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Dalakas MC. Stiff Person Syndrome and GAD Antibody-Spectrum Disorders. Continuum (Minneap Minn) 2024; 30:1110-1135. [PMID: 39088290 DOI: 10.1212/con.0000000000001457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
OBJECTIVE Antibodies against glutamic acid decarboxylase (GAD), originally associated with stiff person syndrome (SPS), define the GAD antibody-spectrum disorders that also include cerebellar ataxia, autoimmune epilepsy, limbic encephalitis, progressive encephalomyelitis with rigidity and myoclonus (PERM), and eye movement disorders, all of which are characterized by autoimmune neuronal excitability. This article elaborates on the diagnostic criteria for SPS and SPS spectrum disorders, highlights disease mimics and misdiagnoses, describes the electrophysiologic mechanisms and underlying autoimmunity of stiffness and spasms, and provides a step-by-step therapeutic scheme. LATEST DEVELOPMENTS Very-high serum GAD antibody titers are diagnostic for GAD antibody-spectrum disorders and also predict the presence of GAD antibodies in the CSF, increased intrathecal synthesis, and reduced CSF γ-aminobutyric acid (GABA) levels. Low serum GAD antibody titers or the absence of antibodies generates diagnostic challenges that require careful distinction in patients with a variety of painful spasms and stiffness, including functional neurologic disorders. Antibodies against glycine receptors, first found in patients with PERM, are seen in 13% to 15% of patients with SPS, whereas amphiphysin and gephyrin antibodies, seen in 5% of patients with SPS spectrum disorders, predict a paraneoplastic association. GAD-IgG from different SPS spectrum disorders recognizes the same dominant GAD intracellular epitope and, although the pathogenicity is unclear, is an excellent diagnostic marker. The biological basis of muscle stiffness and spasms is related to autoimmune neuronal hyperexcitability caused by impaired reciprocal γ-aminobutyric acid-mediated (GABA-ergic) inhibition, which explains the therapeutic response to GABA-enhancing agents and immunotherapies. ESSENTIAL POINTS It is essential to distinguish SPS spectrum disorders from disease mimics to avoid both overdiagnoses and misdiagnoses, considering that SPS is treatable if managed correctly from the outset to prevent disease progression. A step-by-step, combination therapy of GABA-enhancing medications along with immunotherapies ensures prolonged clinical benefits.
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Fattahzadeh Ardalani G, Samady Khanghah A, Jahanpanah M, Mokhtari D, Samady Khanghah P. Successfully treated anti-GAD limbic encephalitis in a 15-year-old diabetic boy with intravenous immunoglobulin: case report. Ann Med Surg (Lond) 2024; 86:1173-1181. [PMID: 38333287 PMCID: PMC10849452 DOI: 10.1097/ms9.0000000000001653] [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: 10/16/2023] [Accepted: 12/13/2023] [Indexed: 02/10/2024] Open
Abstract
Introduction and importance Limbic encephalitides (LE) have symptoms and signs of new-onset seizures accompanied by cognitive impairment and signal changes in the MRI of the limbic system in the brain. Numerous antibodies against the neurons and synapses have been detected so far. Of those, antiglutamic acid decarboxylase antibody (Anti-GAD Ab) impairs the gamma amino butyric acid, one of the primary mediators that naturally prevents abnormal neuronal activity causing seizure. Case presentation The authors have reported a case of anti-GAD Ab LE in a diabetic male adolescent who responded dramatically to intravenous immunoglobulin and reviewed all similar pediatric cases for 15 years now. Clinical discussion The symptoms in children suffering from anti-GAD LE in three categories, systemic, psychiatric, and neurological, are heterogeneous. The most common manifestations were seizures followed by altered mental status and behavioral changes, respectively. The two main clinical scenarios described in GAD65-mediated autoimmune epilepsy are (1) an acute/subacute onset of seizures alone or seizures (including new-onset refractory status epilepticus, NORSE) accompanied by some degrees of cognitive and psychiatric manifestations, including amnesia and mesiotemporal inflammatory involvement consistent with LE and (2) epilepsy without clinical or MRI evidence of active central nervous system inflammation. Conclusion Although rare, the neurologist should consider the potential role of anti-GAD ab-associated encephalitis in the presence of diabetes mellitus.
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Affiliation(s)
| | | | - Mohammad Jahanpanah
- Department of Genetics and Pathology
- Department of Neurology, School of Medicine, Ardabil University of Medical Sciences
| | - Diana Mokhtari
- Department of Genetics and Pathology
- Department of Neurology, School of Medicine, Ardabil University of Medical Sciences
| | - Parisa Samady Khanghah
- Department of Cellular and Molecular Biology, University of Mohaghegh Ardabili, Ardabil, Iran
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Rajmohan R, Baveja S, Nguyen D, Shah E, Sy M, Attaripour S, Swope D. Case report: Approaches to treatment-refractory and super-refractory glutamic acid decarboxylase antibody-spectrum disorders. Front Immunol 2024; 14:1297340. [PMID: 38259445 PMCID: PMC10800536 DOI: 10.3389/fimmu.2023.1297340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/12/2023] [Indexed: 01/24/2024] Open
Abstract
Background Glutamic acid decarboxylase antibody-spectrum disorders (GAD-SDs) include a group of autoimmune neurological diseases associated with neuronal excitability, most noticeably stiff person syndrome. Immune modulators are the mainstay of treatment, but a significant number of patients remain refractory. Methods We present our single-center experience of eight cases of GAD-SD, two of which were refractory to immune modulatory treatments. Results Of the two cases that were refractory to immunomodulation, one showed significant improvement with bilateral globus pallidus interna deep brain stimulation (GPi DBS) placement, and the other showed significant improvement with autologous hematopoietic stem cell transplant (aHSCT). Discussion To our knowledge, this is the first instance of GPi DBS placement being noted to improve GAD-SD movements.
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Affiliation(s)
- Ravi Rajmohan
- Department of Neurology, University of California, Irvine, CA, United States
| | - Shivali Baveja
- School of Medicine, University of California, Irvine, CA, United States
| | - Dai Nguyen
- Department of Internal Medicine, University of California, Davis, CA, United States
| | - Eshita Shah
- Department of Neurology, University of California, Irvine, CA, United States
| | - Michael Sy
- Department of Neurology, University of California, Irvine, CA, United States
| | - Sanaz Attaripour
- Department of Neurology, University of California, Irvine, CA, United States
| | - David Swope
- Department of Neurology, University of California, Irvine, CA, United States
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YILDIRIM R, GÜNBEY C. Electroencephalographic abnormalities in children with type 1 diabetes mellitus: a prospective study. Turk J Med Sci 2023; 53:1794-1798. [PMID: 38813513 PMCID: PMC10760570 DOI: 10.55730/1300-0144.5749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 12/12/2022] [Accepted: 10/12/2023] [Indexed: 05/31/2024] Open
Abstract
Background/aim The aim herein was to investigate epileptiform discharges on electroencephalogram (EEG), their correlation with glutamic acid decarboxylase 65 autoantibody (GAD-ab) in newly diagnosed pediatric type 1 diabetes mellitus (T1DM) patients and interpret their medium-term utility in predicting epilepsy. Materials and methods Children presenting with T1DM between July 2018 and December 2019 were included in this prospective longitudinal study. Patients with a history of head injury, chronic illness, neurological disorder, seizure, autism, or encephalopathy were excluded. EEGs were obtained within the first 7 days of diagnosis and later reviewed by a pediatric neurologist. All of the children were clinically followed-up in pediatric endocrinology and neurology clinics for 2 years after their diagnosis. Results A total of 105 children (46 male, 43.8%) were included. The mean age at the time of diagnosis was 9.6 ± 4.1 years (range: 11 months-17.5 years). At the time of admission, 24 (22.9%), 29 (27.6%), and 52 (49.5%) patients had hyperglycemia, ketosis, and diabetic ketoacidosis, respectively. GAD-ab was positive in 55 children (52.4%). No background or sleep architecture abnormalities or focal slowing were present on the EEGs. Of the patients, 3 (2.9%) had focal epileptiform discharges. The mean GAD-ab levels of the remaining 102 patients were 7.48 ± 11.97 U/mL (range: 0.01-50.54) (p = 0.2). All 3 children with EEG abnormality had higher levels of GAD-ab (3.59 U/mL, 31.3 U/mL, and 7.09 U/mL, respectively). None of the patients developed epilepsy during the follow-up, although 1 patient experienced Guillain-Barré syndrome (GBS). Conclusion The prevalence of epileptiform discharges in the patients was similar to those of previous studies, in which healthy children were also included. No relationship was found between the epileptiform discharges and GAD-ab, and none of the patients manifested seizures during the first 2 years of follow-up of T1DM. These data support the findings of previous studies reporting that T1DM patients with confirmed electroencephalographic abnormalities do not have an increased risk of epilepsy. On the other hand, GBS might be considered as another autoimmune disease that may be associated with T1DM in children.
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Affiliation(s)
- Ruken YILDIRIM
- Department of Pediatric Endocrinology, Diyarbakır Children’s Hospital, Diyarbakır,
Turkiye
| | - Ceren GÜNBEY
- Department of Pediatric Neurology, Diyarbakır Children’s Hospital, Diyarbakır,
Turkiye
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Sadaghiani MS, Roman S, Wang Y, Rowe SP, Leal JP, Newsome SD, Solnes LB. Assessment of anti-GAD65-associated cerebellar ataxia with 18F-FDG cerebellar uptake: ROC analysis. Ann Nucl Med 2023; 37:528-534. [PMID: 37378737 DOI: 10.1007/s12149-023-01853-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023]
Abstract
OBJECTIVE Anti-glutamic acid decarboxylase 65 (anti-GAD65)-associated neurological disorders include two major phenotypes, namely Stiff person syndrome (SPS) and cerebellar ataxia (CA). Considering the potential for better outcomes with prompt immunotherapy, early detection of CA is crucial. Hence, a non-invasive imaging biomarker to detect CA with high specificity is desired. Herein, we evaluated brain 2-deoxy-2-[18F]fluoro-D-glucose (18F-FDG) PET in detecting CA based on cerebellar uptake using receiver operating characteristic (ROC) analysis and five-fold cross-validation. METHODS This study was based on STARD 2015 guidelines: thirty patients with anti-GAD65-associated neurological disorders, 11 of whom with CA were studied. Five test sets were created after patients were randomly sorted and divided into 5 equal folds. Each iteration included 24 patients for ROC analysis and 6 patients reserved for testing. The Z scores of left cerebellum, vermis, right cerebellum, and the average of the three regions were used in ROC analysis to determine areas with significant area under the curve (AUC). The cut-off values with high specificity were determined among the 24 patients in each iteration and tested against the reserved 6 patients. RESULTS Left cerebellum and average of the three regions showed significant AUC above 0.5 in all iterations with left cerebellum being the highest AUC in 4 iterations. Testing the cut-off values of the left cerebellum against the reserved 6 patients in each iteration showed 100% specificity with sensitivities ranging from 0 to 75%. CONCLUSIONS Cerebellar 18F-FDG PET uptake can differentiate CA phenotypes from patients with SPS with high specificity.
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Affiliation(s)
- Mohammad S Sadaghiani
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N. Caroline St, Baltimore, MD, 21287, USA
| | - Samantha Roman
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Yujie Wang
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Steven P Rowe
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N. Caroline St, Baltimore, MD, 21287, USA
| | - Jeffery P Leal
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N. Caroline St, Baltimore, MD, 21287, USA
| | - Scott D Newsome
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Lilja B Solnes
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N. Caroline St, Baltimore, MD, 21287, USA.
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Abstract
Autoimmune encephalitis is a common and treatable cause of encephalitis in children and adults. Individuals present with a variety of symptoms, including altered mental status, behavioral changes, irritability, insomnia, developmental regression, seizures, dyskinetic movements, and autonomic instability. Evaluation includes electroencephalography, magnetic resonance imaging, and lumbar puncture. Once infectious and other causes are reasonably ruled out, treatment should be started empirically without waiting for antibody confirmation. Early clinical suspicion is key, as the outcome depends on early initiation of immunotherapy, including corticosteroids, intravenous immunoglobulin, and/or plasmapheresis. Severe or refractory cases require other treatments, such as rituximab, cyclophosphamide, or other immunotherapies using novel monoclonal antibodies. Psychiatry should be involved early for the management of behavioral issues. Additional considerations include management of seizures and dyskinesias. ICU admission may be required for management of hypoventilation necessitating mechanical ventilation (either intrinsic or iatrogenic, eg, from sedatives), refractory seizures, and dysautonomia. Anti-N-methyl-d-aspartate receptor and other forms of autoimmune encephalitis are less often associated with neoplasia (such as ovarian teratoma) in children compared with adults, but screening and removal of tumor if present should be performed.
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Affiliation(s)
- Saba Jafarpour
- Division of Neurology, Department of Pediatrics, Children's Hospital of Los Angles, Los Angeles, CA
| | - Jonathan D Santoro
- Division of Neurology, Department of Pediatrics, Children's Hospital of Los Angles, Los Angeles, CA.,Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Dalakas MC. Stiff-person Syndrome and GAD Antibody-spectrum Disorders: GABAergic Neuronal Excitability, Immunopathogenesis and Update on Antibody Therapies. Neurotherapeutics 2022; 19:832-847. [PMID: 35084720 PMCID: PMC9294130 DOI: 10.1007/s13311-022-01188-w] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2022] [Indexed: 01/10/2023] Open
Abstract
Although antibodies against Glutamic Acid Decarboxylase (GAD) were originally associated with Stiff Person Syndrome (SPS), they now denote the "GAD antibody-spectrum disorders (GAD-SD)" that include Cerebellar Ataxia, Autoimmune Epilepsy, Limbic Encephalitis, PERM and eye movement disorder. In spite of the unique clinical phenotype that each of these disorders has, there is significant overlapping symptomatology characterized by autoimmune neuronal excitability. In addition to GAD, three other autoantibodies, against glycine receptors, amphiphysin and gephyrin, are less frequently or rarely associated with SPS-SD. Very high serum anti-GAD antibody titers are a key diagnostic feature for all GAD-SD, commonly associated with the presence of GAD antibodies in the CSF, a reduced CSF GABA level and increased anti-GAD-specific IgG intrathecal synthesis denoting stimulation of B-cell clones in the CNS. Because anti-GAD antibodies from the various hyperexcitability syndromes recognize the same dominant GAD epitope, the clinical heterogeneity among GAD-SD patients remains unexplained. The paper highlights the biologic basis of autoimmune hyperexcitability connected with the phenomenon of reciprocal inhibition as the fundamental mechanism of the patients' muscle stiffness and spasms; addresses the importance of high-GAD antibody titers in diagnosis, pinpointing the diagnostic challenges in patients with low-GAD titers or their distinction from functional disorders; and discusses whether high GAD-antibodies are disease markers or pathogenic in the context of their association with reduced GABA level in the brain and CSF. Finally, it focuses on therapies providing details on symptomatic GABA-enhancing drugs and the currently available immunotherapies in a step-by-step approach. The prospects of future immunotherapeutic options with antibody therapies are also summarized.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit National and Kapodistrian University of Athens Medical School, Athens, Greece.
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Lin BC, Johal J, Sivakumar K, Romano AE, Yacoub HA. Stiff-person syndrome: an atypical presentation and a review of the literature. Hosp Pract (1995) 2021; 49:384-390. [PMID: 34313523 DOI: 10.1080/21548331.2021.1961456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: Stiff-person syndrome (SPS) is a rare autoimmune neurological disorder associated with muscle rigidity and spasms. A number of antibodies have been associated with disorder, including anti-glutamic acid decarboxylase and anti-amphiphysin.Case report; In this report, we present a rare case of a 79-year-old woman who presented with bilateral lower extremity weakness who was ultimately diagnosed with stiff-limb syndrome, a rare variant of SPS. Extensive laboratory and CSF studies were unrevealing. Electromyography showed significant peroneal motor neuropathy and complex repetitive discharges in the left tibialis anterior muscle. Antibodies to glutamic acid decarboxylase were significantly elevated at 124 units/mL. She was subsequently started on oral diazepam with significant improvement in her symptoms.Conclusion: The presentation of SPS can vary based on epidemiologic factors, clinical symptoms, and associated disorders. These forms can have overlapping features which may make the categorization of patients into one of these forms challenging.
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Affiliation(s)
- Benjamin C Lin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jaspreet Johal
- Department of Neurology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Keithan Sivakumar
- Division of Neurology, Sunnybrook Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Alissa E Romano
- Department of Neurology, Lehigh Valley Health Network, Allentown, PA, USA.,Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Hussam A Yacoub
- Department of Neurology, Lehigh Valley Health Network, Allentown, PA, USA.,Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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9
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Kanekar S, Zacharia T, Agarwal A. Neoplastic Meningitis and Paraneoplastic Syndromes. Radiol Clin North Am 2021; 59:409-423. [PMID: 33926686 DOI: 10.1016/j.rcl.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Neoplastic meningitis (NM) and paraneoplastic syndromes (PNSs) are a rare group of disorders present in patients with cancer. Clinical diagnosis of these conditions is challenging, and imaging and laboratory analysis play a significant role in diagnosing. Diagnosis of NM largely depends on documenting circulating tumor cells in the cerebrospinal fluid (CSF) and/or leptomeningeal and nodular enhancement on contrast-enhanced MR imaging of the brain or axial spine. PNSs encompass a variety of symptoms or syndromes. Paraneoplastic neuronal disorder diagnosis requires a multidimensional approach, high clinical suspicion, CSF and serum examination, and imaging. Neuroimaging is an integral part in the evaluation.
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Affiliation(s)
- Sangam Kanekar
- Department of Radiology, Penn State Health, Mail Code H066, 500 University drive, Hershey, PA 17033, USA; Department of Neurology, Penn State Health, Mail Code H066, 500 University drive, Hershey, PA 17033, USA.
| | - Thomas Zacharia
- Department of Radiology, Penn State Health, Mail Code H066, 500 University drive, Hershey, PA 17033, USA
| | - Amit Agarwal
- Department of Radiology, UT Southwestern Medical School and Parkland Hospital, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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Tsiortou P, Alexopoulos H, Dalakas MC. GAD antibody-spectrum disorders: progress in clinical phenotypes, immunopathogenesis and therapeutic interventions. Ther Adv Neurol Disord 2021; 14:17562864211003486. [PMID: 33854562 PMCID: PMC8013924 DOI: 10.1177/17562864211003486] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 02/27/2021] [Indexed: 12/14/2022] Open
Abstract
Antibodies against glutamic acid decarboxylase (GAD), originally linked to stiff person syndrome (SPS), now denote the "GAD antibody-spectrum disorders" (GAD-SD) that also include autoimmune epilepsy, limbic encephalitis, cerebellar ataxia and nystagmus with overlapping symptomatology highlighting autoimmune neuronal excitability disorders. The reasons for the clinical heterogeneity among GAD-antibody associated syndromes remain still unsettled, implicating variable susceptibility of GABAergic neurons to anti-GAD or other still unidentified autoantibodies. Although anti-GAD antibody titers do not correlate with clinical severity, very high serum titers, often associated with intrathecal synthesis of anti-GAD-specific IgG, point to in-situ effects of GAD or related autoantibodies within the central nervous system. It remains, however, uncertain what drives these antibodies, why they persist and whether they are disease markers or have pathogenic potential. The review, focused on these concerns, describes the widened clinical manifestations and overlapping features of all GAD-SD; addresses the importance of GAD antibody titers and potential significance of GAD epitopes; summarizes the biologic basis of autoimmune hyperexcitability; highlights the electrophysiological basis of reciprocal inhibition in muscle stiffness; and provides practical guidelines on symptomatic therapies with gamma-aminobutyric acid-enhancing drugs or various immunotherapies.
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Affiliation(s)
- Popianna Tsiortou
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Philadelphia, PA 19107, USA; Neuroimmunology Unit, National and Kapodistrian University of Athens, Athens, Greece
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11
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Saini L, Sondhi V. CNS autoimmunity in children: An unwanted wrinkle in a smooth narrative. Med J Armed Forces India 2021; 77:138-146. [PMID: 33867628 DOI: 10.1016/j.mjafi.2021.03.005] [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: 02/28/2021] [Accepted: 03/13/2021] [Indexed: 11/25/2022] Open
Abstract
The emerging paradigm of childhood autoimmune neurological disorders has exploded in recent times due to reliable diagnostic methods and their ease of availability, well-defined diagnostic criteria, and universal awareness about these disorders. The most important aspect of these disorders is a considerable recovery in response to early targeted immunotherapy. If left untreated and/or ill-treated, these can lead to mortality or lifelong morbidity. Autoantibodies can target any part of the central nervous system (CNS), ranging from superficial structures like myelin to deep intracellular ion channels like voltage-gated potassium channels, resulting in contrasting and at times overlapping symptomatology. Though neuroimaging characteristics and serological tests confirm these disorders' diagnosis, it is essential to suspect them clinically and start management before the reports are available for minimizing morbidity and mortality. In the pediatric age group, several metabolic conditions, like mitochondrial disorders and enzyme deficiencies like HMG-CoA-lyase deficiency, can develop neuroimaging patterns similar to those seen in childhood CNS autoimmune disorders and may also show a favorable response to steroids in acute phases. Hence, the clinician must suspect and work up the index patient appropriately. Here, we briefly discuss the pathophysiology, clinical clues, and potential therapeutic targets related to pediatric CNS autoimmune disorders.
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Affiliation(s)
- Lokesh Saini
- Assistant Professor (Pediatrics), Pediatric Neurology Unit, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sondhi
- Associate Professor, Department of Pediatrics, Armed Forces Medical College, Pune, India
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12
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Hoffmann C, Zong S, Mané-Damas M, Stevens J, Malyavantham K, Küçükali Cİ, Tüzün E, De Hert M, van Beveren NJM, González-Vioque E, Arango C, Damoiseaux JGMC, Rutten BP, Molenaar PC, Losen M, Martinez-Martinez P. The search for an autoimmune origin of psychotic disorders: Prevalence of autoantibodies against hippocampus antigens, glutamic acid decarboxylase and nuclear antigens. Schizophr Res 2021; 228:462-471. [PMID: 33581586 DOI: 10.1016/j.schres.2020.12.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 12/12/2020] [Accepted: 12/30/2020] [Indexed: 12/31/2022]
Abstract
The etiology of psychotic disorders is still unknown, but in a subgroup of patients symptoms might be caused by an autoimmune reaction. In this study, we tested patterns of autoimmune reactivity against potentially novel hippocampal antigens. Serum of a cohort of 621 individuals with psychotic disorders and 257 controls were first tested for reactivity on neuropil of rat brain sections. Brain reactive sera (67 diseased, 27 healthy) were further tested for antibody binding to glutamic acid decarboxylase (GAD) isotype 65 and 67 by cell-based assay (CBA). A sub-cohort of 199 individuals with psychotic disorders and 152 controls was tested for the prevalence of anti-nuclear antibodies (ANA) on HEp2-substrate as well as for reactivity to double-stranded DNA, ribosomal P (RPP), and cardiolipin (CL). Incubation of rat brain with serum resulted in unidentified hippocampal binding patterns in both diseased and control groups. Upon screening with GAD CBA, one of these patterns was identified as GAD65 in one individual with schizophrenia and also in one healthy individual. Two diseased and two healthy individuals had low antibody levels targeting GAD67 by CBA. Antibody reactivity on HEp-2-substrate was increased in patients with schizoaffective disorder, but only in 3 patients did antibody testing hint at a possible diagnosis of systemic lupus erythematosus. Although reactivity of serum to intracellular antigens might be increased in patients with psychotic disorder, no specific targets could be identified. GAD antibodies are very rare and do not seem increased in serum of patients with psychotic disorders.
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Affiliation(s)
- Carolin Hoffmann
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Shenghua Zong
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Marina Mané-Damas
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Jo Stevens
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | | | - Cem İsmail Küçükali
- Department of Neuroscience, Institute for Experimental Medical Research (DETAE), Istanbul University, Istanbul, Turkey
| | - Erdem Tüzün
- Department of Neuroscience, Institute for Experimental Medical Research (DETAE), Istanbul University, Istanbul, Turkey
| | - Marc De Hert
- UPC KU Leuven, KU Leuven Department of Neurosciences, Belgium; Antwerp Health Law and Ethics Chair - AHLEC, University Antwerp, Antwerp, Belgium
| | - Nico J M van Beveren
- Department of Psychiatry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Emiliano González-Vioque
- Child and Adolescent Psychiatry Department, Hospital General Universitario, Gregorio Marañón, School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, Madrid, Spain
| | - Celso Arango
- Child and Adolescent Psychiatry Department, Hospital General Universitario, Gregorio Marañón, School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, Madrid, Spain
| | - Jan G M C Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Bart P Rutten
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Peter C Molenaar
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Mario Losen
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Pilar Martinez-Martinez
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
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13
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Dalakas MC. Limited Benefits Halt Enrollment in Hematopoietic Stem Cell Transplantation Trial for Stiff-Person Syndrome: Should There Be More to Come? Neurology 2020; 96:239-240. [PMID: 33318165 DOI: 10.1212/wnl.0000000000011349] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Marinos C Dalakas
- From the Department of Neurology, Thomas Jefferson University, Philadelphia, PA; and the Neuroimmunology Unit, National and Kapodistrian University of Athens Medical School, Greece.
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Fundamental Mechanisms of Autoantibody-Induced Impairments on Ion Channels and Synapses in Immune-Mediated Cerebellar Ataxias. Int J Mol Sci 2020; 21:ijms21144936. [PMID: 32668612 PMCID: PMC7404345 DOI: 10.3390/ijms21144936] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 12/13/2022] Open
Abstract
In the last years, different kinds of limbic encephalitis associated with autoantibodies against ion channels and synaptic receptors have been described. Many studies have demonstrated that such autoantibodies induce channel or receptor dysfunction. The same mechanism is discussed in immune-mediated cerebellar ataxias (IMCAs), but the pathogenesis has been less investigated. The aim of the present review is to evaluate what kind of cerebellar ion channels, their related proteins, and the synaptic machinery proteins that are preferably impaired by autoantibodies so as to develop cerebellar ataxias (CAs). The cerebellum predictively coordinates motor and cognitive functions through a continuous update of an internal model. These controls are relayed by cerebellum-specific functions such as precise neuronal discharges with potassium channels, synaptic plasticity through calcium signaling pathways coupled with voltage-gated calcium channels (VGCC) and metabotropic glutamate receptors 1 (mGluR1), a synaptic organization with glutamate receptor delta (GluRδ), and output signal formation through chained GABAergic neurons. Consistently, the association of CAs with anti-potassium channel-related proteins, anti-VGCC, anti-mGluR1, and GluRδ, and anti-glutamate decarboxylase 65 antibodies is observed in IMCAs. Despite ample distributions of AMPA and GABA receptors, however, CAs are rare in conditions with autoantibodies against these receptors. Notably, when the autoantibodies impair synaptic transmission, the autoimmune targets are commonly classified into three categories: release machinery proteins, synaptic adhesion molecules, and receptors. This physiopathological categorization impacts on both our understanding of the pathophysiology and clinical prognosis.
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15
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Li TR, Zhang YD, Wang Q, Shao XQ, Li ZM, Lv RJ. Intravenous methylprednisolone or immunoglobulin for anti-glutamic acid decarboxylase 65 antibody autoimmune encephalitis: which is better? BMC Neurosci 2020; 21:13. [PMID: 32228575 PMCID: PMC7106675 DOI: 10.1186/s12868-020-00561-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 03/21/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Patients positive for anti-glutamic acid decarboxylase 65 (GAD65) antibodies have attracted increasing attention. Their clinical manifestations are highly heterogeneous and can be comorbid with tumors. Currently, there is no consensus on the therapeutic regimen for anti-GAD65-associated neurological diseases due to the clinical complexity, rarity and sporadic distribution. We reported six anti-GAD65 autoimmune encephalitis (AE) patients who received intravenous methylprednisolone (IVMP) or immunoglobulin (IVIG) or both. Then, we evaluated the therapeutic effect of both by summarizing results in previous anti-GAD65 AE patients from 70 published references. RESULTS Our six patients all achieved clinical improvements in the short term. Unfortunately, there was no significant difference between IVMP and IVIG in terms of therapeutic response according to the previous references, and the effectiveness of IVMP and IVIG was 45.56% and 36.71%, respectively. We further divided the patients into different subgroups according to their prominent clinical manifestations. The response rates of IVMP and IVIG were 42.65% and 32.69%, respectively, in epilepsy patients; 60.00% and 77.78%, respectively, in patients with stiff-person syndrome; and 28.57% and 55.56%, respectively, in cerebellar ataxia patients. Among 29 anti-GAD65 AE patients with tumors, the response rates of IVMP and IVIG were 29.41% and 42.11%, respectively. There was no significant difference in effectiveness between the two regimens among the different subgroups. CONCLUSION Except for stiff-person syndrome, we found that this kind of AE generally has a poor response to IVMP or IVIG. Larger prospective studies enrolling large numbers of patients are required to identify the optimal therapeutic strategy in the future.
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Affiliation(s)
- Tao-Ran Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China.,Department of Neurology, Xuanwu Hospital of Capital Medical University, 45 Chang Chun Road, Xicheng District, Beijing, 100053, People's Republic of China
| | - Yu-Di Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China.,Department of Neurology, the Second Hospital of Hebei Medical University, Hebei Medical University, 215 Heping West Road, Xinhua District, Shijiazhuang, 050000, People's Republic of China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China
| | - Xiao-Qiu Shao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China
| | - Zhi-Mei Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China
| | - Rui-Juan Lv
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China.
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16
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Xu M, Bennett DLH, Querol LA, Wu LJ, Irani SR, Watson JC, Pittock SJ, Klein CJ. Pain and the immune system: emerging concepts of IgG-mediated autoimmune pain and immunotherapies. J Neurol Neurosurg Psychiatry 2020; 91:177-188. [PMID: 30224548 DOI: 10.1136/jnnp-2018-318556] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/18/2018] [Accepted: 07/30/2018] [Indexed: 12/30/2022]
Abstract
The immune system has long been recognised important in pain regulation through inflammatory cytokine modulation of peripheral nociceptive fibres. Recently, cytokine interactions in brain and spinal cord glia as well as dorsal root ganglia satellite glia have been identified important- in pain modulation. The result of these interactions is central and peripheral sensitisation of nociceptive processing. Additionally, new insights and the term 'autoimmune pain' have emerged through discovery of specific IgGs targeting the extracellular domains of antigens at nodal and synaptic structures, causing pain directly without inflammation by enhancing neuronal excitability. Other discovered IgGs heighten pain indirectly by T-cell-mediated inflammation or destruction of targets within the nociceptive pathways. Notable identified IgGs in pain include those against the components of channels and receptors involved in inhibitory or excitatory somatosensory synapses or their pathways: nodal and paranodal proteins (LGI1, CASPR1, CASPR2); glutamate detection (AMPA-R); GABA regulation and release (GAD65, amphiphysin); glycine receptors (GLY-R); water channels (AQP4). These disorders have other neurological manifestations of central/peripheral hyperexcitabability including seizures, encephalopathy, myoclonus, tremor and spasticity, with immunotherapy responsiveness. Other pain disorders, like complex regional pain disorder, have been associated with IgGs against β2-adrenergic receptor, muscarinic-2 receptors, AChR-nicotinic ganglionic α-3 receptors and calcium channels (N and P/Q types), but less consistently with immune treatment response. Here, we outline how the immune system contributes to development and regulation of pain, review specific IgG-mediated pain disorders and summarise recent development in therapy approaches. Biological agents to treat pain (anti-calcitonin gene-related peptide and anti-nerve growth factor) are also discussed.
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Affiliation(s)
- Min Xu
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurology, Xuan wu Hospital Capital Medical University, Beijing, China
| | - David L H Bennett
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Luis Antonio Querol
- Neuromuscular Diseases Unit-Neuromuscular Lab Neurology Department, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Long-Jun Wu
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarosh R Irani
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - James C Watson
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Pain Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher J Klein
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA .,Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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17
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Alexopoulos H, Dalakas MC. The immunobiology of autoimmune encephalitides. J Autoimmun 2019; 104:102339. [PMID: 31611142 DOI: 10.1016/j.jaut.2019.102339] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 09/25/2019] [Indexed: 12/17/2022]
Abstract
Autoimmune encephalitides, with an estimated incidence of 1.5 per million population per year, although described only 15 years ago, have already had a remarkable impact in neurology and paved the field to autoimmune neuropsychiatry. Many patients traditionally presented with aberrant behavior, especially of acute or subacute onset, and treated with anti-psychotic therapies, turn out to have a CNS autoimmune disease with pathogenic autoantibodies against synaptic antigens responding to immunotherapies. The review describes the clinical spectrum of these disorders, and the pathogenetic role of key autoantibodies directed against: a) cell surface synaptic antigens and receptors, including NMDAR, GABAa, GABAb, AMPA and glycine receptors; b) channels such as AQP4 water-permeable channel or voltage-gated potassium channels; c) proteins that stabilize voltage-gated potassium channel complex into the membrane, like the LGI1 and CASPR2; and d) enzymes that catalyze the formation of neurotransmitters such as Glutamic Acid Decarboxylase (GAD). These antibodies, effectively target excitatory or inhibitory synapses in the limbic system, basal ganglia or brainstem altering synaptic function and resulting in uncontrolled neurological excitability disorder clinically manifested with psychosis, agitation, behavioral alterations, depression, sleep disturbances, seizure-like phenomena, movement disorders such as ataxia, chorea and dystonia, memory changes or coma. Some of the identified triggering factors include: viruses, especially herpes simplex, accounting for the majority of relapses occurring after viral encephalitis, which respond to immunotherapy rather than antiviral agents; tumors especially teratoma, SCLC and thymomas; and biological cancer therapies (immune-check-point inhibitors). As anti-synaptic antibodies persist after viral infections or tumor removal, augmentation of autoreactive B cells which release autoantigens to draining lymph nodes, molecular mimicry and infection-induced bystander immune activation products play a role in autoimmunization process or perpetuating autoimmune neuroinflammation. The review stresses the importance of early detection, clinical recognition, proper antibody testing and early therapy initiation as these disorders, regardless of a known or not trigger, are potentially treatable responding to systemic immunotherapy with intravenous steroids, IVIg, rituximab or even bortezomid.
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Affiliation(s)
- Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C Dalakas
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece; Department of Neurology, Thomas Jefferson University, Philadelphia, USA.
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18
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Kuo YC, Lin CH. Clinical spectrum of glutamic acid decarboxylase antibodies in a Taiwanese population. Eur J Neurol 2019; 26:1384-1390. [PMID: 31132202 DOI: 10.1111/ene.14005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 05/14/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE High levels of autoantibodies against glutamic acid decarboxylase (GAD-abs) are associated with stiff-person syndrome (SPS). However, the full clinical spectrum associated with GAD-abs in Asians is unclear. The clinical and immunological features of patients positive for GAD-abs were reviewed in a large Taiwanese series. METHODS Retrospective case series and immunological investigations were conducted between July 2007 and July 2017 at a tertiary referral centre in Taiwan. Amongst 361 patients with GAD-ab reactivity, 185 with detailed clinical records were included. RESULTS Twenty-seven patients (14.59%), with a mean age at assessment of 54.8 ± 13.9 years, presented with neurological symptoms. The major neurological presentations (mean GAD-ab concentrations) were SPS (n = 9, 33.3%; 135.45 ± 27.84 U/ml), cerebellar ataxia (n = 3, 11.1%; 95.61 ± 49.63 U/ml), encephalopathy (n = 2, 7.4%; 51.8 ± 49.64 U/ml) and epilepsy (n = 1, 3.7%; 83.3 U/ml). Notably, eight patients fulfilling the clinical diagnosis of multiple system atrophy had relatively lower GAD-ab concentrations (2.57 ± 0.82 U/ml), which has not been reported previously. There was no correlation between disease severity and GAD-ab concentration. Patients presenting with comorbid endocrinopathies (n = 15, 55.5%) had higher GAD-ab concentrations than those without endocrinopathies (n = 12, 44.4%; 104.45 ± 22.51 U/ml vs. 34.08 ± 21.83 U/ml, P = 0.04). Of 158 patients (85.4%) without a neurological presentation, 133 had type 1 diabetes mellitus and 20 had diabetes of other aetiologies (type 2 or gestational diabetes mellitus, or diabetes secondary to pancreatitis); the remaining four patients had pure thyroid disorders. CONCLUSIONS A clinical and immunological evaluation of East Asian patients positive for GAD-abs is presented and a different clinical spectrum of anti-GAD syndrome is identified compared to Caucasians.
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Affiliation(s)
- Y-C Kuo
- Department of Neurology, College of Medicine, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - C-H Lin
- Department of Neurology, College of Medicine, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
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19
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Varvaressos S, Breza M, Marousi S, Printzou M, Georgoulis A, Papageorgiou E, Kartanou C, Karadima G, Tagaris G, Koutsis G, Tzartos JS. Complex phenotype in a
C9ORF72‐
positive patient with high‐titer anti‐glutamic acid decarboxylase antibodies: neuroimmunology meets neurogenetics. Eur J Neurol 2019; 26:e73-e74. [DOI: 10.1111/ene.13926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 01/30/2019] [Indexed: 11/27/2022]
Affiliation(s)
| | - M. Breza
- 1st Department of Neurology Eginition Hospital Medical School National and Kapodistrian University of Athens Athens
| | - S. Marousi
- Department of Neurology Gennimatas General Hospital Athens
| | - M. Printzou
- Department of Neurology Gennimatas General Hospital Athens
| | - A. Georgoulis
- Department of Neurology Gennimatas General Hospital Athens
| | | | - C. Kartanou
- 1st Department of Neurology Eginition Hospital Medical School National and Kapodistrian University of Athens Athens
| | - G. Karadima
- 1st Department of Neurology Eginition Hospital Medical School National and Kapodistrian University of Athens Athens
| | - G. Tagaris
- Department of Neurology Gennimatas General Hospital Athens
| | - G. Koutsis
- 1st Department of Neurology Eginition Hospital Medical School National and Kapodistrian University of Athens Athens
| | - J. S. Tzartos
- 1st Department of Neurology Eginition Hospital Medical School National and Kapodistrian University of Athens Athens
- Tzartos Neurodiagnostics Athens Greece
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20
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Rakocevic G, Alexopoulos H, Dalakas MC. Quantitative clinical and autoimmune assessments in stiff person syndrome: evidence for a progressive disorder. BMC Neurol 2019; 19:1. [PMID: 30606131 PMCID: PMC6317182 DOI: 10.1186/s12883-018-1232-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 12/19/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Stiff Person Syndrome (SPS) is an under-diagnosed disorder that affects mobility and the quality of life of affected patients. The aim of the study is to describe the natural history of SPS, the extent of accumulated disability and the associated clinical and immunological features in patients followed for up to 8 years in a single center. METHODS Our collective cohort included 57 SPS patients. Additionally, 32 of these patients were examined every 6 months for a two-year period in a longitudinal study protocol, to assess disease progression using quantitative measures of stiffness and heightened sensitivity. RESULTS The most frequent initial symptom was leg stiffness, followed by paraspinal muscle rigidity and painful spasms in 95% of the patients. Although none of the patients required assistance for ambulation during the first 2 years of disease onset, 46 patients (80%) lost the ability to walk independently during our follow-up, despite symptomatic medications. In the longitudinal cohort, the number of stiff areas increased (p < 0.0001), consistent with worsening functional status and quality of life. High-titer anti-GAD antibodies were present in serum and CSF with elevated intrathecal GAD-specific IgG synthesis, but they did not correlate with clinical severity or progression. CONCLUSIONS This large study on SPS patients, combining an eight-year follow-up at a single center by the same leading neurologist and his team, is the first to provide longitudinal data in a large patient subgroup using objective clinical measures. One of the main findings is that SPS is a progressive disease leading to physical disability over time.
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Affiliation(s)
- Goran Rakocevic
- Department of Neurology, Thomas Jefferson University, Philadelphia, USA
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C. Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, USA
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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21
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Barba C, Alexopoulos H. Parkinsonism in autoimmune diseases. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2019; 149:419-452. [DOI: 10.1016/bs.irn.2019.10.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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22
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Jayaraman S, Prabhakar BS. Immune Tolerance in Autoimmune Central Nervous System Disorders. CONTEMPORARY CLINICAL NEUROSCIENCE 2019. [PMCID: PMC7121051 DOI: 10.1007/978-3-030-19515-1_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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23
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Meloni A, Corda G, Saba L, Ferri GL, Mariotti S, Cocco C. Reduction of Total Brain and Cerebellum Volumes Associated With Neuronal Autoantibodies in Patients With APECED. J Clin Endocrinol Metab 2019; 104:150-162. [PMID: 30339230 DOI: 10.1210/jc.2018-01313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 10/15/2018] [Indexed: 01/16/2023]
Abstract
CONTEXT In autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), autoantibodies (AutoAbs) labeling brain neurons were reported; conversely, brain MRI alterations associated with these AutoAbs were never reported. OBJECTIVES To describe brain alterations in APECED and to correlate them with AutoAbs against glutamic acid decarboxylase (GAD), tyrosine hydroxylase (TH), and 5-tryptophan hydroxylase (5-HT) neurons. DESIGN AND PARTICIPANTS Fourteen Sardinian patients with APECED and age-matched control subjects were recruited for MRI analysis and blood sampling to detect AutoAbs to GAD, TH, and 5-HT neurons by using rat brain sections. The majority of patients (n = 12) were investigated for AutoAbs a decade earlier, and 7 of 12 were positive for AutoAbs to GAD and TH neurons. MAIN OUTCOMES Patients with APECED had smaller cerebellum and gray matter volumes, with a ventricular enlargement and a total cerebrospinal fluid (CSF) increase, compared with controls (P < 0.01). In 11 of 14 patients, brain abnormalities were associated with AutoAbs to GAD or TH neurons (titer 1:100 to 15,000) that had persisted for 10 years in 7 of 11 patients. AutoAbs to 5-HT neurons were revealed in all patients with AutoAbs to TH neurons. A decrease in whole brain and cerebellum volumes (P = 0.028) was associated with AutoAbs to GAD neurons, and a CSF increase was associated with AutoAbs to GAD and TH/5-HT neurons (P < 0.05). HLA alleles did not appear to be involved in neuronal autoimmunity. CONCLUSIONS Brain alterations and neuronal AutoAbs were observed in 78.6% of Sardinian patients with APECED, suggesting a brain autoimmune reaction. Prolonged clinical follow-up must be conducted for the possible appearance of clinical neurologic consequences.
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Affiliation(s)
- Antonella Meloni
- Clinica Pediatrica II, Ospedale Pediatrico Microcitemico Antonio Cao, Clinical and Molecular Medicine, University of Cagliari, Cagliari (CA), Italy
- Sardinian APECED Association, Baunei (OG), Italy
| | - Giulia Corda
- NEF Laboratory, Department of Biomedical Sciences, University of Cagliari, Monserrato (CA), Italy
| | - Luca Saba
- Department of Radiology, AOU, University of Cagliari, Monserrato (CA), Italy
| | - Gian-Luca Ferri
- NEF Laboratory, Department of Biomedical Sciences, University of Cagliari, Monserrato (CA), Italy
| | - Stefano Mariotti
- Endocrinology Department of Medical Sciences and Public Health, University of Cagliari, Monserrato (CA), Italy
| | - Cristina Cocco
- NEF Laboratory, Department of Biomedical Sciences, University of Cagliari, Monserrato (CA), Italy
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24
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Pei Y, Jiao Z, Dong W, Pei L, He X, Wang H, Xu D. Excitotoxicity and compensatory upregulation of GAD67 in fetal rat hippocampus caused by prenatal nicotine exposure are associated with inhibition of the BDNF pathway. Food Chem Toxicol 2018; 123:314-325. [PMID: 30389584 DOI: 10.1016/j.fct.2018.10.062] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/04/2018] [Accepted: 10/29/2018] [Indexed: 10/28/2022]
Abstract
Prenatal nicotine exposure (PNE) can cause hypersensitivity of hypothalamic-pituitary-adrenal (HPA) axis in offspring with intrauterine growth retardation. The purpose of this study was to explore the original mechanism of intrauterine development that mediates hypersensitivity of the HPA axis in offspring due to PNE. Pregnant Wistar rats were injected subcutaneously with 2 mg/kg·d of nicotine on the 9th to the 20th gestational day (GD9-GD20) and the fetuses were extracted at GD20. Compared with the control group, fetal rats by PNE showed increased hippocampal apoptosis, reduced synaptic plasticity and downregulation of the brain-derived neurotrophic factor (BDNF) pathway, whereas glutamic acid decarboxylase 67 (GAD67) expression was upregulated. Rat fetal hippocampal H19-7/IGF1R cell lines were treated with different concentrations of nicotine (1, 10 and 100 μM) for 3 days, the extracellular fluid glutamate (Glu) level increased and similar effects were observed as in vivo. Intervention treatments caused the opposite results. These results indicated that PNE downregulates the BDNF pathway and mediates the hippocampal excitotoxicity; then, the compensatory upregulation of GAD67 causes the imbalance of signal output in the fetal hippocampus. The negative feedback regulation of the paraventricular hypothalamic nucleus by the hippocampus is unbalanced, eventually causing hypersensitivity of the HPA axis of the offspring.
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Affiliation(s)
- Yun Pei
- Department of Pharmacology, Basic Medical School of Wuhan University, Wuhan 430071, China
| | - Zhexiao Jiao
- Department of Pharmacology, Basic Medical School of Wuhan University, Wuhan 430071, China
| | - Wanting Dong
- Department of Pharmacology, Basic Medical School of Wuhan University, Wuhan 430071, China
| | - Linguo Pei
- Hubei Provincial Key Laboratory of Developmentally Originated Disease, Wuhan 430071, China
| | - Xia He
- Department of Pharmacology, Basic Medical School of Wuhan University, Wuhan 430071, China
| | - Hui Wang
- Department of Pharmacology, Basic Medical School of Wuhan University, Wuhan 430071, China; Hubei Provincial Key Laboratory of Developmentally Originated Disease, Wuhan 430071, China
| | - Dan Xu
- Department of Pharmacology, Basic Medical School of Wuhan University, Wuhan 430071, China; Hubei Provincial Key Laboratory of Developmentally Originated Disease, Wuhan 430071, China.
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25
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Nakajima H, Nakamura Y, Inaba Y, Tsutsumi C, Unoda K, Hosokawa T, Kimura F, Hanafusa T, Date M, Kitaoka H. Neurologic disorders associated with anti-glutamic acid decarboxylase antibodies: A comparison of anti-GAD antibody titers and time-dependent changes between neurologic disease and type I diabetes mellitus. J Neuroimmunol 2018; 317:84-89. [PMID: 29338930 DOI: 10.1016/j.jneuroim.2018.01.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 12/30/2017] [Accepted: 01/08/2018] [Indexed: 01/04/2023]
Abstract
To determine clinical features of neurologic disorders associated with anti-glutamic acid decarboxylase antibodies (anti-GAD-Ab), we examined titers and time-dependent changes of anti-GAD-Ab. Six patients, stiff person syndrome (2), cerebellar ataxia (1), limbic encephalitis (1), epilepsy (1), brainstem encephalitis (1), were compared with 87 type I diabetes mellitus (T1DM) patients without neurologic disorders. Anti-GAD-Ab titers and index were higher in neurologic disorders than in T1DM, suggesting intrathecal antibody synthesis. Anti-GAD-Ab titers in T1DM decreased over time, whereas they remained high in neurologic disorders. Immunotherapy improved neurological disorders and anti-GAD-Ab titers and index provide clinically meaningful information about their diagnostic accuracy.
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Affiliation(s)
- Hideto Nakajima
- Division of Neurology, Department of Internal Medicine IV, Osaka Medical College, Takatsuki, Osaka 569-8686, Japan.
| | - Yoshitsugu Nakamura
- Division of Neurology, Department of Internal Medicine IV, Osaka Medical College, Takatsuki, Osaka 569-8686, Japan
| | - Yuiko Inaba
- Division of Diabetes and Endocrinology, Department of Internal Medicine I, Osaka Medical College, Takatsuki, Osaka 569-8686, Japan
| | - Chiharu Tsutsumi
- Division of Diabetes and Endocrinology, Department of Internal Medicine I, Osaka Medical College, Takatsuki, Osaka 569-8686, Japan
| | - Kiichi Unoda
- Division of Neurology, Department of Internal Medicine IV, Osaka Medical College, Takatsuki, Osaka 569-8686, Japan
| | - Takafumi Hosokawa
- Division of Neurology, Department of Internal Medicine IV, Osaka Medical College, Takatsuki, Osaka 569-8686, Japan
| | - Fumiharu Kimura
- Division of Neurology, Department of Internal Medicine IV, Osaka Medical College, Takatsuki, Osaka 569-8686, Japan
| | - Toshiaki Hanafusa
- Division of Diabetes and Endocrinology, Department of Internal Medicine I, Osaka Medical College, Takatsuki, Osaka 569-8686, Japan
| | - Masamichi Date
- Department of Internal Medicine, Seikeikai Hospital, Sakai, Osaka 590-0064, Japan
| | - Haruko Kitaoka
- Department of Internal Medicine, Seikeikai Hospital, Sakai, Osaka 590-0064, Japan
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26
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Puri S, Shaikh AG. Basic and translational neuro-ophthalmology of visually guided saccades: disorders of velocity. EXPERT REVIEW OF OPHTHALMOLOGY 2017; 12:457-473. [PMID: 30774705 PMCID: PMC6377082 DOI: 10.1080/17469899.2017.1395695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Saccades are rapid, yoked eye movements in an effort to direct a target over fovea. The complex circuitry of saccadic eye movements has been exhaustively described. As a result clinicians can elegantly localize the pathology if it falls on the neuraxis responsible for saccades. Traditionally saccades are studied with their quantitative characteristics such as amplitude, velocity, duration, direction, latency and accuracy. AREAS COVERED Amongst all subtypes, the physiology of the visually guided saccades is most extensively studied. Here we will review the basic and pertinent neuro-anatomy and physiology of visually guided saccade and then discuss common or classic disorders affecting the velocity of visually guided saccades. We will then discuss the basic mechanism for saccade slowing in these disorders. EXPERT COMMENTARY Prompt appreciation of disorders of saccade velocity is critical to reach appropriate diagnosis. Disorders of midbrain, cerebellum, or basal ganglia can lead to prolonged transition time during gaze shift and decreased saccade velocity.
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Affiliation(s)
- Sushant Puri
- Dept. of Neurology, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio, United States
| | - Aasef G. Shaikh
- Dept. of Neurology, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio, United States
- Daroff-DelOsso Ocular Motility Laboratory, Cleveland VA Medical Center, Cleveland, Ohio, United States
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27
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Dalakas MC, Rakocevic G, Dambrosia JM, Alexopoulos H, McElroy B. A double-blind, placebo-controlled study of rituximab in patients with stiff person syndrome. Ann Neurol 2017; 82:271-277. [PMID: 28749549 DOI: 10.1002/ana.25002] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 07/18/2017] [Accepted: 07/21/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE In stiff person syndrome (SPS), an antibody-mediated impaired γ-aminobutyric acidergic (GABAergic) neurotransmission is believed to cause muscle stiffness and spasms. Most patients improve with GABA-enhancing drugs and intravenous immunoglobulin, but some respond poorly and remain disabled. The need for more effective therapy prompted a trial with the anti-CD20 monoclonal antibody rituximab. METHODS This was a placebo-controlled randomized trial of rituximab (2 biweekly infusions of 1g each). The primary outcome was a change in stiffness scores at 6 months. Secondary outcomes were changes in heightened-sensitivity and quality of life scores. Enrolling 24 patients was calculated to detect 50% change in stiffness scores. RESULTS Randomization was balanced for age, sex, disease duration, and glutamic acid decarboxylase autoantibody titers. No significant changes were noted at 6 months after treatment in all outcomes. Specifically, no differences were noted in the stiffness index, the primary outcome, or sensitivity scores, the secondary outcome, at 3 or 6 months. Quality of life scores improved significantly (p < 0.01) at 3 months in both groups, but not at 6 months, denoting an early placebo effect. Blinded self-assessment rating of the overall stiffness for individual patients revealed improvement in 4 patients in each group. At 6 months, improvement persisted in 1 patient in the placebo group versus 3 of 4 in the rituximab group, where these meaningful improvements were also captured by video recordings. INTERPRETATION This is the largest controlled trial conducted in SPS patients and demonstrates no statistically significant difference in the efficacy measures between rituximab and placebo. Rituximab's lack of efficacy could be due to a considerable placebo effect; insensitivity of scales to quantify stiffness, especially in the less severely affected patients; or drug effectiveness in only a small patient subset. Ann Neurol 2017;82:271-277.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA.,Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Goran Rakocevic
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA
| | - James M Dambrosia
- National Institute of Neurological Disorders and Stroke, Bethesda, MD (retired)
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Beverly McElroy
- National Institute of Neurological Disorders and Stroke, Bethesda, MD (retired)
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Burbelo PD, Iadarola MJ, Alevizos I, Sapio MR. Transcriptomic Segregation of Human Autoantigens Useful for the Diagnosis of Autoimmune Diseases. Mol Diagn Ther 2017; 20:415-27. [PMID: 27259330 DOI: 10.1007/s40291-016-0211-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The measurement of autoantibodies in the clinical care of autoimmune patients allows for diagnosis, monitoring, and even disease prediction. Despite their clinical utility, the functional significance of autoantibody target proteins in many autoimmune diseases remains unclear. Here we present a comprehensive review of 52 autoantigens commonly employed for the serological diagnosis of 24 autoimmune diseases. We discuss their function, whether they have extracellular-exposed epitopes, and whether antibodies to these proteins are known to be pathogenic. Transcriptomics (RNA-Seq) datasets were mined to display messenger RNA (mRNA) expression of the autoantigens across 32 tissues and organs. This analysis revealed that autoantigens cluster into one of three groups: expression in the tissue most strongly affected in the disease (Group I), ubiquitous expression with enrichment in immune tissues (Group II), or expression in other tissues not typically associated with the clinical presentation (Group III). Clustering demonstrated that the autoantigens within Group I were often proteins containing extracellular epitopes, many of which are targets of pathogenic autoantibodies. Group II autoantigens were targets for several rheumatological diseases, including Sjögren syndrome, systemic lupus erythematosus, myositis, and systemic sclerosis, and were ubiquitously expressed with enrichment in immune-rich tissues. This raises the possibility that immune cells in Group II disorders may be the source of autoimmunization and/or targets of immune cell responses. Since tissues showing enriched autoantigen gene expression may contribute to the development of autoantibodies and subsequent autoimmunity, the emergent patterns arising from the autoantigen transcriptomic profiles may provide a new heuristic framework to deconvolute these complex disorders.
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Affiliation(s)
- Peter D Burbelo
- Dental Clinical Research Core, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bldg. 10, Rm. 5N102, Bethesda, MD, 20892, USA.
| | - Michael J Iadarola
- Department of Perioperative Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Ilias Alevizos
- Sjögren's Syndrome and Salivary Gland Dysfunction Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Matthew R Sapio
- Department of Perioperative Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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29
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Smith TD, Cunningham-Rundles C. Detection of anti-glutamic acid decarboxylase antibodies in immunoglobulin products. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:260-261. [PMID: 28669890 DOI: 10.1016/j.jaip.2017.04.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/04/2017] [Accepted: 04/26/2017] [Indexed: 11/15/2022]
Affiliation(s)
- Tukisa D Smith
- Division of Allergy and Clinical Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
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30
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Tohid H. Anti-glutamic acid decarboxylase antibody positive neurological syndromes. ACTA ACUST UNITED AC 2017; 21:215-22. [PMID: 27356651 PMCID: PMC5107286 DOI: 10.17712/nsj.2016.3.20150596] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
A rare kind of antibody, known as anti-glutamic acid decarboxylase (GAD) autoantibody, is found in some patients. The antibody works against the GAD enzyme, which is essential in the formation of gamma aminobutyric acid (GABA), an inhibitory neurotransmitter found in the brain. Patients found with this antibody present with motor and cognitive problems due to low levels or lack of GABA, because in the absence or low levels of GABA patients exhibit motor and cognitive symptoms. The anti-GAD antibody is found in some neurological syndromes, including stiff-person syndrome, paraneoplastic stiff-person syndrome, Miller Fisher syndrome (MFS), limbic encephalopathy, cerebellar ataxia, eye movement disorders, and epilepsy. Previously, excluding MFS, these conditions were calledhyperexcitability disorders. However, collectively, these syndromes should be known as "anti-GAD positive neurological syndromes." An important limitation of this study is that the literature is lacking on the subject, and why patients with the above mentioned neurological problems present with different symptoms has not been studied in detail. Therefore, it is recommended that more research is conducted on this subject to obtain a better and deeper understanding of these anti-GAD antibody induced neurological syndromes.
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Affiliation(s)
- Hassaan Tohid
- Valley View Court, Fairfield, California, United States of America. E-mail:
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31
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McKeon A, Tracy JA. GAD65 neurological autoimmunity. Muscle Nerve 2017; 56:15-27. [PMID: 28063151 DOI: 10.1002/mus.25565] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 01/04/2017] [Indexed: 12/11/2022]
Abstract
The glutamic acid decarboxylase 65-kilodalton isoform (GAD65) antibody is a biomarker of autoimmune central nervous system (CNS) disorders and, more commonly, nonneurological autoimmune diseases. Type 1 diabetes, autoimmune thyroid disease, and pernicious anemia are the most frequent GAD65 autoimmune associations. One or more of these disorders coexists in approximately 70% of patients with GAD65 neurological autoimmunity. Neurological phenotypes have CNS localization and include limbic encephalitis, epilepsy, cerebellar ataxia, and stiff-person syndrome (SPS), among others. Classic SPS is a disorder on the spectrum of CNS hyperexcitability which also includes phenotypes that are either more restricted (stiff-limb syndrome) or more widespread (progressive encephalomyelitis with rigidity and myoclonus). GAD65 antibody is not highly predictive of a paraneoplastic cause for neurological disorders, but diverse cancer types have been occasionally reported. For all phenotypes, responses to immunotherapy are variable (approximately 50% improve). GAD65 autoimmunity is important to recognize for both coexisting nonneurological autoimmune associations and potential immunotherapy-response. Muscle Nerve 56: 15-27, 2017.
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Affiliation(s)
- Andrew McKeon
- Department of Neurology, College of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota, 55905, USA.,Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jennifer A Tracy
- Department of Neurology, College of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota, 55905, USA
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Abstract
OBJECTIVE Epilepsy is a chronic neurological disease characterised with seizures. The aetiology of the most generalised epilepsies cannot be explicitly determined and the seizures are pronounced to be genetically determined by disturbances of receptors in central nervous system. Besides, neurotransmitter distributions or other metabolic problems are supposed to involve in epileptogenesis. Lack of adequate data about pharmacological agents that have antiepileptogenic effects point to need of research on this field. Thus, in this review, inflammatory aspects of epileptogenesis has been focussed via considering several concepts like role of immune system, blood-brain barrier and antibody involvement in epileptogenesis. METHODS We conducted an evidence-based review of the literatures in order to evaluate the possible participation of inflammatory processes to epileptogenesis and also, promising agents which are effective to these processes. We searched PubMed database up to November 2015 with no date restrictions. RESULTS In the present review, 163 appropriate articles were included. Obtained data suggests that inflammatory processes participate to epileptogenesis in several ways like affecting fibroblast growth factor-2 and tropomyosin receptor kinase B signalling pathways, detrimental proinflammatory pathways [such as the interleukin-1 beta (IL-1β)-interleukin-1 receptor type 1 (IL-1R1) system], mammalian target of rapamycin pathway, microglial activities, release of glial inflammatory proteins (such as macrophage inflammatory protein, interleukin 6, C-C motif ligand 2 and IL-1β), adhesion molecules that are suggested to function in signalling pathways between neurons and microglia and also linkage between these molecules and proinflammatory cytokines. CONCLUSION The literature research indicated that inflammation is a part of epileptogenesis. For this reason, further studies are necessary for assessing agents that will be effective in clinical use for therapeutic treatment of epileptogenesis.
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33
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Gao Y, Yan H, Jin R, Lei P. Antiepileptic activity of total triterpenes isolated from Poria cocos is mediated by suppression of aspartic and glutamic acids in the brain. PHARMACEUTICAL BIOLOGY 2016; 54:2528-2535. [PMID: 27159135 DOI: 10.3109/13880209.2016.1168853] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
CONTEXT Triterpenes from Poria cocos Wolf (Polyporaceae) have been used to treat various diseases in traditional Chinese medicine. However, the antiepileptic effects and mechanism are not fully understood. OBJECTIVE The objective of this study is to investigate the antiepileptic properties of total triterpenes (TTP) from the whole P. cocos. MATERIALS AND METHODS The ethanol extract TTP was identified by HPLC fingerprint analysis. Male ICR mice were gavaged (i.g.) with TTP (5, 20, 80 or 160 mg/kg) or reference drugs twice a day for 7 d. Antiepileptic activities of TTP were evaluated by maximal electroshock (MES)- and pentylenetetrazole (PTZ)-induced seizures in mice for 30 and 60 min, respectively. Locomotor activity and Rota-rod tests were performed for 60 min and 5 min, respectively. The levels of glutamic acid (Glu), aspartic acid (Asp), γ-aminobutyric acid (GABA) and glycine (Gly) in convulsive mice were estimated. The chronic epileptic model of Wistar rats was built to measure expressions of glutamate decarboxylase 65 (GAD65) and GABAA in rat brain after TTP treatment. RESULTS The LC50 of TTP (i.g.) was above 6 g/kg. TTP (5-160 mg/kg) protected mice against MES- and PTZ-induced convulsions at 65.0% and 62.5%, respectively, but have no effect on rota-rod treadmill; TTP (20-160 mg/kg) significantly reduced the locomotor activities, shortened the onset of pentobarbital sodium-induced sleep; TTP decreased Glu and Asp levels in convulsive mice, but increased the GAD65 and GABAA expressions in chronic epileptic rats at doses usage. DISCUSSION AND CONCLUSION TTP extracted from P. cocos possessed potential antiepileptic properties and is a candidate for further antiepileptic drug development.
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Affiliation(s)
- Yanqiong Gao
- a Department of Testing , Shannxi Provincial People's Hospital , Xi'an , China
| | - Hua Yan
- b Department of the First West Yard , Shannxi Provincial People's Hospital , Xi'an , China
| | - Ruirui Jin
- c China Unit 61068 of People's Liberation Army Hospital , Xi'an , China
| | - Peng Lei
- d Department of Traditional Chinese Medicine , Shannxi Provincial People's Hospital , Xi'an , China
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Kampylafka EI, Alexopoulos H, Fouka P, Moutsopoulos HM, Dalakas MC, Tzioufas AG. Epileptic syndrome in systemic lupus erythematosus and neuronal autoantibody associations. Lupus 2016; 25:1260-5. [DOI: 10.1177/0961203316636473] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 01/25/2016] [Indexed: 11/15/2022]
Abstract
We investigated systemic lupus erythematosus (SLE) patients with epilepsy, a major and organic neurological symptom. Our aim was to test patients for the autoimmune epilepsy-associated antibodies anti-GAD, anti-NMDAR, anti-AMPAR1/2, anti-GABABR and anti-VGKC. We tested sera from ten SLE patients with current or previous episodes of epileptic seizures. In addition, sera were tested for staining on primary hippocampal neurons. The patients’ clinical and neuroimaging profile, disease activity and accumulated damage scores and therapeutic regimens administered were recorded, and correlations were evaluated. Patients were negative for all anti-neuronal autoantibodies tested, and showed no staining on primary hippocampal cells, which suggests the absence of autoantibodies against neuronal cell surface antigens. Epileptic seizures were all tonic–clonic, and all patients had high disease activity (mean SLE Damage Acticity Index score 19.3 ± 7.3). Six patients had minor or no brain magnetic resonance imaging findings, and three had major findings. 9/10 patients received immunosuppression for 5 ± 4 months, while anti-convulsive treatment was administered to all patients (4.2 ± 3 years). Our results suggest that the majority of SLE-related epileptic seizures cannot be attributed to the action of a single antibody against neuronal antigens. Studies with larger neuropsychiatric SLE populations and stricter inclusion criteria are necessary to verify these findings.
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Affiliation(s)
- E I Kampylafka
- Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - H Alexopoulos
- Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - P Fouka
- Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - H M Moutsopoulos
- Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - M C Dalakas
- Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, Thomas Jefferson University, Philadelphia, USA
| | - A G Tzioufas
- Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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35
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Louraki M, Katsalouli M, Kanaka-Gantenbein C, Kafassi N, Critselis E, Kallinikou D, Tsentidis C, Karavanaki K. The prevalence of early subclinical somatic neuropathy in children and adolescents with Type 1 diabetes mellitus and its association with the persistence of autoantibodies to glutamic acid decarboxylase (GAD) and islet antigen-2 (IA-2). Diabetes Res Clin Pract 2016; 117:82-90. [PMID: 27329026 DOI: 10.1016/j.diabres.2016.04.044] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 04/17/2016] [Accepted: 04/22/2016] [Indexed: 12/20/2022]
Abstract
AIM To evaluate the prevalence of early somatic neuropathy in children and adolescents with Type 1 diabetes mellitus (Type 1 DM) and its association with the presence of glutamic acid decarboxylase and islet antigen-2 autoantibodies (GADA and IA-2A). METHODS A cross-sectional study was conducted in a hospital-based cohort of pediatric Type 1 DM patients (n=85, mean(±SD) age: 13.5±3.4years, mean(±SD) disease duration 5.5±3.4years). Peripheral neuropathy was assessed with nerve conduction studies (NCS). GADA and IA-2A titers were measured with radioligand assays. RESULTS Among the study population, 34.1% had at least one abnormal electrophysiological parameter, although predominantly asymptomatic. The highest rates of abnormality were detected in sensory peroneal nerve (25.9%) followed by sural nerve (15.3%). Affected patients were not different in terms of age, diabetes duration or glycaemic control. Among the participants, 62.4% had positive GADA, 58.8% positive IA-2A and 42.4% double antibody positivity. Abnormal NCS correlated neither with GADA nor with IA-2A levels or positivity. However lower sensory nerve action potential in the peroneal nerve, indicative of early axonal dysfunction, was observed in patients with GADA or IA-2A positivity. Absence of both antibodies was associated with better action potentials in all the examined nerves of the lower limbs. CONCLUSIONS Impaired indices of subclinical peripheral primarily sensory neuropathy were present among one third of Type 1 DM children and adolescents, with no impact of diabetes duration or glycaemic control. GADA and IA-2A seem to be involved in the development of axonal degeneration, in a pathway which remains to be identified.
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Affiliation(s)
- Maria Louraki
- Diabetic Clinic, Second Pediatric Department, University of Athens, "P&A Kyriakou" Children's Hospital, Athens, Greece
| | - Marina Katsalouli
- Neurologic Department, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Christina Kanaka-Gantenbein
- Diabetes Center, First Department of Paediatrics, University of Athens, "Aghia Sophia" Children's Hospital, Athens, Greece
| | | | - Eleni Critselis
- Diabetic Clinic, Second Pediatric Department, University of Athens, "P&A Kyriakou" Children's Hospital, Athens, Greece
| | - Dimitra Kallinikou
- Diabetic Clinic, Second Pediatric Department, University of Athens, "P&A Kyriakou" Children's Hospital, Athens, Greece
| | - Charalampos Tsentidis
- Diabetic Clinic, Second Pediatric Department, University of Athens, "P&A Kyriakou" Children's Hospital, Athens, Greece
| | - Kyriaki Karavanaki
- Diabetic Clinic, Second Pediatric Department, University of Athens, "P&A Kyriakou" Children's Hospital, Athens, Greece.
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36
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Miller-Fisher Syndrome: Are Anti-GAD Antibodies Implicated in Its Pathophysiology? Case Rep Neurol Med 2016; 2016:3431849. [PMID: 27239355 PMCID: PMC4867055 DOI: 10.1155/2016/3431849] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 04/11/2016] [Indexed: 12/22/2022] Open
Abstract
Miller-Fisher syndrome (MFS) is considered as a variant of the Guillain-Barre syndrome (GBS) and its characteristic clinical features are ophthalmoplegia, ataxia, and areflexia. Typically, it is associated with anti-GQ1b antibodies; however, a significant percentage (>10%) of these patients are seronegative. Here, we report a 67-year-old female patient who presented with the typical clinical features of MFS. Workup revealed antibodies against glutamic acid decarboxylase (GAD) in relatively high titers while GQ1b antibodies were negative. Neurological improvement was observed after intravenous gamma globulin and follow-up examinations showed a continuous clinical amelioration with simultaneous decline of anti-GAD levels which finally returned to normal values. This case indicates that anti-GAD antibodies may be associated with a broader clinical spectrum and future studies in GQ1b-seronegative patients could determine ultimately their clinical and pathogenetic significance in this syndrome.
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Graus F, Titulaer MJ, Balu R, Benseler S, Bien CG, Cellucci T, Cortese I, Dale RC, Gelfand JM, Geschwind M, Glaser CA, Honnorat J, Höftberger R, Iizuka T, Irani SR, Lancaster E, Leypoldt F, Prüss H, Rae-Grant A, Reindl M, Rosenfeld MR, Rostásy K, Saiz A, Venkatesan A, Vincent A, Wandinger KP, Waters P, Dalmau J. A clinical approach to diagnosis of autoimmune encephalitis. Lancet Neurol 2016; 15:391-404. [PMID: 26906964 PMCID: PMC5066574 DOI: 10.1016/s1474-4422(15)00401-9] [Citation(s) in RCA: 2325] [Impact Index Per Article: 290.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 12/08/2015] [Accepted: 12/16/2015] [Indexed: 12/18/2022]
Abstract
Encephalitis is a severe inflammatory disorder of the brain with many possible causes and a complex differential diagnosis. Advances in autoimmune encephalitis research in the past 10 years have led to the identification of new syndromes and biomarkers that have transformed the diagnostic approach to these disorders. However, existing criteria for autoimmune encephalitis are too reliant on antibody testing and response to immunotherapy, which might delay the diagnosis. We reviewed the literature and gathered the experience of a team of experts with the aims of developing a practical, syndrome-based diagnostic approach to autoimmune encephalitis and providing guidelines to navigate through the differential diagnosis. Because autoantibody test results and response to therapy are not available at disease onset, we based the initial diagnostic approach on neurological assessment and conventional tests that are accessible to most clinicians. Through logical differential diagnosis, levels of evidence for autoimmune encephalitis (possible, probable, or definite) are achieved, which can lead to prompt immunotherapy.
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Affiliation(s)
- Francesc Graus
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Service of Neurology, Hospital Clinic, Barcelona, Spain.
| | | | - Ramani Balu
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Susanne Benseler
- Department of Pediatrics, Alberta Children Hospital, Calgary, AB, Canada
| | | | - Tania Cellucci
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - Irene Cortese
- Neuroimmunology Clinic, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Russell C Dale
- Neuroimmunology Group, Children's Hospital at Westmead, University of Sydney, Sydney, NSW, Australia
| | - Jeffrey M Gelfand
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Michael Geschwind
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Carol A Glaser
- Division of Pediatric Infectious Diseases, Kaiser Permanente, Oakland Medical Center and University of California, San Francisco, CA, USA
| | - Jerome Honnorat
- French Reference Center on Paraneoplastic Neurological Syndrome, Hospices Civils De Lyon, Hôpital Neurologique, Inserm U1028, CNRS UMR 5292, Lyon's Neurosciences Research Center, Université Claude-Bernard Lyon-1, Lyon, France
| | - Romana Höftberger
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Takahiro Iizuka
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Sarosh R Irani
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Eric Lancaster
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Frank Leypoldt
- Neuroimmunology, Institute of Clinical Chemistry, and Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Harald Prüss
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany; German Center for Neurodegenerative Disorders Berlin, Berlin, Germany
| | | | - Markus Reindl
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Myrna R Rosenfeld
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Kevin Rostásy
- Department of Pediatric Neurology, Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany
| | - Albert Saiz
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Service of Neurology, Hospital Clinic, Barcelona, Spain
| | - Arun Venkatesan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Klaus-Peter Wandinger
- Institute of Clinical Chemistry and Department of Neurology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Patrick Waters
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Josep Dalmau
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA; Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain.
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Mitoma H, Adhikari K, Aeschlimann D, Chattopadhyay P, Hadjivassiliou M, Hampe CS, Honnorat J, Joubert B, Kakei S, Lee J, Manto M, Matsunaga A, Mizusawa H, Nanri K, Shanmugarajah P, Yoneda M, Yuki N. Consensus Paper: Neuroimmune Mechanisms of Cerebellar Ataxias. CEREBELLUM (LONDON, ENGLAND) 2016; 15:213-32. [PMID: 25823827 PMCID: PMC4591117 DOI: 10.1007/s12311-015-0664-x] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In the last few years, a lot of publications suggested that disabling cerebellar ataxias may develop through immune-mediated mechanisms. In this consensus paper, we discuss the clinical features of the main described immune-mediated cerebellar ataxias and address their presumed pathogenesis. Immune-mediated cerebellar ataxias include cerebellar ataxia associated with anti-GAD antibodies, the cerebellar type of Hashimoto's encephalopathy, primary autoimmune cerebellar ataxia, gluten ataxia, Miller Fisher syndrome, ataxia associated with systemic lupus erythematosus, and paraneoplastic cerebellar degeneration. Humoral mechanisms, cell-mediated immunity, inflammation, and vascular injuries contribute to the cerebellar deficits in immune-mediated cerebellar ataxias.
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Affiliation(s)
- Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, Tokyo, Japan.
| | - Keya Adhikari
- Department of Haematology, Nil Ratan Sircar Medical College, 138 A J C Bose Road, Kolkata, 700014, West Bengal, India
| | - Daniel Aeschlimann
- Matrix Biology &Tissue Repair Research Unit, School of Dentistry, College of Biomedical and Life Sciences, Cardiff University, Cardiff, Wales, UK
| | - Partha Chattopadhyay
- Department of General Medicine, College of Medicine & Sagore Dutta Hospital, 578 B T Road, Kamarhati-Kolkata, 700056, West Bengal, India
| | | | - Christiane S Hampe
- School of Medicine, University of Washington, 850 Republication, Seattle, WA, 98109, USA
| | - Jérôme Honnorat
- University Lyon 1, University Lyon, Rue Guillaume Paradin, 69372, Lyon Cedex 08, France
- INSERM, UMR-S1028, CNRS, UMR-5292, Neuro-Oncology and Neuro-Inflammation Team, 7, Lyon Neuroscience Research Center, Rue Guillaume Paradin, 69372, Lyon Cedex 08, France
- National Reference Centre for Paraneoplastic Neurological Diseases, Hospices Civils de Lyon, Hôpital Neurologique, 69677, Bron, France
- Hospices Civils de Lyon, Neuro-oncology, Hôpital Neurologique, 69677, Bron, France
| | - Bastien Joubert
- University Lyon 1, University Lyon, Rue Guillaume Paradin, 69372, Lyon Cedex 08, France
- INSERM, UMR-S1028, CNRS, UMR-5292, Neuro-Oncology and Neuro-Inflammation Team, 7, Lyon Neuroscience Research Center, Rue Guillaume Paradin, 69372, Lyon Cedex 08, France
| | - Shinji Kakei
- Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Jongho Lee
- Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Mario Manto
- Unité d'Etude du Mouvement, FNRS, Neurologie ULB-Erasme, 808 Route de Lennik, 1070, Brussels, Belgium
| | - Akiko Matsunaga
- Department of Neurology, University of Fukui Hospital, Fukui, Japan
| | | | - Kazunori Nanri
- Department of Neurology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Priya Shanmugarajah
- Academic Department of Neurosciences, Royal Hallamshire Hospital, Sheffield, UK
| | - Makoto Yoneda
- Faculty of Nursing and Social Welfare Sciences, Fukui Prefectural University, Fukui, Japan
| | - Nobuhiro Yuki
- Departments of Medicine and Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Chefdeville A, Honnorat J, Hampe CS, Desestret V. Neuronal central nervous system syndromes probably mediated by autoantibodies. Eur J Neurosci 2016; 43:1535-52. [PMID: 26918657 DOI: 10.1111/ejn.13212] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 02/09/2016] [Accepted: 02/15/2016] [Indexed: 01/17/2023]
Abstract
In the last few years, a rapidly growing number of autoantibodies targeting neuronal cell-surface antigens have been identified in patients presenting with neurological symptoms. Targeted antigens include ionotropic receptors such as N-methyl-d-aspartate receptor or the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor, metabotropic receptors such as mGluR1 and mGluR5, and other synaptic proteins, some of them belonging to the voltage-gated potassium channel complex. Importantly, the cell-surface location of these antigens makes them vulnerable to direct antibody-mediated modulation. Some of these autoantibodies, generally targeting ionotropic channels or their partner proteins, define clinical syndromes resembling models of pharmacological or genetic disruption of the corresponding antigen, suggesting a direct pathogenic role of the associated autoantibodies. Moreover, the associated neurological symptoms are usually immunotherapy-responsive, further arguing for a pathogenic effect of the antibodies. Some studies have shown that some patients' antibodies may have structural and functional in vitro effects on the targeted antigens. Definite proof of the pathogenicity of these autoantibodies has been obtained for just a few through passive transfer experiments in animal models. In this review we present existing and converging evidence suggesting a pathogenic role of some autoantibodies directed against neuronal cell-surface antigens observed in patients with central nervous system disorders. We describe the main clinical symptoms characterizing the patients and discuss conflicting arguments regarding the pathogenicity of these antibodies.
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Affiliation(s)
- Aude Chefdeville
- Institut NeuroMyoGène, INSERM U1217/UMR CNRS 5310, Lyon, France.,Université de Lyon, Lyon, France
| | - Jérôme Honnorat
- Institut NeuroMyoGène, INSERM U1217/UMR CNRS 5310, Lyon, France.,Université de Lyon, Lyon, France.,French Reference Center on Paraneoplastic Neurological Syndrome, F-69677, Bron, France.,Department of Neurology, Hospices Civils de Lyon, Hôpital Neurologique, F-69677, Bron, France
| | | | - Virginie Desestret
- Institut NeuroMyoGène, INSERM U1217/UMR CNRS 5310, Lyon, France.,Université de Lyon, Lyon, France.,French Reference Center on Paraneoplastic Neurological Syndrome, F-69677, Bron, France.,Department of Neurology, Hospices Civils de Lyon, Hôpital Neurologique, F-69677, Bron, France
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40
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Prud'homme GJ, Glinka Y, Wang Q. Immunological GABAergic interactions and therapeutic applications in autoimmune diseases. Autoimmun Rev 2015; 14:1048-56. [DOI: 10.1016/j.autrev.2015.07.011] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 07/17/2015] [Indexed: 12/20/2022]
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41
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Glover RL, DeNiro LV, Lasala PA, Weidenheim KM, Graber JJ, Boro A. ILAE type 3 hippocampal sclerosis in patients with anti-GAD-related epilepsy. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2015; 2:e122. [PMID: 26161431 PMCID: PMC4484895 DOI: 10.1212/nxi.0000000000000122] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 05/05/2015] [Indexed: 11/17/2022]
Abstract
Objective: To describe the neuropathologic findings and clinical course of 2 patients who underwent temporal lobectomy for medically refractive epilepsy and were later found to have high anti–glutamic acid decarboxylase (GAD) concentrations. Methods: Small case series. Results: Neuropathologic examination of both patients revealed International League Against Epilepsy (ILAE) type 3 hippocampal sclerosis. Following surgery, both developed signs and symptoms of stiff person syndrome and later cerebellar ataxia. Laboratory studies demonstrated high concentrations of anti-GAD antibodies in both patients. Conclusions: These cases suggest that ILAE type 3 hippocampal sclerosis may be immunologically related to and may exist as part of a broader anti-GAD–related neurologic syndrome in some instances.
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Affiliation(s)
- Robert L Glover
- Department of Neurology (R.L.G., L.V.D., K.M.W., J.J.G., A.B.), Department of Neurological Surgery (P.A.L., K.M.W.), and Department of Pathology (K.M.W.), Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Lauren V DeNiro
- Department of Neurology (R.L.G., L.V.D., K.M.W., J.J.G., A.B.), Department of Neurological Surgery (P.A.L., K.M.W.), and Department of Pathology (K.M.W.), Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Patrick A Lasala
- Department of Neurology (R.L.G., L.V.D., K.M.W., J.J.G., A.B.), Department of Neurological Surgery (P.A.L., K.M.W.), and Department of Pathology (K.M.W.), Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Karen M Weidenheim
- Department of Neurology (R.L.G., L.V.D., K.M.W., J.J.G., A.B.), Department of Neurological Surgery (P.A.L., K.M.W.), and Department of Pathology (K.M.W.), Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Jerome J Graber
- Department of Neurology (R.L.G., L.V.D., K.M.W., J.J.G., A.B.), Department of Neurological Surgery (P.A.L., K.M.W.), and Department of Pathology (K.M.W.), Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Alexis Boro
- Department of Neurology (R.L.G., L.V.D., K.M.W., J.J.G., A.B.), Department of Neurological Surgery (P.A.L., K.M.W.), and Department of Pathology (K.M.W.), Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
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42
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Anti-GAD-associated inflammatory myopathy presenting with dropped head syndrome. Neurol Sci 2015; 36:1517-9. [PMID: 26017349 DOI: 10.1007/s10072-015-2185-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 03/19/2015] [Indexed: 01/25/2023]
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Farooq AV, Soin K, Moss HE. Alternating skew deviation in association with anti-glutamic acid decarboxylase antibodies. Neuroophthalmology 2015; 39:140-143. [PMID: 26594078 DOI: 10.3109/01658107.2015.1011755] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The presence of an elevated anti-glutamic acid decarboxylase (GAD) antibody level has been associated with a number of eye movement abnormalities, as well as other findings including cerebellar ataxia and insulin dependent diabetes mellitus. Skew deviation in association with anti-GAD antibodies has not been previously reported. Here we report a case of alternating skew deviation along with cerebellar-brainstem signs in a patient with an elevated anti-GAD antibody titer. Follow-up neurologic evaluation after treatment with intravenous immunoglobulin revealed improvement in cerebellar-brainstem signs, while ophthalmic evaluation was stable.
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Affiliation(s)
- Asim V Farooq
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL
| | - Ketki Soin
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL
| | - Heather E Moss
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL
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44
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Acquired ataxias: the clinical spectrum, diagnosis and management. J Neurol 2015; 262:1385-93. [DOI: 10.1007/s00415-015-7685-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 02/14/2015] [Accepted: 02/16/2015] [Indexed: 12/29/2022]
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45
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Gresa-Arribas N, Ariño H, Martínez-Hernández E, Petit-Pedrol M, Sabater L, Saiz A, Dalmau J, Graus F. Antibodies to inhibitory synaptic proteins in neurological syndromes associated with glutamic acid decarboxylase autoimmunity. PLoS One 2015; 10:e0121364. [PMID: 25774787 PMCID: PMC4361655 DOI: 10.1371/journal.pone.0121364] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 01/31/2015] [Indexed: 12/12/2022] Open
Abstract
Antibodies to glutamic acid decarboxylase (GAD-ab) associate to different neurological syndromes. It is unknown if the diversity in syndrome association represents epitopes in different immunodominant domains or co-existence of antibodies to other proteins of the inhibitory synapsis. We examined the serum and CSF of 106 patients with anti-GAD related syndromes (39 cerebellar ataxia, 32 stiff-person syndrome [SPS], 18 epilepsy, and 17 limbic encephalitis [LE]). GAD65-ab titres were quantified by ELISA. Immunoblot was used to determine if the antibody-targeted epitopes of GAD65 and GAD67 were linear. A cell-based assay (CBA) with HEK293 cells expressing the GAD65 N-terminal, central catalytic domain, or C-terminal was used to investigate the immunodominant domains. Antibodies to GAD67, gamma-aminobutyric acid A receptor (GABAaR), glycine receptor (GlyR), GABAaR-associated protein (GABARAP), and gephyrin were determined with CBA. GAD-ab internalization was investigated using cultured rat hippocampal neurons. CSF GAD65-ab titres were higher in patients with cerebellar ataxia and LE compared to those with SPS (p = 0.02). GAD67-ab were identified in 81% of sera and 100% of CSF. GAD65-ab recognized linear epitopes in 98% of the patients and GAD67-ab in 42% (p<0.001). The GAD65 catalytic domain was recognized by 93% of sera, and the three domains by 22% of sera and 74% of CSF (p<0.001). Six patients had GABAaR-ab and another 6 had GlyR-ab without association to distinctive symptoms. None of the patients had gephyrin- or GABARAP-ab. GAD65-ab were not internalized by live neurons. Overall, these findings show that regardless of the neurological syndrome, the CSF immune response against GAD is more widespread than that of the serum and that there is no specific association between clinical phenotype and the presence of antibodies against other proteins of the inhibitory synapsis.
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Affiliation(s)
- Nuria Gresa-Arribas
- Neuroimmunology Program, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Helena Ariño
- Neuroimmunology Program, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Service of Neurology, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Eugenia Martínez-Hernández
- Neuroimmunology Program, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Service of Neurology, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Mar Petit-Pedrol
- Neuroimmunology Program, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Lidia Sabater
- Neuroimmunology Program, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Albert Saiz
- Neuroimmunology Program, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Service of Neurology, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Josep Dalmau
- Neuroimmunology Program, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Francesc Graus
- Neuroimmunology Program, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Service of Neurology, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
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Fouka P, Alexopoulos H, Akrivou S, Trohatou O, Politis PK, Dalakas MC. GAD65 epitope mapping and search for novel autoantibodies in GAD-associated neurological disorders. J Neuroimmunol 2015; 281:73-7. [PMID: 25867471 DOI: 10.1016/j.jneuroim.2015.03.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 03/06/2015] [Accepted: 03/07/2015] [Indexed: 10/23/2022]
Abstract
Antibodies against Glutamic-acid-decarboxylase (GAD65) are seen in various CNS excitability disorders including stiff-person syndrome, cerebellar ataxia, encephalitis and epilepsy. To explore pathogenicity, we examined whether distinct epitope specificities or other co-existing antibodies may account for each disorder. The epitope recognized by all 27 tested patients, irrespective of clinical phenotype, corresponded to the catalytic core of GAD. No autoantibodies against known GABAergic antigens were found. In a screen for novel specificities using live hippocampal neurons, three epilepsy patients, but no other, were positive. We conclude that no GAD-specific epitope defines any neurological syndrome but other antibody specificities may account for certain phenotypes.
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Affiliation(s)
- P Fouka
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Greece; Center for Basic Research, Biomedical Research Foundation of the Academy of Athens, Greece
| | - H Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Greece
| | - S Akrivou
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Greece
| | - O Trohatou
- Center for Basic Research, Biomedical Research Foundation of the Academy of Athens, Greece
| | - P K Politis
- Center for Basic Research, Biomedical Research Foundation of the Academy of Athens, Greece
| | - M C Dalakas
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Greece.
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Velardo D, Nuara A, Martinelli V, Comi G, Fazio R. Anti-GAD antibody-positive myoclonic leg jerks. Neurol Sci 2015; 36:647-8. [PMID: 25557237 DOI: 10.1007/s10072-014-2058-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 12/28/2014] [Indexed: 11/29/2022]
Affiliation(s)
- D Velardo
- Division of Neuroscience, San Raffaele Scientific Institute, Via Olgettina, 60, Milan, Italy,
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Ohara N, Kojima N, Sato T, Ikarashi T, Sone H, Oki Y, Kamoi K, Hara M, Sasaki H. Type 1 diabetes mellitus and isolated adrenocorticotropin deficiency manifested by parkinsonism: a case report and literature review. Intern Med 2015; 54:2629-35. [PMID: 26466701 DOI: 10.2169/internalmedicine.54.5022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 67-year-old woman developed isolated adrenocorticotropin deficiency (IAD), which manifested as lethargy, a 20-kg body weight loss, hypoglycemia, and parkinsonism, and began corticosteroid replacement. Her symptoms resolved rapidly, and her weight returned to normal within six months. However, she then developed slowly progressive type 1 diabetes mellitus (T1D) with co-existing Hashimoto thyroiditis, and commenced insulin therapy. To our knowledge, this is the first reported case of parkinsonism associated with IAD. In addition, because diabetes mellitus, including T1D, could be latent in patients with untreated IAD, careful assessment of glucose metabolism is needed after commencing corticosteroid replacement until weight regain is achieved.
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Affiliation(s)
- Nobumasa Ohara
- Department of Endocrinology and Metabolism, Niigata Medical Center, Japan
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Dalakas MC. Mechanistic effects of IVIg in neuroinflammatory diseases: conclusions based on clinicopathologic correlations. J Clin Immunol 2014; 34 Suppl 1:S120-6. [PMID: 24722854 DOI: 10.1007/s10875-014-0024-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 03/19/2014] [Indexed: 12/29/2022]
Abstract
The mechanisms of action of IVIg on immunoregulatory and neuroinflammatory network have been predominantly based on in vitro experiments and animal studies, rather than direct effects on human tissues. Based on clinicopathologic correlations and tissues obtained before and after IVIg therapy, the better documented and clinically-relevant in-vivo actions of IVIg include effects on: a) Antibodies. An extracted antigen-specific anti-immunoglobulin (idiotypic) fraction appears partially responsible for its effect in myasthenia gravis and GBS; b) Complement. Sera from Dermatomyositis (DM) patients responding to IVIg, inhibit complement consumption and intercept MAC formation leading to disappearance of MAC deposits in the repeated muscle biopsies and normalization of muscle tissue; c) Genes. In repeated muscle biopsies from DM patients who improved after IVIg, but not from Inclusion-Body-Myositis (IBM) who did not improve, there is a 2-fold alteration of 2206 tissue genes associated with inflammation, fibrosis, tissue remodeling and regeneration; and d) degenerative-proinflammatory molecules and β-amyloid, implicated in neurodegenerative CNS diseases and IBM. In repeated muscle biopsies of IBM patients who did not respond to IVIg, the mRNA or protein expression for chemokines, IFN-γ, TGF-ß, IL-10, Ubiquitin and aB-crystallin is reduced, but not for the key molecules ICOS, ICOSL, IL-6, IL1-β, perforin, APP, nitric oxide synthase and nitrotyrosine, in spite of good IVIg penetration in muscles. Collectively, the selective effectiveness of IVIg in human diseases seems to correlate in vivo with inhibition of causative inflammatory mediators. Study of accessible tissues before and after therapy and clinicopathologic correlations, may help explain the differential effect of IVIg in autoimmune or neuroinflammatory diseases.
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