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Ohashi N, Kamijima S, Watanabe R, Tazawa KI. [Peripheral neuropathy associated with severe glial fibrillary acidic protein (GFAP) astrocytopathy: a case report]. Rinsho Shinkeigaku 2024; 64:403-407. [PMID: 38797687 DOI: 10.5692/clinicalneurol.cn-001940] [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: 05/29/2024]
Abstract
A 44-year-old man was admitted due to a fever. He developed unconsciousness and respiratory failure, necessitating mechanical ventilation. After the administration of methylprednisolone and intravenous immunoglobulin for suspected autoimmune encephalitis, his consciousness and respiratory state improved. However, he exhibited pronounced tetraparalysis and impaired sensation below the neck. A spinal MRI revealed swelling of the entire spinal cord, indicating myelitis. Deep tendon reflexes were diminished in all extremities, and a nerve conduction study confirmed motor-dominant axonal polyneuropathy. Subsequently, he developed a fever and headache. Brain MRI demonstrated FLAIR hyperintensities in the basal ganglia and brain stem. CSF analysis for anti-glial fibrillary acidic protein (GFAP) antibody turned out positive, leading to the diagnosis of GFAP astrocytopathy. Although the steroid re-administration improved muscle strength in his upper limbs and reduced the range of diminished sensation, severe hemiparalysis remained. Severe GFAP astrocytopathy can be involved with polyneuropathy. Early detection and therapeutic intervention for this condition may lead to a better prognosis.
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Affiliation(s)
| | | | - Rie Watanabe
- Department of Neurology, Nagano Red Cross Hospital
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Chen Y, Luo C, Zhou G, Wang H, Dai K, Wu W, Wang S, Su Z, Peng F, Jiang Y. The discrimination between autoimmune glial fibrillary acidic protein astrocytopathy and tuberculous meningitis. Mult Scler Relat Disord 2024; 85:105527. [PMID: 38432014 DOI: 10.1016/j.msard.2024.105527] [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: 11/16/2023] [Revised: 02/25/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE The differential diagnosis between autoimmune glial fibrillary acidic protein astrocytopathy (AGFAPA) mimicking tuberculous meningitis and tuberculous meningitis (TBM) remains challenging in clinical practice. This study aims to identify the clinical, laboratory parameters, and clinical score systems that may be helpful in differentiating AGFAPA from TBM. METHOD Overall 22 AGFAPA patients who were initially misdiagnosed as TBM (AGFAPA-TBM) and 30 confirmed TBM patients were included. The clinical, laboratory, imaging parameters, Thwaites systems, and Lancet consensus scoring systems (LCSS) of all patients were reviewed. Logistic regression was employed to establish a diagnostic formula to differentiate AGFAPA-TBM from TBM. The receiver operating characteristic (ROC) curve was applied to determine the best diagnostic critical point of the formula. RESULTS Urinary retention was more frequent in AGFAPA-TBM patients (72.7% vs 33.3%, p = 0.012). A significantly lower ratio of T-SPOT. TB was noted in AGFAPA-TBM patients (9.1% vs 82.1%, p < 0.001). We found the LCSS was able to differentiate AGFAPA-TBM from TBM (AUC value 0.918, 95% CI=0.897-0.924). Furthermore, we set up a new scoring system with three variables: urinary retention, T-SPOT. TB, and cerebral imaging criteria in LCSS. The proposed diagnostic score ranges from -8 to 2, and a score of ≥ 0 was suggestive of AGFAPA-TBM (AUC value 0.938, 95% CI=0.878-0.951). CONCLUSIONS This study is the first to evaluate the Thwaites system and LCSS in AGFAPA-TBM and TBM. We provide an alternative diagnostic formula to differentiate AGFAPA-TBM from TBM and suggest testing for GFAP antibodies to avoid misdiagnosis when this scoring system meets AGFAPA-TBM.
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Affiliation(s)
- Yanxiang Chen
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China; Department of Neurology, Xiaolan People's Hospital of Zhongshan, 65#, Middle Section of Jucheng Avenue, Xiaolan, Zhongshan, Guangdong Province 528400, China
| | - Chongliang Luo
- Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St Louis, MO 63110, USA
| | - Guonan Zhou
- Department of Encephalopathy, Zhongshan Chenxinghai Hospital of Integrated Traditional Chinese and Western Medicine, 18# Zhuyuan Road, Zhongshan, Guangdong Province 528400, China
| | - Hui Wang
- Department of Neurology, Xiaolan People's Hospital of Zhongshan, 65#, Middle Section of Jucheng Avenue, Xiaolan, Zhongshan, Guangdong Province 528400, China
| | - Kai Dai
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China
| | - Weijuan Wu
- Department of Neurology, Sanshui District People's Hospital, Sanshui, Foshan, Guangdong Province 528100, China
| | - Siguang Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China
| | - Zhihui Su
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China
| | - Fuhua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China.
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China.
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Shosha E, Connolly C, Budhram A. Case report: Headache as the sole neurological symptom in autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy. Front Neurol 2024; 15:1366263. [PMID: 38699059 PMCID: PMC11063300 DOI: 10.3389/fneur.2024.1366263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/14/2024] [Indexed: 05/05/2024] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a recently emerging autoimmune disease of the central nervous system (CNS); GFAP astrocytopathy is characterized by optic neuritis and meningoencephalomyelitis. We report the case of a 55-year-old man, otherwise healthy, who presented with isolated headaches for three months, without other features of meningoencephalitis or myelitis. His neurological examination and fundoscopy were unremarkable. Gadolinium-enhanced brain MRI demonstrated increased T2 hyperintensity within the right sub-lenticular basal ganglia, with additional leptomeningeal enhancement along the bilateral perisylvian regions and mesial temporal lobes. Cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis, elevated protein, matching oligoclonal bands, and a negative infectious and cytological workup. Cell-based assays for anti-aquaporin-4, anti-myelin oligodendrocyte glycoprotein, autoimmune encephalitis panel, and vasculitis workup were all negative, except for CSF positivity for GFAP α antibody. Oncological screening, including CT of the chest, abdomen, pelvis, and scrotal US, was unremarkable. Immunotherapy with high-dose intravenous steroids for five days and subsequent single four-weekly doses resulted in the resolution of both clinical and radiographic features, with a maintained status 24 months after onset. This case highlights isolated headache and basal ganglia, mesial temporal lobe involvement as a rare presentation of autoimmune GFAP astrocytopathy.
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Affiliation(s)
- Eslam Shosha
- Neurology Division, Department of Medicine, McMaster University, Hamilton Health Science Center, Hamilton, ON, Canada
| | - Colleen Connolly
- Neurology Division, Department of Medicine, McMaster University, Hamilton Health Science Center, Hamilton, ON, Canada
| | - Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Science Center, London, ON, Canada
- Department of Pathology and Laboratory Medicine, Western University, London Health Science Center, London, ON, Canada
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Ke G, Jian S, Yang T, Zhao X. Clinical characteristics and MRI features of autoimmune glial fibrillary acidic protein astrocytopathy: a case series of 34 patients. Front Neurol 2024; 15:1375971. [PMID: 38585352 PMCID: PMC10995392 DOI: 10.3389/fneur.2024.1375971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 03/11/2024] [Indexed: 04/09/2024] Open
Abstract
Objectives To analyze the clinical and imaging characteristics of autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A). Methods Forty-three patients diagnosed with GFAP-A between March 2017 and July 2023 were retrospectively recruited. The clinical characteristics and magnetic resonance imaging (MRI) features were collected. Results Twenty-one patients (61.8%) had a fever and 16 (47.1%) had a headache. Five patients (14.7%) had coexisting neural autoantibodies and one patient (2.9%) had a coexisting neoplasm. The most common presentation was meningoencephalomyelitis (13/34, 38.3%), followed by meningoencephalitis (12/34, 35.3%). The other clinical manifestations included blurred visions (5/34, 14.7%) and peripheral nervous system involvement (4/34, 11.8%). Twenty-six patients (76.5%) had elevated nucleated cell count, predominantly lymphocytes (15/15, 100%), and 27 (79.4%) had elevated protein levels of cerebrospinal fluid. One-half (50%) of the patients presented with hyponatremia. A majority of the patients (30/33, 90.9%) exhibited abnormal hyperintense lesions on T2WI, which were often located in juxtacortical white matter (18/33, 54.5%), followed by periventricular white matter (16/33, 48.5%), basal ganglia (15/ 33, 45.5%), brainstem (11/33, 33.3%), and thalamic lesions (9/33, 27.3%). Twenty-four patients (72.7%) had abnormal brain enhancement, with supratentorial leptomeningeal enhancement being the most frequent enhancement pattern (15/33, 45.5%), followed by linear perivascular radial enhancement (14/33, 42.4%). Nineteen patients (70.4%) had hyperintense intramedullary spinal cord lesions, with long segments (15/27, 55.6%) and transverse lesions (14/27, 51.9%) being the most frequent lesions. Most cases were sensitive to immunotherapy, such as glucocorticoids, intravenous immunoglobulin, and tacrolimus, with three patients (8.8%) experiencing relapses. Patients with brainstem lesions had higher onset modified Rankin scale scores and were more prone to intensive care unit admissions. Linear perivascular radial enhancement was positively associated with poor prognosis (p < 0.05). Conclusion GFAP-A presented with meningoencephalomyelitis and meningoencephalitis. The brain lesions were often located in juxtacortical white matter, periventricular white matter, basal ganglia, brainstem, and thalamus. Long segments and transverse were the most frequent spine lesions. Leptomeningeal enhancement was the most frequent enhancement pattern, followed by linear perivascular radial enhancement, which may provide new insight into the differential diagnosis of GFAP-A.
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Affiliation(s)
| | | | | | - Xu Zhao
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Liang Y, Wang G, Li B, Li G, Zeng H. Autoimmune glial fibrillary acidic protein astrocytosis mimicking tuberculous meningitis: a retrospective study. J Neurol 2023; 270:4860-4867. [PMID: 37338614 PMCID: PMC10511357 DOI: 10.1007/s00415-023-11818-8] [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: 02/23/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND This study aimed to summarize the clinical features of Autoimmune Glial Fibrillary Acidic Protein Astrocytosis mimicking tuberculosis meningitis to improve clinicians' understanding of this disease. METHODS We retrospectively analyzed the clinical manifestations, cerebrospinal fluid results, and imaging data of five patients with Autoimmune Glial Fibrillary Acidic Protein Astrocytosis mimicking tuberculous meningitis who were admitted to Xiangya Hospital Central South University between October 2021 and July 2022. RESULTS Five patients were aged 31-59 years, with a male-to-female ratio of 4:1. Among the cases reviewed, four had a history of prodromal infections manifesting as fever and headache. One patient developed limb weakness and numbness with clinical manifestations of meningitis, meningoencephalitis, encephalomyelitis, or meningomyelitis. Cerebrospinal fluid analysis revealed an increased cell count in five cases, with a lymphocyte majority. All five cases had a CSF protein level > 1.0 g/L, CSF/blood glucose ratio < 0.5, and two patients had CSF glucose < 2.2 mmol/L. Decreased CSF chloride was observed in three cases, while increased ADA was observed in one case. Both serum and cerebrospinal fluid were positive for anti-GFAP antibodies in three cases, while in two cases, only CSF was positive for anti-GFAP antibodies. Additionally, hyponatremia and hypochloremia were observed in three cases. No tumors were detected in any of the five patients during tumor screening, and all five cases had a good prognosis following immunotherapy. CONCLUSION Anti-GFAP antibody testing should be routinely performed in patients with suspected tuberculosis meningitis to avoid misdiagnosis.
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Affiliation(s)
- Yingfang Liang
- Department of Comprehensive Internal Medicine, The Affiliated Tumor Hospital of Guangxi Medical University, 71#Hedi Rd, Nanning, GuangXi, China
| | - Gangqi Wang
- Department of Neurology, Xiangya Hospital, Central South University, 87#Xiangya Rd, Changsha, Hunan, China
| | - Bixun Li
- Department of Comprehensive Internal Medicine, The Affiliated Tumor Hospital of Guangxi Medical University, 71#Hedi Rd, Nanning, GuangXi, China
| | - Guoliang Li
- Department of Neurology, Xiangya Hospital, Central South University, 87#Xiangya Rd, Changsha, Hunan, China.
| | - Hao Zeng
- Department of Spine and Osteopathy Surgery, The First Affiliated Hospital of Guangxi Medical University, 6#Shuangyong Rd, Nanning, GuangXi, China.
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Liu D, Lin PH, Li HL, Yang J, You Y, Yang X, Jiang LH, Ma CY, Xu LF, Zhang QX, Liao S, Chen H, Yue JJ, Lu YY, Lian C, Liu Y, Wang ZH, Ye JL, Qiu W, Shu YQ, Wang HY, Liu HL, Wang Y, Duan CM, Yang H, Wu XL, Zhang L, Feng HY, Chen H, Zhou HS, Xu QH, Zhao GX, Ou TF, Wang JL, Lu YH, Mao ZF, Gao C, Guo J, Zhang HY, Chen S, Li J, Long YM. Early autoimmunity and outcome in virus encephalitis: a retrospective study based on tissue-based assay. J Neurol Neurosurg Psychiatry 2023; 94:605-613. [PMID: 37225405 PMCID: PMC10359542 DOI: 10.1136/jnnp-2022-330626] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 02/28/2023] [Indexed: 05/26/2023]
Abstract
To explore the autoimmune response and outcome in the central nervous system (CNS) at the onset of viral infection and correlation between autoantibodies and viruses. METHODS A retrospective observational study was conducted in 121 patients (2016-2021) with a CNS viral infection confirmed via cerebrospinal fluid (CSF) next-generation sequencing (cohort A). Their clinical information was analysed and CSF samples were screened for autoantibodies against monkey cerebellum by tissue-based assay. In situ hybridisation was used to detect Epstein-Barr virus (EBV) in brain tissue of 8 patients with glial fibrillar acidic protein (GFAP)-IgG and nasopharyngeal carcinoma tissue of 2 patients with GFAP-IgG as control (cohort B). RESULTS Among cohort A (male:female=79:42; median age: 42 (14-78) years old), 61 (50.4%) participants had detectable autoantibodies in CSF. Compared with other viruses, EBV increased the odds of having GFAP-IgG (OR 18.22, 95% CI 6.54 to 50.77, p<0.001). In cohort B, EBV was found in the brain tissue from two of eight (25.0%) patients with GFAP-IgG. Autoantibody-positive patients had a higher CSF protein level (median: 1126.00 (281.00-5352.00) vs 700.00 (76.70-2899.00), p<0.001), lower CSF chloride level (mean: 119.80±6.24 vs 122.84±5.26, p=0.005), lower ratios of CSF-glucose/serum-glucose (median: 0.50[0.13-0.94] vs 0.60[0.26-1.23], p=0.003), more meningitis (26/61 (42.6%) vs 12/60 (20.0%), p=0.007) and higher follow-up modified Rankin Scale scores (1 (0-6) vs 0 (0-3), p=0.037) compared with antibody-negative patients. A Kaplan-Meier analysis revealed that autoantibody-positive patients experienced significantly worse outcomes (p=0.031). CONCLUSIONS Autoimmune responses are found at the onset of viral encephalitis. EBV in the CNS increases the risk for autoimmunity to GFAP.
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Affiliation(s)
- Ding Liu
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Pei-Hao Lin
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Hui-Lu Li
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jie Yang
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yong You
- Department of Neurology, The Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan, China
| | - Xiao Yang
- Department of Neurology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Li-Hong Jiang
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Cai-Yu Ma
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Lu-Fen Xu
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Qing-Xia Zhang
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Sha Liao
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Han Chen
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jia-Jia Yue
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yu-Ying Lu
- Key Laboratory of Microbial Molecular Biology of Hunan Province, Hunan Provincial Center for Disease Control and Prevention, Changsha, Hunan, China
| | - Chun Lian
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yin Liu
- Department of Radiology, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Zhan-Hang Wang
- Department of Neurology, Guangdong 999 Brain Hospital, Guangzhou, Guangdong, China
| | - Jin-Long Ye
- Department of Neurology, Guangdong 999 Brain Hospital, Guangzhou, Guangdong, China
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Ya-Qing Shu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Hai-Yang Wang
- Department of Neurology, Jining No. 1 People's Hospital, Jining, China
| | - Hong-Li Liu
- Department of Neurology, First Hospital of Qinhuangdao, Qinhuangdao, Hebei, China
| | - Yue Wang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Chun-Mei Duan
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Xiu-Ling Wu
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, Hebei, China
| | - Lu Zhang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Hui-Yu Feng
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Huan Chen
- Department of Neurology, Shantou Central Hospital, Shantou, Guangdong, China
| | - Hou-Shi Zhou
- Department of Neurology, Shantou Central Hospital, Shantou, Guangdong, China
| | - Qian-Hui Xu
- Department of Neurology, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Gui-Xian Zhao
- Department of Neurology, Huashan Hospital of Fudan University, Shanghai, China
| | - Teng-Fei Ou
- Department of Neurology, The Second People's Hospital of Foshan, Foshan, Guangdong, China
| | - Jin-Liang Wang
- Department of Neurology, The Second People's Hospital of Foshan, Foshan, Guangdong, China
| | - Yu-Hua Lu
- Department of Neurology, People's Hospital of Chongqing Banan District, Chongqing, China
| | - Zhi-Feng Mao
- Neurimmunology Group, Institution of Kingmed, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Cong Gao
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jun Guo
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Hong-Ya Zhang
- Department of Neurology, Shenzhen University General Hospital, Shenzhen, Guangdong, China
| | - Sheng Chen
- Department of Neurology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jing Li
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - You-Ming Long
- Department of Neurology, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
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Lin J, Dong L, Yu L, Huang J. Autoimmune glial fibrillary acidic protein astrocytopathy coexistent with reversible splenial lesion syndrome: A case report and literature review. Front Neurol 2023; 14:1192118. [PMID: 37305765 PMCID: PMC10249068 DOI: 10.3389/fneur.2023.1192118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/03/2023] [Indexed: 06/13/2023] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a rare autoimmune disorder. Reversible splenial lesion syndrome (RESLES) is a transient clinical-imaging syndrome characterized by specific magnetic resonance imaging (MRI) pattern. A 58-year-old man was admitted with a fever, headache, and confusion for 1 week. Brain MRI showed abnormal leptomeningeal enhancement in the brainstem and high signal intensity on diffusion-weighted MRI of the corpus callosum. Anti-GFAP antibody was positive in the serum and cerebrospinal fluid analysis. This patient significantly improved and had no relapse after glucocorticoid and immune suppressant therapy. A repeated brain MRI revealed the lesion in the corpus callosum and abnormal leptomeningeal enhancement in the brainstem disappeared. Linear perivascular radial enhancement is the characteristic pattern of autoimmune GFAP astrocytopathy which is rarely coexistent with RESLES.
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Qin N, Wu X, Wang J, Wang W, Wang X, Ma Y, Wang L. Case report: Autoimmune glial fibrillary acidic protein astrocytopathy misdiagnosed as tuberculous meningitis. Front Neurol 2023; 14:1123603. [PMID: 36970528 PMCID: PMC10034075 DOI: 10.3389/fneur.2023.1123603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/13/2023] [Indexed: 03/11/2023] Open
Abstract
IntroductionAutoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a new form of autoimmunity-mediated central nervous system disease. It is especially easy to misdiagnose when clinical symptoms and cerebrospinal fluid (CSF) indicators are similar to those observed in patients with tuberculous meningitis (TBM).MethodsWe retrospectively analyzed five cases of autoimmune GFAP astrocytopathy that were initially misdiagnosed as TBM.ResultsIn the five reported cases, all but one patient had meningoencephalitis in the clinic, and all patients exhibited increased pressure, lymphocytosis, increased protein levels, and decreased glucose levels in their CSF results and did not have typical imaging findings of autoimmune GFAP astrocytopathy. TBM was the initial diagnosis in all five patients. However, we found no direct evidence of tuberculosis infection, and anti-tuberculosis treatment had inconclusive effects. Following a GFAP antibody test, the diagnosis of autoimmune GFAP astrocytopathy was made.ConclusionWhen there is a suspected diagnosis of TBM but TB-related tests are negative, the possibility of autoimmune GFAP astrocytopathy should be considered.
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Kimura A, Takekoshi A, Shimohata T. Characteristics of Movement Disorders in Patients with Autoimmune GFAP Astrocytopathy. Brain Sci 2022; 12:brainsci12040462. [PMID: 35447992 PMCID: PMC9028698 DOI: 10.3390/brainsci12040462] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/26/2022] [Accepted: 03/29/2022] [Indexed: 11/28/2022] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy (GFAP-A) is a type of autoimmune corticosteroid-responsive meningoencephalitis that occurs with or without myelitis. Movement disorders have been reported in GFAP-A patients but have not been characterized. In this study, we examined the characteristics of movement disorders in GFAP-A patients. We retrospectively reviewed clinical data from 87 consecutive patients with GFAP-A attending Gifu University Hospital in Japan. We compared the demographics, clinical features, cerebrospinal fluid characteristics, and neuroimaging findings from patients with and without movement disorders. Seventy-four patients (85%) had movement disorders, including ataxia (49%), tremor (45%), myoclonus (37%), dyskinesia (2%), opsoclonus (2%), rigidity (2%), myokymia (1%), and choreoathetosis (1%). GFAP-A patients with movement disorders were significantly older than those without. Movement disorders are therefore common in GFAP-A patients, and the main types of movement disorders observed in this population were ataxia, tremor, and myoclonus. These abnormal movements can serve as clinical features that facilitate the early diagnosis of GFAP-A. Elderly GFAP-A patients are more likely to have movement disorder complications than younger patients.
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Affiliation(s)
- Akio Kimura
- Correspondence: ; Tel.: +81-58-230-6253; Fax: +81-58-230-6256
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Fang J, Tong Z, Lu W. Case Report: Need for Caution in the Diagnosis of GFAP Astrocytopathy—A Case of GFAP Astrocytopathy Coexistent With Primary Central Nervous System Lymphoma. Front Neurol 2022; 13:806224. [PMID: 35153997 PMCID: PMC8831885 DOI: 10.3389/fneur.2022.806224] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 01/11/2022] [Indexed: 11/13/2022] Open
Abstract
We reported a case of primary central nervous system lymphoma (PCNSL) coexistent with glial fibrillary acidic protein (GFAP) astrocytopathy, and discussed the problems needing attention in the diagnosis and differential diagnosis of GFAP astrocytopathy. Our patient was a 51-year-old female who presented with somnolence for a month, and memory declination for 10 days. Brain magnetic resonance imaging (MRI) demonstrated multiple abnormal enhancement lesions in bilateral basal ganglia and around the third ventricle, as well as transient T2-weighted hyper-intensity lesions at the splenium of the corpus callosum during the course of the disease. The cerebrospinal fluid (CSF) was positive for anti-GFAP antibodies by antigen-transfected HEK293 cell-based assay (indirect immunofluorescence assay). She was initially diagnosed with autoimmune GFAP astrocytopathy. After treatment with corticosteroids for about 2 months, she displayed poor response and even worsened clinical manifestations when the dose of prednisone reduced to 45 mg. Stereotactic brain biopsy was adopted and the diagnosis of large B-cell lymphoma, non-germinal center type was established on pathological examination. The results of brain biopsy also showed perivascular inflammation and CD8+ T cell infiltration, which also accorded with GFAP astrocytopathy. After chemotherapy with rituximab and methotrexate, the patient showed clinical and radiological improvement significantly. Our findings suggest that positivity of GFAP antibody calls for cautious interpretation. Cancer screening appropriate for age, sex, and risk factors is recommended for GFAP antibody-positive patients, especially for patients with atypical clinical and radiologic manifestations.
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Affiliation(s)
- Jia Fang
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Zhongyi Tong
- Department of Pathology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Wei Lu
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Wei Lu
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