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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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Shelly S, Dubey D, Mills JR, Klein CJ. Paraneoplastic neuropathies and peripheral nerve hyperexcitability disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:239-273. [PMID: 38494281 DOI: 10.1016/b978-0-12-823912-4.00020-7] [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
Peripheral neuropathy is a common referral for patients to the neurologic clinics. Paraneoplastic neuropathies account for a small but high morbidity and mortality subgroup. Symptoms include weakness, sensory loss, sweating irregularity, blood pressure instability, severe constipation, and neuropathic pain. Neuropathy is the first presenting symptom of malignancy among many patients. The molecular and cellular oncogenic immune targets reside within cell bodies, axons, cytoplasms, or surface membranes of neural tissues. A more favorable immune treatment outcome occurs in those where the targets reside on the cell surface. Patients with antibodies binding cell surface antigens commonly have neural hyperexcitability with pain, cramps, fasciculations, and hyperhidrotic attacks (CASPR2, LGI1, and others). The antigenic targets are also commonly expressed in the central nervous system, with presenting symptoms being myelopathy, encephalopathy, and seizures with neuropathy, often masked. Pain and autonomic components typically relate to small nerve fiber involvement (nociceptive, adrenergic, enteric, and sudomotor), sometimes without nerve fiber loss but rather hyperexcitability. The specific antibodies discovered help direct cancer investigations. Among the primary axonal paraneoplastic neuropathies, pathognomonic clinical features do not exist, and testing for multiple antibodies simultaneously provides the best sensitivity in testing (AGNA1-SOX1; amphiphysin; ANNA-1-HU; ANNA-3-DACH1; CASPR2; CRMP5; LGI1; PCA2-MAP1B, and others). Performing confirmatory antibody testing using adjunct methods improves specificity. Antibody-mediated demyelinating paraneoplastic neuropathies are limited to MAG-IgM (IgM-MGUS, Waldenström's, and myeloma), with the others associated with cytokine elevations (VEGF, IL6) caused by osteosclerotic myeloma, plasmacytoma (POEMS), and rarely angiofollicular lymphoma (Castleman's). Paraneoplastic disorders have clinical overlap with other idiopathic antibody disorders, including IgG4 demyelinating nodopathies (NF155 and Contactin-1). This review summarizes the paraneoplastic neuropathies, including those with peripheral nerve hyperexcitability.
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Affiliation(s)
- Shahar Shelly
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Neurology, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Christopher J Klein
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
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Chen LW, Guasp M, Olivé-Cirera G, Martínez-Hernandez E, Ruiz García R, Naranjo L, Saiz A, Armangue T, Dalmau J. Antibody Investigations in 2,750 Children With Suspected Autoimmune Encephalitis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200182. [PMID: 37968128 PMCID: PMC10683852 DOI: 10.1212/nxi.0000000000200182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/06/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVES To assess the frequency and types of neuronal and glial (neural) antibodies in children with suspected autoimmune encephalitis (AE). METHODS Patients younger than 18 years with suspected AE other than acute disseminated encephalomyelitis, whose serum or CSF samples were examined in our center between January 1, 2011, and April 30, 2022, were included in this study. Samples were systematically examined using brain immunohistochemistry; positive immunostaining was further investigated with cell-based assays (CBA), immunoblot, or live neuronal immunofluorescence. RESULTS Of 2,750 children, serum or CSF samples of 542 (20%) showed brain immunoreactivity, mostly (>90%) against neural cell surface antigens, and 19 had antibodies only identified by CBA. The most frequent targets were N-methyl-d-aspartate receptor (NMDAR, 76%) and myelin oligodendrocyte glycoprotein (MOG, 5%), followed by glutamic acid decarboxylase 65 (2%) and γ-aminobutyric acid A receptor (2%). Antibodies against other known cell surface or intracellular neural antigens (altogether 6% of positive cases) and unknown antigens (9%) were very infrequent. DISCUSSION The repertoire of antibodies in children with AE is different from that of the adults. Except for NMDAR and MOG antibodies, many of the antibodies included in diagnostic panels are rarely positive and their up-front testing in children seems unneeded.
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Affiliation(s)
- Li-Wen Chen
- From the Neuroimmunology Program (L.-W.C., M.G., G.O.-C., E.M.-H., R.R.G., A.S., T.A., J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Department of Pediatrics (L.-W.C.), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Neurology Department (M.G., E.M.-H., A.S., J.D.), University of Barcelona; Centro de Investigación Biomédica en Red (M.G., J.D.), Enfermedades Raras (CIBERER) Madrid, Spain; Pediatric Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell; Immunology Department (R.R.G., L.N.), Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu Children's Hospital, 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
| | - Mar Guasp
- From the Neuroimmunology Program (L.-W.C., M.G., G.O.-C., E.M.-H., R.R.G., A.S., T.A., J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Department of Pediatrics (L.-W.C.), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Neurology Department (M.G., E.M.-H., A.S., J.D.), University of Barcelona; Centro de Investigación Biomédica en Red (M.G., J.D.), Enfermedades Raras (CIBERER) Madrid, Spain; Pediatric Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell; Immunology Department (R.R.G., L.N.), Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu Children's Hospital, 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
| | - Gemma Olivé-Cirera
- From the Neuroimmunology Program (L.-W.C., M.G., G.O.-C., E.M.-H., R.R.G., A.S., T.A., J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Department of Pediatrics (L.-W.C.), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Neurology Department (M.G., E.M.-H., A.S., J.D.), University of Barcelona; Centro de Investigación Biomédica en Red (M.G., J.D.), Enfermedades Raras (CIBERER) Madrid, Spain; Pediatric Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell; Immunology Department (R.R.G., L.N.), Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu Children's Hospital, 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
| | - Eugenia Martínez-Hernandez
- From the Neuroimmunology Program (L.-W.C., M.G., G.O.-C., E.M.-H., R.R.G., A.S., T.A., J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Department of Pediatrics (L.-W.C.), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Neurology Department (M.G., E.M.-H., A.S., J.D.), University of Barcelona; Centro de Investigación Biomédica en Red (M.G., J.D.), Enfermedades Raras (CIBERER) Madrid, Spain; Pediatric Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell; Immunology Department (R.R.G., L.N.), Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu Children's Hospital, 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
| | - Raquel Ruiz García
- From the Neuroimmunology Program (L.-W.C., M.G., G.O.-C., E.M.-H., R.R.G., A.S., T.A., J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Department of Pediatrics (L.-W.C.), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Neurology Department (M.G., E.M.-H., A.S., J.D.), University of Barcelona; Centro de Investigación Biomédica en Red (M.G., J.D.), Enfermedades Raras (CIBERER) Madrid, Spain; Pediatric Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell; Immunology Department (R.R.G., L.N.), Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu Children's Hospital, 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
| | - Laura Naranjo
- From the Neuroimmunology Program (L.-W.C., M.G., G.O.-C., E.M.-H., R.R.G., A.S., T.A., J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Department of Pediatrics (L.-W.C.), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Neurology Department (M.G., E.M.-H., A.S., J.D.), University of Barcelona; Centro de Investigación Biomédica en Red (M.G., J.D.), Enfermedades Raras (CIBERER) Madrid, Spain; Pediatric Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell; Immunology Department (R.R.G., L.N.), Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu Children's Hospital, 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
| | - Albert Saiz
- From the Neuroimmunology Program (L.-W.C., M.G., G.O.-C., E.M.-H., R.R.G., A.S., T.A., J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Department of Pediatrics (L.-W.C.), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Neurology Department (M.G., E.M.-H., A.S., J.D.), University of Barcelona; Centro de Investigación Biomédica en Red (M.G., J.D.), Enfermedades Raras (CIBERER) Madrid, Spain; Pediatric Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell; Immunology Department (R.R.G., L.N.), Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu Children's Hospital, 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
| | - Thaís Armangue
- From the Neuroimmunology Program (L.-W.C., M.G., G.O.-C., E.M.-H., R.R.G., A.S., T.A., J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Department of Pediatrics (L.-W.C.), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Neurology Department (M.G., E.M.-H., A.S., J.D.), University of Barcelona; Centro de Investigación Biomédica en Red (M.G., J.D.), Enfermedades Raras (CIBERER) Madrid, Spain; Pediatric Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell; Immunology Department (R.R.G., L.N.), Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu Children's Hospital, 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 Neuroimmunology Program (L.-W.C., M.G., G.O.-C., E.M.-H., R.R.G., A.S., T.A., J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Department of Pediatrics (L.-W.C.), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Neurology Department (M.G., E.M.-H., A.S., J.D.), University of Barcelona; Centro de Investigación Biomédica en Red (M.G., J.D.), Enfermedades Raras (CIBERER) Madrid, Spain; Pediatric Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell; Immunology Department (R.R.G., L.N.), Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu Children's Hospital, 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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Lee JS, Kim S, Ha J, Youn J, Cho JW, Ahn JH. A Case of Post-Malaria Neurological Syndrome Presenting With Cortical Tremor. J Mov Disord 2024; 17:115-117. [PMID: 37914527 PMCID: PMC10846977 DOI: 10.14802/jmd.23164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/17/2023] [Accepted: 11/01/2023] [Indexed: 11/03/2023] Open
Affiliation(s)
- Jun Seok Lee
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Neuroscience Center, Samsung Medical Center, Seoul, Korea
| | - Seongmi Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Neuroscience Center, Samsung Medical Center, Seoul, Korea
| | - Jongmok Ha
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Neuroscience Center, Samsung Medical Center, Seoul, Korea
| | - Jinyoung Youn
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Neuroscience Center, Samsung Medical Center, Seoul, Korea
| | - Jin Whan Cho
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Neuroscience Center, Samsung Medical Center, Seoul, Korea
| | - Jong Hyeon Ahn
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Neuroscience Center, Samsung Medical Center, Seoul, Korea
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Sun T, Zhao D, Zhang G, Huang Y, Guo J, Jiang W, Jia R, Maimaiti M, Liu J, Bu N, Li Z, Yan Y, Zhang X, Sun C, Zhao C, Jia X, Mao B, Tian H, Liu Y, Chen Z, Fan Z, Guo X, Lu J, Ren K, Li H, Guo J. Late-Onset Anti-GABA B Receptor Encephalitis: Clinical Characteristics and Outcomes Differing From Early-Onset Patients. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:10/4/e200131. [PMID: 37230544 DOI: 10.1212/nxi.0000000000200131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/13/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Existing evidence indicates anti-GABAB receptor encephalitis (GABABR-E) seems to occur more commonly later in life, yet the age-associated differences in clinical features and outcomes are not well determined. This study aims to explore the demographic, clinical characteristics, and prognostic differences between late-onset and early-onset GABABR-E and identify predictors of favorable long-term outcomes. METHODS This is an observational retrospective study conducted in 19 centers from China. Data from 62 patients with GABABR-E were compared between late-onset (aged 50 years or older) and early-onset (younger than 50 years) groups and between groups with favorable outcomes (modified Rankin scale (mRS) ≤ 2) and poor outcomes (mRS >2). Logistic regression analyses were applied to identify factors affecting long-term outcomes. RESULTS Forty-one (66.1%) patients experienced late-onset GABABR-E. A greater proportion of males, a higher mRS score at onset, higher frequencies of ICU admission and tumors, and a higher risk of death were demonstrated in the late-onset group than in the early-onset group. Compared with poor outcomes, patients with favorable outcomes had a younger onset age, a lower mRS score at onset, lower frequencies of ICU admission and tumors, and a greater proportion with immunotherapy maintenance for at least 6 months. On multivariate regression analysis, age at onset (OR, 0.849, 95% CI 0.739-0.974, p = 0.020) and the presence of underlying tumors (OR, 0.095, 95% CI 0.015-0.613, p = 0.013) were associated with poorer long-term outcomes, whereas immunotherapy maintenance for at least 6 months was associated with favorable outcomes (OR, 10.958, 95% CI 1.469-81.742, p = 0.020). DISCUSSION These results demonstrate the importance of risk stratification of GABABR-E according to age at onset. More attention should be paid to older patients especially with underlying tumors, and immunotherapy maintenance for at least 6 months is recommended to achieve a favorable outcome.
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Affiliation(s)
- Tangna Sun
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Daidi Zhao
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Gejuan Zhang
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yue Huang
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jia Guo
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China.
| | - Wen Jiang
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Rui Jia
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Maynur Maimaiti
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jianguo Liu
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ning Bu
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Zunbo Li
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yaping Yan
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaoyan Zhang
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Chenjing Sun
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Cong Zhao
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaotao Jia
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Baoyi Mao
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Hui Tian
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Liu
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Zheng Chen
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Zilian Fan
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaoyan Guo
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China.
| | - Jiarui Lu
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Kaixi Ren
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Hongzeng Li
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jun Guo
- From the Department of Neurology (T.S., D.Z., J. Lu, K.R., H.L., Jun Guo), Tangdu Hospital, Air Force Medical University; Department of Neurology (G.Z.), Xi'an No.3 Hospital; Department of Neurology (Y.H.), Henan Provincial People's Hospital, Zhengzhou; Department of Neurology (Jia Guo), Lanzhou University Second Hospital; Department of Neurology (W.J.), Xijing Hospital, Air Force Medical University; Department of Neurology (R.J.), The First Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (M.M.), People's Hospital of Xinjiang Uygur Autonomous Region; Department of Neurology (J. Liu, C.S.), The Sixth Medical Center of PLA General Hospital, Beijing; Department of Neurology (N.B.), The Second Affiliated Hospital of Xi'an Jiaotong University; Department of Neurology (Z.L.), Xi'an Gaoxin Hospital; College of Life Sciences (Y.Y.), Shaanxi Normal University, Xi'an; Department of Neurology (X.Z.), No. 940 Hospital of the PLA Joint Logistics Support Force, Lanzhou; Department of Neurology (C.Z.), Air Force Medical Center of PLA, Beijing; Department of Neurology (X.J.), Xi'an Central Hospital; Department of Neurology (B.M.), Yuncheng Central Hospital; Department of Neurology (H.T.), Xi'an North Hospital; Department of Neurology (Y.L.), Weinan Central Hospital; Department of Neurology (Z.C.), Hanzhong Central Hospital; Department of Neurology (Z.F.), The First People's Hospital of Guangyuan; and Department of Neurology (X.G.), The Affiliated Hospital of Southwest Medical University, Luzhou, China.
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6
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Grubb S, Joshi A, Hubbell L. Paraneoplastic-Like Syndrome in a Breast Cancer Patient With a Negative Paraneoplastic Panel: A Case Report. Cureus 2023; 15:e40030. [PMID: 37425573 PMCID: PMC10323977 DOI: 10.7759/cureus.40030] [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: 04/24/2023] [Accepted: 06/06/2023] [Indexed: 07/11/2023] Open
Abstract
Breast cancer is a leading cause of cancer death in the United States, with an increasing incidence in recent years. Paraneoplastic syndromes are uncommon but increasingly recognized complications of many types of cancer, including breast cancer. Here, we describe a case of a patient presenting with confounding symptoms, who was diagnosed with breast cancer and believed to have a paraneoplastic syndrome despite a negative paraneoplastic panel. This case underscores the need for more standardized diagnostic modalities and prompt recognition and treatment of these rare but serious syndromes.
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Affiliation(s)
- Sydney Grubb
- Emergency Medicine, Alabama College of Osteopathic Medicine, Dothan, USA
| | - Aarti Joshi
- Obstetrics and Gynecology, Alabama College of Osteopathic Medicine, Dothan, USA
| | - Linette Hubbell
- Internal Medicine, Tallahassee Memorial Healthcare, Tallahassee, USA
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7
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Marsili L, Marcucci S, LaPorta J, Chirra M, Espay AJ, Colosimo C. Paraneoplastic Neurological Syndromes of the Central Nervous System: Pathophysiology, Diagnosis, and Treatment. Biomedicines 2023; 11:biomedicines11051406. [PMID: 37239077 DOI: 10.3390/biomedicines11051406] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/04/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023] Open
Abstract
Paraneoplastic neurological syndromes (PNS) include any symptomatic and non-metastatic neurological manifestations associated with a neoplasm. PNS associated with antibodies against intracellular antigens, known as "high-risk" antibodies, show frequent association with underlying cancer. PNS associated with antibodies against neural surface antigens, known as "intermediate- or low-risk" antibodies, are less frequently associated with cancer. In this narrative review, we will focus on PNS of the central nervous system (CNS). Clinicians should have a high index of suspicion with acute/subacute encephalopathies to achieve a prompt diagnosis and treatment. PNS of the CNS exhibit a range of overlapping "high-risk" clinical syndromes, including but not limited to latent and overt rapidly progressive cerebellar syndrome, opsoclonus-myoclonus-ataxia syndrome, paraneoplastic (and limbic) encephalitis/encephalomyelitis, and stiff-person spectrum disorders. Some of these phenotypes may also arise from recent anti-cancer treatments, namely immune-checkpoint inhibitors and CAR T-cell therapies, as a consequence of boosting of the immune system against cancer cells. Here, we highlight the clinical features of PNS of the CNS, their associated tumors and antibodies, and the diagnostic and therapeutic strategies. The potential and the advance of this review consists on a broad description on how the field of PNS of the CNS is constantly expanding with newly discovered antibodies and syndromes. Standardized diagnostic criteria and disease biomarkers are fundamental to quickly recognize PNS to allow prompt treatment initiation, thus improving the long-term outcome of these conditions.
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Affiliation(s)
- Luca Marsili
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Samuel Marcucci
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Joseph LaPorta
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Martina Chirra
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Alberto J Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Carlo Colosimo
- Department of Neurology, Santa Maria University Hospital, 05100 Terni, Italy
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8
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Graus F, Dalmau J. MOGAD comes of age with new criteria. Lancet Neurol 2023; 22:193-194. [PMID: 36706772 DOI: 10.1016/s1474-4422(22)00520-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/12/2022] [Indexed: 01/26/2023]
Affiliation(s)
- Francesc Graus
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - 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 Institute for Research and Advanced Studies, Barcelona, Spain.
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9
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Stamm B, DiBiase R, Harris GR, Kaprielian H, Brahmbhatt N, Wu AD, Baker J, Liotta EM. Clinical Reasoning: A Young Adult Man With Cognitive Changes, Gait Difficulty, and Renal Insufficiency. Neurology 2023; 100:206-212. [PMID: 36323524 DOI: 10.1212/wnl.0000000000201500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 09/16/2022] [Indexed: 01/22/2023] Open
Abstract
A 22-year-old right-handed man with recently diagnosed gout and renal insufficiency presented with 3 months of progressive gait instability and cognitive changes. He initially presented to an outside institution and underwent a broad workup, but an etiology for his symptoms was not found. On subsequent presentation to our institution, his examination revealed multidomain cognitive dysfunction, spasticity, hyperreflexia, and clonus. A broad workup was again pursued and was notable for an MRI of the brain, revealing cortical atrophy advanced for his age, bland CSF, and a weakly positive serum acetylcholine receptor ganglionic neuronal antibody of unclear significance. The history of gout and inadequately explained renal insufficiency led to a workup for inborn errors of metabolism, including urine amino acid analysis, which revealed a homocysteine peak. This finding prompted further evaluation, revealing markedly elevated serum homocysteine and methylmalonic acid and low methionine. He ultimately developed superficial venous thromboses, a segmental pulmonary embolism, and clinical and electrographic seizures. He was initiated on appropriate treatment, and his symptoms markedly improved. The case serves as a reminder to include late-onset inborn errors of metabolism in the differential for young adult patients with onset of neurologic, psychiatric, renal, and thromboembolic symptoms.
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Affiliation(s)
- Brian Stamm
- From the Ken & Ruth Davee Department of Neurology (B.S., R.D., G.R.H., H.K., N.B., A.D.W., E.M.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Pediatrics (J.B.), Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Rebecca DiBiase
- From the Ken & Ruth Davee Department of Neurology (B.S., R.D., G.R.H., H.K., N.B., A.D.W., E.M.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Pediatrics (J.B.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Glenn Ryan Harris
- From the Ken & Ruth Davee Department of Neurology (B.S., R.D., G.R.H., H.K., N.B., A.D.W., E.M.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Pediatrics (J.B.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Hagop Kaprielian
- From the Ken & Ruth Davee Department of Neurology (B.S., R.D., G.R.H., H.K., N.B., A.D.W., E.M.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Pediatrics (J.B.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Nupur Brahmbhatt
- From the Ken & Ruth Davee Department of Neurology (B.S., R.D., G.R.H., H.K., N.B., A.D.W., E.M.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Pediatrics (J.B.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Allan D Wu
- From the Ken & Ruth Davee Department of Neurology (B.S., R.D., G.R.H., H.K., N.B., A.D.W., E.M.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Pediatrics (J.B.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Joshua Baker
- From the Ken & Ruth Davee Department of Neurology (B.S., R.D., G.R.H., H.K., N.B., A.D.W., E.M.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Pediatrics (J.B.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Eric M Liotta
- From the Ken & Ruth Davee Department of Neurology (B.S., R.D., G.R.H., H.K., N.B., A.D.W., E.M.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Pediatrics (J.B.), Northwestern University Feinberg School of Medicine, Chicago, IL
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10
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Lazar EB, Porter AL, Prusinski CC, Dunham SR, Lopez-Chiriboga AS, Hammami MB, Dubey D, Day GS. Improving Early Recognition of Creutzfeldt-Jakob Disease Mimics. Neurol Clin Pract 2022; 12:406-413. [PMID: 36540139 PMCID: PMC9757107 DOI: 10.1212/cpj.0000000000200097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 09/15/2022] [Indexed: 11/15/2022]
Abstract
Background and Objectives Diagnostic criteria emphasize the use of sensitive and disease-specific tests to distinguish patients with rapidly progressive dementia (RPD) due to Creutzfeldt-Jakob disease (CJD) vs other causes (mimics). These tests are often performed in specialized centers, with results taking days to return. There is a need to leverage clinical features and rapidly reporting tests to distinguish patients with RPD due to CJD from those due to other causes (mimics) early in the symptomatic course. Methods In this case-control series, clinical features and the results of diagnostic tests were compared between mimics (n = 11) and patients with definite (pathologically proven, n = 33) or probable CJD (with positive real-time quaking-induced conversion [RT-QuIC], n = 60). Patients were assessed at Mayo Clinic Enterprise or Washington University from January 2014 to February 2021. Mimics were enrolled in prospective studies of RPD; mimics met the diagnostic criteria for probable CJD but did not have CJD. Results Mimics were ultimately diagnosed with autoimmune encephalitis (n = 6), neurosarcoidosis, frontotemporal lobar degeneration with motor neuron disease, dural arteriovenous fistula, cerebral amyloid angiopathy with related inflammation, and systemic lupus erythematous with polypharmacy. Age at symptom onset, sex, presenting features, and MRI and EEG findings were similar in CJD cases and mimics. Focal motor abnormalities (49/93, 11/11), CSF leukocytosis (4/92, 5/11), and protein >45 mg/dL (39/92, 10/11) were more common in mimics (p < 0.01). Positive RT-QuIC (77/80, 0/9) and total tau >1149 pg/mL (74/82, 2/10) were more common in CJD cases (all p < 0.01). Protein 14-3-3 was elevated in 64/89 CJD cases and 4/10 mimics (p = 0.067). Neural-specific autoantibodies associated with autoimmune encephalitis were detected within the serum (5/9) and CSF (5/10) of mimics; nonspecific antibodies were detected within the serum of 9/71 CJD cases. Discussion Immune-mediated, vascular, granulomatous, and neurodegenerative diseases may mimic CJD at presentation and should be considered in patients with early motor dysfunction and abnormal CSF studies. The detection of atypical features-particularly elevations in CSF leukocytes and protein-should prompt evaluation for mimics and consideration of empiric treatment while waiting for the results of more specific tests.
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Affiliation(s)
- Evelyn B Lazar
- Department of Neurology (E.B.L., A.L.P., C.C.P., A.S.L.-C., G.S.D.), Mayo Clinic in Florida, Jacksonville, FL; Department of Neurology (S.R.D.), Washington University School of Medicine, Saint Louis, MO; Department of Laboratory Medicine and Pathology (M.B.H., D.D.), Mayo Clinic, Rochester, MN
| | - Amanda L Porter
- Department of Neurology (E.B.L., A.L.P., C.C.P., A.S.L.-C., G.S.D.), Mayo Clinic in Florida, Jacksonville, FL; Department of Neurology (S.R.D.), Washington University School of Medicine, Saint Louis, MO; Department of Laboratory Medicine and Pathology (M.B.H., D.D.), Mayo Clinic, Rochester, MN
| | - Christian C Prusinski
- Department of Neurology (E.B.L., A.L.P., C.C.P., A.S.L.-C., G.S.D.), Mayo Clinic in Florida, Jacksonville, FL; Department of Neurology (S.R.D.), Washington University School of Medicine, Saint Louis, MO; Department of Laboratory Medicine and Pathology (M.B.H., D.D.), Mayo Clinic, Rochester, MN
| | - S Richard Dunham
- Department of Neurology (E.B.L., A.L.P., C.C.P., A.S.L.-C., G.S.D.), Mayo Clinic in Florida, Jacksonville, FL; Department of Neurology (S.R.D.), Washington University School of Medicine, Saint Louis, MO; Department of Laboratory Medicine and Pathology (M.B.H., D.D.), Mayo Clinic, Rochester, MN
| | - A Sebastian Lopez-Chiriboga
- Department of Neurology (E.B.L., A.L.P., C.C.P., A.S.L.-C., G.S.D.), Mayo Clinic in Florida, Jacksonville, FL; Department of Neurology (S.R.D.), Washington University School of Medicine, Saint Louis, MO; Department of Laboratory Medicine and Pathology (M.B.H., D.D.), Mayo Clinic, Rochester, MN
| | - M Bakri Hammami
- Department of Neurology (E.B.L., A.L.P., C.C.P., A.S.L.-C., G.S.D.), Mayo Clinic in Florida, Jacksonville, FL; Department of Neurology (S.R.D.), Washington University School of Medicine, Saint Louis, MO; Department of Laboratory Medicine and Pathology (M.B.H., D.D.), Mayo Clinic, Rochester, MN
| | - Divyanshu Dubey
- Department of Neurology (E.B.L., A.L.P., C.C.P., A.S.L.-C., G.S.D.), Mayo Clinic in Florida, Jacksonville, FL; Department of Neurology (S.R.D.), Washington University School of Medicine, Saint Louis, MO; Department of Laboratory Medicine and Pathology (M.B.H., D.D.), Mayo Clinic, Rochester, MN
| | - Gregory S Day
- Department of Neurology (E.B.L., A.L.P., C.C.P., A.S.L.-C., G.S.D.), Mayo Clinic in Florida, Jacksonville, FL; Department of Neurology (S.R.D.), Washington University School of Medicine, Saint Louis, MO; Department of Laboratory Medicine and Pathology (M.B.H., D.D.), Mayo Clinic, Rochester, MN
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11
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Lancaster E. Autoantibody Encephalitis: Presentation, Diagnosis, and Management. J Clin Neurol 2022; 18:373-390. [PMID: 35796263 PMCID: PMC9262450 DOI: 10.3988/jcn.2022.18.4.373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/22/2022] [Accepted: 04/22/2022] [Indexed: 02/07/2023] Open
Abstract
Autoantibody encephalitis causes distinct clinical syndromes involving alterations in mentation, abnormal movements, seizures, psychiatric symptoms, sleep disruption, spasms, and neuromyotonia. The diagnoses can be confirmed by specific antibody tests, although some antibodies may be better detected in spinal fluid and others in serum. Each disorder conveys a risk of certain tumors which may inform diagnosis and be important for treatment. Autoantibodies to receptors and other neuronal membrane proteins are generally thought to be pathogenic and result in loss of function of the targets, so understanding the pharmacology of the receptors may inform our understanding of the syndromes. Patients may be profoundly ill but the syndromes usually respond to immune therapy, although there are differences in the types of immune therapy that are thought to be most effective for the various disorders.
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Affiliation(s)
- Eric Lancaster
- Department of Neurology, The University of Pennsylvania, Philadelphia, PA, USA.
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12
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Avasarala J, Das S, Mathias S, Qaiser S. Antibody panels for autoimmune and paraneoplastic disorders: A pandora's box for clinicians. Mult Scler Relat Disord 2022; 64:103947. [DOI: 10.1016/j.msard.2022.103947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 06/05/2022] [Indexed: 10/18/2022]
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13
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Abstract
PURPOSE OF REVIEW This article presents a practical approach to the evaluation of patients with rapidly progressive dementia. RECENT FINDINGS The approach presented in this article builds upon the standard dementia evaluation, leveraging widely available tests and emergent specific markers of disease to narrow the differential diagnosis and determine the cause(s) of rapid progressive decline. The discovery of treatment-responsive causes of rapidly progressive dementia underscores the need to determine the cause early in the symptomatic course when treatments are most likely to halt or reverse cognitive decline. SUMMARY A pragmatic and organized approach to patients with rapidly progressive dementia is essential to mitigate diagnostic and therapeutic challenges and optimize patient outcomes.
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14
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Preston DC, Logigian EL. Positive paraneoplastic panels: Probabilities, perils, and pearls. Muscle Nerve 2022; 65:489-491. [PMID: 35211996 DOI: 10.1002/mus.27529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/15/2022] [Accepted: 02/19/2022] [Indexed: 11/11/2022]
Affiliation(s)
- David C Preston
- Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Eric L Logigian
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
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15
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Poore B, Hamilton R, Kelliher MT, Mahmood S, Mindiola-Romero AE, Richards R, Motanagh S, Cervinski MA, Nerenz RD. Retrospective Evaluation of the Antibody Prevalence in Epilepsy and Encephalopathy (APE2) Score. J Appl Lab Med 2022; 7:36-45. [PMID: 34996088 DOI: 10.1093/jalm/jfab106] [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: 05/18/2021] [Accepted: 08/16/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND Autoimmune encephalitis (AE) is a rare collection of disorders that present with a diverse and often nebulous set of clinical symptoms. Indiscriminate use of multi-antibody panels decreases their overall utility and predictive value. Application of a standardized scoring system may help reduce the number of specimens that generate misleading or uninformative results. METHODS The results of autoimmune encephalopathy, epilepsy, or dementia autoantibody panels performed on serum (n = 251) or cerebrospinal fluid (CSF) (n = 235) specimens from October 9th, 2016 to October 11th, 2019 were collected. Retrospective chart review was performed to calculate the Antibody Prevalence in Epilepsy and Encephalopathy (APE2) score for patients with an antibody above the assay-specific reference interval and to classify results as true or false positive. RESULTS Of the 486 specimens, 60 (12.3%) generated positive results for any AE antibody (6 CSF and 54 serum). After removing 2 duplicate specimens collected from a single patient, 10 of the remaining 58 were determined to be true positives and 8 contained neural-specific antibodies. Application of the APE2 score revealed that 89% of all true positives and 86% of specimens with neural-specific antibodies had a score ≥4. In contrast, 76% of false positives, 74% of clinically nonspecific antibodies, and 85% of the negative specimens had an APE2 score <4. CONCLUSION The APE2 score can improve the diagnostic utility of autoimmune encephalopathy evaluation panels.
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Affiliation(s)
- Brad Poore
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Robert Hamilton
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Michael T Kelliher
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Sundis Mahmood
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Andres E Mindiola-Romero
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Ryland Richards
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Samaneh Motanagh
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Mark A Cervinski
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Robert D Nerenz
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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16
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Novak P, Mukerji SS, Alabsi HS, Systrom D, Marciano SP, Felsenstein D, Mullally WJ, Pilgrim DM. Multisystem Involvement in Post-acute Sequelae of COVID-19 (PASC). Ann Neurol 2021; 91:367-379. [PMID: 34952975 PMCID: PMC9011495 DOI: 10.1002/ana.26286] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/15/2021] [Accepted: 12/20/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To describe cerebrovascular, neuropathic and autonomic features of post-acute sequelae of COVID-19 (PASC). METHODS This retrospective study evaluated consecutive patients with chronic fatigue, brain fog and orthostatic intolerance consistent with PASC. Controls included postural tachycardia syndrome patients (POTS) and healthy participants. Analyzed data included surveys and autonomic (Valsalva maneuver, deep breathing, sudomotor and tilt tests), cerebrovascular (cerebral blood flow velocity (CBFv) monitoring in middle cerebral artery), respiratory (capnography monitoring) and neuropathic (skin biopsies for assessment of small fiber neuropathy) testing and inflammatory/autoimmune markers. RESULTS Nine PASC patients were evaluated 0.7±0.3 years after a mild COVID-19 infection, treated as home observations. Autonomic, pain, brain fog, fatigue and dyspnea surveys were abnormal in PASC and POTS (n=10), compared to controls (n=15). Tilt table test reproduced the majority of PASC symptoms. Orthostatic CBFv declined in PASC (-20.0±13.4%) and POTS (-20.3±15.1%), compared to controls (-3.0±7.5%,p=0.001) and was independent of end-tidal carbon dioxide in PASC, but caused by hyperventilation in POTS. Reduced orthostatic CBFv in PASC included both subjects without (n=6) and with (n=3) orthostatic tachycardia. Dysautonomia was frequent (100% in both PASC and POTS) but was milder in PASC (p=0.013). PASC and POTS cohorts diverged in frequency of small fiber neuropathy (89% vs. 60%) but not in inflammatory markers (67% vs. 70%). Supine and orthostatic hypocapnia was observed in PASC. INTERPRETATION PASC following mild COVID-19 infection is associated with multisystem involvement including: 1) cerebrovascular dysregulation with persistent cerebral arteriolar vasoconstriction; 2) small fiber neuropathy and related dysautonomia; 3) respiratory dysregulation; 4) chronic inflammation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Peter Novak
- Department of Neurology, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Shibani S Mukerji
- Department of Neurology, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Haitham S Alabsi
- Department of Neurology, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - David Systrom
- Department of Medicine, Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Sadie P Marciano
- Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Donna Felsenstein
- Department of Infectious Disease and Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - William J Mullally
- Department of Neurology, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - David M Pilgrim
- Department of Neurology, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
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17
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Data on the utilization of paraneoplastic syndrome autoantibody testing at an academic medical center. Data Brief 2021; 39:107578. [PMID: 34877371 PMCID: PMC8627986 DOI: 10.1016/j.dib.2021.107578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/28/2021] [Accepted: 11/10/2021] [Indexed: 12/20/2022] Open
Abstract
Paraneoplastic syndromes are rare conditions associated with characteristic autoantibodies produced by malignancy, although similar autoantibodies and clinical presentations may occur in the absence of any neoplasm. Testing for paraneoplastic syndromes often involves panels of autoantibody assays. While autoantibody testing may reveal or confirm actionable clinical diagnoses, inappropriate utilization of testing may be low yield and further lead to false positives that may confuse the clinical picture. There is thus opportunity to improve patient care by analyzing patterns of paraneoplastic autoantibody test utilization. The data in this article provides results from detailed retrospective review of patients tested by 7 autoantibody tests or test panels offered by two large reference laboratories in the United States. The data include 1,446 tests performed on 1,338 unique patients at an academic medical center. For all results, detailed chart review revealed main category of presenting symptoms, patient location at time of testing (either inpatient or outpatient), sex, age, whether cancer was present at the time of testing or later detected, and the specific results of the testing. The data are summarized by category of testing and specific autoantibodies.
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18
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Frykman H, Kumar P. An Opinion on the Clinical Laboratory Testing following the New 2021 PNS-Care Diagnostic Criteria. J Appl Lab Med 2021; 7:367-372. [PMID: 34875062 DOI: 10.1093/jalm/jfab154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 10/28/2021] [Indexed: 11/14/2022]
Affiliation(s)
- Hans Frykman
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada.,BC Neuroimmunology Laboratory, Vancouver, BC, Canada
| | - Pankaj Kumar
- BC Neuroimmunology Laboratory, Vancouver, BC, Canada
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19
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Graus F. Towards a better recognition of paraneoplastic brainstem encephalitis. J Neurol Neurosurg Psychiatry 2021; 92:1141. [PMID: 34408007 DOI: 10.1136/jnnp-2021-327386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 08/01/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Francesc Graus
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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20
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Autoimmune autonomic ganglionopathy: Ganglionic acetylcholine receptor autoantibodies. Autoimmun Rev 2021; 21:102988. [PMID: 34728435 DOI: 10.1016/j.autrev.2021.102988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/28/2021] [Indexed: 11/24/2022]
Abstract
Autoimmune Autonomic Ganglionopathy (AAG) is a rare immune-mediated disease of the autonomic nervous system. The incidence of AAG is unknown and diagnosis is often difficult due to the multicompartmental nature of the autonomic nervous system - sympathetic, parasympathetic and enteric components - with variable severity and number of components affected. Diagnostic confidence is increased when ganglionic acetylcholine receptor (gnACHR) autoantibodies are detected. Three gnACHR autoantibody diagnostic assays have been described (two binding assays, one receptor immunomodulation assay), but cross-validation between assays is limited. The prevalence of gnACHR autoantibodies in AAG is not known, with application of different clinical and laboratory criteria in the few studies of AAG cohorts and large retrospective laboratory studies of positive gnACHR autoantibodies lacking adequate clinical characterisation. Furthermore, the rate of unexpected gnACHR autoantibody positivity in conditions without overt autonomic dysfunction (false positive results) adds to the complexity of their interpretation. We review the pathophysiology of gnACHR autoantibodies and assays for their detection, with immunomodulation and high titer radioimmunoprecipitation results likely offering better AAG disease identification.
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21
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Lozier BK, Haven TR, Tebo AE, Peterson LK. Performance evaluation of a radioimmunoprecipitation assay for the detection of N-type voltage-gated calcium channel antibodies. J Immunol Methods 2021; 496:113102. [PMID: 34298066 DOI: 10.1016/j.jim.2021.113102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 07/12/2021] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND In this study, we assessed the performance characteristics of a laboratory-developed radioimmunoassay (RIA) to detect N-type voltage-gated calcium channel (N-VGCC) antibodies found in several autoimmune neurologic diseases. METHODS Four hundred and forty-five (n = 445) sera were evaluated, including 156 sera (50 positive and 106 negative for N-VGCC antibodies) previously tested at Mayo Clinic Laboratories (MCL) and 289 controls (n = 187 disease and n = 102 healthy). Specimens were analyzed with the RIA using N-VGCC labeled with 125I-ω-conotoxin GVIA. The RIA was compared to the predicate MCL assay using a tiered positive predictive value (PPV) approach. Other performance characteristics evaluated included specificity, precision, interference, and stability. RESULTS Qualitative inter-laboratory agreement based on tiered PPVs was 100% for results >1.00 nmol/L (71% PPV), 48% for results of 0.10-0.99 nmol/L (24% PPV) and 22% for results of 0.04-0.10 nmol/L (19% PPV). Negative results showed 90% agreement (n = 106). Specificity in controls positive for other neural autoantibodies and healthy controls were 87% and 100%, respectively. Acceptable results were observed for other performance characteristics. CONCLUSIONS Inter-laboratory correlations demonstrate equivalence between assays with some discrepancies between low positive results. Collaborative efforts aimed at assessing the clinical spectrum associated with these antibodies and consensus for harmonizing test performance are required for optimal categorization of patients.
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Affiliation(s)
- Bucky K Lozier
- ARUP Institute for Clinical and Experimental Pathology, 500 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Thomas R Haven
- ARUP Institute for Clinical and Experimental Pathology, 500 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Anne E Tebo
- ARUP Institute for Clinical and Experimental Pathology, 500 Chipeta Way, Salt Lake City, UT 84108, USA; Department of Pathology, University of Utah, 15 N Medical Dr. East Ste. 1100, Salt Lake City, UT 84112, USA
| | - Lisa K Peterson
- ARUP Institute for Clinical and Experimental Pathology, 500 Chipeta Way, Salt Lake City, UT 84108, USA; Department of Pathology, University of Utah, 15 N Medical Dr. East Ste. 1100, Salt Lake City, UT 84112, USA.
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22
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Fredrich SE, Vernino S, Blackburn KM. Antibody Testing for Neurological Autoimmune Disorders: Evaluation of Best Practices at a Tertiary Referral Center. Front Neurol 2021; 12:690415. [PMID: 34276541 PMCID: PMC8277913 DOI: 10.3389/fneur.2021.690415] [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: 04/02/2021] [Accepted: 06/04/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Autoimmune neurology is a rapidly evolving field of study, where best practices for neurological antibody testing have yet to be determined. The growing number of options for antibody panel testing can create confusion amongst ordering clinicians and lead to ordering several concurrent panels (i.e., overlapping evaluations) or repeat panel evaluations. This study determined the frequency of these evaluations for autoimmune and paraneoplastic disorders and investigated how these practices informed clinical decision making and management. Methods: This was a retrospective observational study of adult patients presenting to University of Texas Southwestern (UTSW) in 2017 with requests for antibody panels for autoimmune encephalitis and paraneoplastic disorders. Individuals with more than one panel requested were defined as either an overlapping evaluation (more than one panel requested within 14 days) or repeat evaluation (more than one panel requested 14 or more days apart). For those individuals with repeat panel testing, the proportion of panels with a change in antibody status or subsequent changes in clinical diagnosis and decision making were recorded. Results: There was a total of 813 panels sent on 626 individuals. Twenty percent (126 individuals) had more than one panel requested. Only 10% of individuals had a matched serum and CSF evaluation. Forty-seven overlapping evaluations were performed in 46 (7.3%) of the individuals studied. Fifty-four (8.6%) individuals underwent 70 repeat evaluations encompassing 79 panels (9.7% of total panels ordered). Ten repeat evaluations showed a change in antibody status, of which only two were clinically significant. There was a single case where clinical management was affected by repeat autoantibody evaluation. Conclusions: Ordering practices for suspected autoimmune encephalitis and paraneoplastic disorders are suboptimal with frequent overlapping antibody panel evaluations and non-paired serum/CSF samples at our center. Repeat autoantibody testing is a commonplace practice yet yielded novel information in only a minority of cases. These new results were, as a rule, clinically irrelevant and changed clinical decision making in <1% of cases. There is limited utility in these practice patterns. Future efforts should be directed at the development and standardization of neurological autoimmune and paraneoplastic autoantibody testing practice standards.
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Affiliation(s)
- Sarah E Fredrich
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Steven Vernino
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Kyle M Blackburn
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, United States
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23
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Urriola N, Spies JM, Blazek K, Lang B, Adelstein S. A Flow Cytometric Assay to Detect Functional Ganglionic Acetylcholine Receptor Antibodies by Immunomodulation in Autoimmune Autonomic Ganglionopathy. Front Immunol 2021; 12:705292. [PMID: 34249013 PMCID: PMC8261233 DOI: 10.3389/fimmu.2021.705292] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/07/2021] [Indexed: 12/13/2022] Open
Abstract
Autoimmune Autonomic Ganglionopathy (AAG) is an uncommon immune-mediated neurological disease that results in failure of autonomic function and is associated with autoantibodies directed against the ganglionic acetylcholine receptor (gnACHR). The antibodies are routinely detected by immunoprecipitation assays, such as radioimmunoassays (RIA), although these assays do not detect all patients with AAG and may yield false positive results. Autoantibodies against the gnACHR exert pathology by receptor modulation. Flow cytometric analysis is able to determine if this has occurred, in contrast to the assays in current use that rely on immunoprecipitation. Here, we describe the first high-throughput, non-radioactive flow cytometric assay to determine autoantibody mediated gnACHR immunomodulation. Previously identified gnACHR antibody seronegative and seropositive sera samples (RIA confirmed) were blinded and obtained from the Oxford Neuroimmunology group along with samples collected locally from patients with or without AAG. All samples were assessed for the ability to cause gnACHR immunomodulation utilizing the prototypical gnACHR expressing cell line, IMR-32. Decision limits were calculated from healthy controls, and Receiver Operating Characteristic (ROC) curves were constructed after unblinding all samples. One hundred and ninety serum samples were analyzed; all 182 expected negative samples (from healthy controls, autonomic disorders not thought to be AAG, other neurological disorders without autonomic dysfunction and patients with Systemic Lupus Erythematosus) were negative for immunomodulation (<18%), as were the RIA negative AAG and unconfirmed AAG samples. All RIA positive samples displayed significant immunomodulation. There were no false positive or negative samples. There was perfect qualitative concordance as compared to RIA, with an Area Under ROC of 1. Detection of Immunomodulation by flow cytometry for the identification of gnACHR autoantibodies offers excellent concordance with the gnACHR antibody RIA, and overcomes many of the shortcomings of immunoprecipitation assays by directly measuring the pathological effects of these autoantibodies at the cellular level. Further work is needed to determine the correlation between the degree of immunomodulation and disease severity.
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Affiliation(s)
- Nicolás Urriola
- Department of Clinical Immunology and Allergy, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Judith M Spies
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Katrina Blazek
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Bethan Lang
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Stephen Adelstein
- Department of Clinical Immunology and Allergy, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Central Sydney Immunopathology Laboratory, NSW Health Pathology, Sydney, NSW, Australia
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24
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Shelly S, Mills JR, Dubey D, McKeon A, Zekeridou A, Pittock SJ, Harper CM, Naddaf E, Milone M, Mandrekar J, Klein CJ. Clinical Utility of Striational Antibodies in Paraneoplastic and Myasthenia Gravis Paraneoplastic Panels. Neurology 2021; 96:e2966-e2976. [PMID: 33903199 DOI: 10.1212/wnl.0000000000012050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 03/15/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To critically assess the clinical utility of striational antibodies (StrAbs) within paraneoplastic and myasthenia gravis (MG) serologic evaluations. METHODS All Mayo Clinic patients tested for StrAbs from January 1, 2012, to December 31, 2018, utilizing Mayo's Unified Data Platform (UDP) were reviewed for neurologic diagnosis and cancer. RESULTS A total of 38,502 unique paraneoplastic evaluations and 1,899 patients with MG were tested. In paraneoplastic evaluations, the StrAbs positivity rate was higher in cancer vs without cancer (5% [321/6,775] vs 4% [1,154/31,727]; p < 0.0001; odds ratio [OR] 1.35; confidence interval [CI] 1.19-1.53), but receiver operating characteristic (ROC) analysis indicated no diagnostic accuracy in cancer (area under the ROC curve [AUC] 0.505). No neurologic phenotype was significantly associated with StrAbs in the paraneoplastic group. Positivity was more common in all MG cancers compared to paraneoplastic cancers (p < 0.0001). In MG evaluations, the StrAbs positivity rate was higher in those with cancer vs without (46% [217/474] vs 26% [372/1,425]; p < 0.0001; OR 2.39, CI 1.9-2.96), with ROC analysis indicating poor diagnostic accuracy for thymic cancer (AUC 0.634, recommended cutoff = 1:60, sensitivity = 56%, specificity = 71%), with worse accuracy for extrathymic cancers (AUC 0.543). In paraneoplastic or MG evaluations, the value of antibody positivity did not improve cancer predictions. Paraneoplastic evaluated patients with positive StrAbs were more likely to obtain CT (p = 0.0001), with cancer found in 3% (12/468). CONCLUSION Despite a statistically significant association with cancer, an expansive review of performance in clinical service demonstrates that StrAbs are neither specific nor sensitive in predicting malignancy or neurologic phenotypes. CT imaging is overutilized with positive StrAbs results. Removal of StrAbs from paraneoplastic or MG evaluations will improve the diagnostic characteristics of the current MG test. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that the presence of StrAbs does not accurately identify patients with malignancy or neurologic phenotypes.
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Affiliation(s)
- Shahar Shelly
- From the Departments of Neurology (S.S., D.D., A.M., A.Z., S.J.P., C.M.H., E.N., M.M., C.J.K.), Laboratory Medicine and Pathology (S.S., J.R.M., D.D., A.M., A.Z., S.J.P., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic, Rochester MN
| | - John R Mills
- From the Departments of Neurology (S.S., D.D., A.M., A.Z., S.J.P., C.M.H., E.N., M.M., C.J.K.), Laboratory Medicine and Pathology (S.S., J.R.M., D.D., A.M., A.Z., S.J.P., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic, Rochester MN.
| | - Divyanshu Dubey
- From the Departments of Neurology (S.S., D.D., A.M., A.Z., S.J.P., C.M.H., E.N., M.M., C.J.K.), Laboratory Medicine and Pathology (S.S., J.R.M., D.D., A.M., A.Z., S.J.P., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic, Rochester MN
| | - Andrew McKeon
- From the Departments of Neurology (S.S., D.D., A.M., A.Z., S.J.P., C.M.H., E.N., M.M., C.J.K.), Laboratory Medicine and Pathology (S.S., J.R.M., D.D., A.M., A.Z., S.J.P., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic, Rochester MN
| | - Anastasia Zekeridou
- From the Departments of Neurology (S.S., D.D., A.M., A.Z., S.J.P., C.M.H., E.N., M.M., C.J.K.), Laboratory Medicine and Pathology (S.S., J.R.M., D.D., A.M., A.Z., S.J.P., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic, Rochester MN
| | - Sean J Pittock
- From the Departments of Neurology (S.S., D.D., A.M., A.Z., S.J.P., C.M.H., E.N., M.M., C.J.K.), Laboratory Medicine and Pathology (S.S., J.R.M., D.D., A.M., A.Z., S.J.P., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic, Rochester MN
| | - C Michel Harper
- From the Departments of Neurology (S.S., D.D., A.M., A.Z., S.J.P., C.M.H., E.N., M.M., C.J.K.), Laboratory Medicine and Pathology (S.S., J.R.M., D.D., A.M., A.Z., S.J.P., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic, Rochester MN
| | - Elie Naddaf
- From the Departments of Neurology (S.S., D.D., A.M., A.Z., S.J.P., C.M.H., E.N., M.M., C.J.K.), Laboratory Medicine and Pathology (S.S., J.R.M., D.D., A.M., A.Z., S.J.P., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic, Rochester MN
| | - Margherita Milone
- From the Departments of Neurology (S.S., D.D., A.M., A.Z., S.J.P., C.M.H., E.N., M.M., C.J.K.), Laboratory Medicine and Pathology (S.S., J.R.M., D.D., A.M., A.Z., S.J.P., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic, Rochester MN
| | - Jay Mandrekar
- From the Departments of Neurology (S.S., D.D., A.M., A.Z., S.J.P., C.M.H., E.N., M.M., C.J.K.), Laboratory Medicine and Pathology (S.S., J.R.M., D.D., A.M., A.Z., S.J.P., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic, Rochester MN
| | - Christopher J Klein
- From the Departments of Neurology (S.S., D.D., A.M., A.Z., S.J.P., C.M.H., E.N., M.M., C.J.K.), Laboratory Medicine and Pathology (S.S., J.R.M., D.D., A.M., A.Z., S.J.P., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic, Rochester MN.
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25
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Witek N, Afshari M, Liu Y, Ouyang B, Hall D. Inpatient vs Outpatient Evaluation of Suspected Paraneoplastic Cerebellar Degeneration. Neurol Clin Pract 2021; 11:33-42. [PMID: 33968470 DOI: 10.1212/cpj.0000000000000854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/04/2020] [Indexed: 11/15/2022]
Abstract
Objective To determine the differences in outcomes of adult patients with ataxia initially evaluated for paraneoplastic cerebellar degeneration (PCD) as inpatients or outpatients. Methods In this retrospective cohort analysis, diagnosis, workup, and functional outcomes based on the change in the modified Rankin Scale (mRS) score were compared between patients with ataxia who underwent workup for PCD initially as inpatients vs outpatients between March 2011 and June 2018 at Rush University Medical Center. Results There were 78 patients included in the analysis; 59% were women, and the average age at symptom onset was 57 ± 19.5 years. Nineteen patients (24.3%) underwent evaluation as inpatients and 59 (75.6%) as outpatients. Admitted patients were more likely to receive immunotherapy (73.7% vs 20.3%, p < 0.0001) and received it faster than outpatients (0.40 months for inpatients, interquartile range [IQR] 0.03-1 months, vs 6.6 months for outpatients, IQR 2-11.7 months; p = 0.01). A greater percentage of inpatients improved based on the mRS score compared with those who underwent evaluation as outpatients (52.63% vs 22.81%, p = 0.01). Conclusions More patients improved from baseline in the inpatient cohort. Classification of Evidence This study provides Class III evidence that for patients undergoing initial evaluation for PCD, patients undergoing inpatient evaluation have better outcomes compared with those undergoing outpatient evaluation.
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Affiliation(s)
- Natalie Witek
- Division of Movement Disorders (NW, MA, DH), Rush University Medical Center, and Biostatistical Analysis (YL, BO), Department of Neurological Sciences, Rush University Medical Center, Chicago, IL
| | - Mitra Afshari
- Division of Movement Disorders (NW, MA, DH), Rush University Medical Center, and Biostatistical Analysis (YL, BO), Department of Neurological Sciences, Rush University Medical Center, Chicago, IL
| | - Yuanqing Liu
- Division of Movement Disorders (NW, MA, DH), Rush University Medical Center, and Biostatistical Analysis (YL, BO), Department of Neurological Sciences, Rush University Medical Center, Chicago, IL
| | - Bichun Ouyang
- Division of Movement Disorders (NW, MA, DH), Rush University Medical Center, and Biostatistical Analysis (YL, BO), Department of Neurological Sciences, Rush University Medical Center, Chicago, IL
| | - Deborah Hall
- Division of Movement Disorders (NW, MA, DH), Rush University Medical Center, and Biostatistical Analysis (YL, BO), Department of Neurological Sciences, Rush University Medical Center, Chicago, IL
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26
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Abboud H, Probasco J, Irani SR, Ances B, Benavides DR, Bradshaw M, Christo PP, Dale RC, Fernandez-Fournier M, Flanagan EP, Gadoth A, George P, Grebenciucova E, Jammoul A, Lee ST, Li Y, Matiello M, Morse AM, Rae-Grant A, Rojas G, Rossman I, Schmitt S, Venkatesan A, Vernino S, Pittock SJ, Titulaer M. Autoimmune encephalitis: proposed recommendations for symptomatic and long-term management. J Neurol Neurosurg Psychiatry 2021; 92:jnnp-2020-325302. [PMID: 33649021 PMCID: PMC8292591 DOI: 10.1136/jnnp-2020-325302] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 01/30/2021] [Accepted: 01/31/2021] [Indexed: 12/12/2022]
Abstract
The objective of this paper is to evaluate available evidence for each step in autoimmune encephalitis management and provide expert opinion when evidence is lacking. The paper approaches autoimmune encephalitis as a broad category rather than focusing on individual antibody syndromes. Core authors from the Autoimmune Encephalitis Alliance Clinicians Network reviewed literature and developed the first draft. Where evidence was lacking or controversial, an electronic survey was distributed to all members to solicit individual responses. Sixty-eight members from 17 countries answered the survey. The most popular bridging therapy was oral prednisone taper chosen by 38% of responders while rituximab was the most popular maintenance therapy chosen by 46%. Most responders considered maintenance immunosuppression after a second relapse in patients with neuronal surface antibodies (70%) or seronegative autoimmune encephalitis (61%) as opposed to those with onconeuronal antibodies (29%). Most responders opted to cancer screening for 4 years in patients with neuronal surface antibodies (49%) or limbic encephalitis (46%) as opposed to non-limbic seronegative autoimmune encephalitis (36%). Detailed survey results are presented in the manuscript and a summary of the diagnostic and therapeutic recommendations is presented at the conclusion.
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Affiliation(s)
- Hesham Abboud
- Neurology, Case Western Reserve University, Cleveland, Ohio, USA
- Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Cleveland, Ohio, USA
| | - John Probasco
- Neurology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, John Radcliffe Hospital, Oxford, UK
| | - Beau Ances
- Neurology, Washington University in St Louis, St Louis, Missouri, USA
| | - David R Benavides
- Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael Bradshaw
- Neurology, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
- Neurology, Billings Clinic, Billings, Montana, USA
| | - Paulo Pereira Christo
- Neurology, Minas Gerais Federal University Risoleta Tolentino Neves Hospital, Belo Horizonte, Brazil
| | - Russell C Dale
- Neuroimmunology Group, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | | | | | - Avi Gadoth
- Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Elena Grebenciucova
- Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Soon-Tae Lee
- Neurology, Seoul National University College of Medicine, Seoul, The Republic of Korea
| | - Yuebing Li
- Neurology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marcelo Matiello
- Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne Marie Morse
- Pediatric Neurology, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | | | - Galeno Rojas
- Neurology, Sanatorio de La Trinidad Mitre, Buenos Aires, Argentina
- Favaloro Foundation, Buenos Aires, Argentina
| | - Ian Rossman
- Neuro-developmental Science Center, Akron Children's Hospital, Akron, Ohio, USA
| | | | | | | | | | - Maarten Titulaer
- Neurology, Erasmus Medical Center, Rotterdam, Zuid-Holland, Netherlands
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Amin M, Li Y, Daly TM, Marquardt RJ. Evaluating the frequency of positive paraneoplastic antibodies and associated malignancy risk. J Neurol Sci 2021; 423:117347. [PMID: 33640579 DOI: 10.1016/j.jns.2021.117347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/10/2021] [Accepted: 02/11/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the association between malignancy and frequently positive paraneoplastic antibodies. METHODS A retrospective cohort study was carried out for all patients who received paraneoplastic antibody testing in 2013-2014 at a tertiary referral center. Available medical records on included patients were reviewed through July 2020. Patients were divided into antibody positive and negative subgroups. Focused analysis was performed on the subgroup of patients who received testing via a commonly used antibody panel. RESULTS A total of 1860 patients (the full cohort) received 19,323 antibody testing via panel or individual antibody testing, and were followed-up for a mean period of 36.2 months (range 0-83 months). Altogether 229 antibodies in 196 patients were positive, and 9 (3.9%) in 7 patients were against onconeuronal antigens. The remaining 220 (96.1%) were positive for mostly antibodies against cell surface or synaptic antigens. A total of 1161 patients received Mayo Clinic paraneoplastic antibody panel tests (the panel cohort), and 14.9% (173) of these patients possessed one or more positive antibodies. For the panel cohort, no difference was found between antibody positive and negative groups with respect to the prevalence of previously existing malignancy (15.6% versus 16.6%, p = 0.745) or incidence of new malignancy (4.0% vs. 3.7%, p = 0.848) during the follow-up period. No difference was observed in the incidence of new malignancy during follow-up between the antibody positive and negative groups for the 7 most frequently positive antibodies. CONCLUSIONS The presence of frequently positive antibodies, mostly to cell surface or synaptic antigens, is not clearly associated with the development of malignancy in the subsequent three years.
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Affiliation(s)
- Moein Amin
- Neurological Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Yuebing Li
- Neurological Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Thomas M Daly
- Neurological Institute, Cleveland Clinic, Cleveland, OH, United States of America; Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Robert J Marquardt
- Neurological Institute, Cleveland Clinic, Cleveland, OH, United States of America.
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Li Y, Tymchuk S, Barry J, Muppidi S, Le S. Antibody Prevalence in Epilepsy before Surgery (APES) in drug-resistant focal epilepsy. Epilepsia 2021; 62:720-728. [PMID: 33464599 DOI: 10.1111/epi.16820] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 12/26/2020] [Accepted: 12/27/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE There is a growing recognition of immune-mediated causes in patients with focal drug-resistant epilepsy (DRE); however, they are not systematically assessed in the pre-surgical diagnostic workup. Early diagnosis and initiation of immunotherapy is associated with a favorable outcome in immune-mediated seizures. Patients with refractory focal epilepsy with neuronal antibodies (Abs) tend to have a worse surgical prognosis when compared to other etiologies. METHODS We studied the prevalence of serum Abs in patients ≥18 years of age with DRE of unknown cause before surgery. We proposed and calculated a clinical APES (Antibody Prevalence in Epilepsy before Surgery) score for each subject, which was modified based on Dubey's previously published APE2 score. RESULTS`: A total of 335 patients were screened and 86 subjects were included in final analysis. The mean age at the time of recruitment was 44.84 ± 14.86 years, with age at seizure onset 30.89 ± 19.88 years. There were no significant differences among baseline clinical features between retrospective and prospective sub-cohorts. The prevalence of at least one positive Ab was 33.72%, and central nervous system (CNS)-specific Abs was 8.14%. APES score ≥4 showed slightly better overall prediction (area under the curve [AUC]: 0.84 vs 0.74) and higher sensitivity (100% vs 71.4%), with slightly lower but similar specificity (44.3% vs 49.4%), when compared to APE2 score ≥4. For subjects who had available positron emission tomography (PET) results and all components of APES score (n = 60), the sensitivity of APES score ≥4 yielded a similar prediction potential with an AUC of 0.80. SIGNIFICANCE Our findings provide persuasive evidence that a subset of patients with focal DRE have potentially immune-mediated causes. We propose an APES score to help identify patients who may benefit from a workup for immune etiologies during the pre-surgical evaluation for focal refractory epilepsy with unknown cause.
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Affiliation(s)
- Yi Li
- Stanford Comprehensive Epilepsy Center, Stanford University, Palo Alto, CA, USA
| | - Sarah Tymchuk
- Department of Psychiatry, University of Alberta Hospital, Alberta, Canada
| | - John Barry
- Stanford Department of Psychiatry, Stanford University, Palo Alto, CA, USA
| | - Srikanth Muppidi
- Stanford Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Scheherazade Le
- Stanford Comprehensive Epilepsy Center, Stanford University, Palo Alto, CA, USA
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Galetta K, Gheihman G, Rosen A, Klein JP, Bhattacharyya S. Influence of Autoimmune Antibody Testing on the Use of Immunotherapy on an Inpatient Neurology Service. Neurohospitalist 2020; 11:214-220. [PMID: 34163547 DOI: 10.1177/1941874420977761] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective To determine the frequency of autoimmune antibody testing in an inpatient neurology setting and its influence on immunotherapy use on an inpatient neurology service. Methods A retrospective descriptive cohort study of patients admitted to the neurology inpatient service at a large tertiary academic medical center who had autoimmune and/or paraneoplastic antibody testing performed between 10/1/2017 and 10/1/2018. Characteristics of patients' initial clinical presentation, antibody testing results, test timing in relation to initiating immunotherapy, and final diagnosis using consensus criteria were extracted and analyzed. Case reports of patients with positive antibody panels are presented. Results Of 1,604 patients, 50 patients (3.1%) had an antibody panel sent. Tests resulted after an average of 17 days (range 7-27). The most common clinical presenting symptom in those with a panel sent was encephalopathy. There were 5 (10%) positive serum panels and no positive CSF panels. Only one of these 5 patients had autoimmune encephalitis and was treated with immunotherapy. Of those with negative serum and CSF panels, 15 were treated acutely with empiric immunotherapy and the remainder with supportive care. Of those treated with immunotherapy, 14/15 (93%) were treated before the panel tests resulted. Four patients who had negative panels but were empirically treated met consensus criteria for an autoimmune-mediated neurologic process. Conclusion Our study suggests that the results of antibody testing did not influence inpatient neurologists' decision to treat with immunotherapy as most treatments began prior to final results being available.
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Affiliation(s)
- Kristin Galetta
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Galina Gheihman
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Amy Rosen
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Joshua P Klein
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Shamik Bhattacharyya
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
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Sharp CN, Fletcher A, Muluhngwi P, Snyder J, Linder MW, Jortani SA. A Shared Diagnostic Stewardship Approach toward Improving Autoimmune Encephalopathy Send-out Testing Utilization. J Appl Lab Med 2020; 6:387-396. [PMID: 33674881 DOI: 10.1093/jalm/jfaa123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/24/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND For many laboratories, autoimmune encephalopathy (AE) panels are send-out tests. These tests are expensive, and ordering patterns vary greatly. There is also a lack of consensus on which panel to order and poor understanding of the clinical utility of these panels. These challenges were presented to our newly formed, multidisciplinary, diagnostic stewardship committee (DSC). Through this collaboration, we developed an algorithm for ordering AE panels; combining diagnostic criteria with practice guidelines. METHODS We analyzed test-ordering patterns in 2018 and calculated a true-positive rate based on clinical presentation and panel interpretation. An evidence-based approach was combined with input from the Department of Neurology to synthesize our algorithm. Efficacy of the algorithm (number of panels ordered, cost, and true positives) was assessed before and after implementation. RESULTS In 2018, 77 AE-related panels were ordered, costing $137 510. The true-positive rate was 10%, although ordering multiple, similar panels for the same patient was common. Before implementing the algorithm (January 1-July 31, 2019), 55 panels were ordered, costing $105 120. The total true-positive rate was 3.6%. After implementation, 23 tests were ordered in a 5-month period, totaling $50 220. The true-positive rate was 13%. CONCLUSION With the DSC-directed mandate, we developed an algorithm for ordering AE panels. Comparison of pre- and postimplementation data showed a higher true-positive rate, indicating that our algorithm was able to successfully identify the at-risk population for AE disorders. This was met with a 43% decrease in the number of tests ordered, with total cost savings of $25 000 over 5 months.
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Affiliation(s)
- Cierra N Sharp
- Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY
| | - Anita Fletcher
- Department of Neurology, University of Louisville, Louisville, KY
| | - Penn Muluhngwi
- Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY
| | - James Snyder
- Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY
| | - Mark W Linder
- Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY
| | - Saeed A Jortani
- Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY
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31
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Brier MR, Bucelli RC, Day GS. An Elderly Man with Dementia. Clin Chem 2020; 66:415-420. [PMID: 32109302 DOI: 10.1093/clinchem/hvz002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/04/2019] [Indexed: 11/12/2022]
Affiliation(s)
- Matthew R Brier
- Department of Neurology, School of Medicine, Washington University in St. Louis, Saint Louis, MO
| | - Robert C Bucelli
- Department of Neurology, School of Medicine, Washington University in St. Louis, Saint Louis, MO
| | - Gregory S Day
- Department of Neurology, School of Medicine, Washington University in St. Louis, Saint Louis, MO.,Knight Alzheimer Disease Research Center, Washington University in St. Louis, Saint Louis, MO
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32
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Jung NY, Woo KN, Cho JW, Kim HW. Anti-Yo-associated autoimmune encephalitis after colon cancer treatment. JOURNAL OF NEUROCRITICAL CARE 2020. [DOI: 10.18700/jnc.200013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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33
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Shelly S, Paul P, Bi H, Dubey D, Milone M, Sorenson EJ, Crum BA, Laughlin RS, Liewluck T, Mandrekar J, Pittock SJ, Zekeridou A, McKeon A, Harper MC, Mills JR, Klein CJ. Improving accuracy of myasthenia gravis autoantibody testing by reflex algorithm. Neurology 2020; 95:e3002-e3011. [PMID: 32938782 DOI: 10.1212/wnl.0000000000010910] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 07/22/2020] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To improve myasthenia gravis (MG) autoantibody testing. METHODS MG serologic tests with confirmatory or refuting clinical-electrodiagnostic (EDX) testing and cancer evaluations were reviewed over 4 years (2012-2015). All patients had acetylcholine receptor-binding (AChR-Bi), modulating (AChR-Mo), and striational (STR) autoantibody testing, and negatives reflexed to muscle-specific kinase (MuSK). Thymoma and cancer occurrences were correlated with STR and reflexed glutamic acid decarboxylase 65 (GAD65), ganglionic acetylcholine receptor (α3), collapsin response mediating protein-5, and voltage-gated potassium channel complex autoantibodies. RESULTS Of 433 samples tested, 133 (31%) met clinical-EDX criteria for MG. Best sensitivity (90%) occurred at AChR-Bi >0.02 nmol/L, leaving 14 negative (6 ocular MG, 7 generalized MG, 1 MuSK MG) with specificity 90% (31 false-positives). Using AChR-Mo antibodies (>20% loss), specificity was better (92%, 24 false-positives), but sensitivity dropped (85%). Specificity improved (95%) by testing AChR-Mo when AChR-Bi are positive, resulting in 45% reduction of false-positives (31-17), maintaining AChR-Bi 90% sensitivity. Cutoff values recommended by area under the curve analysis did not outperform this approach. AChR-Bi and AChR-Mo values were significantly higher in true-positives. CT evaluations in 121 MG samples revealed 16 thymomas. Historical or subsequent cancers occurred in 22. STR and reflexed autoantibodies were not more common in MG with thymoma or other cancers. Full-body CT (n = 34) was performed in those with STR and reflex autoantibody positivity, but without additional cancers found. CONCLUSION Accuracy of MG serologic testing is improved by reflexing AChR-Bi-positive cases to AChR-Mo. STR and other reflexed cancer evaluation autoantibodies did not provide value beyond standard CT chest imaging at the time of MG diagnosis. Diagnostic certainty is informed by AChR-Bi and AChR-Mo with higher values increasing specificity.
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Affiliation(s)
- Shahar Shelly
- From the Departments of Neurology (S.S., P.P., H.B., D.D., M.M., E.J.S., B.A.C., R.S.L., T.L., S.J.P., A.Z., A.M., M.C.H., C.J.K.), Laboratory Medicine and Pathology (D.D., S.J.P., A.Z., A.M., J.R.M., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic Foundation, Rochester, MN
| | - Pritikanta Paul
- From the Departments of Neurology (S.S., P.P., H.B., D.D., M.M., E.J.S., B.A.C., R.S.L., T.L., S.J.P., A.Z., A.M., M.C.H., C.J.K.), Laboratory Medicine and Pathology (D.D., S.J.P., A.Z., A.M., J.R.M., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic Foundation, Rochester, MN
| | - Hongyan Bi
- From the Departments of Neurology (S.S., P.P., H.B., D.D., M.M., E.J.S., B.A.C., R.S.L., T.L., S.J.P., A.Z., A.M., M.C.H., C.J.K.), Laboratory Medicine and Pathology (D.D., S.J.P., A.Z., A.M., J.R.M., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic Foundation, Rochester, MN
| | - Divyanshu Dubey
- From the Departments of Neurology (S.S., P.P., H.B., D.D., M.M., E.J.S., B.A.C., R.S.L., T.L., S.J.P., A.Z., A.M., M.C.H., C.J.K.), Laboratory Medicine and Pathology (D.D., S.J.P., A.Z., A.M., J.R.M., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic Foundation, Rochester, MN
| | - Margherita Milone
- From the Departments of Neurology (S.S., P.P., H.B., D.D., M.M., E.J.S., B.A.C., R.S.L., T.L., S.J.P., A.Z., A.M., M.C.H., C.J.K.), Laboratory Medicine and Pathology (D.D., S.J.P., A.Z., A.M., J.R.M., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic Foundation, Rochester, MN
| | - Eric J Sorenson
- From the Departments of Neurology (S.S., P.P., H.B., D.D., M.M., E.J.S., B.A.C., R.S.L., T.L., S.J.P., A.Z., A.M., M.C.H., C.J.K.), Laboratory Medicine and Pathology (D.D., S.J.P., A.Z., A.M., J.R.M., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic Foundation, Rochester, MN
| | - Brian A Crum
- From the Departments of Neurology (S.S., P.P., H.B., D.D., M.M., E.J.S., B.A.C., R.S.L., T.L., S.J.P., A.Z., A.M., M.C.H., C.J.K.), Laboratory Medicine and Pathology (D.D., S.J.P., A.Z., A.M., J.R.M., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic Foundation, Rochester, MN
| | - Ruple S Laughlin
- From the Departments of Neurology (S.S., P.P., H.B., D.D., M.M., E.J.S., B.A.C., R.S.L., T.L., S.J.P., A.Z., A.M., M.C.H., C.J.K.), Laboratory Medicine and Pathology (D.D., S.J.P., A.Z., A.M., J.R.M., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic Foundation, Rochester, MN
| | - Teerin Liewluck
- From the Departments of Neurology (S.S., P.P., H.B., D.D., M.M., E.J.S., B.A.C., R.S.L., T.L., S.J.P., A.Z., A.M., M.C.H., C.J.K.), Laboratory Medicine and Pathology (D.D., S.J.P., A.Z., A.M., J.R.M., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic Foundation, Rochester, MN
| | - Jay Mandrekar
- From the Departments of Neurology (S.S., P.P., H.B., D.D., M.M., E.J.S., B.A.C., R.S.L., T.L., S.J.P., A.Z., A.M., M.C.H., C.J.K.), Laboratory Medicine and Pathology (D.D., S.J.P., A.Z., A.M., J.R.M., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic Foundation, Rochester, MN
| | - Sean J Pittock
- From the Departments of Neurology (S.S., P.P., H.B., D.D., M.M., E.J.S., B.A.C., R.S.L., T.L., S.J.P., A.Z., A.M., M.C.H., C.J.K.), Laboratory Medicine and Pathology (D.D., S.J.P., A.Z., A.M., J.R.M., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic Foundation, Rochester, MN
| | - Anastasia Zekeridou
- From the Departments of Neurology (S.S., P.P., H.B., D.D., M.M., E.J.S., B.A.C., R.S.L., T.L., S.J.P., A.Z., A.M., M.C.H., C.J.K.), Laboratory Medicine and Pathology (D.D., S.J.P., A.Z., A.M., J.R.M., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic Foundation, Rochester, MN
| | - Andrew McKeon
- From the Departments of Neurology (S.S., P.P., H.B., D.D., M.M., E.J.S., B.A.C., R.S.L., T.L., S.J.P., A.Z., A.M., M.C.H., C.J.K.), Laboratory Medicine and Pathology (D.D., S.J.P., A.Z., A.M., J.R.M., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic Foundation, Rochester, MN
| | - Michael C Harper
- From the Departments of Neurology (S.S., P.P., H.B., D.D., M.M., E.J.S., B.A.C., R.S.L., T.L., S.J.P., A.Z., A.M., M.C.H., C.J.K.), Laboratory Medicine and Pathology (D.D., S.J.P., A.Z., A.M., J.R.M., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic Foundation, Rochester, MN
| | - John R Mills
- From the Departments of Neurology (S.S., P.P., H.B., D.D., M.M., E.J.S., B.A.C., R.S.L., T.L., S.J.P., A.Z., A.M., M.C.H., C.J.K.), Laboratory Medicine and Pathology (D.D., S.J.P., A.Z., A.M., J.R.M., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic Foundation, Rochester, MN
| | - Christopher J Klein
- From the Departments of Neurology (S.S., P.P., H.B., D.D., M.M., E.J.S., B.A.C., R.S.L., T.L., S.J.P., A.Z., A.M., M.C.H., C.J.K.), Laboratory Medicine and Pathology (D.D., S.J.P., A.Z., A.M., J.R.M., C.J.K.), and Biomedical Statistics and Bioinformatics (J.M.), Mayo Clinic Foundation, Rochester, MN.
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Ruiz-García R, Martínez-Hernández E, Saiz A, Dalmau J, Graus F. The Diagnostic Value of Onconeural Antibodies Depends on How They Are Tested. Front Immunol 2020; 11:1482. [PMID: 32760403 PMCID: PMC7372120 DOI: 10.3389/fimmu.2020.01482] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/08/2020] [Indexed: 12/15/2022] Open
Abstract
Detection of onconeural antibodies is important because establishes a definitive diagnosis of paraneoplastic neurological syndrome (PNS). The recommended method for diagnosis of onconeural antibodies is by immunohistochemistry on rodent brain sections and confirmation of results by immunoblot. However, in many diagnostic laboratories samples are only tested with commercial line blots. In this study we inquired whether this change in diagnostic methodology (line blot alone vs. combined immunohistochemistry and line blot) would affect the results. Among 439 samples examined by immunohistochemistry and a commercial line blot (Euroimmun, Lübeck, Germany) 96 (22%) were positive by line blot, and their clinical information was reviewed. Onconeural antibodies were detected by both assays in 46/96 (48%) patients (concordant group) whereas 50 (52%) were only positive by line blot (discordant group). In the concordant group 42/46 (91%) patients had a definite diagnosis of PNS whereas in the discordant group only 4/50 (8%) had PNS (p < 0.00001). None of the 14 patients with ZIC4 antibodies and 1/13 (8%) with Yo antibodies demonstrated only by line blot had PNS. These findings show a robust diagnostic value of combined diagnostic techniques, and both should be used to demonstrate onconeural antibodies, If antibody testing is performed only with line blot assay, positive bands should be confirmed by rodent brain immunohistochemistry. For ZIC4 or Yo antibody testing, line blot positivity with negative immunohistochemistry has no diagnostic significance, and for the rest of onconeural antibodies the predictive diagnostic value is low.
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Affiliation(s)
- Raquel Ruiz-García
- Immunology Department, Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona, Spain
| | - Eugenia Martínez-Hernández
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Neurology Service, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Albert Saiz
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Neurology Service, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Josep Dalmau
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Catalan Institution of Research and Advanced Studies (ICREA), Barcelona, Spain.,Neurology Department, University of Pennsylvania, Philadelphia, PA, United States
| | - Francesc Graus
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Herskovits AZ, Joseph LJ. Reference Laboratory Testing for Neurologic Disorders. Clin Lab Med 2020; 40:317-329. [PMID: 32718502 DOI: 10.1016/j.cll.2020.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Laboratory testing plays a critical role in the diagnosis and monitoring of patients with neurologic disorders. Although common tests are often performed in a central hospital laboratory, an increasing number of essential but esoteric tests are performed at reference laboratories or other outside health care facilities. In this article, we analyze recent trends in neurologic disease testing within the overall context of reference laboratory testing and discuss strategies to facilitate the provision of high-quality, cost-effective laboratory services.
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Affiliation(s)
- A Zara Herskovits
- Department of Pathology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA.
| | - Loren J Joseph
- Department of Pathology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
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36
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Abstract
The recent discovery of several neuronal autoantibodies linked to neurologic syndromes that are fully or partially responsive to immunosuppressive therapy has revolutionized neuroimmunology and expanded the scope of classical paraneoplastic and antibody-related syndromes. A great deal of understanding of the techniques of neuronal antibody testing, the sensitivity and specificity of serum and cerebrospinal fluid sampling, and the value of the specific type and titer of each antibody is imperative. This article provides an overview of neuronal antibody and paraneoplastic panel testing with emphasis on how to differentiate clinically relevant from clinically irrelevant results and the downstream implications of those results.
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37
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Guidon AC. Lambert-Eaton Myasthenic Syndrome, Botulism, and Immune Checkpoint Inhibitor-Related Myasthenia Gravis. Continuum (Minneap Minn) 2020; 25:1785-1806. [PMID: 31794471 DOI: 10.1212/con.0000000000000807] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW This article reviews the pathophysiology, epidemiology, clinical presentation, diagnosis, and treatment of Lambert-Eaton myasthenic syndrome (LEMS) and of botulism, and immune-related myasthenia gravis (MG) occurring in the context of immune checkpoint inhibitor therapy for cancer. RECENT FINDINGS The suspicion that LEMS is rare but also likely underdiagnosed is supported by recent epidemiologic data. A validated, LEMS-specific scale now exists to assess and monitor disease, and symptomatic and immunomodulatory treatments are available. As presynaptic disorders of neuromuscular transmission, LEMS and botulism share electrodiagnostic abnormalities but have important distinguishing features. Knowledge of the clinical features of botulism is needed, particularly with continued cases of infant botulism, the opioid epidemic increasing the incidence of wound botulism, and medical use of botulinum toxin, which may cause iatrogenic botulism. Foodborne botulism remains rare. Prompt recognition of botulism and administration of antitoxin can improve outcomes. MG may be exacerbated or may present de novo in the context of immune activation from immune checkpoint inhibitor therapies for cancer. Immune-related MG commonly overlaps with myositis and myocarditis. Corticosteroids typically result in improvement. However, immune-related MG can be more fulminant than its idiopathic counterpart and may cause permanent disability or death. SUMMARY The diagnosis of LEMS, botulism, or immune-related MG can generally be made from the patient's history, supplemented with directed questions, a physical examination designed to demonstrate abnormalities, and laboratory and electrodiagnostic testing. Early diagnosis and carefully selected treatment not only improve outcomes of the neuromuscular disease but can affect the prognosis of underlying malignancy, when present.
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Yetimler B, Tzartos J, Şengül B, Dursun E, Ulukan Ç, Karagiorgou K, Gezen-Ak D, Sezgin M, Papaconstantinou A, Tzartos S, Orhan EK, Ekizoğlu E, Küçükali Cİ, Baykan B, Tüzün E. Serum glial fibrillary acidic protein (GFAP)-antibody in idiopathic intracranial hypertension. Int J Neurosci 2020; 131:775-779. [PMID: 32303142 DOI: 10.1080/00207454.2020.1758084] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AIM Idiopathic intracranial hypertension (IIH), a disease of obscure origin, is characterized by headache and visual disturbances due to increased intracranial pressure. Recent line of evidence has suggested involvement of inflammation in IIH pathogenesis thus bringing forward anti-glial autoimmunity as a potential contributor of IIH. Glial fibrillary acidic protein (GFAP) is a major astrocytic autoantigen associated with a specific form of meningoencephalitis. MATERIALS AND METHODS In this study, we investigated the presence of GFAP-antibody in 65 sera (49 obtained during active disease and 16 during remission) and in 15 cerebrospinal fluid (CSF) samples of 58 consecutively recruited IIH patients using cell based assay and indirect immunohistochemistry. RESULTS GFAP-antibody was found in active period sera of 2 IIH patients with classical symptoms and good treatment response. Two remission period sera obtained at different time points from one of these cases showed lower titers of GFAP-antibody positivity. IgG from positive samples yielded an astrocytic immunoreactivity pattern. None of the CSF samples showed GFAP-antibodies. CONCLUSIONS These results suggest that anti-astrocyte autoimmunity might be present in a fraction of IIH patients. Exact pathogenic significance of this association needs to be further studied.
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Affiliation(s)
- Berrak Yetimler
- Department of Neuroscience, Aziz Sancar Institute for Experimental Medical Research, Istanbul University, Istanbul, Turkey
| | - John Tzartos
- Tzartos NeuroDiagnostics, Athens, Greece.,1st Department of Neurology, Eginition Hospital, Medical School, University of Athens, Athens, Greece
| | - Büşra Şengül
- Department of Medical Biology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Erdinç Dursun
- Department of Medical Biology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey.,Department of Neuroscience, Institute of Neurological Sciences, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Çağrı Ulukan
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Duygu Gezen-Ak
- Department of Medical Biology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Mine Sezgin
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Socrates Tzartos
- Tzartos NeuroDiagnostics, Athens, Greece.,Hellenic Pasteur Institute, Athens, Greece
| | - Elif Kocasoy Orhan
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Esme Ekizoğlu
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Cem İsmail Küçükali
- Department of Neuroscience, Aziz Sancar Institute for Experimental Medical Research, Istanbul University, Istanbul, Turkey
| | - Betül Baykan
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Erdem Tüzün
- Department of Neuroscience, Aziz Sancar Institute for Experimental Medical Research, Istanbul University, Istanbul, Turkey
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Greenstein PE. Commentary on An Elderly Man with Dementia. Clin Chem 2020; 66:415-420. [DOI: 10.1093/clinchem/hvz019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 10/24/2019] [Indexed: 11/12/2022]
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Zidan A, Fein A, Zuchowski K. The use, misuse and abuse of paraneoplastic panels in neurological disorders. A retrospective study. Clin Neurol Neurosurg 2019; 186:105545. [PMID: 31622896 DOI: 10.1016/j.clineuro.2019.105545] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/22/2019] [Accepted: 09/30/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The field of paraneoplastic neurological syndromes PNS has grown exponentially with the increased identification of associated antibodies. Testing for these antibodies is commonly done in "panels" to increase sensitivity, and these panels have become a routine test on CSF samples obtained for a variety of clinical indications. Excessive testing has raised concerns about the correct utilization of these panels. Our study investigates the appropriateness of use of paraneoplastic panel in an academic, tertiary-care medical center. PATIENTS AND METHODS We retrospectively reviewed charts of all patients who had autoimmune paraneoplastic panel testing in one year period. We collected date on demographics, clinical presentations and ancillary testings on all reviewed charts. Then, we devised an algorithm based on available data to define cases where testing had been unnecessary or likely unnecessary. RESULTS We collected 60 cases that had undergone autoimmune paraneoplastic testing serum and/or CSF. Testing was unnecessary in 10 cases (16%), in which presentations had a definitive confirmatory tests. Testing was unlikely necessary in 11 cases (18%), in which all ancillary testing was normal in 6 cases, and presentation was not compatible with any known syndrome in 5 cases. Collectively, paraneoplastic panel testing was of extremely low yield on more than one third of the cases where where w testing was done. CONCLUSION Our results adds to the growing concerns about the utilization of paraneoplastic panels, and the urgent need for enhanced screening and establishing a framework that can guide neurologists on when testing can have a sufficient yield to warrant it. Such framework should be built using diagnostic algorithms based on risk, clinical manifestations, characterization of autoantibodies and their associations.
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Callaghan BC, Burke JF. Author response: Unintended consequences of Mayo paraneoplastic evaluations. Neurology 2019; 93:606-607. [DOI: 10.1212/wnl.0000000000008180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Brier MR, Bucelli RC, Day GS. Reader response: Unintended consequences of Mayo paraneoplastic evaluations. Neurology 2019; 93:603. [DOI: 10.1212/wnl.0000000000008178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Pittock SJ, Mills JR, McKeon A. Reader response: Unintended consequences of Mayo paraneoplastic evaluations. Neurology 2019; 93:606. [PMID: 31551274 DOI: 10.1212/wnl.0000000000008179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Kelkar P. Reader response: Unintended consequences of Mayo paraneoplastic evaluations. Neurology 2019; 93:602. [DOI: 10.1212/wnl.0000000000008174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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What's happening in Innovations in Care Delivery. Neurology 2019. [DOI: 10.1212/wnl.0000000000007026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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What's happening in Innovations in Care Delivery. Neurology 2019. [DOI: 10.1212/wnl.0000000000007018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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What's happening in Innovations in Care Delivery. Neurology 2019. [DOI: 10.1212/wnl.0000000000006753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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