK5) encephalitis, was first reported. This disease is more common in elderly males, with limbic encephalitis as the core phenotype (characterized by subacute anterograde amnesia, sometimes with psychiatric symptoms, and rarely with seizures). Brain magnetic resonance imaging typically demonstrated initial temporal lobe T2/fluid-attenuated inversion recovery hyperintensities, and subsequent atrophy. No concomitant tumors have been found yet. AK5 antibody, targeting the intracellular antigen, is a biomarker for a non-paraneoplastic T-cell autoimmunity response, and can be detected in serum and cerebrospinal fluid using tissue-based and cell-based assays. Cytotoxic T-cell-mediating neuronal injury and loss play a pivotal role in the immunopathogenesis of anti-AK5 encephalitis. Patients mostly show poor response to immunotherapy and thus a poor prognosis in the long run. Herein, we review the literature and provide updated knowledge of this less-known entity, focusing on clinical characteristics, paraclinical findings, diagnosis process, and therapeutic approaches.
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Affiliation(s)
- Er-Chuang Li
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
- Department of Neurology, Taikang Ningbo Hospital, Ningbo, 315042, China
| | - Qi-Lun Lai
- Department of Neurology, Zhejiang Hospital, Hangzhou, 310013, China
| | - Meng-Ting Cai
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Gao-Li Fang
- Department of Neurology, Zhejiang Chinese Medicine and Western Medicine Integrated Hospital, Hangzhou, 310003, China
| | - Chun-Hong Shen
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Mei-Ping Ding
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Yin-Xi Zhang
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
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23
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Andzelm MM, Stredny CM. Mechanisms and Emerging Therapies for Treatment of Seizures in Pediatric Autoimmune Encephalitis and Autoinflammatory/Autoimmune-Associated Epilepsy. Rheum Dis Clin North Am 2023; 49:875-893. [PMID: 37821201 DOI: 10.1016/j.rdc.2023.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
There has been increasing understanding of the role of inflammation in seizures and epilepsy, as well as targeted immunomodulatory treatments. In children, immune-mediated seizures often present acutely in the setting of autoimmune encephalitis and are very responsive to immunotherapy with low rates of subsequent epilepsy. Conversely, seizures in autoimmune-associated epilepsies, such as Rasmussen syndrome, can remain refractory to multimodal therapy, including immunomodulation. In this review, the authors discuss the presentations of immune-mediated seizures in children, underlying mechanisms, and emerging therapies.
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Affiliation(s)
- Milena M Andzelm
- Program in Neuroimmunology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Coral M Stredny
- Program in Neuroimmunology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Van Steenhoven RW, de Vries JM, Bruijstens AL, Paunovic M, Nagtzaam MM, Franken SC, Bastiaansen AE, De Bruijn MA, Van Sonderen A, Schreurs MWJ, Gardeniers M, Verdijk RM, Balvers RK, Sillevis Smitt PA, Neuteboom RF, Titulaer MJ. Mimics of Autoimmune Encephalitis: Validation of the 2016 Clinical Autoimmune Encephalitis Criteria. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200148. [PMID: 37582614 PMCID: PMC10427145 DOI: 10.1212/nxi.0000000000200148] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/27/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND AND OBJECTIVES The clinical criteria for autoimmune encephalitis (AE) were proposed by Graus et al. in 2016. In this study, the AE criteria were validated in the real world, and common AE mimics were described. In addition, criteria for probable anti-LGI1 encephalitis were proposed and validated. METHODS In this retrospective cohort study, patients referred to our national referral center with suspicion of AE and specific neuroinflammatory disorders with similar clinical presentations were included from July 2016 to December 2019. Exclusion criteria were pure cerebellar or peripheral nerve system disorders. All patients were evaluated according to the AE criteria. RESULTS In total, 239 patients were included (56% female; median age 42 years, range 1-85). AE was diagnosed in 104 patients (44%) and AE mimics in 109 patients (46%). The most common AE mimics and misdiagnoses were neuroinflammatory CNS disorders (26%), psychiatric disorders (19%), epilepsy with a noninflammatory cause (13%), CNS infections (7%), neurodegenerative diseases (7%), and CNS neoplasms (6%). Common confounding factors were mesiotemporal lesions on brain MRI (17%) and false-positive antibodies in serum (12%). Additional mesiotemporal features (involvement extralimbic structures, enhancement, diffusion restriction) were observed more frequently in AE mimics compared with AE (61% vs 24%; p = 0.005). AE criteria showed the following sensitivity and specificity: possible AE, 83% (95% CI 74-89) and 27% (95% CI 20-36); definite autoimmune limbic encephalitis (LE), 10% (95% CI 5-17) and 98% (95% CI 94-100); and probable anti-NMDAR encephalitis, 50% (95% CI 26-74) and 96% (95% CI 92-98), respectively. Specificity of the criteria for probable seronegative AE was 99% (95% CI 96-100). The newly proposed criteria for probable anti-LGI1 encephalitis showed a sensitivity of 66% (95% CI 47-81) and specificity of 96% (95% CI 93-98). DISCUSSION AE mimics occur frequently. Common pitfalls in AE misdiagnosis are mesiotemporal lesions (predominantly with atypical features) and false-positive serum antibodies. As expected, the specificity of the criteria for possible AE is low because these criteria represent the minimal requirements for entry in the diagnostic algorithm for AE. Criteria for probable AE (-LGI1, -NMDAR, seronegative) and definite autoimmune LE are applicable for decisions on immunotherapy in early disease stage, as specificity is high.
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Affiliation(s)
- Robin W Van Steenhoven
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Juna M de Vries
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Arlette L Bruijstens
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Manuela Paunovic
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Mariska M Nagtzaam
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Suzanne C Franken
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Anna E Bastiaansen
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marienke A De Bruijn
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Agnes Van Sonderen
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marco W J Schreurs
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Mayke Gardeniers
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Robert M Verdijk
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Rutger K Balvers
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Peter A Sillevis Smitt
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Rinze F Neuteboom
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Maarten J Titulaer
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
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Qin M, Chen J, Guo X, Xiang X, Nie L, Wang Y, Mao L. Movement disorders in autoimmune encephalitis: an update. J Neurol 2023; 270:5288-5302. [PMID: 37523063 DOI: 10.1007/s00415-023-11881-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/13/2023] [Accepted: 07/13/2023] [Indexed: 08/01/2023]
Abstract
Autoimmune encephalitis (AE) is a form of encephalitis resulting from an immune response targeting central nervous system antigens, which is characterized by cognitive impairment, neuropsychiatric symptoms, seizures, movement disorders (MDs), and other encephalopathy symptoms. MDs frequently manifest throughout the progression of the disease, with recurrent involuntary movements leading to discomfort and, in some cases, necessitating admission to the intensive care unit. Prompt identification and management of MDs can aid in the diagnosis and prognosis of AE. This review synthesizes current knowledge on the characteristics, underlying mechanisms, and treatment options for MDs in the context of AE.
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Affiliation(s)
- Mengting Qin
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiaojiao Chen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoqing Guo
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuying Xiang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lei Nie
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yong Wang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Ling Mao
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Hansen N, Rentzsch K, Hirschel S, Wiltfang J, Schott BH, Malchow B, Bartels C. Persisting Verbal Memory Encoding and Recall Deficiency after mGluR5 Autoantibody-Mediated Encephalitis. Brain Sci 2023; 13:1537. [PMID: 38002497 PMCID: PMC10669453 DOI: 10.3390/brainsci13111537] [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: 09/25/2023] [Revised: 10/16/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Metabotropic glutamate receptors type 5 (mGluR5) play a central role in persistent forms of synaptic plasticity and memory formation. Antibodies to mGluR5 have been reported to be clinically associated with memory impairment. Here, we report on a patient with persistent amnestic cognitive impairment in a single cognitive domain after resolution of mGluR5-associated encephalitis. METHODS We report on the clinical data of a patient in our Department of Psychiatry and Psychotherapy who underwent several diagnostic investigations including a detailed neuropsychological examination, magnetic resonance imaging, and cerebrospinal fluid analysis involving the determination of neural autoantibodies. RESULTS A 54-year-old woman presented to our memory clinic with pleocytosis 4 months after remission of probable anti-mGluR5-mediated encephalitis, revealing initial pleocytosis and serum proof of anti-mGluR5 autoantibodies (1:32). A neuropsychological examination revealed mild cognitive impairment in verbal memory encoding and recall. The patient received immunotherapy with corticosteroids, and a subsequent cerebrospinal fluid analysis 1.5 months after the onset of encephalitis confirmed no further signs of inflammation. CONCLUSIONS Our results suggest that although immunotherapy resulted in the remission of anti-mGluR5 encephalitis, a verbal memory encoding and recall dysfunction persisted. It remains unclear whether the reason for the persistent verbal memory impairment is attributable to insufficiently long immunotherapy or initially ineffective immunotherapy. Because mGluR5 plays an essential role in persistent synaptic plasticity in the hippocampus, it is tempting to speculate that the mGluR5 antibody-antigen complex could lead to persistent cognitive dysfunction, still present after the acute CNS inflammation stage of encephalitis.
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Affiliation(s)
- Niels Hansen
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Von-Siebold-Str. 5, 37075 Goettingen, Germany; (S.H.); (J.W.); (B.H.S.); (B.M.); (C.B.)
- Clinical Immunological Laboratory Prof. Stöcker, 23627 Groß Grönau, Germany
| | - Kristin Rentzsch
- German Center for Neurodegenerative Diseases (DZNE), Von-Siebold-Str. 3a, 37075 Goettingen, Germany;
| | - Sina Hirschel
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Von-Siebold-Str. 5, 37075 Goettingen, Germany; (S.H.); (J.W.); (B.H.S.); (B.M.); (C.B.)
| | - Jens Wiltfang
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Von-Siebold-Str. 5, 37075 Goettingen, Germany; (S.H.); (J.W.); (B.H.S.); (B.M.); (C.B.)
- Neurosciences and Signaling Group, Institute of Biomedicine (iBiMED), Department of Medical Sciences, University of Aveiro, 3810-193 Aveiro, Portugal
- Leibniz-Institute of Neurobiology, University of Magdeburg, 39106 Magdeburg, Germany
| | - Björn H. Schott
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Von-Siebold-Str. 5, 37075 Goettingen, Germany; (S.H.); (J.W.); (B.H.S.); (B.M.); (C.B.)
- German Center for Neurodegenerative Diseases (DZNE), Von-Siebold-Str. 3a, 37075 Goettingen, Germany;
- Leibniz-Institute of Neurobiology, University of Magdeburg, 39106 Magdeburg, Germany
| | - Berend Malchow
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Von-Siebold-Str. 5, 37075 Goettingen, Germany; (S.H.); (J.W.); (B.H.S.); (B.M.); (C.B.)
| | - Claudia Bartels
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Von-Siebold-Str. 5, 37075 Goettingen, Germany; (S.H.); (J.W.); (B.H.S.); (B.M.); (C.B.)
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Zhang MM, Wang J, Sun D, Wang JX, Zhang JH, Xu JW. Case Report: Autoimmune encephalitis and other neurological syndromes with rare neuronal surface antibody in children after hematopoietic stem cell transplantation. Front Immunol 2023; 14:1274420. [PMID: 37954605 PMCID: PMC10637573 DOI: 10.3389/fimmu.2023.1274420] [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: 08/08/2023] [Accepted: 10/12/2023] [Indexed: 11/14/2023] Open
Abstract
Introduction Neuronal surface antibody syndromes (NSAS) encompass a growing set of autoimmune neurological disorders, with their predominant clinical presentation being autoimmune encephalitis (AE). The most extensively documented form within NSAS is anti-N-methyl-D-aspartate receptor (NMDAR) autoimmunity. In contrast, other NSAS, such as anti-metabotropic glutamate receptor-5 (mGluR5) autoimmunity, are less common and less comprehensively characterized, particularly in pediatric cases. Case description In this instance, we present the case of a 7-year-old girl who exhibited abnormal behaviors following hematopoietic stem cell transplantation (HSCT). She received a diagnosis of anti-mGluR5 AE, and her Electroencephalogram (EEG) displayed an increased number of generalized slow waves during wakefulness. Treatment involved intravenous administration of gamma globulin and methylprednisolone, followed by oral prednisone tablets. Levetiracetam was introduced as an antiepileptic therapy during the pulse steroid therapy. Notably, the abnormal behaviors exhibited significant improvement after treatment. Conclusions To the best of our knowledge, this is the first report of rare pediatric NSAS involving anti-mGluR5 AE following HSCT. Enhancing our understanding and characterization of this condition may facilitate its recognition and treatment in children. Serum antibody testing could enable early identification and treatment of anti-mGluR5 AE.
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Affiliation(s)
- Ming-min Zhang
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Wang
- Division of Neurology, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dan Sun
- Division of Neurology, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing-xuan Wang
- Wisdom Lake Academy of Pharmacy, Xi’an Jiaotong-Liverpool University, Suzhou, China
| | - Jun-hong Zhang
- Department of Pediatrics, The Central Hospital of Jingmen, Jingmen, China
| | - Jia-wei Xu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Guasp M, Dalmau J. Searching for Neuronal Antibodies in Psychiatric Diseases: Uncertain Findings and Implications. Neurology 2023; 101:656-660. [PMID: 37353340 PMCID: PMC10585692 DOI: 10.1212/wnl.0000000000207486] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/18/2023] [Indexed: 06/25/2023] Open
Abstract
In recent years, neurology and psychiatry journals have been inundated with reports on individual symptoms of autoimmune encephalitis (AE) that are described as distinct entities such as autoimmune psychosis, obsessive-compulsive disorders, or depression. It is unquestionable that for AE the demonstration of antibodies against neuronal-surface proteins is intrinsically linked to distinct disorders (some defining new diseases) that are usually treatment-responsive and associate with comorbidities that vary according to the antigen. By contrast, for psychiatric diseases, the apparent detection of antibodies has not defined any disorder or affected the diagnosis and treatment of patients. Although these studies frequently use anti-N-methyl-D-aspartate receptor encephalitis to rationalize the findings, they rarely adopt the same rigorous investigations or address the clinical and pathogenic significance of the antibodies or discuss the limitations related to the biological sample or antibody-testing techniques. It is imperative to consider (1) some antibodies (GAD65, TPO) occur in serum of 8%-13% of healthy people; (2) VGKC antibodies are not useful unless LGI1 or CASPR2 are investigated; (3) commercial-clinical testing for Ma2, Zic4, and SOX1 antibodies causes a high number of false-positive results; (4) GlyR antibodies have unclear disease specificity when examined only in serum; and (5) the significance of antibodies against unknown antigens of endothelium, astrocytes, myelin fibers, or granule cells of hippocampus and cerebellum is questioned by the lack of disease specificity and appropriate controls. These limitations and problems are a frequent cause of neurologic consultations. Here we discuss some of these problems, emphasizing the importance of clinical judgment over antibody findings.
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Affiliation(s)
- Mar Guasp
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.D.); Neurology Service (M.G., J.D.), Hospital Clínic de Barcelona, University of Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institution for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain
| | - Josep Dalmau
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.G., J.D.); Neurology Service (M.G., J.D.), Hospital Clínic de Barcelona, University of Barcelona, Spain; Department of Neurology (J.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Catalan Institution for Research and Advanced Studies (ICREA) (J.D.), Barcelona, Spain.
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Goddu Govindappa SK, Adiga CP, Srinarahari V, Kumar S. Ophelia syndrome followed by tubercular meningitis in a patient with relapsed Hodgkin lymphoma, could MR imaging have saved his life? Acta Neurol Belg 2023; 123:1993-1996. [PMID: 35831778 PMCID: PMC9281219 DOI: 10.1007/s13760-022-02019-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 06/23/2022] [Indexed: 11/13/2022]
Affiliation(s)
| | | | | | - Sujit Kumar
- Department of Neurology, Apollo Hospitals, Sheshadripuram, Bangalore, India
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Efthymiou E, Baumann CR, Balint B. The Expanding Field of Autoimmune Sleep-Wake Disorders-Implications for the Movement Disorders Clinical Practice. Mov Disord Clin Pract 2023; 10:1476-1477. [PMID: 37868921 PMCID: PMC10585957 DOI: 10.1002/mdc3.13869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/13/2023] [Accepted: 08/01/2023] [Indexed: 10/24/2023] Open
Affiliation(s)
- Evdokia Efthymiou
- Department of NeurologyUniversity Hospital Zurich, University of ZurichZurichSwitzerland
| | - Christian R. Baumann
- Department of NeurologyUniversity Hospital Zurich, University of ZurichZurichSwitzerland
| | - Bettina Balint
- Department of NeurologyUniversity Hospital Zurich, University of ZurichZurichSwitzerland
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Yu X, Wax J, Riemekasten G, Petersen F. Functional autoantibodies: Definition, mechanisms, origin and contributions to autoimmune and non-autoimmune disorders. Autoimmun Rev 2023; 22:103386. [PMID: 37352904 DOI: 10.1016/j.autrev.2023.103386] [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: 05/08/2023] [Revised: 06/06/2023] [Accepted: 06/18/2023] [Indexed: 06/25/2023]
Abstract
A growing body of evidence underscores the relevance of functional autoantibodies in the development of various pathogenic conditions but also in the regulation of homeostasis. However, the definition of functional autoantibodies varies among studies and a comprehensive overview on this emerging topic is missing. Here, we do not only explain functional autoantibodies but also summarize the mechanisms underlying the effect of such autoantibodies including receptor activation or blockade, induction of receptor internalization, neutralization of ligands or other soluble extracellular antigens, and disruption of protein-protein interactions. In addition, in this review article we discuss potential triggers of production of functional autoantibodies, including infections, immune deficiency and tumor development. Finally, we describe the contribution of functional autoantibodies to autoimmune diseases including autoimmune thyroid diseases, myasthenia gravis, autoimmune pulmonary alveolar proteinosis, autoimmune autonomic ganglionopathy, pure red cell aplasia, autoimmune encephalitis, pemphigus, acquired thrombotic thrombocytopenic purpura, idiopathic dilated cardiomyopathy and systemic sclerosis, as well as non-autoimmune disorders such as allograft rejection, infectious diseases and asthma.
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Affiliation(s)
- Xinhua Yu
- Priority Area Chronic Lung Diseases, Research Center Borstel, Members of the German Center for Lung Research (DZL), 23845 Borstel, Germany.
| | - Jacqueline Wax
- Priority Area Chronic Lung Diseases, Research Center Borstel, Members of the German Center for Lung Research (DZL), 23845 Borstel, Germany
| | - Gabriela Riemekasten
- Department of Rheumatology and Clinical Immunology, University Clinic of Schleswig Holstein, University of Lübeck, 23538 Lübeck, Germany
| | - Frank Petersen
- Priority Area Chronic Lung Diseases, Research Center Borstel, Members of the German Center for Lung Research (DZL), 23845 Borstel, Germany
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Sun Y, Tao JX, Han X, Wang X, Zhu Y, Lian Y, Ren G, Wang Q. Clinical features and brain MRI volumetric changes in anti-mGluR5 encephalitis. Ann Clin Transl Neurol 2023; 10:1407-1416. [PMID: 37329164 PMCID: PMC10424662 DOI: 10.1002/acn3.51831] [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: 04/11/2023] [Revised: 05/24/2023] [Accepted: 06/03/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Anti-metabotropic glutamate receptor 5 (mGluR5) encephalitis is a rare and under-recognized autoimmune encephalitis. This study is conducted to characterize its clinical and neuroimaging features. METHODS Twenty-nine patients with anti-mGluR5 encephalitis (15 new cases identified in this study and 14 previously reported cases) were included in this study and their clinical features were characterized. Brain MRI volumetric analysis using FreeSurfer software was performed in 9 new patients and compared with 25 healthy controls at both early (≤6 months of onset) and chronic (>1 year of onset) disease stages. RESULTS The common clinical manifestations of anti-mGluR5 encephalitis included cognitive deficits (n = 21, 72.4%), behavioral and mood disturbances (n = 20, 69%), seizures (n = 16, 55.2%), and sleep disorder (n = 13, 44.8%). Tumors were observed in 7 patients. Brain MRI T2/FLAIR signal hyperintensities were observed predominantly in mesiotemporal and subcortical regions in 75.9% patients. MRI volumetric analysis demonstrated significant amygdala enlargement in both early and chronic disease stages compared to healthy controls (P < 0.001). Twenty-six patients had complete or partial recovery, one remained stable, one died and one was lost to follow-up. CONCLUSION Our findings demonstrated that cognitive impairment, behavioral disturbance, seizures, and sleep disorder are the prominent clinical manifestations of anti-mGluR5 encephalitis. Most patients showed a good prognosis with full recovery, even in the paraneoplastic disease variants. The amygdala enlargement in the early and chronic disease stages is a distinct MRI feature, which exploratively offer a valuable perspective for the study of the disease processes.
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Affiliation(s)
- Yueqian Sun
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- National Center for Clinical Medicine of Neurological DiseasesBeijingChina
| | - James X. Tao
- Department of NeurologyThe University of ChicagoChicagoUSA
| | - Xiong Han
- Department of NeurologyHenan Provincial People's HospitalZhengzhouChina
| | - Xiangqing Wang
- Department of NeurologyChinese PLA General HospitalBeijingChina
| | - Yulan Zhu
- Department of NeurologyThe Second Affiliated Hospital of Harbin Medical UniversityHarbinHeilongjiangChina
| | - Yajun Lian
- Department of NeurologyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouHenanChina
| | - Guoping Ren
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- National Center for Clinical Medicine of Neurological DiseasesBeijingChina
| | - Qun Wang
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- National Center for Clinical Medicine of Neurological DiseasesBeijingChina
- Collaborative Innovation Center for Brain DisordersBeijing Institute of Brain Disorders, Capital Medical UniversityBeijingChina
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Dalmau J, Graus F. Diagnostic criteria for autoimmune encephalitis: utility and pitfalls for antibody-negative disease. Lancet Neurol 2023; 22:529-540. [PMID: 37210100 DOI: 10.1016/s1474-4422(23)00083-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/25/2023] [Accepted: 02/09/2023] [Indexed: 05/22/2023]
Abstract
Increased awareness of autoimmune encephalitis has led to two unintended consequences: a high frequency of misdiagnoses and the inappropriate use of diagnostic criteria for antibody-negative disease. Misdiagnoses typically occur for three reasons: first, non-adherence to reported clinical requirements for considering a disorder as possible autoimmune encephalitis; second, inadequate assessment of inflammatory changes in brain MRI and CSF; and third, absent or limited use of brain tissue assays along with use of cell-based assays that include only a narrow range of antigens. For diagnosis of possible autoimmune encephalitis and probable antibody-negative autoimmune encephalitis, clinicians should adhere to published criteria for adults and children, focusing particularly on exclusion of alternative disorders. Moreover, for diagnosis of probable antibody-negative autoimmune encephalitis, the absence of neural antibodies in CSF and serum should be well substantiated. Neural antibody testing should use tissue assays along with cell-based assays that include a broad range of antigens. Live neuronal studies in specialised centres can assist in resolving inconsistencies with respect to syndrome-antibody associations. Accurate diagnosis of probable antibody-negative autoimmune encephalitis will identify patients with similar syndromes and biomarkers, which will provide homogeneous populations for future assessments of treatment response and outcome.
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Affiliation(s)
- Josep Dalmau
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Neurology Department, Institute of Neuroscience, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain.
| | - Francesc Graus
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
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Kecskés K, Devos J, Goffin K, van Son B, Demaerel P. Ophelia syndrome. Acta Neurol Belg 2023:10.1007/s13760-023-02279-x. [PMID: 37219762 DOI: 10.1007/s13760-023-02279-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 05/05/2023] [Indexed: 05/24/2023]
Affiliation(s)
- Kinga Kecskés
- Department of Radiology, University Hospital KU Leuven, Leuven, Belgium
- Department of Radiology, Semmelweis University, Budapest, Hungary
| | - Johannes Devos
- Department of Radiology, University Hospital KU Leuven, Leuven, Belgium
| | - Karolien Goffin
- Department of Nuclear Medicine, University Hospital KU Leuven, Leuven, Belgium
| | | | - Philippe Demaerel
- Department of Radiology, University Hospital KU Leuven, Leuven, Belgium.
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Chen S, Ren H, Lin F, Fan S, Cao Y, Zhao W, Guan H. Anti-metabotropic glutamate receptor 5 encephalitis: Five case reports and literature review. Brain Behav 2023; 13:e3003. [PMID: 37060179 PMCID: PMC10175974 DOI: 10.1002/brb3.3003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/04/2023] [Accepted: 03/28/2023] [Indexed: 04/16/2023] Open
Abstract
OBJECTIVE To describe the clinical and radiological characteristics of anti-metabotropic glutamate receptor 5 (mGluR5) encephalitis. METHODS We reviewed the clinical data of five patients with anti-mGluR5 encephalitis, and performed a literature review. RESULTS The five cases included a 52-year-old man who developed a biphasic course of anti-mGluR5 encephalitis after herpes simplex encephalitis, a 22-year-old woman who showed bilateral basal ganglia lesions on brain magnetic resonance imaging (MRI), and a 36-year-old man with mixed aphasia and generalized tonic-clonic seizures, a 51-year-old man presented with personality changes, hallucinations, delusions, sleeping disorders and a 58-year-old man with short-term memory deficits and absence seizures.. There are 16 reported cases of anti-mGluR5 encephalitis worldwide. Of all 21 patients, with a median onset age of 35 years old, the main neurological symptoms were cognitive impairment (85.7%, 18/21), psychiatric or behavior problems (76.2%, 16/21), seizures (57.1%, 12/21), sleeping disorders (52.4%, 11/21), different degrees of decreased consciousness (42.9%, 9/21), and movement disorders (23.8%, 5/21). Brain MRI was normal in 11 of 21 patients. Lesions of the limbic lobes were presented in 5 patients, while involvement of other extralimbic regions was also reported. Seven of 21 (33.3%) cases were combined with tumors. Elevated white blood cell counts or specific oligoclonal IgG bands in the cerebrospinal fluid were found in 18 of 21 patients, with marked improvements observed after immunotherapy. DISCUSSION Patients with anti-mGluR5 encephalitis typically present with diffuse, rather than purely limbic, encephalitis. Anti-mGluR5 encephalitis can be triggered by herpes simplex encephalitis. The risk of a combined tumor may be reduced in anti-mGluR5 encephalitis patients.
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Affiliation(s)
- Sixian Chen
- 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
| | - Fuhong Lin
- Department of Neurology, Affiliated Hospital of Chifeng University, Chifeng, Inner Mongolia, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuze Cao
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Weili Zhao
- Department of Neurology, Affiliated Hospital of Chifeng University, Chifeng, Inner Mongolia, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Abstract
PURPOSE OF REVIEW To provide an overview and highlight recent updates in the field of paraneoplastic neurologic disorders. RECENT FINDINGS The prevalence of paraneoplastic neurologic disorders is greater than previously reported and the incidence has been rising over time, due to improved recognition in the era of antibody biomarkers. Updated diagnostic criteria that are broadly inclusive and also contain diagnostic risk for clinical presentations (high and intermediate) and diagnostic antibodies (high, intermediate, and low) have replaced the original 2004 criteria. Antibody biomarkers continue to be characterized (e.g., KLHL-11 associated with seminoma in men with brainstem encephalitis). Some paraneoplastic antibodies also provide insight into likely immunotherapy response and prognosis. The rise of immune checkpoint inhibitors as cancer therapeutics has been associated with newly observed immune-mediated adverse effects including paraneoplastic neurological disorders. The therapeutic approach to paraneoplastic neurologic disorders is centered around cancer care and trials of immune therapy. The field of paraneoplastic neurologic disorders continues to be advanced by the identification of novel antibody biomarkers which have diagnostic utility, and give insight into likely treatment responses and outcomes.
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Affiliation(s)
- Michael Gilligan
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, St Vincent's University Hospital, Dublin, Ireland
| | | | - Andrew McKeon
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN, USA.
- Department of Neurology, College of Medicine, Mayo Clinic, 200 1st ST SW, Rochester, MN, 55905, USA.
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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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Zhang Y, Lian B, Yang S, Huang X, Zhou Y, Cao L. Metabotropic glutamate receptor 5-related autoimmune encephalitis with reversible splenial lesion syndrome following SARS-CoV-2 vaccination. Medicine (Baltimore) 2023; 102:e32971. [PMID: 36800591 PMCID: PMC9936002 DOI: 10.1097/md.0000000000032971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 01/25/2023] [Indexed: 02/19/2023] Open
Abstract
RATIONALE Metabotropic glutamate receptor 5 (mGluR5)-related autoimmune encephalitis (AE) has been rarely reported; however, there are no reports on mGluR5-related AE with reversible splenial lesion syndrome following vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). PATIENT CONCERNS A 29-year-old man was admitted with a history of headache and fever for 9 days and 6 days, respectively. DIAGNOSIS He was initially diagnosed with an intracranial infection, however the final diagnosis was corrected as anti-mGluR5-related AE with reversible splenial lesion syndrome. INTERVENTIONS He had received an inactivated SARS-CoV-2 vaccine 3 weeks prior to the examination and was initially diagnosed with an intracranial infection. Physical examination revealed bilateral horizontal nystagmus, ataxia, and neck rigidity. Antiinfective therapy was minimally helpful. An analysis of the cerebrospinal fluid did not reveal pathogens for sequencing. Magnetic resonance imaging displayed abnormal signals in the splenium of the corpus callosum. OUTCOMES We identified mGluR5 antibodies in the cerebrospinal fluid and serum. Subsequently, intravenous methylprednisolone pulse and gamma-globulin pulse therapies were administered, which substantially improved the symptoms. Follow-up did not reveal abnormal neurological symptoms, and the lesion in the corpus callosum had resolved. LESSONS AE with mGluR5 antibodies could arise from SARS-CoV-2 vaccination, which warrants the awareness of healthcare workers. Reversible splenial lesion syndrome may accompany mGluR5-related AE and mimic intracranial infection. Thus, early treatment can prevent serious residual signs and symptoms.
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Affiliation(s)
- Yu Zhang
- Department of Orthopaedics, Zhejiang Hospital, Hangzhou, China
- Clinical College of the Shenzhen Second People’s Hospital, Anhui Medical University, Shenzhen, China
| | - Baorong Lian
- Shantou University Medical College, Shantou University, Shantou, China
| | - Shiwei Yang
- Clinical College of the Shenzhen Second People’s Hospital, Anhui Medical University, Shenzhen, China
- Teaching office, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Xuming Huang
- Department of Internal Medicine, Shenzhen Shiyan People’s Hospital, Shenzhen, China
| | - Yanxia Zhou
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Liming Cao
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Hunan Key Laboratory of the Research and Development of Novel Pharmaceutical Preparations, Changsha Medical University, Changsha, China
- * Correspondence: Liming Cao, Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City 518000, China (e-mail: )
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Hodgkin Lymphoma Cell Lines and Tissues Express mGluR5: A Potential Link to Ophelia Syndrome and Paraneoplastic Neurological Disease. Cells 2023; 12:cells12040606. [PMID: 36831273 PMCID: PMC9953995 DOI: 10.3390/cells12040606] [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: 12/22/2022] [Revised: 02/05/2023] [Accepted: 02/10/2023] [Indexed: 02/15/2023] Open
Abstract
Ophelia syndrome is characterized by the coincidence of severe neuropsychiatric symptoms, classical Hodgkin lymphoma, and the presence of antibodies to the metabotropic glutamate 5 receptor (mGluR5). Little is known about the pathogenetic link between these symptoms and the role that anti-mGluR5-antibodies play. We investigated lymphoma tissue from patients with Ophelia syndrome and with isolated classical Hodgkin lymphoma by quantitative immunocytochemistry for mGluR5-expression. Further, we studied the L-1236, L-428, L-540, SUP-HD1, KM-H2, and HDLM-2 classical Hodgkin lymphoma cell lines by FACS and Western blot for mGluR5-expression, and by transcriptome analysis. mGluR5 surface expression differed significantly in terms of receptor density, distribution pattern, and percentage of positive cells. The highest expression levels were found in the L-1236 line. RNA-sequencing revealed more than 800 genes that were higher expressed in the L-1236 line in comparison to the other classical Hodgkin lymphoma cell lines. High mGluR5-expression was associated with upregulation of PI3K/AKT and MAPK pathways and of downstream targets (e.g., EGR1) known to be involved in classical Hodgkin lymphoma progression. Finally, mGluR5 expression was increased in the classical Hodgkin lymphoma-tissue of our Ophelia syndrome patient in contrast to five classical Hodgkin lymphoma-patients without autoimmune encephalitis. Given the association of encephalitis and classical Hodgkin lymphoma in Ophelia syndrome, it is possible that mGluR5-expression in classical Hodgkin lymphoma cells not only drives tumor progression but also triggers anti-mGluR5 encephalitis even before classical Hodgkin lymphoma becomes manifest.
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Li Y, Zhang M, Liu D, Wei M, Sheng J, Wang Z, Xue S, Yu T, Xue W, Zhu B, He J. Case report: Autoimmune encephalitis with multiple auto-antibodies with reversible splenial lesion syndrome and bilateral ovarian teratoma. Front Immunol 2023; 13:1029294. [PMID: 36713425 PMCID: PMC9878315 DOI: 10.3389/fimmu.2022.1029294] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 12/30/2022] [Indexed: 01/14/2023] Open
Abstract
Background Reversible splenial lesion syndrome (RESLES) is a spectrum of disease radiologically characterized by reversible lesions caused by multiple factors, primarily involving the splenium of the corpus callosum (SCC). The most common causes of RESLES include infection, antiepileptic drug use and withdrawal, and severe metabolic disorders. Nevertheless, cases of autoimmune encephalitis (AE) are uncommon. Case presentation A 26-year-old female computer programming engineer with no previous medical or psychiatric history reported to the psychiatric hospital due to a 3-day episode of irritability, babbling, limb stiffness, sleepwalking, hallucinations, and paroxysmal mania. Brain MRI revealed abnormal signals of the SCC. Lumbar puncture was performed and further testing for auto-antibodies was conducted in both the CSF and serum. CSF of the patient was positive for anti-NMDAR (titer of 1:3.2) antibodies, and serum was also positive for anti-NMDAR (titer of 1:32) as well as mGluR5 (titer of 1:10) antibodies. Enhanced CT of the pelvis showed an enlarged pelvic mass; bilateral ovarian teratomas (mature teratoma and immature teratoma) were evaluated, which were pathologically confirmed after transabdominal left adnexal resection, right ovarian biopsy, and ovarian cystectomy. The patient considerably improved after intravenous administration of steroids, immunoglobulin, oral prednisone, surgical treatment, and chemotherapy. A follow-up MRI revealed completely resolved lesions. During a 3-month follow-up, the patient experienced complete resolution of symptoms without any sign of recurrence and tumors. The titer of the anti-NMDAR antibody decreased to 1:10 in serum. Conclusion Herein, we report a rare case of AE with overlapping auto-antibodies, along with RESLES and bilateral ovarian teratomas. The current case provides the possibility of the concurrence of mGluR5 antibodies in anti-NMDAR encephalitis. However, the underlying mechanism remains elusive. Furthermore, we provide additional evidence that overlapping antibodies-related pathology may be one of the many causes of RESLES. Nonetheless, caution should be observed in interpreting the observation, considering that this is a single-case study.
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Affiliation(s)
- Yaqiang Li
- Department of Neurology, First Affiliated Hospital of Anhui University of Science and Technology (First People’s Hospital of Huainan), Huainan, China,Department of Neurology, People’s Hospital of Lixin County, Bozhou, China
| | - Mei Zhang
- Department of Neurology, First Affiliated Hospital of Anhui University of Science and Technology (First People’s Hospital of Huainan), Huainan, China,*Correspondence: Mei Zhang,
| | - Deshun Liu
- Department of Radiology, First Affiliated Hospital of Anhui University of Science and Technology (First People’s Hospital of Huainan), Huainan, China
| | - Ming Wei
- Department of Radiology, First Affiliated Hospital of Anhui University of Science and Technology (First People’s Hospital of Huainan), Huainan, China
| | - Jun Sheng
- Department of Radiology, First Affiliated Hospital of Anhui University of Science and Technology (First People’s Hospital of Huainan), Huainan, China
| | - Zhixin Wang
- Department of Gynecology and Obstetrics, First Affiliated Hospital of Anhui University of Science and Technology (First People’s Hospital of Huainan), Huainan, China
| | - Song Xue
- Department of Pathology, First Affiliated Hospital of Anhui University of Science and Technology (First People’s Hospital of Huainan), Huainan, China
| | - Tingting Yu
- Department of Neurology, First Affiliated Hospital of Anhui University of Science and Technology (First People’s Hospital of Huainan), Huainan, China
| | - Weimin Xue
- Department of Neurology, First Affiliated Hospital of Anhui University of Science and Technology (First People’s Hospital of Huainan), Huainan, China
| | - Beibei Zhu
- Department of Neurology, First Affiliated Hospital of Anhui University of Science and Technology (First People’s Hospital of Huainan), Huainan, China
| | - Jiale He
- Department of Neurology, First Affiliated Hospital of Anhui University of Science and Technology (First People’s Hospital of Huainan), Huainan, China
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Yokota Y, Hara M, Oshita N, Mizoguchi T, Nishimaki H, Hao H, Nakajima H. Case report: Anti- N-methyl-D-aspartate receptor antibody-associated autoimmunity triggered by primary central nervous system B-cell lymphoma. Front Neurol 2023; 13:1048953. [PMID: 36712446 PMCID: PMC9878211 DOI: 10.3389/fneur.2022.1048953] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/16/2022] [Indexed: 01/15/2023] Open
Abstract
Background We herein detail our experience with a unique patient with a primary central nervous system (PCNS) B-cell lymphoma concomitant with anti-N-methyl-d-aspartate receptor (NMDAR) antibodies that satisfied the criteria of "probable anti-NMDAR encephalitis (ProNMDARE)" based on the Graus criteria 2016. Case presentation A 73-year-old Japanese woman presented with acute pyrexia, agitation, and disturbance of consciousness. She gradually developed a reduction in speech frequency and truncal dystonia causing abnormal posture. Brain magnetic resonance imaging (MRI) demonstrated high-intensity lesions in the bilateral frontal lobes, and her cerebrospinal fluid revealed mild pleocytosis. She was diagnosed with acute encephalitis and treated with acyclovir and intravenous dexamethasone; however, no improvement was observed. She was transferred to our hospital 6 weeks after the onset of her symptoms, and anti-NMDAR antibodies were identified in her cerebrospinal fluid through indirect immunolabeling with rat brain frozen sections and cell-based assays with NR1/NR2 transfected HEK cells. Follow-up MRI showed enlargement of the lesions in the right frontal lobe with gadolinium enhancement, suggesting a brain tumor. Stereotactic surgery was implemented, with subsequent pathological examination revealing that the tumor was consistent with diffuse large B-cell lymphoma (DLBCL) without evidence of systemic satellite lesions. Stereotactic irradiative therapies were then added to her treatment regimen, which partly improved her neurological symptoms with only mild cognitive dysfunction still remaining. A decrease in anti-NMDAR antibody titer was also confirmed after immunotherapy and tumor removal. Conclusions We herein report our experience with a novel case of PCNS-DLBCL masquerading as anti-NMDAR encephalitis that satisfied the diagnostic criteria of "proNMDARE." Treatment, including tumor removal, ameliorated disease severity and antibody titers of the patient. Our findings suggest that anti-NMDAR antibody-associated autoimmunity can be triggered by PCNS B-cell tumors, although primary brain tumors need to be excluded before establishing a diagnosis of autoimmune encephalitis.
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Affiliation(s)
- Yuki Yokota
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Makoto Hara
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan,*Correspondence: Makoto Hara ✉
| | - Natsuki Oshita
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Tomotaka Mizoguchi
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Haruna Nishimaki
- Division of Oncologic Pathology, Department of Pathology and Microbiology, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroyuki Hao
- Division of Human Pathology, Department of Pathology and Microbiology, Nihon University School of Medicine, Tokyo, Japan
| | - Hideto Nakajima
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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Guo K, Liu X, Gong X, Li A, Liu Y, Li X, Zhou D, Hong Z. Autoimmune encephalitis with mGluR5 antibodies: A case series from China and review of the literature. Front Immunol 2023; 14:1146536. [PMID: 37025999 PMCID: PMC10070949 DOI: 10.3389/fimmu.2023.1146536] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/03/2023] [Indexed: 04/08/2023] Open
Abstract
Background Only 15 patients of autoimmune encephalitis with metabotropic glutamate receptor 5 (mGluR5) antibodies have been reported worldwide since 2011, mostly from western countries. Patients with different genetic backgrounds are necessary to further clarify the clinical phenotype and prognosis of this rare disease. Objective We initially describe a case series from China to confirm the previous findings, expand the clinical phenotype, and identify the prognostic factors of autoimmune encephalitis with mGluR5 antibodies. Methods Observational data with follow-up were prospectively collected from autoimmune encephalitis patients with mGluR5 antibodies. Clinical information and outcomes on current and previously reported cases were combined and analyzed. Results We identified five patients (median age 35 years); two were female. The main clinical manifestations were behavioral/personality changes (five of five, 100%) and cognitive disorders (four of five, 80%), accompanied with other neurologic symptoms. Hypoventilation occurred in two (40%) patients, which was life-threatening. One patient had meningoencephalitis, suggesting a new phenotype in anti-mGluR5 encephalitis. All patients received immunotherapy. At the last follow-up (median 18 months), two (40%) patients showed complete recovery, two (40%) patients showed partial recovery, and one (20%) patient died. One (20%) patient had multiple relapses. Together with the 15 previously reported cases, associated tumors occurred in seven of 12 (58%) Western patients vs. one of eight (13%) Chinese patients. Modified Rankin Scale (mRS) scores at the last follow-up (median 31 months) were available in 16 patients. Patients with bad outcomes (mRS > 2, n = 4) were more likely to have hypoventilation at onset and higher mRS scores at peak of the disease. Conclusions In patients with different genetic background, as Chinese, the clinical phenotype of anti-mGluR5 encephalitis is similar. Fewer paraneoplastic cases were observed in Chinese patients. Most patients showed good responses to immunotherapy and cancer treatment. The clinical outcomes were favorable in most patients.
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Affiliation(s)
- Kundian Guo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Institute of Brain Science and Brain-inspired Technology of West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xu Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Institute of Brain Science and Brain-inspired Technology of West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xue Gong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Institute of Brain Science and Brain-inspired Technology of West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Aiqing Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Institute of Brain Science and Brain-inspired Technology of West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yue Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Institute of Brain Science and Brain-inspired Technology of West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xingjie Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Institute of Brain Science and Brain-inspired Technology of West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Institute of Brain Science and Brain-inspired Technology of West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhen Hong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Institute of Brain Science and Brain-inspired Technology of West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Neurology, Chengdu Shangjin Nanfu Hospital, Chengdu, Sichuan, China
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Duong SL, Prüss H. Molecular disease mechanisms of human antineuronal monoclonal autoantibodies. Trends Mol Med 2023; 29:20-34. [PMID: 36280535 DOI: 10.1016/j.molmed.2022.09.011] [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: 08/05/2022] [Revised: 09/28/2022] [Accepted: 09/30/2022] [Indexed: 11/22/2022]
Abstract
Autoantibodies targeting brain antigens can mediate a wide range of neurological symptoms ranging from epileptic seizures to psychosis to dementia. Although earlier experimental work indicated that autoantibodies can be directly pathogenic, detailed studies on disease mechanisms, biophysical autoantibody properties, and target interactions were hampered by the availability of human material and the paucity of monospecific disease-related autoantibodies. The emerging generation of patient-derived monoclonal autoantibodies (mAbs) provides a novel platform for the detailed characterization of immunobiology and autoantibody pathogenicity in vitro and in animal models. This Feature Review focuses on recent advances in mAb generation and discusses their potential as powerful scientific tools for high-resolution imaging, antigenic target identification, atomic-level structural analyses, and the development of antibody-selective immunotherapies.
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Affiliation(s)
- Sophie L Duong
- 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, 10117 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, Charitéplatz 1, 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, 10117 Berlin, Germany.
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Khojah O, Makkawi S, Alghamdi S. Anti-mGluR1 encephalitis: Case illustration and systematic review. Front Neurol 2023; 14:1142160. [PMID: 37139064 PMCID: PMC10149714 DOI: 10.3389/fneur.2023.1142160] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/29/2023] [Indexed: 05/05/2023] Open
Abstract
Background The literature for immune-mediated neurological disorders is evolving like no other field of neurological illnesses. Many new antibodies or disorders have been described in the last decade. The cerebellum is a brain structure susceptible to these immune-mediated pathologies, and anti-metabotropic glutamate receptor 1 (mGluR1) antibody has a predilection to the cerebellar tissue. Anti-mGluR1 encephalitis is a rare autoimmune disease affecting the central and peripheral nervous systems, triggering an acute or subacute cerebellar syndrome with varying degrees of severity. Anti-mGluR1 encephalitis is a rare autoimmune disease affecting the central nervous system. We aimed to systematically review reported cases of anti-mGluR1 encephalitis and summarize their clinical presentation, management, outcomes, and case reports. Methods A search of the PubMed and Google Scholar databases was conducted and included all cases of anti-mGluR1 encephalitis published in English before October 1, 2022. A comprehensive systematic review was conducted using "metabotropic glutamate receptor type 1," "mGluR1," autoantibodies," "autoantibodies," "autoimmunity," and "antibody" as keywords. The risk of bias assessment of the evidence was performed using appropriate tools. The qualitative variables were presented as frequency and percentage. Results Including our case, 36 cases of anti-mGluR1 encephalitis (19 males, median age 52.5 years, 11.1% pediatric cases) have been reported. The most common clinical manifestations are ataxia, dysarthria, and nystagmus. Initial imaging was normal in 44.4% of patients; however, 75% of patients showed abnormality later in the disease course. The first-line therapy options include glucocorticoids, intravenous immunoglobulin, and plasma exchange. Rituximab is the most commonly used second-line treatment. Complete remission was achieved in only 22.2% of patients, and 61.8% were disabled by the end of their course. Conclusion Anti-mGluR1 encephalitis manifests as symptoms of cerebellar pathology. Although the natural history has not been completely elucidated, early diagnosis with prompt initiation of immunotherapy could be imperative. Any patient suspected to have autoimmune cerebellitis should be tested for the presence of anti-mGluR1 antibody in the serum and cerebrospinal fluid. Escalation to an aggressive therapy approach should be applied in cases that do not respond to first-line therapies, and extended follow-up durations are required in all cases.
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Affiliation(s)
- Osama Khojah
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- Department of Medicine, Ministry of the National Guard-Health Affairs, Jeddah, Saudi Arabia
| | - Seraj Makkawi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- Department of Medicine, Ministry of the National Guard-Health Affairs, Jeddah, Saudi Arabia
| | - Saeed Alghamdi
- Neuroscience Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
- *Correspondence: Saeed Alghamdi,
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Younger DS. Paraneoplastic motor disorders. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:231-250. [PMID: 37620071 DOI: 10.1016/b978-0-323-98817-9.00018-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Paraneoplastic neurological disorders (PNDs) are heterogeneous clinicopathologic syndromes that occur throughout the neuraxis resulting from damage to organs or tissues remote from the site of a malignant neoplasm or its metastases. The discordance between severe neurological disability and even an indolent malignancy suggests an underlying neuroimmunologic host immune response that inflicts nervous tissue damage while inhibiting malignant tumor growth. Motor system involvement, like other symptoms and signs, is associated with focal or diffuse involvement of the brain, spinal cord, peripheral nerve, neuromuscular junction or muscle, alone or in combination due to an underlying neuroimmune and neuroinflammatory process targeting neural-specific antigens. Unrecognized and therefore untreated, PNDs are often lethal making early detection and aggressive treatment of paramount importance. While the combination of clinical symptoms and signs, and analysis of detailed body and neuroimaging, clinical neurophysiology and electrodiagnostic studies, and tumor and nervous system tissue biopsies are all vitally important, the certain diagnosis of a PND rests with the discovery of a corresponding neural-specific paraneoplastic autoantibody in the blood and/or spinal cerebrospinal fluid.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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Abstract
Detection of autoantibodies against neurons and glia cells has brought about the early and specific diagnosis of autoimmune encephalitis in patients with variable neurological and psychiatric symptoms. Growing knowledge not only resulted in profound changes in treatment algorithms including immunotherapy but also in the understanding of disease mechanisms and etiological factors. The still increasing numbers of new autoantibodies calls for continuous updates on the state of the art in antibody diagnostics, frequencies of associated tumors and the clinical spectrum linked to each antibody, which can range from mood changes, cognitive impairment and epileptic seizures to abnormal movements, autonomic dysfunction and impaired levels of consciousness. This article summarizes the recent developments in the predominant clinical presentations of autoimmune encephalitis patients in imaging and cerebrospinal fluid diagnostics and also in prognostic markers, in the establishment of innovative immunotherapies, in the use of diagnostic pathways even before the results of the antibody tests are available and the understanding of the autoimmune etiology.
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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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Focal motor seizure as a presenting symptom in anti-mGluR5 encephalitis: A case report. Seizure 2022; 103:82-85. [DOI: 10.1016/j.seizure.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/12/2022] [Accepted: 10/27/2022] [Indexed: 11/27/2022] Open
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Abstract
RATIONALE Anti-LGI1 antibody encephalitis and anti-mGluR5 are both uncommon encephalitis, and we report the first case of autoimmune encephalitis (AE) with dual seropositive antibodies of leucine-rich glioma-inactivated 1 (LGI1) and mGluR5. PATIENT CONCERNS We present a case of AE with dual seropositive antibodies of LGI1 and mGluR5 in a 65-year-old woman who presented with sudden onset left faciobrachial dystonic seizures and unresponsive for 5 hours. DIAGNOSIS The patient was diagnosed with anti-LGI1 AE and anti-mGluR5 AE mainly based on the clinical symptoms and further test of the antibody in serum and cerebral spinal fluid (CSF). INTERVENTIONS AND OUTCOMES The patient was treated with glucocorticoid intravenous drip. We also gave her the therapy of immunoglobulin (25 g q.d) for 5 days and anti-epileptic therapy. She had no more convulsions on the left side of the face and limbs. She did not complain of any uncomfort until July 18. LESSONS Early recognition of AE is crucial. Specific autoantibodies are associated with corresponding syndromes. Our patient was initially diagnosed with acute ischemic stroke. Therefore, we should conduct further study on the related symptoms of AE.
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Affiliation(s)
- Tiantian Huo
- Department of Neurology, Hebei General Hospital, Shijiazhuang, China
| | - Xintong Luo
- Department of Neurology, Hebei General Hospital, Shijiazhuang, China
| | - Jingru Zhao
- Department of Neurology, Hebei General Hospital, Shijiazhuang, China
| | - Tianjun Wang
- Department of Neurology, Hebei General Hospital, Shijiazhuang, China
| | - Jinghong Chen
- Department of Neurology, Hebei General Hospital, Shijiazhuang, China
- *Correspondence: Jinghong Chen, Department of Neurology, Hebei General Hospital, No. 348 Heping Road, Xinhua District, Shijiazhuang, Hebei 050051,China (e-mail: )
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Sakamoto M, Matsumoto R, Shimotake A, Togawa J, Takeyama H, Kobayashi K, Leypoldt F, Wandinger KP, Kondo T, Takahashi R, Ikeda A. Diagnostic value of an algorithm for autoimmune epilepsy in a retrospective cohort. Front Neurol 2022; 13:902157. [PMID: 36188368 PMCID: PMC9518792 DOI: 10.3389/fneur.2022.902157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/19/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose This study aims to propose a diagnostic algorithm for autoimmune epilepsy in a retrospective cohort and investigate its clinical utility. Methods We reviewed 60 patients with focal epilepsy with a suspected autoimmune etiology according to board-certified neurologists and epileptologists. To assess the involvement of the autoimmune etiology, we used the patients' sera or cerebrospinal fluid (CSF) samples to screen for antineuronal antibodies using rat brain immunohistochemistry. Positive samples were analyzed for known antineuronal antibodies. The algorithm applied to assess the data of all patients consisted of two steps: evaluation of clinical features suggesting autoimmune epilepsy and evaluation using laboratory and imaging findings (abnormal CSF findings, hypermetabolism on fluorodeoxyglucose-positron emission tomography, magnetic resonance imaging abnormalities, and bilateral epileptiform discharges on electroencephalography). Patients were screened during the first step and classified into five groups according to the number of abnormal laboratory findings. The significant cutoff point of the algorithm was assessed using a receiver-operating characteristic curve analysis. Results Fourteen of the 60 patients (23.3%) were seropositive for antineuronal antibodies using rat brain immunohistochemistry. Ten patients had antibodies related to autoimmune epilepsy/encephalitis. The cutoff analysis of the number of abnormal laboratory and imaging findings showed that the best cutoff point was two abnormal findings, which yielded a sensitivity of 78.6%, a specificity of 76.1%, and an area under the curve of 0.81. Conclusion The proposed algorithm could help predict the underlying autoimmune etiology of epilepsy before antineuronal antibody test results are available.
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Affiliation(s)
- Mitsuhiro Sakamoto
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Neurology, Rakuwakai Otowa Hospital, Kyoto, Japan
| | - Riki Matsumoto
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Division of Neurology, Kobe University Graduate School of Medicine, Kobe, Japan
- *Correspondence: Riki Matsumoto
| | - Akihiro Shimotake
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Jumpei Togawa
- Department of Respiratory Care and Sleep Control Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hirofumi Takeyama
- Department of Respiratory Care and Sleep Control Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Neurology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Katsuya Kobayashi
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Frank Leypoldt
- Neuroimmunology, Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Klaus-Peter Wandinger
- Neuroimmunology, Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Takayuki Kondo
- Department of Neurology, Kansai Medical University Medical Center, Moriguchi, Japan
| | - Ryosuke Takahashi
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akio Ikeda
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Akio Ikeda
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