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Vallortigara J, Greenfield J, Hunt B, Hoffman D, Booth S, Morris S, Giunti P. Comparison of specialist ataxia centres with non-specialist services in terms of treatment, care, health services resource utilisation and costs in the UK using patient-reported data. BMJ Open 2024; 14:e084865. [PMID: 39242169 PMCID: PMC11381710 DOI: 10.1136/bmjopen-2024-084865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2024] Open
Abstract
OBJECTIVES This study aims to assess the patient-reported benefits and the costs of coordinated care and multidisciplinary care at specialist ataxia centres (SACs) in the UK compared with care delivered in standard neurological clinics. DESIGN A patient survey was distributed between March and May 2019 to patients with ataxia or carers of patients with ataxia through the Charity Ataxia UK's mailing list, website, magazine and social media to gather information about the diagnosis, management of the ataxias in SAC and non-specialist settings, utilisation of various healthcare services and patients' satisfaction. We compared mean resource use for each contact type and health service costs per patient, stratifying patients by whether they were currently attending a SAC or never attended one. SETTING Secondary care including SACs and general neurology clinics. PARTICIPANTS We had 277 participants in the survey, aged 16 years old and over, diagnosed with ataxia and living in the UK. PRIMARY OUTCOME MEASURES Patient experience and perception of the two healthcare services settings, patient level of satisfaction, difference in healthcare services use and costs. RESULTS Patients gave positive feedback about the role of SAC in understanding their condition (96.8% of SAC group), in coordinating referrals to other healthcare specialists (86.6%), and in offering opportunities to take part in research studies (85.2%). Participants who attended a SAC reported a better management of their symptoms and a more personalised care received compared with participants who never attended a SAC (p<0.001). Costs were not significantly different in between those attending a SAC and those who did not. We identified some barriers for patients in accessing the SACs, and some gaps in the care provided, for which we made some recommendations. CONCLUSIONS This study provides useful information about ataxia patient care pathways in the UK. Overall, the results showed significantly higher patient satisfaction in SAC compared with non-SAC, at similar costs. The findings can be used to inform policy recommendations on how to improve treatment and care for people with these very rare and complex neurological diseases. Improving access to SAC for patients across the UK is one key policy recommendation of this study.
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Affiliation(s)
- Julie Vallortigara
- Ataxia Centre, Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, University College London, London, UK
| | | | | | | | - Suzanne Booth
- Ataxia Centre, Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, University College London, London, UK
| | | | - Paola Giunti
- Ataxia Centre, Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, University College London, London, UK
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Mitoma H, Manto M. Recent advances in diagnosis of immune-mediated cerebellar ataxias: novel concepts and fundamental questions on autoimmune mechanisms. J Neurol 2024:10.1007/s00415-024-12596-7. [PMID: 39052041 DOI: 10.1007/s00415-024-12596-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 07/16/2024] [Accepted: 07/18/2024] [Indexed: 07/27/2024]
Abstract
Immune-mediated cerebellar ataxias (IMCAs) represent a group of disorders in which the immune system targets mainly the cerebellum and related structures. We address fundamental questions on the diagnosis and immunological pathogenesis of IMCAs, as illuminated by recent advances in the field. Various types of IMCAs have been identified, including post-infectious cerebellitis, Miller Fisher syndrome, gluten ataxia, paraneoplastic cerebellar degeneration (PCD), opsoclonus and myoclonus syndrome, and anti-GAD ataxia. In some cases, identification of several well-characterized autoantibodies points to a specific etiology in IMCAs and leads to a firm diagnosis. In other cases, various autoantibodies have been reported, but their interpretation requires a careful consideration. Indeed, some autoantibodies have only been documented in a limited number of cases and the causal relationship is not established. In order to facilitate an early treatment and prevent irreversible lesions, new entities have been defined in recent years, such as primary autoimmune cerebellar ataxia (PACA) and latent autoimmune cerebellar ataxia (LACA). PACA is characterized by autoimmune features which do not align with traditional etiologies, while LACA corresponds to a prodromal stage. LACA does not imply the initiation of an immunotherapy but requires a close follow-up. Concurrently, accumulation of clinical data has led to intriguing hypotheses regarding the mechanisms of autoimmunity, such as a pathogenesis of autoimmunity against synapses (synaptopathies), and the vulnerability of the entire nervous system when the immunity targets ion channels and astrocytes. The development of PCD in patients treated with immune-checkpoint inhibitors suggests that molecular mimicry specifically determines the direction of autoimmunity, and that the strength of this response is modulated by co-signaling molecules that either enhance or dampen signals from the antigen-specific T cell receptor.
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Affiliation(s)
- Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, Tokyo, Japan
| | - Mario Manto
- Service de Neurologie, Médiathèque Jean Jacquy, CHU-Charleroi, 6000, Charleroi, Belgium.
- Service des Neurosciences, University of Mons, 7000, Mons, Belgium.
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Liu M, Fan S, Geng C, Ren H, Chen S, Xie M, Cui R, Guan H. COVID-19-Associated Cerebellar Ataxia: A Case Series. CEREBELLUM (LONDON, ENGLAND) 2024:10.1007/s12311-024-01712-y. [PMID: 38985238 DOI: 10.1007/s12311-024-01712-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/16/2024] [Indexed: 07/11/2024]
Abstract
COVID-19-associated cerebellar ataxia has rarely been reported and its clinical characteristics remain understudied. This study aims to report patients with COVID-19-associated cerebellar ataxia from our institution. COVID-19-associated cerebellar ataxia was diagnosed based on the prodromal COVID-19 infection and the exclusion of other causes. This study provides a summary of the patients' clinical presentations, neuroimaging features, and the results of anti-cerebellar antibody examinations. Our study included 11 patients and 4 were male. The median onset age was 38 years. Five patients also demonstrated signs of encephalopathy. Brain magnetic resonance imaging (MRI) was either unremarkable (n = 6) or showed bilateral cerebellar lesions (n = 5), which were typically transient, although brain atrophy could be observed later in the disease course. Anti-Homer-3 and anti-Yo antibodies were each detected in one patient, respectively. All patients received immunotherapy and nine improved. Compared with the late-onset group, individuals who exhibited ataxia earlier following COVID-19 onset (interval<5 days) were significantly younger [median age 18 (15.5-31) vs. 53.5 (44-64.8) years, p = 0.009] and more likely to present with encephalopathy (5/5 vs. 0/6, p = 0.002).They also experienced more severe symptoms [median modified Rankin scale (mRS) score at zenith 5 (5-5) vs. 2 (1.75-2.75), p = 0.017] and had a less favorable prognosis [median mRS score at the last follow-up 4 (2-5) vs. 1 (0-1.25), p = 0.009]. COVID-19-associated cerebellar ataxia can appear with encephalopathy. Brain MRI may show transient bilateral cerebellar lesions and brain atrophy later. Patients who exhibited ataxia earlier following COVID-19 were younger, had more severe symptoms and poorer outcomes.
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Affiliation(s)
- Mange Liu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Chang Geng
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Sixian Chen
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Manqing Xie
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Ruixue Cui
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
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4
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Saiz A, Graus F. Neuronal antibodies in nonparaneoplastic autoimmune cerebellar ataxias. Curr Opin Neurol 2024; 37:322-328. [PMID: 38483149 DOI: 10.1097/wco.0000000000001260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2024]
Abstract
PURPOSE OF REVIEW To describe relevant advances in nonparaneoplastic autoimmune cerebellar ataxias (ACA) with neuronal antibodies. RECENT FINDINGS Apart from metabotropic glutamate receptor 1(mGluR1) antibodies, in recent years, the number of neuronal antibodies against surface antigens in ACA has increased with the description of glutamate kainate receptor subunit 2 (GluK2) antibodies in young patients with cerebellitis. Around 20% of patients with contactin-associated protein-like 2 (CASPR2) encephalitis also present prominent cerebellar ataxia. However, isolate cerebellar ataxia is unusual (<4%). Outcome in patients with neuronal antibodies against surface antigens remains suboptimal despite the cerebellar ataxia probably is antibody-mediated.Concerning neuronal antibodies against intracellular antigens, up to 25% of patients with glutamic acid decarboxylase (GAD) antibodies present transient episodes of vertigo or diplopia that antedate the development of the ACA. There is in-vitro evidence that septin-5 is partially exposed to the membrane and the antibodies may interfere with septin-5 function. The clinical significance of the remaining antibodies against intracellular antigens remains unclear. SUMMARY The number of antibodies against surface antigens is increasing in ACA, but the response to the immunotherapy remains suboptimal. More studies are needed to clarify the role of most of the antibodies against intracellular antigens described in these patients.
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Affiliation(s)
- Albert Saiz
- Service of Neurology, Hospital Clinic
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Francesc Graus
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Nijim W, Morgan J, Montalvo M, McKeon A, McLeod C. Case Presentation of Autoimmune Septin-5 Cerebellar Ataxia. Mov Disord Clin Pract 2024; 11:734-737. [PMID: 38561872 PMCID: PMC11145106 DOI: 10.1002/mdc3.14028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 01/28/2024] [Accepted: 03/03/2024] [Indexed: 04/04/2024] Open
Affiliation(s)
| | - John Morgan
- Neurology DepartmentMedical College of GeorgiaAugustaGAUSA
| | - Mayra Montalvo
- Neurology DepartmentFixel Institute for Neurological Diseases/University of FloridaGainesvilleFLUSA
| | | | - Colin McLeod
- Neurology DepartmentMedical College of GeorgiaAugustaGAUSA
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6
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Kasat PR, Parihar P, Kashikar SV, Sachani P, Nunna B. Neurological Conundrum: A Case of Cerebellar Hemispheric Enlargement and Atypical Symptoms. Cureus 2024; 16:e58096. [PMID: 38741826 PMCID: PMC11088972 DOI: 10.7759/cureus.58096] [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: 03/18/2024] [Accepted: 04/12/2024] [Indexed: 05/16/2024] Open
Abstract
Cerebellar hemispheric enlargement with atypical neurological symptoms poses diagnostic challenges in clinical practice. We present the case of a 57-year-old female with persistent headache, left facial paraesthesia, dysarthria, gait ataxia, and longstanding neck swelling. Imaging studies revealed enlargement of the left cerebellar hemisphere with associated mass effect and compression of adjacent structures. The underlying etiology remained uncertain despite extensive evaluation, including magnetic resonance imaging and angiography. Differential diagnoses included neoplastic, vascular, inflammatory, and metabolic etiologies, but none fully accounted for the clinical findings. Management strategies focused on symptomatic relief and close monitoring. This case underscores the complexity of diagnosing and managing patients with rare neurological manifestations and highlights the need for continued research and collaborative approaches in optimising patient care.
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Affiliation(s)
- Paschyanti R Kasat
- Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Pratap Parihar
- Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Shivali V Kashikar
- Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Pratiksha Sachani
- Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Bhagyasri Nunna
- Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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Shimizu F. [Blood-brain barrier breakdown and autoimmune cerebellar ataxia]. Rinsho Shinkeigaku 2024; 64:148-156. [PMID: 38403685 DOI: 10.5692/clinicalneurol.cn-001932] [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: 02/27/2024]
Abstract
Autoimmune cerebellar ataxia is a disease entity that affects the cerebellum and is induced by autoimmune mechanisms. The disease is classified into several etiologies, including gluten ataxia, anti-glutamate decarboxylase (GAD) ataxia, paraneoplastic cerebellar degeneration, primary autoimmune cerebellar ataxia and postinfectious cerebellar ataxia. The autoimmune response in the periphery cross-reacts with similar antigens in the cerebellum due to molecular mimicry. Breakdown of the blood‒brain barrier (BBB) could potentially explain the vulnerability of the cerebellum during the development of autoimmune cerebellar ataxia, as it gives rise to the entry of pathogenic autoantibodies or lymphocytes into the cerebellum. In this review, the maintenance of the BBB under normal conditions and the molecular basis of BBB disruption under pathological conditions are highlighted. Next, the pathomechanism of BBB breakdown in each subtype of autoimmune cerebellar ataxia is discussed. We recently identified glucose-regulated protein (GRP) 78 antibodies in paraneoplastic cerebellar degeneration and Lambert-Eaton myasthenic syndrome, and GRP78 antibodies induced by cross-reactivity with tumors can disrupt the BBB and penetrate anti-P/Q type voltage-gated calcium channel (VGCC) antibodies into the cerebellum, thus leading to cerebellar ataxia in this disease.
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Affiliation(s)
- Fumitaka Shimizu
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
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8
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Norrito RL, Puleo MG, Pintus C, Basso MG, Rizzo G, Di Chiara T, Di Raimondo D, Parrinello G, Tuttolomondo A. Paraneoplastic Cerebellar Degeneration Associated with Breast Cancer: A Case Report and a Narrative Review. Brain Sci 2024; 14:176. [PMID: 38391750 PMCID: PMC10887192 DOI: 10.3390/brainsci14020176] [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: 12/27/2023] [Revised: 01/23/2024] [Accepted: 02/07/2024] [Indexed: 02/24/2024] Open
Abstract
Paraneoplastic neurological syndromes (PNSs) are an uncommon complication of cancer, affecting nearby 1/10,000 subjects with a tumour. PNSs can involve all the central and peripheral nervous systems, the muscular system, and the neuromuscular junction, causing extremely variable symptomatology. The diagnosis of the paraneoplastic disease usually precedes the clinical manifestations of cancer, making an immediate recognition of the pathology crucial to obtain a better prognosis. PNSs are autoimmune diseases caused by the expression of common antigens by the tumour and the nervous system. Specific antibodies can help clinicians diagnose them, but unfortunately, they are not always detectable. Immunosuppressive therapy and the treatment of cancer are the cornerstones of therapy for PNSs. This paper reports a case of PNSs associated with breast tumours and focuses on the most common paraneoplastic neurological syndromes. We report a case of a young female with a clinical syndrome of the occurrence of rigidity in the right lower limb with postural instability with walking supported and diplopia, with a final diagnosis of paraneoplastic cerebellar degeneration and seronegative rigid human syndrome associated with infiltrating ductal carcinoma of the breast.
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Affiliation(s)
- Rosario Luca Norrito
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Maria Grazia Puleo
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Chiara Pintus
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Maria Grazia Basso
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Giuliana Rizzo
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Tiziana Di Chiara
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Domenico Di Raimondo
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Gaspare Parrinello
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Antonino Tuttolomondo
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, 90127 Palermo, Italy
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Zhang M, Pan G, Zhou S, Shen J, Li W, Zhou Y, Yu L, Zhang L. Etiologies and clinical characteristics of acute ataxia in a single national children's medical center. Brain Dev 2024; 46:103-107. [PMID: 38000948 DOI: 10.1016/j.braindev.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/12/2023] [Accepted: 10/21/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVE To analyze etiologic factors of pediatric acute ataxia and to identify the severity of its underlying causes for urgent medical intervention. METHODS Clinical data of children diagnosed with acute ataxia between December 2015 and December 2021 from one national medical center were analyzed retrospectively. RESULTS A total of 99 children (59 boys, 40 girls), median age at disease onset 55 (range: 12-168) months, were enrolled. The median follow period was 46 (range 6-78) months. Eighty-six (86.9 %) children were diagnosed with immune-associated acute ataxia, among which acute post-infectious cerebellar ataxia (APCA) was the most common diagnosis (50.5 %), followed by demyelinating diseases of the central nervous system (18.2 %) and Guillain-Barré syndrome (9.1 %). On cerebrospinal fluid (CSF) examination, 35/73 (47.9 %) patients had pleocytosis (>5 cells/mm3), and 18/73 (24.7 %) had elevated protein levels. Thirty-one patients (31.3 %) had an abnormal cerebral MRI. Children with other immune-associated acute cerebellar ataxia had more extracerebellar symptoms, intracranial MRI lesions, abnormal CSF results, longer hospital stay, higher recurrence rates and incidence of neurological sequelae than children with APCA. CONCLUSION Immune-associated acute ataxia is the main cause of pediatric acute ataxia, among which APCA is the most common phenotype. However, some immune-associated diseases, especially autoantibody-mediated disease, which has a higher recurrence rate and neurological sequelae account for an increasing proportion of pediatric acute ataxia. When children present with extracerebellar symptoms, abnormal cranial MRI or CSF results, and without prodromal infection, prudent differential diagnosis is recommended.
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Affiliation(s)
- Min Zhang
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, 399# Wan Yuan Road, 201102 Shanghai, China
| | - Gang Pan
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, 399# Wan Yuan Road, 201102 Shanghai, China
| | - Shuizhen Zhou
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, 399# Wan Yuan Road, 201102 Shanghai, China
| | - Jin Shen
- Department of Radiology, Children's Hospital of Fudan University, National Children's Medical Center, 399# Wan Yuan Road, 201102 Shanghai, China
| | - Wenhui Li
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, 399# Wan Yuan Road, 201102 Shanghai, China
| | - Yuanfeng Zhou
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, 399# Wan Yuan Road, 201102 Shanghai, China
| | - Lifei Yu
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, 399# Wan Yuan Road, 201102 Shanghai, China
| | - Linmei Zhang
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, 399# Wan Yuan Road, 201102 Shanghai, China.
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Guo L, Ren H, Fan S, Chao X, Liu M, Guan H, Wang J. Autoantibodies against eukaryotic translation elongation factor 1 delta in two patients with autoimmune cerebellar ataxia. Front Immunol 2024; 14:1289175. [PMID: 38332912 PMCID: PMC10850295 DOI: 10.3389/fimmu.2023.1289175] [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: 09/05/2023] [Accepted: 12/26/2023] [Indexed: 02/10/2024] Open
Abstract
Background Autoantibodies are useful biomarkers for the early detection and diagnosis of autoimmune cerebellar ataxia (ACA). Objective To identify novel autoantibody candidates in ACA patients. Methods Patients with cerebellar ataxia of unknown cause were recruited from July 2018 to February 2023. Anti-neural autoantibodies in patient samples were detected by tissue-based indirect immunofluorescence assay (TBA) on rat cerebellum sections. TBA-positive samples were further screened for well-established anti-neural autoantibodies using commercial kits. Tissue-immunoprecipitation (TIP) and subsequent mass spectrometric (MS) analysis were used to explore the target antigens of autoantibodies in samples that were TBA-positive but negative for known autoantibodies. The specific binding between autoantibodies and the identified target antigen was confirmed by neutralization experiments, recombinant cell-based indirect immunofluorescence assay (CBA), and western blotting experiments. Results The eukaryotic translation elongation factor 1 delta (EEF1D) protein was identified as a target antigen of autoantibodies in samples from a 43-year-old female ACA patient, while the specific binding of autoantibodies and EEF1D was confirmed by subsequent experiments. A second anti-EEF1D autoantibody-positive ACA patient, a 59-year-old female, was detected in simultaneous screening. The main clinical manifestations in each of the two patients were cerebellar syndrome, such as unsteady walking and limb ataxia. Both patients received immunotherapy, including corticosteroids, intravenous immunoglobulin, and mycophenolate mofetil. Their outcomes provided evidence to support the effectiveness of immunotherapy, but the cerebellar atrophy that occurred before treatment may be irreversible. Conclusion In the current study, we identified anti-EEF1D autoantibody as a novel autoantibody candidate in ACA. Its pathological roles and diagnostic value need to be further verified in larger-scale studies.
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Affiliation(s)
- Liyuan Guo
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xingchen Chao
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Mange Liu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Wang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
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Li J, Deng B, Song W, Li K, Ai J, Liu X, Zhang H, Zhang Y, Lin K, Shao G, Liu C, Zhang W, Chen X, Zhang Y. Immunotherapies for the Effective Treatment of Primary Autoimmune Cerebellar Ataxia: a Case Series. CEREBELLUM (LONDON, ENGLAND) 2023; 22:1216-1222. [PMID: 36434494 DOI: 10.1007/s12311-022-01496-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 11/26/2022]
Abstract
Primary autoimmune cerebellar ataxia (PACA) is an idiopathic sporadic cerebellar ataxia that is thought to be immune-mediated but lacks biomarkers or a known cause. Here, we report two cases of immune-mediated cerebellar ataxia that responded favorably to immunotherapy, in which tissue-based indirect immunofluorescence test for serum or cerebrospinal fluid (CSF) samples yielded positive results. Case 1 was a 78-year-old man who presented with subacute progressive gait ataxia with truncal instability and dysarthria in response to steroids. Case 2 was a 62-year-old man who presented with relapses and remissions of acute progressive cerebellar ataxia occurring 1-2 times per year. Despite a favorable response to steroid treatment, he relapsed repeatedly in the absence of long-term immunosuppression. In the case of "idiopathic" cerebellar ataxia, immune-mediated causes should be investigated, and immunotherapy may have therapeutic effects.
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Affiliation(s)
- Jiao Li
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Bo Deng
- Department of Neurology, Huashan Hospital and Institute of Neurology, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Wenli Song
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Keru Li
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Jingwen Ai
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Xiaoni Liu
- Department of Neurology, Huashan Hospital and Institute of Neurology, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Haocheng Zhang
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Yi Zhang
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Ke Lin
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Guofu Shao
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Chunfeng Liu
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Wenhong Zhang
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Xiangjun Chen
- Department of Neurology, Huashan Hospital and Institute of Neurology, Fudan University, Shanghai, China.
- National Center for Neurological Disorders, Shanghai, China.
- Human Phenome Institute, Fudan University, Shanghai, China.
| | - Yanlin Zhang
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China.
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Meira AT, de Moraes MPM, Ferreira MG, Franklin GL, Rezende Filho FM, Teive HAG, Barsottini OGP, Pedroso JL. Immune-mediated ataxias: Guide to clinicians. Parkinsonism Relat Disord 2023; 117:105861. [PMID: 37748994 DOI: 10.1016/j.parkreldis.2023.105861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/13/2023] [Accepted: 09/17/2023] [Indexed: 09/27/2023]
Abstract
Immune-mediated cerebellar ataxias were initially described as a clinical entity in the 1980s, and since then, an expanding body of evidence has contributed to our understanding of this topic. These ataxias encompass various etiologies, including postinfectious cerebellar ataxia, gluten ataxia, paraneoplastic cerebellar degeneration, opsoclonus-myoclonus-ataxia syndrome and primary autoimmune cerebellar ataxia. The increased permeability of the brain-blood barrier could potentially explain the vulnerability of the cerebellum to autoimmune processes. In this manuscript, our objective is to provide a comprehensive review of the most prevalent diseases within this group, emphasizing clinical indicators, pathogenesis, and current treatment approaches.
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Affiliation(s)
- Alex T Meira
- Universidade Federal da Paraíba, Departamento de Medicina Interna, Serviço de Neurologia, João Pessoa, PB, Brazil.
| | | | - Matheus G Ferreira
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Serviço de Neurologia, Curitiba, PR, Brazil
| | - Gustavo L Franklin
- Pontifícia Universidade Católica, Departamento de Medicina Interna, Serviço de Neurologia, Curitiba, PR, Brazil
| | | | - Hélio A G Teive
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Serviço de Neurologia, Curitiba, PR, Brazil
| | | | - José Luiz Pedroso
- Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo, SP, Brazil
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Chen Q, Tang J, Zhang H, Qin L. Case report: Desquamating dermatitis, bilateral cerebellar lesions in a late-onset methylmalonic acidemia patient. Front Neurol 2023; 14:1255128. [PMID: 37808496 PMCID: PMC10556654 DOI: 10.3389/fneur.2023.1255128] [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: 07/08/2023] [Accepted: 08/28/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction Cobalamin C (cblC) deficiency is a rare hereditary disorder affecting intracellular cobalamin metabolism, primarily caused by mutations in MMACHC. This condition is characterized by combined methylmalonic acidemia and hyperhomocysteinemia, displaying a wide range of clinical manifestations involving multiple organs. Owing to its uncommon occurrence and diverse clinical phenotypes, diagnosing cblC deficiency is challenging and often leads to delayed or missed diagnoses. Case description In this report, we present a case of late-onset cblC deficiency with brown desquamating dermatitis on the buttocks. Magnetic resonance imaging (MRI) of the brain revealed bilateral cerebellar abnormalities. The suspicion of an inherited metabolic disorder was raised by abnormal serum amino acid and acylcarnitine levels, along with increased urine methylmalonic acid and serum homocysteine levels. Whole-exome sequencing helped identify a homozygous variant (c.482G>A) in MMACHC, confirming the diagnosis of cblC deficiency. However, despite receiving treatment with hydroxocobalamin and betaine, the patient did not experience clinical improvement, which may be attributed to the delayed diagnosis as indicated by the declining homocysteine and methylmalonic acid levels. Conclusion Collectively, we emphasize the significance of recognizing the skin lesions and observing serial MRI changes in patients with cblC deficiency. Our case underscores the importance of early diagnosis and timely therapeutic intervention for this severe yet frequently manageable condition.
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Affiliation(s)
| | | | | | - Lixia Qin
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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Manto M, Cendelin J, Strupp M, Mitoma H. Advances in cerebellar disorders: pre-clinical models, therapeutic targets, and challenges. Expert Opin Ther Targets 2023; 27:965-987. [PMID: 37768297 DOI: 10.1080/14728222.2023.2263911] [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: 11/03/2022] [Accepted: 09/24/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Cerebellar ataxias (CAs) represent neurological disorders with multiple etiologies and a high phenotypic variability. Despite progress in the understanding of pathogenesis, few therapies are available so far. Closing the loop between preclinical studies and therapeutic trials is important, given the impact of CAs upon patients' health and the roles of the cerebellum in multiple domains. Because of a rapid advance in research on CAs, it is necessary to summarize the main findings and discuss future directions. AREAS COVERED We focus our discussion on preclinical models, cerebellar reserve, the therapeutic management of CAs, and suitable surrogate markers. We searched Web of Science and PubMed using keywords relevant to cerebellar diseases, therapy, and preclinical models. EXPERT OPINION There are many symptomatic and/or disease-modifying therapeutic approaches under investigation. For therapy development, preclinical studies, standardization of disease evaluation, safety assessment, and demonstration of clinical improvements are essential. Stage of the disease and the level of the cerebellar reserve determine the goals of the therapy. Deficits in multiple categories and heterogeneity of CAs may require disease-, stage-, and symptom-specific therapies. More research is needed to clarify how therapies targeting the cerebellum influence both basal ganglia and the cerebral cortex, poorly explored domains in CAs.
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Affiliation(s)
- Mario Manto
- Service des Neurosciences, University of Mons, Mons, Belgium
| | - Jan Cendelin
- Department of Pathophysiology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
| | - Hiroshi Mitoma
- Department of Medical Education, Tokyo medical University, Tokyo, Japan
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15
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Liu M, Ren H, Zhu Y, Fan S, Bai L, Wang J, Cui L, Guan H. Autoimmune Cerebellar Ataxia: Etiology and Clinical Characteristics of a Case Series from China. CEREBELLUM (LONDON, ENGLAND) 2023; 22:379-385. [PMID: 35618871 DOI: 10.1007/s12311-022-01412-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 04/25/2023]
Abstract
Autoimmune cerebellar ataxia (ACA) is an important and potentially treatable cause of sporadic cerebellar syndrome, but studies with large sample size are limited. This study reported a large ACA series in China and described its etiology and clinical characteristics. We reviewed all ACA patients from our hospital (2013-2021) and analyzed their clinical and paraclinical features, treatment, and outcome. ACA subtypes investigated included paraneoplastic cerebellar degeneration (PCD), primary autoimmune cerebellar ataxia (PACA), anti-glutamate decarboxylase (GAD)-associated cerebellar ataxia, opsoclonus-myoclonus syndrome (OMS), Miller Fisher syndrome (MFS), and ACA-associated with autoimmune encephalitis. A total of 127 patients were identified and 40.9% were male. The median onset age was 47.0 years. Gait ataxia was the most prevalent feature followed by limb ataxia, dizziness, and dysarthria/dysphagia. Extracerebellar manifestations included pyramidal signs (28.3%) and peripheral neuropathy/radiculopathy (15.0%). ACA subtypes were PCD (30.7%), PACA (37.8%), ACA associated with autoimmune encephalitis (12.6%), anti-GAD-associated ACA (8.7%), MFS (7.1%), and OMS (3.1%). Neuronal antibodies were positive in 67.7% of patients. Brain magnetic resonance imaging was unremarkable (55.7%) or showed atrophy (18.3%) or abnormal signal intensity (26.1%, most of which was extracerebellar). Although most patients received immunotherapy, the modified Rankin scale at last follow-up was ≤ 2 in only 47.3% patients. Thirteen patients died and 24 relapsed. Compared with PACA, PCD patients were older and had poorer outcome. This study illustrates the heterogeneity in the clinical features of ACA and suggests the importance of neuronal antibody testing in ACA diagnosis. PCD and PACA are the dominant ACA subtypes, and the former has a less favorable prognosis.
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Affiliation(s)
- Mange Liu
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yicheng Zhu
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Lin Bai
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Jing Wang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, 16 Lincui Road, Chaoyang District, Beijing, 100101, China
- University of Chinese Academy of Sciences, 19 A Yuquan Rd, Shijingshan District, Beijing, 100049, China
| | - Liying Cui
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China.
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.
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Tierney P, Zekeridou A, Adam O. Phosphodiesterase 10A autoimmunity presenting as cerebellar ataxia responsive to plasma exchange: a case report. J Neurol 2023; 270:2325-2328. [PMID: 36571632 DOI: 10.1007/s00415-022-11542-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/16/2022] [Accepted: 12/17/2022] [Indexed: 12/27/2022]
Affiliation(s)
- Patrick Tierney
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Anastasia Zekeridou
- Department of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Octavian Adam
- The Parkinson Disease and Movement Disorders Center, Albany Medical College, 47 New Scotland Ave, Albany, NY, USA.
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17
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Mitoma H, Manto M. Advances in the Pathogenesis of Auto-antibody-Induced Cerebellar Synaptopathies. CEREBELLUM (LONDON, ENGLAND) 2023; 22:129-147. [PMID: 35064896 PMCID: PMC9883363 DOI: 10.1007/s12311-021-01359-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/12/2021] [Indexed: 02/07/2023]
Abstract
The presence of auto-antibodies that target synaptic machinery proteins was documented recently in immune-mediated cerebellar ataxias. The autoantigens include glutamic acid decarboxylase 65 (GAD65), voltage-gated Ca2+ channel (VGCC), metabotropic glutamate receptor type 1 (mGluR1), and glutamate receptor delta (GluRdelta). GAD65 is involved in the synthesis, packaging, and release of GABA, whereas the other three play important roles in the induction of long-term depression (LTD). Thus, the auto-antibodies toward these synaptic molecules likely impair fundamental synaptic machineries involved in unique functions of the cerebellum, potentially leading to the development of cerebellar ataxias (CAs). This concept has been substantiated recently by a series of physiological studies. Anti-GAD65 antibody (Ab) acts on the terminals of inhibitory neurons that suppress GABA release, whereas anti-VGCC, anti-mGluR1, and anti-GluR Abs impair LTD induction. Notably, the mechanisms that link synaptic dysfunction with the manifestations of CAs can be explained by disruption of the "internal models." The latter can be divided into three levels. First, since chained inhibitory neurons shape the output signals through the mechanism of disinhibition/inhibition, impairments of GABA release and LTD distort the conversion process from the "internal model" to the output signals. Second, these antibodies impair the induction of synaptic plasticity, rebound potentiation, and LTD, on Purkinje cells, resulting in loss of restoration and compensation of the distorted "internal models." Finally, the cross-talk between glutamate and microglia/astrocytes could involve a positive feedback loop that accelerates excitotoxicity. This mini-review summarizes the pathophysiological mechanisms and aims to establish the basis of "auto-antibody-induced cerebellar synaptopathies."
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Affiliation(s)
- Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, Tokyo, Japan
| | - Mario Manto
- Unité des Ataxies Cérébelleuses, Service de Neurologie, Médiathèque Jean Jacquy, CHU-Charleroi, 6000 Charleroi, Belgium ,Service des Neurosciences, University of Mons, 7000 Mons, Belgium
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18
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Reinecke R, Reiländer A, Seiler A, Koch C, Voss M. Opsoclonus-myoclonus syndrome associated with pancreatic neuroendocrine tumor: a case report. BMC Neurol 2022; 22:507. [PMID: 36581905 PMCID: PMC9801616 DOI: 10.1186/s12883-022-03012-6] [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: 02/02/2022] [Accepted: 12/06/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Opsoclonus-myoclonus syndrome (OMS) is a rare, immune-mediated neurological disorder. In adults, the pathogenesis can be idiopathic, post-infectious or paraneoplastic, the latter etiology belonging to the ever-expanding group of defined paraneoplastic neurological syndromes (PNS). In contrast to other phenotypes of PNS, OMS cannot be ascribed to a single pathogenic autoantibody. Here, we report the first detailed case of paraneoplastic, antibody-negative OMS occurring in association with a pancreatic neuroendocrine tumor (pNET). CASE PRESENTATION A 33-year-old female presented with a two-week history of severe ataxia of stance and gait, dysarthria, head tremor, myoclonus of the extremities and opsoclonus. Her past medical history was notable for a metastatic pancreatic neuroendocrine tumor, and she was subsequently diagnosed with paraneoplastic opsoclonus-myoclonus syndrome. Further workup did not reveal a paraneoplastic autoantibody. She responded well to plasmapheresis, as she was refractory to the first-line therapy with corticosteroids. CONCLUSIONS This case expands current knowledge on tumors associated with paraneoplastic opsoclonus-myoclonus syndrome and the age group in which it can occur. It further adds evidence to the effectiveness of plasmapheresis in severe cases of opsoclonus-myoclonus syndrome with a lack of response to first-line therapy.
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Affiliation(s)
- Raphael Reinecke
- grid.7839.50000 0004 1936 9721Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721Dr. Senckenberg Institute of Neurooncology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Annemarie Reiländer
- grid.7839.50000 0004 1936 9721Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Alexander Seiler
- grid.7839.50000 0004 1936 9721Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Christine Koch
- grid.7839.50000 0004 1936 9721Department of Gastroenterology, Hepatology and Endocrinology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Martin Voss
- grid.7839.50000 0004 1936 9721Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721Dr. Senckenberg Institute of Neurooncology, Goethe University Frankfurt, Frankfurt am Main, Germany
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Takeuchi Y, Nomura T, Nakahara K, Ueda M. Autoimmune Polyglandular Syndrome with Refractory Gait Disturbance. Intern Med 2022. [PMID: 36450465 PMCID: PMC10400394 DOI: 10.2169/internalmedicine.0476-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Autoimmune polyglandular syndrome (APS) causes autoimmune diseases of multiple organs and can also present with neurological symptoms. We here report a 58-year-old man who presented with progressive gait disturbance that had started 7 years ago. He had spasticity, reduced deep sensations, and truncal cerebellar ataxia. Laboratory examinations revealed autoantibody-related cobalamin deficiency and the presence of anti-thyroid antibodies and anti-glutamic acid decarboxylase antibodies. His gait worsened after cobalamin replenishment, but additional steroid therapy was effective. APS can cause refractory gait disturbance that requires not only cobalamin replenishment but also immunotherapy.
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Affiliation(s)
- Yosuke Takeuchi
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Toshiya Nomura
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Keiichi Nakahara
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
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20
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A Comprehensive Review of the Neurological Manifestations of Celiac Disease and Its Treatment. Diseases 2022; 10:diseases10040111. [PMID: 36412605 PMCID: PMC9680226 DOI: 10.3390/diseases10040111] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/16/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022] Open
Abstract
Celiac disease (CD) is a common chronic inflammatory disorder occurring in genetically predisposed individuals secondary to gluten ingestion. CD usually presents with gastrointestinal symptoms such as pain, bloating, flatulence, and constipation or diarrhea. However, individuals can present in a nonclassical manner with only extraintestinal symptoms. The neurological manifestations of CD include ataxia, cognitive impairment, epilepsy, headache, and neuropathy. A lifelong gluten-free diet is the current recommended treatment for CD. This review discusses the relevant neurological manifestations associated with CD and the novel therapeutics. Further research is required to get a better understanding of the underlying pathophysiology of the neurological manifestations associated with CD. Clinicians should keep CD in the differential diagnosis in individuals presenting with neurological dysfunction of unknown cause.
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21
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Stezin A, Pal PK. Treatable Ataxias: How to Find the Needle in the Haystack? J Mov Disord 2022; 15:206-226. [PMID: 36065614 DOI: 10.14802/jmd.22069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 07/05/2022] [Indexed: 11/24/2022] Open
Abstract
Treatable ataxias are a group of ataxic disorders with specific treatments. These disorders include genetic and metabolic disorders, immune-mediated ataxic disorders, and ataxic disorders associated with infectious and parainfectious etiology, vascular causes, toxins and chemicals, and endocrinopathies. This review provides a comprehensive overview of different treatable ataxias. The major metabolic and genetic treatable ataxic disorders include ataxia with vitamin E deficiency, abetalipoproteinemia, cerebrotendinous xanthomatosis, Niemann-Pick disease type C, autosomal recessive cerebellar ataxia due to coenzyme Q10 deficiency, glucose transporter type 1 deficiency, and episodic ataxia type 2. The treatment of these disorders includes the replacement of deficient cofactors and vitamins, dietary modifications, and other specific treatments. Treatable ataxias with immune-mediated etiologies include gluten ataxia, anti-glutamic acid decarboxylase antibody-associated ataxia, steroid-responsive encephalopathy associated with autoimmune thyroiditis, Miller-Fisher syndrome, multiple sclerosis, and paraneoplastic cerebellar degeneration. Although dietary modification with a gluten-free diet is adequate in gluten ataxia, other autoimmune ataxias are managed by short-course steroids, plasma exchange, or immunomodulation. For autoimmune ataxias secondary to malignancy, treatment of tumor can reduce ataxic symptoms. Chronic alcohol consumption, antiepileptics, anticancer drugs, exposure to insecticides, heavy metals, and recreational drugs are potentially avoidable and treatable causes of ataxia. Infective and parainfectious causes of cerebellar ataxias include acute cerebellitis, postinfectious ataxia, Whipple's disease, meningoencephalitis, and progressive multifocal leukoencephalopathy. These disorders are treated with steroids and antibiotics. Recognizing treatable disorders is of paramount importance when dealing with ataxias given that early treatment can prevent permanent neurological sequelae.
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Affiliation(s)
- Albert Stezin
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India.,Centre for Brain Research, Indian Institute of Science, Bengaluru, India
| | - Pramod Kumar Pal
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
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22
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Kang L, Wan C. Paraneoplastic syndrome in neuroophthalmology. J Neurol 2022; 269:5272-5282. [PMID: 35779086 DOI: 10.1007/s00415-022-11247-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/19/2022] [Accepted: 06/19/2022] [Indexed: 12/16/2022]
Abstract
Paraneoplastic syndrome is a group of clinical symptoms that occur in the state of systemic malignant tumors. Paraneoplastic syndrome of the nervous system can affect any part of the central and peripheral nervous system and may also affect the eyes. In neuroophthalmology, paraneoplastic syndrome has a variety of manifestations that can affect both the afferent and efferent visual systems. The afferent system may involve the optic nerve, retina and uvea; the efferent system may involve eye movement, neuromuscular joints or involuntary eye movements and pupil abnormalities and may also have other neurological symptoms outside the visual system. This article discusses the clinical manifestations, pathological mechanisms, detection methods and treatment methods of paraneoplastic syndrome in neuroophthalmology. The performance of paraneoplastic syndrome is diverse, the diagnosis is difficult, and the treatment should be considered systematically. Differential diagnosis, optimal evaluation and management of these manifestations is not only the key to treatment but also a challenge.
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Affiliation(s)
- Longdan Kang
- Department of Ophthalmology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Chao Wan
- Department of Ophthalmology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China.
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23
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Lin J, Zhu M, Mao X, Jin Z, Zhou M, Hong D. Anti-dipeptidyl-peptidase-like protein 6 encephalitis with pure cerebellar ataxia: a case report. BMC Neurol 2022; 22:242. [PMID: 35778696 PMCID: PMC9248153 DOI: 10.1186/s12883-022-02769-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 06/24/2022] [Indexed: 11/24/2022] Open
Abstract
Background Anti-dipeptidyl-peptidase-like protein 6 (DPPX) encephalitis is a rare autoimmune encephalitis. The clinical symptoms of anti-DPPX encephalitis are often severe, manifested as diarrhea/weight loss, central nervous system hyperexcitability and cognitive dysfunction. Case presentation An 18-year-old boy was admitted for 1-week-long cerebellar symptoms including dizziness, unsteady gait and frequent vomiting. Magnetic resonance imaging (MRI) displayed no abnormal findings. However, autoimmune encephalitis panel revealed anti-DPPX antibody was positive in the serum. This patient completely recovered after immunoglobulin and corticoids therapy. In addition, repeat serum antibody test for DPPX was negative within one month. Conclusion In addition to the classic triad, anti-DPPX encephalitis may manifest as mild and rare symptoms due to lower antibody titers. Fast identification of rare symptoms can help to quickly diagnosis and effective treatment.
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Affiliation(s)
- Jing Lin
- Department of Neurology, Dong'hu District, The First Affiliated Hospital of Nanchang University, No.17, Yongwaizheng Road, Nanchang, 330000, China
| | - Min Zhu
- Department of Neurology, Dong'hu District, The First Affiliated Hospital of Nanchang University, No.17, Yongwaizheng Road, Nanchang, 330000, China
| | - Xiaocheng Mao
- Department of Neurology, Dong'hu District, The First Affiliated Hospital of Nanchang University, No.17, Yongwaizheng Road, Nanchang, 330000, China
| | - Zeqing Jin
- Department of Neurology, Dong'hu District, The First Affiliated Hospital of Nanchang University, No.17, Yongwaizheng Road, Nanchang, 330000, China
| | - Meihong Zhou
- Department of Neurology, Dong'hu District, The First Affiliated Hospital of Nanchang University, No.17, Yongwaizheng Road, Nanchang, 330000, China
| | - Daojun Hong
- Department of Neurology, Dong'hu District, The First Affiliated Hospital of Nanchang University, No.17, Yongwaizheng Road, Nanchang, 330000, China.
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24
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Jia Y, Li M, Li D, Zhang M, Wang H, Jiao L, Huang Z, Ye J, Liu A, Wang Y. Immune-Mediated Cerebellar Ataxia Associated With Neuronal Surface Antibodies. Front Immunol 2022; 13:813926. [PMID: 35250990 PMCID: PMC8891139 DOI: 10.3389/fimmu.2022.813926] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/01/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Immune-mediated cerebellar ataxias (IMCAs) are common in paraneoplastic cerebellar degeneration (PCD) but rarely occur in patients with neuronal surface antibodies (NSAbs). Although cerebellar ataxias (CAs) associated with anti-NMDAR and anti-CASPR2 have been reported in a few cases, they have never been studied systematically. This study aimed to analyze the characteristics of anti-NSAbs-associated CAs. METHODS A retrospective investigation was conducted to identify patients using the keywords IMCAs and NSAbs. We collected the clinical data of 14 patients diagnosed with anti-NSAbs-associated CAs. RESULTS The median age was 33 years (16-66), and the male-to-female ratio was 4:3. Nine were positive for NMDAR-Ab, two for LGI1-Ab, two for CASPR2-Ab, and one for AMPA2R-Ab. CAs were initial symptoms in three patients and presented during the first two months of the disease course (10 days on average) among the rest of the patients. After the immunotherapy, two cases were free from symptoms, and eight cases recovered satisfactorily (10/14, 71.4%). Compared with other causes of IMCAs, anti-NSAbs were more frequently associated with additional extra-cerebellar symptoms (85.7%), mostly seizures (78.6%) and mental abnormalities (64.3%). In the CSF analysis, pleocytosis was detected in ten patients (71.4%) and oligoclonal bands (OB) were observed in nine patients (64.3%). Moreover, compared with PCD and anti-GAD65-Ab-associated CAs, anti-NSAbs-associated CAs showed a better response to immunotherapy. CONCLUSION IMCAs are rare and atypical in autoimmune encephalitis with neuronal surface antibodies. Compared with other forms of IMCAs, more symptoms of encephalopathy, a higher rate of pleocytosis and positive OB in CSF, and positive therapeutic effect were the key features of anti-NSAbs-associated CAs.
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Affiliation(s)
- Yu Jia
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Mingyu Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Dawei Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Mengyao Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Huifang Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lidong Jiao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhaoyang Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neuromodulation, Capital Medical University, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Capital Medical University, Ministry of Science and Technology, Beijing, China.,Institute of Sleep and Consciousness Disorders, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Jing Ye
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neuromodulation, Capital Medical University, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Capital Medical University, Ministry of Science and Technology, Beijing, China
| | - Aihua Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neuromodulation, Capital Medical University, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Capital Medical University, Ministry of Science and Technology, Beijing, China
| | - Yuping Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neuromodulation, Capital Medical University, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Capital Medical University, Ministry of Science and Technology, Beijing, China.,Institute of Sleep and Consciousness Disorders, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
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25
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Parvez MSA, Ohtsuki G. Acute Cerebellar Inflammation and Related Ataxia: Mechanisms and Pathophysiology. Brain Sci 2022; 12:367. [PMID: 35326323 PMCID: PMC8946185 DOI: 10.3390/brainsci12030367] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 12/11/2022] Open
Abstract
The cerebellum governs motor coordination and motor learning. Infection with external microorganisms, such as viruses, bacteria, and fungi, induces the release and production of inflammatory mediators, which drive acute cerebellar inflammation. The clinical observation of acute cerebellitis is associated with the emergence of cerebellar ataxia. In our animal model of the acute inflammation of the cerebellar cortex, animals did not show any ataxia but hyperexcitability in the cerebellar cortex and depression-like behaviors. In contrast, animal models with neurodegeneration of the cerebellar Purkinje cells and hypoexcitability of the neurons show cerebellar ataxia. The suppression of the Ca2+-activated K+ channels in vivo is associated with a type of ataxia. Therefore, there is a gap in our interpretation between the very early phase of cerebellar inflammation and the emergence of cerebellar ataxia. In this review, we discuss the hypothesized scenario concerning the emergence of cerebellar ataxia. First, compared with genetically induced cerebellar ataxias, we introduce infection and inflammation in the cerebellum via aberrant immunity and glial responses. Especially, we focus on infections with cytomegalovirus, influenza virus, dengue virus, and SARS-CoV-2, potential relevance to mitochondrial DNA, and autoimmunity in infection. Second, we review neurophysiological modulation (intrinsic excitability, excitatory, and inhibitory synaptic transmission) by inflammatory mediators and aberrant immunity. Next, we discuss the cerebellar circuit dysfunction (presumably, via maintaining the homeostatic property). Lastly, we propose the mechanism of the cerebellar ataxia and possible treatments for the ataxia in the cerebellar inflammation.
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Affiliation(s)
- Md. Sorwer Alam Parvez
- Department of Drug Discovery Medicine, Kyoto University Graduate School of Medicine, Kyoto 606-8397, Japan;
- Department of Genetic Engineering & Biotechnology, Shahjalal University of Science & Technology, Sylhet 3114, Bangladesh
| | - Gen Ohtsuki
- Department of Drug Discovery Medicine, Kyoto University Graduate School of Medicine, Kyoto 606-8397, Japan;
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26
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Hampe CS, Mitoma H. A Breakdown of Immune Tolerance in the Cerebellum. Brain Sci 2022; 12:brainsci12030328. [PMID: 35326284 PMCID: PMC8946792 DOI: 10.3390/brainsci12030328] [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: 01/27/2022] [Revised: 02/22/2022] [Accepted: 02/25/2022] [Indexed: 11/21/2022] Open
Abstract
Cerebellar dysfunction can be associated with ataxia, dysarthria, dysmetria, nystagmus and cognitive deficits. While cerebellar dysfunction can be caused by vascular, traumatic, metabolic, genetic, inflammatory, infectious, and neoplastic events, the cerebellum is also a frequent target of autoimmune attacks. The underlying cause for this vulnerability is unclear, but it may be a result of region-specific differences in blood–brain barrier permeability, the high concentration of neurons in the cerebellum and the presence of autoantigens on Purkinje cells. An autoimmune response targeting the cerebellum—or any structure in the CNS—is typically accompanied by an influx of peripheral immune cells to the brain. Under healthy conditions, the brain is protected from the periphery by the blood–brain barrier, blood–CSF barrier, and blood–leptomeningeal barrier. Entry of immune cells to the brain for immune surveillance occurs only at the blood-CSF barrier and is strictly controlled. A breakdown in the barrier permeability allows peripheral immune cells uncontrolled access to the CNS. Often—particularly in infectious diseases—the autoimmune response develops because of molecular mimicry between the trigger and a host protein. In this review, we discuss the immune surveillance of the CNS in health and disease and also discuss specific examples of autoimmunity affecting the cerebellum.
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Affiliation(s)
- Christiane S. Hampe
- Department of Medicine, University of Washington, Seattle, WA 98195, USA
- Correspondence: ; Tel.: +1-206-554-9181
| | - Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, Tokyo 160-0023, Japan;
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27
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Autoimmune cerebellar hypermetabolism: Report of three cases and literature overview. Rev Neurol (Paris) 2021; 178:337-346. [PMID: 34657731 DOI: 10.1016/j.neurol.2021.07.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/19/2021] [Accepted: 07/23/2021] [Indexed: 11/23/2022]
Abstract
We report three cases of vermian cerebellar hypermetabolism in patients with autoimmune encephalitis. One of our patients was positive for anti-Ma2 antibodies and one for anti-Zic4 antibodies while the remaining patient did not present any known antibodies. The seronegative patient deteriorated after immune checkpoint inhibitor treatment for a pulmonary adenocarcinoma and improved with immunosuppressive drugs, which is in favour of an underlying autoimmune mechanism. They all presented with subacute neurological symptoms. Brain magnetic resonance imaging was normal except in one patient, where hyperintensities were present on FLAIR sequence around the third ventricle and the cerebral aqueduct. 18F-FDG brain positron emission tomography with computed tomography (18F-FDG PET-CT) demonstrated an unusual vermian cerebellar hypermetabolism in the three cases. While cerebellar hypermetabolism on 18F-FDG PET-CT has been described in various neurological diseases, such vermian - and more broadly cerebellar - hypermetabolism was seldom described in previous studies on autoimmune encephalitis. When differential diagnoses have been ruled out, this pattern may be of interest for the positive diagnosis of autoimmune encephalitis in difficult diagnostic cases.
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Liu M, Ren H, Fan S, Zhang W, Xu Y, Zhao W, Guan H. Neurological Autoimmunity Associated With Homer-3 Antibody: A Case Series From China. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/6/e1077. [PMID: 34580182 PMCID: PMC8477375 DOI: 10.1212/nxi.0000000000001077] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/06/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE To present 6 new cases with Homer-3 antibodies that expand their clinical spectra and to evaluate the effect of immunotherapy. METHODS Patients with suspected autoimmune cerebellar disorder were tested for rare autoimmune cerebellar ataxia (ACA) antibodies (anti-Tr(DNER)/Zic4/ITPR1/Homer-3/NCDN/PKCγ/PCA-2/AP3B2/mGluR1/ATP1A3 antibodies) using both cell-based and tissue-based assays. Patients with positive serum or CSF results who were diagnosed with ACA were registered and followed up. This study reports and analyzes cases with Homer-3 antibodies. RESULTS Of the serum and CSF samples of 750 patients tested, 6 were positive for Homer-3 antibodies. All manifested subacute or insidious-onset cerebellar ataxia. Furthermore, 2 patients each exhibited encephalopathy, myeloradiculopathy, REM sleep behavior disorder, and autonomic dysfunction. Brain magnetic resonance images were normal (n = 1) or revealed cerebellar atrophy (n = 1), cerebellum and pons atrophy with the hot cross bun sign (n = 2), and bilateral cerebral abnormalities (n = 2). Definite leukocytosis was identified in the CSF of 2 patients, protein concentration elevation was observed in the CSF of 1 patient, and oligoclonal bands were present in 2 patients. All patients received immunotherapy, including corticosteroid, IV immunoglobulin, plasma exchange, and mycophenolate mofetil, after which the residual disability was still severe (modified Rankin Scale score ≥3 at the last follow-up in 4 patients and final Scale for the Assessment and Rating of Ataxia scores of 12-29), although 4 patients partially improved and 1 patient stabilized. The remaining 1 patient continued to deteriorate after repeated immunotherapy. Two patients relapsed. DISCUSSION Disorders associated with Homer-3 antibody can mimic multiple system atrophy with cerebellar features in both clinical and radiologic aspects. Accurate identification of autoimmune-mediated cases is critical. Timely, comprehensive immunotherapy is warranted, given the possibility of long-term clinical benefit.
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Affiliation(s)
- Mange Liu
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China
| | - Haitao Ren
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China
| | - Siyuan Fan
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China
| | - Weihe Zhang
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China
| | - Yao Xu
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China
| | - Weili Zhao
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China
| | - Hongzhi Guan
- From the Department of Neurology (M.L., H.R., S.F., H.G.), Peking Union Medical College Hospital, Beijing; Peking Union Medical College and Chinese Academy of Medical Sciences (M.L., H.R., S.F., H.G.), Beijing; Department of Neurology (Weihe Zhang), China-Japan Friendship Hospital, Beijing; Department of Neurology (Y.X.), Medical Collage of Yangzhou University, Jiangsu; and Department of Neurology (Weili Zhao), Affiliated Hospital of Chifeng University, Inner Mongolia, China.
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A case series of two post-infectious acute cerebellitis an insidious path to the diagnosis and therapy. Neurol Sci 2021; 42:4843-4846. [PMID: 34515890 DOI: 10.1007/s10072-021-05590-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022]
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30
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Emekli AS, Parlak A, Göcen NY, Kürtüncü M. Anti-GAD associated post-infectious cerebellitis after COVID-19 infection. Neurol Sci 2021; 42:3995-4002. [PMID: 34328578 PMCID: PMC8322110 DOI: 10.1007/s10072-021-05506-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 07/18/2021] [Indexed: 12/20/2022]
Abstract
The coronavirus disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), continues to spread rapidly all over the world. Besides severe pneumonia, it causes multisystemic disease, including neurological findings. Here, we present a patient with anti–glutamic acid decarboxylase (anti-GAD) antibody-associated cerebellitis developed after COVID-19 infection. The patient responded well to the immune treatments. Our knowledge about SARS-CoV-2 infection–related neurological disorders is limited. New data are needed to recognize the clinical spectrum of autoimmune neurological disorders that emerges after SARS-CoV-2 infection.
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Affiliation(s)
- Ahmed Serkan Emekli
- Department of Neurology, Karabuk University Training and Research Hospital, Karabuk, Turkey.
| | - Asuman Parlak
- Department of Neurology, Karabuk University Training and Research Hospital, Karabuk, Turkey
| | - Nejla Yılmaz Göcen
- Department of Infectious Diseases, Karabuk University Training and Research Hospital, Karabuk, Turkey
| | - Murat Kürtüncü
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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31
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Moreno-Escobar MC, Feizi P, Podury S, Tandon M, Munir B, Alvi M, Adcock A, Sriwastava S. Acute cerebellitis following SARS-CoV-2 infection: A case report and review of the literature. J Med Virol 2021; 93:6818-6821. [PMID: 34314031 PMCID: PMC8427025 DOI: 10.1002/jmv.27232] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/24/2021] [Indexed: 12/13/2022]
Abstract
Novel coronavirus disease (COVID‐19) first described in Wuhan, China in December 2019, has rapidly spread across the world and become a global public health emergency. Literature on the neurological manifestations of COVID‐19 is limited. We report a 24‐year‐old male, who presented with vertigo, dysarthria, and bradyphrenia 3 weeks after being diagnosed with COVID‐19 on nasopharyngeal reverse transcription polymerase chain reaction. The patient was diagnosed with acute cerebellitis based on magnetic resonance imaging features and showed improvement posttreatment with intravenous methylprednisone for 5 days. The scope of this article is to highlight the importance of early identification of neurological symptoms and timely management as the outcomes may be catastrophic.
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Affiliation(s)
- Maria Camila Moreno-Escobar
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Parissa Feizi
- Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | | | - Medha Tandon
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Badria Munir
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Muhammad Alvi
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Amelia Adcock
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA.,West Virginia Clinical and Translational Science Institute, Morgantown, West Virginia, USA
| | - Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA.,West Virginia Clinical and Translational Science Institute, Morgantown, West Virginia, USA
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32
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Mizuma A, Enokida K, Nagata E, Takizawa S. Cerebellitis in a human T-lymphotropic virus type 1 carrier: a case report. BMJ Case Rep 2021; 14:14/6/e241366. [PMID: 34099448 DOI: 10.1136/bcr-2020-241366] [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: 01/08/2023] Open
Abstract
Human T-lymphotropic virus type I (HTLV-I) is a retrovirus associated with adult T-cell lymphoma (ATL) and HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP). In addition to HAM/TSP and ATL, HTLV-I-associated encephalopathy and cerebellar involvement have been reported. We report a case of an 87-year-old Japanese woman presenting with progressive dysarthria and gait disturbance. Neurological examination showed word-finding difficulty, scanning speech, saccadic eye movements, ocular dysmetria, gaze-evoked nystagmus and bilateral dysmetria. There was no motor weakness or spasticity. HTLV-I antibody was detected in both her serum and cerebrospinal fluid. Cerebrospinal fluid neopterin (57 pg/mL) and IgG index (3.27) were significantly elevated. MRI showed cerebellar swelling. She was finally diagnosed with HTLV-I associated cerebellitis. Two courses of high-dose intravenous methylpredonine therapy attenuated cerebellar ataxia and cerebellar swelling. It suggests that cerebellitis can result from HTLV-I infection, regardless of the existence of ATL or HAM/TSP.
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Affiliation(s)
- Atsushi Mizuma
- Department of Neurology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Kumiko Enokida
- Department of Neurology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Eiichiro Nagata
- Department of Neurology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Shunya Takizawa
- Department of Neurology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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Feldheim J, Deuschl C, Glas M, Kleinschnitz C, Hagenacker T. Simultaneous paraneoplastic cerebellar degeneration, Lambert-Eaton syndrome and neuropathy associated with AGNA/anti-SOX1 and VGCC antibodies. Neurol Res Pract 2021; 3:30. [PMID: 34030742 PMCID: PMC8142469 DOI: 10.1186/s42466-021-00129-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 05/06/2021] [Indexed: 12/17/2022] Open
Abstract
Anti-glial nuclear antibody (AGNA) is an onconeuroal antibody targeting the nuclei of Bergmann glia in the cerebellum and Anti-SRY-related HMG-box 1 (SOX1). It is highly specific for small cell lung cancer (SCLC) and correlates to the appearance of paraneoplastic neurological syndromes such as Lambert-Eaton myasthenic syndrome (pLEMS) and paraneoplastic cerebellar degeneration (PCD) amongst others. Herein, we present a SCLC patient with rapidly progressive PCD, LEMS and axonal polyneuropathy associated with AGNA/SOX1-antibodies, successfully treated with plasma-exchange (PLEX).
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Affiliation(s)
- Jonas Feldheim
- Department of Neurology, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany.,Department of Neurology, Division of Clinical Neurooncology, University Hospital, Essen, Germany.,Tumorbiology Laboratory, Department of Neurosurgery, University of Würzburg, Würzburg, Germany
| | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Martin Glas
- Department of Neurology, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany.,Department of Neurology, Division of Clinical Neurooncology, University Hospital, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany.,Department of Neurology, Division of Clinical Neurooncology, University Hospital, Essen, Germany
| | - Tim Hagenacker
- Department of Neurology, University Hospital Essen, Essen, Germany. .,Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany.
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Cerebellar ataxia and myeloradiculopathy associated with AP3B2 antibody: a case report and literature review. J Neurol 2021; 268:4163-4169. [PMID: 33988764 DOI: 10.1007/s00415-021-10496-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 02/20/2021] [Accepted: 02/23/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AP3B2 is one of the subunits of vesicle coat protein AP3 and is specifically expressed in central nervous system neurons. AP3B2 antibody has been reported in patients with autoimmune cerebellar ataxia and various extracerebellar symptoms. However, there have been few reports on its clinical features and treatment response. METHODS We report a 47-year-old man with AP3B2 antibody who presented with insidious-onset paresthesia and gait disturbance. His serum and cerebrospinal fluid (CSF) showed reactivity with the cytoplasm of Purkinje cells and granular layer synapses comparable to the reported specific pattern of anti-AP3B2 IgG, and this was confirmed by a cell-based assay. His symptoms improved after the administration of intravenous immunoglobulin, and oral prednisone and mycophenolate mofetil. Extensive examination and long-term follow-up showed no evidence of malignancy. A literature review was included to emphasize the neurological syndrome associated with this rare autoantibody. RESULTS Eleven cases with AP3B2 antibody, including our patient, were identified. The diversity of symptoms, including cerebellar and sensory ataxia, paresthesia, and weakness, was in line with the extensive binding of AP3B2 antibody to the spinal cord gray matter, dorsal root ganglia, cerebellar cortex, and nucleus. In the CSF, half of patients had elevated white blood cell counts, increased protein concentrations, or CSF-specific oligoclonal bands. All previous cases had subacute onsets and no improvement was noted after immunotherapy. CONCLUSION Our case indicated that disorders associated with AP3B2 antibody can also start insidiously. Immunotherapy is warranted given the possibility of clinical improvement.
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35
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Mitoma H, Manto M, Hadjivassiliou M. Immune-Mediated Cerebellar Ataxias: Clinical Diagnosis and Treatment Based on Immunological and Physiological Mechanisms. J Mov Disord 2021; 14:10-28. [PMID: 33423437 PMCID: PMC7840241 DOI: 10.14802/jmd.20040] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/04/2020] [Indexed: 12/24/2022] Open
Abstract
Since the first description of immune-mediated cerebellar ataxias (IMCAs) by Charcot in 1868, several milestones have been reached in our understanding of this group of neurological disorders. IMCAs have diverse etiologies, such as gluten ataxia, postinfectious cerebellitis, paraneoplastic cerebellar degeneration, opsoclonus myoclonus syndrome, anti-GAD ataxia, and primary autoimmune cerebellar ataxia. The cerebellum, a vulnerable autoimmune target of the nervous system, has remarkable capacities (collectively known as the cerebellar reserve, closely linked to plasticity) to compensate and restore function following various pathological insults. Therefore, good prognosis is expected when immune-mediated therapeutic interventions are delivered during early stages when the cerebellar reserve can be preserved. However, some types of IMCAs show poor responses to immunotherapies, even if such therapies are introduced at an early stage. Thus, further research is needed to enhance our understanding of the autoimmune mechanisms underlying IMCAs, as such research could potentially lead to the development of more effective immunotherapies. We underscore the need to pursue the identification of robust biomarkers.
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Affiliation(s)
- Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, Tokyo, Japan
| | - Mario Manto
- Service de Neurologie, Médiathèque Jean Jacquy, CHU-Charleroi, Charleroi, Belgium.,Service des Neurosciences, University of Mons, Mons, Belgium
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36
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Mitoma H, Honnorat J, Yamaguchi K, Manto M. Cerebellar long-term depression and auto-immune target of auto-antibodies: the concept of LTDpathies. MOLECULAR BIOMEDICINE 2021; 2:2. [PMID: 35006439 PMCID: PMC8607360 DOI: 10.1186/s43556-020-00024-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/07/2020] [Indexed: 01/04/2023] Open
Abstract
There is general agreement that auto-antibodies against ion channels and synaptic machinery proteins can induce limbic encephalitis. In immune-mediated cerebellar ataxias (IMCAs), various synaptic proteins, such as GAD65, voltage-gated Ca channel (VGCC), metabotropic glutamate receptor type 1 (mGluR1), and glutamate receptor delta (GluR delta) are auto-immune targets. Among them, the pathophysiological mechanisms underlying anti-VGCC, anti-mGluR1, and anti-GluR delta antibodies remain unclear. Despite divergent auto-immune and clinical profiles, these subtypes show common clinical features of good prognosis with no or mild cerebellar atrophy in non-paraneoplastic syndrome. The favorable prognosis reflects functional cerebellar disorders without neuronal death. Interestingly, these autoantigens are all involved in molecular cascades for induction of long-term depression (LTD) of synaptic transmissions between parallel fibers (PFs) and Purkinje cells (PCs), a crucial mechanism of synaptic plasticity in the cerebellum. We suggest that anti-VGCC, anti-mGluR1, and anti-GluR delta Abs-associated cerebellar ataxias share one common pathophysiological mechanism: a deregulation in PF-PC LTD, which results in impairment of restoration or maintenance of the internal model and triggers cerebellar ataxias. The novel concept of LTDpathies could lead to improvements in clinical management and treatment of cerebellar patients who show these antibodies.
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Affiliation(s)
- Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, Tokyo, Japan.
| | - Jerome Honnorat
- French Reference Center on Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, 69677, Bron, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, 69372, Lyon, France
| | - Kazuhiko Yamaguchi
- Department of Ultrastructural Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Mario Manto
- Unité des Ataxies Cérébelleuses, Service de Neurologie, Médiathèque Jean Jacquy, CHU-Charleroi, 6000, Charleroi, Belgium.,Service des Neurosciences, University of Mons, 7000, Mons, Belgium
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Quantitative brain imaging analysis of neurological syndromes associated with anti-GAD antibodies. NEUROIMAGE: CLINICAL 2021; 32:102826. [PMID: 34563986 PMCID: PMC8476448 DOI: 10.1016/j.nicl.2021.102826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 08/30/2021] [Accepted: 09/09/2021] [Indexed: 11/21/2022] Open
Abstract
The pattern of cortical atrophy is present throughout all anti-GAD phenotypes. The radiomic features correctly classify anti-GAD patients versus healthy subjects. The different neurological anti-GAD phenotypes should be considered as a continuum.
Neurological disorders associated with anti-glutamic acid decarboxylase (GAD) autoimmunity are rare and include a variety of neurological syndromes: stiff-person syndrome, cerebellar ataxia or limbic encephalitis. The diagnosis remains challenging due to the variety of symptoms and normal brain imaging. The morphological MRI of 26 patients (T1-weighted and Fluid-attenuated inversion recovery (FLAIR)-weighted images) was analyzed at the initial stage of diagnosis, matched by age and sex to 26 healthy subjects. We performed a vertex-wise analysis using a generalized linear model, adjusting by age, to compare the brain cortical thickness of both populations. In addition, we used a voxel-based morphometry of cerebellum thickness obtained by CEREbellum Segmentation (CERES), as well as the hippocampus volumetry comparison using HIPpocampus subfield Segmentation (HIPS). Finally, we extracted 62 radiomics features using LifeX to assess the classification performance using a random forest model to identify an anti-GAD related MRI. The results suggest a peculiar profile of atrophy in patients with anti-GAD, with a significant atrophy in the temporal and frontal lobes (adjusted p-value < 0.05), and a focal cerebellar atrophy of the V-lobule, independently of the anti-GAD phenotype. Finally, the MRIs from anti-GAD patients were correctly classified when compared to the control group, with an area under the curve (AUC) of 0.98. This study suggests a particular pattern of cortical atrophy throughout all anti-GAD phenotypes. These results reinforce the notion that the different neurological anti-GAD phenotypes should be considered as a continuum due to their similar cortical thickness profiles.
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Herzog R, Brüggemann N, Sprenger A, Münte TF. Recoverin antibody-associated late-onset ataxia without retinopathy. BMJ Case Rep 2020; 13:13/12/e237479. [PMID: 33334756 PMCID: PMC7747605 DOI: 10.1136/bcr-2020-237479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
Acquired cerebellar ataxia is a rare, in many cases immune-modulated and paraneoplastic illness. Acute and slowly progredient processes are possible. An early treatment is important for a good clinical outcome. Here we present the case of female patient in her 60s with an antirecoverin associated cerebellitis without retinopathia and neoplasia. After an immunosuppressive therapy with steroids and rituximab the symptoms improved, and the progression could be stopped.
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Affiliation(s)
- Rebecca Herzog
- Department of Neurology, Universitätsklinikum Schleswig-Holstein Campus Lübeck Klinik für Neurologie, Lubeck, Schleswig-Holstein, Germany .,Institute of Systems Motor Science, Universität zu Lübeck, Lubeck, Schleswig-Holstein, Germany
| | - Norbert Brüggemann
- Department of Neurology, Universitätsklinikum Schleswig-Holstein Campus Lübeck Klinik für Neurologie, Lubeck, Schleswig-Holstein, Germany
| | - Andreas Sprenger
- Department of Neurology, Universitätsklinikum Schleswig-Holstein Campus Lübeck Klinik für Neurologie, Lubeck, Schleswig-Holstein, Germany
| | - Thomas F Münte
- Department of Neurology, Universitätsklinikum Schleswig-Holstein Campus Lübeck Klinik für Neurologie, Lubeck, Schleswig-Holstein, Germany
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Blum TG, Misch D, Kollmeier J, Thiel S, Bauer TT. Autoimmune disorders and paraneoplastic syndromes in thymoma. J Thorac Dis 2020; 12:7571-7590. [PMID: 33447448 PMCID: PMC7797875 DOI: 10.21037/jtd-2019-thym-10] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Thymomas are counted among the rare tumour entities which are associated with autoimmune disorders (AIDs) and paraneoplastic syndromes (PNS) far more often than other malignancies. Through its complex immunological function in the context of the selection and maturation of T cells, the thymus is at the same time highly susceptible to disruptive factors caused by the development and growth of thymic tumours. These T cells, which are thought to develop to competent immune cells in the thymus, can instead adopt autoreactive behaviour due to the uncontrolled interplay of thymomas and become the trigger for AID or PNS affecting numerous organs and tissues within the human body. While myasthenia gravis is the most prevalent PNS in thymoma, numerous others have been described, be they related to neurological, cardiovascular, gastrointestinal, haematological, dermatological, endocrine or systemic disorders. This review article sheds light on the pathophysiology, epidemiology, specific clinical features and therapeutic options of the various forms as well as courses and outcomes of AID/PNS in association with thymomas. Whenever suitable and backed by the limited available evidence, the perspectives from both the thymoma and the affected organ/tissue will be highlighted. Specific issues addressed are the prognostic significance of thymectomy on myasthenia gravis and other thymoma-associated AID/PND and further the impact and safety of immunotherapies on AID and PND relating to thymomas.
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Affiliation(s)
- Torsten Gerriet Blum
- Department of Pneumology, Lungenklinik Heckeshorn, Helios Klinikum Emil von Behring, Berlin, Germany
| | - Daniel Misch
- Department of Pneumology, Lungenklinik Heckeshorn, Helios Klinikum Emil von Behring, Berlin, Germany
| | - Jens Kollmeier
- Department of Pneumology, Lungenklinik Heckeshorn, Helios Klinikum Emil von Behring, Berlin, Germany
| | - Sebastian Thiel
- Department of Pneumology, Lungenklinik Heckeshorn, Helios Klinikum Emil von Behring, Berlin, Germany
| | - Torsten T Bauer
- Department of Pneumology, Lungenklinik Heckeshorn, Helios Klinikum Emil von Behring, Berlin, Germany
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Cabaraux P, Poncelet A, Honnorat J, Demeester R, Cherifi S, Manto M. CSF HIV RNA Escape in Opsoclonus-Myoclonus-Ataxia Syndrome: Case Report and Review of the Literature. Front Neurol 2020; 11:585527. [PMID: 33329331 PMCID: PMC7719769 DOI: 10.3389/fneur.2020.585527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 10/26/2020] [Indexed: 11/22/2022] Open
Abstract
Background: Human immunodeficiency viruses (HIV) infection is associated with a broad range of neurological manifestations, including opsoclonus-myoclonus ataxia syndrome (OMAS) occurring in primary infection, immune reconstitution syndrome or in case of opportunistic co-infection. Case: We report the exceptional case of a 43-year-old female under HIV treatment for 10 years who presented initially with suspected epileptic seizure. Although the clinical picture slightly improved under anti-epileptic treatment, it was rapidly attributed to OMAS. The patient exhibited marked opsoclonus, mild dysarthria, upper limbs intermittent myoclonus, ataxia in 4 limbs, truncal ataxia, and a severe gait ataxia (SARA score: 34). The diagnostic work-up showed radiological and biological signs of central nervous system (CNS) inflammation and cerebral venous sinus thromboses. The HIV viral load was higher in cerebrospinal fluid (CSF) than in the blood (4,560 copies/ml vs. 76 copies/ml). She was treated for 5 days with pulsed corticotherapy. Dolutegravir and anticoagulation administration were initiated. Follow-ups at 2 and 4 months showed a dramatic improvement of clinical neurologic status (SARA score at 4 months: 1), reduction of CNS inflammation and revealed undetectable CSF and serum viral loads. Conclusion: This case underlines the importance of the evaluation of the CSF viral load in HIV patients developing OMAS and suggests CSF HIV RNA escape as a novel cause for OMAS.
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Affiliation(s)
- Pierre Cabaraux
- Unité des Ataxies Cérébelleuses, Service de Neurologie, Centre Hospitalier Universitaire (CHU)-Charleroi, Charleroi, Belgium
- *Correspondence: Pierre Cabaraux
| | - Arthur Poncelet
- Service de Médecine Interne, Centre Hospitalier Universitaire (CHU)-Charleroi, Charleroi, Belgium
| | - Jérome Honnorat
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Remy Demeester
- Service de Médecine Interne, Centre Hospitalier Universitaire (CHU)-Charleroi, Charleroi, Belgium
| | - Soraya Cherifi
- Service de Médecine Interne, Centre Hospitalier Universitaire (CHU)-Charleroi, Charleroi, Belgium
| | - Mario Manto
- Unité des Ataxies Cérébelleuses, Service de Neurologie, Centre Hospitalier Universitaire (CHU)-Charleroi, Charleroi, Belgium
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Suppression of microglial activation and monocyte infiltration ameliorates cerebellar hemorrhage induced-brain injury and ataxia. Brain Behav Immun 2020; 89:400-413. [PMID: 32717406 DOI: 10.1016/j.bbi.2020.07.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/20/2020] [Accepted: 07/20/2020] [Indexed: 02/07/2023] Open
Abstract
Ataxia, characterized by uncoordinated movement, is often found in patients with cerebellar hemorrhage (CH), leading to long-term disability without effective management. Microglia are among the first responders to CNS insult. Yet the role and mechanism of microglia in cerebellar injury and ataxia after CH are still unknown. Using Ki20227, an inhibitor for colony-stimulating factor 1 receptor which mediates the signaling responsible for the survival of microglia, we determined the impact of microglial depletion on cerebellar injury and ataxia in a murine model of CH. Microglial depletion reduced cerebellar lesion volume and alleviated gait abnormality, motor incoordination, and locomotor dysfunction after CH. Suppression of CH-initiated microglial activation with minocycline ameliorated cerebellum infiltration of monocytes/macrophages, as well as production of proinflammatory cytokines and chemokine C-C motif ligand-2 (CCL-2) that recruits monocytes/macrophages. Furthermore, both minocycline and bindarit, a CCL-2 inhibitor, prevented apoptosis and electrophysiological dysfunction of Purkinje cells, the principal neurons and sole outputs of the cerebellar cortex, and consequently improved ataxia-like motor abnormalities. Our findings suggest a detrimental role of microglia in neuroinflammation and ataxic motor symptoms after CH, and pave a new path to understand the neuroimmune mechanism underlying CH-induced cerebellar ataxia.
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Ren H, Zhao D, Xu X, Yang Y, Fan S, Li W, Guan H. Paraneoplastic cerebellar degeneration associated with anti-protein kinase Cgamma antibodies in a Chinese patient. J Neuroimmunol 2020; 350:577408. [PMID: 33217719 DOI: 10.1016/j.jneuroim.2020.577408] [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] [Received: 07/17/2020] [Revised: 09/11/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022]
Abstract
Anti-protein kinase Cgamma (anti-PKCγ) antibodies are rare onconeural antibodies associated with paraneoplastic cerebellar degeneration (PCD). To date, only two patients with PCD and anti-PKCγ antibodies have been reported. Here, we report a Chinese patient with PCD and anti-PKCγ antibodies. Screening for tumor revealed lymphoepithelial carcinoma in tonsil. The patient's symptoms improved gradually after radiotherapy for the lymphoepithelial carcinoma and intravenous immunoglobulin immunotherapy.
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Affiliation(s)
- Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Dachun Zhao
- Department of Pathology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaolu Xu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yingmai Yang
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Wenhan Li
- Oumeng V Medical Laboratory, Hangzhou, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
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Gluten Ataxia Associated with Dietary Protein Cross-Reactivity with GAD-65. REPORTS 2020. [DOI: 10.3390/reports3030024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Cross-reactivity occurs when antibodies formed against an antigen have amino acid sequence homology with another target protein. This allows antibodies formed against the antigen to also bind to similar proteins that share structural similarity. Autoimmune reactions to gluten can lead to sporadic ataxia in susceptible genotypes due to cross-reactivity. With gluten ataxia, dietary consumption of gluten proteins induce immunological cross-reactivity with glutamic-acid decarboxylase-65 (GAD-65) target proteins found in the cerebellum. Implementation of a strict gluten-free diet has been shown to improve the expression of this form of ataxia with most patients in this subgroup. However, there are some subjects that have limited clinical responses to only a strict gluten-free diet. Dietary protein cross-reactivity to other food proteins, besides gluten, that also share structural similarity to GAD-65 may also play a role in this reaction. In this case report, we report of a patient suffering from gluten-ataxia in which a gluten-free diet alone did not generate significant clinical outcomes until other foods that cross-react with GAD-65 were also removed from their diet.
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Bozzola E, Guolo S, Macchiarulo G, Festa L, Spina G, Krzysztofiak A, Grandin A, Bozzola M, Raponi M, Villani A. Hospitalization for acute cerebellitis in children affected by varicella: how much does it cost? Ital J Pediatr 2020; 46:114. [PMID: 32762761 PMCID: PMC7410155 DOI: 10.1186/s13052-020-00875-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 07/27/2020] [Indexed: 11/16/2022] Open
Abstract
Background Chickenpox is a highly contagious airborne disease caused by the varicella zoster virus. It is generally benign and self-limiting, but it may be responsible of life-threatening complications. Acute cerebellitis (AC) is the most common neurological complication and is associated with prolonged hospitalization in the acute phase (HAP). Aim of the study To estimate the costs of AC HAP in children affected by varicella. Materials and methods We retrospectively reviewed the medical records of a pediatric cohort hospitalized for chickenpox AC over a period of 15 years (from October 2003 to October 2018) and we analyzed acute care costs. For any patient the HAP has been calculated. The final value includes cost of hospital accommodation and management at the Pediatric and Infectious Diseases Unit. To this cost, the price of procedures (imaging, laboratory exams, medical and paramedical evaluations) and medical treatments was added. Results In the study period, 856 children had been hospitalized for varicella. Out of them, 65 met a diagnosis of AC and were included in the study. The hospitalization length was of 10 days (range 3–20 days). The median cost of HAP for each patient was of 5366 euro, with an average annual cost of 23,252 €. The most significant part of HAP is due to the cost of hospital accommodation and management at the Pediatric Infectious Diseases Unit, which was about € 537.78 for a single day. Discussion Although AC post-varicella is rare, its HAP cost is not negligible resulting in substantial economic burden. Vaccination would have probably prevented varicella and AC complication, avoiding hospitalization. Conclusions Financial studies are important for evaluate the cost saving in order to influence public funding decisions. Further studies are necessary to investigate the economic burden of the disease.
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Affiliation(s)
- Elena Bozzola
- Pediatric and Infectious Disease Unit, Bambino Gesù Children Hospital, Rome, Italy.
| | - Stefano Guolo
- Medical Direction, Bambino Gesù Children Hospital, Rome, Italy
| | - Giulia Macchiarulo
- Pediatric and Infectious Disease Unit, Bambino Gesù Children Hospital, Rome, Italy
| | - Lidia Festa
- Pediatric and Infectious Disease Unit, Bambino Gesù Children Hospital, Rome, Italy
| | - Giulia Spina
- Pediatric and Infectious Disease Unit, Bambino Gesù Children Hospital, Rome, Italy
| | - Andrzej Krzysztofiak
- Pediatric and Infectious Disease Unit, Bambino Gesù Children Hospital, Rome, Italy
| | - Annalisa Grandin
- Pediatric and Infectious Disease Unit, Bambino Gesù Children Hospital, Rome, Italy
| | | | | | - Alberto Villani
- Pediatric and Infectious Disease Unit, Bambino Gesù Children Hospital, Rome, Italy
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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: 14] [Impact Index Per Article: 3.5] [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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Dade M, Berzero G, Izquierdo C, Giry M, Benazra M, Delattre JY, Psimaras D, Alentorn A. Neurological Syndromes Associated with Anti-GAD Antibodies. Int J Mol Sci 2020; 21:E3701. [PMID: 32456344 PMCID: PMC7279468 DOI: 10.3390/ijms21103701] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 12/11/2022] Open
Abstract
Glutamic acid decarboxylase (GAD) is an intracellular enzyme whose physiologic function is the decarboxylation of glutamate to gamma-aminobutyric acid (GABA), the main inhibitory neurotransmitter within the central nervous system. GAD antibodies (Ab) have been associated with multiple neurological syndromes, including stiff-person syndrome, cerebellar ataxia, and limbic encephalitis, which are all considered to result from reduced GABAergic transmission. The pathogenic role of GAD Ab is still debated, and some evidence suggests that GAD autoimmunity might primarily be cell-mediated. Diagnosis relies on the detection of high titers of GAD Ab in serum and/or in the detection of GAD Ab in the cerebrospinal fluid. Due to the relative rarity of these syndromes, treatment schemes and predictors of response are poorly defined, highlighting the unmet need for multicentric prospective trials in this population. Here, we reviewed the main clinical characteristics of neurological syndromes associated with GAD Ab, focusing on pathophysiologic mechanisms.
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Affiliation(s)
- Maëlle Dade
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Giulia Berzero
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
- Neuroncology Unit, IRCCS Mondino Foundation, 27100 Pavia, Italy
| | - Cristina Izquierdo
- Department of Neuroscience, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, 08916 Badalona, Spain;
| | - Marine Giry
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Marion Benazra
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Jean-Yves Delattre
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Dimitri Psimaras
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Agusti Alentorn
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
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Paraneoplastic cerebellar degeneration in a patient with breast cancer associated with carbonic anhydrase-related protein VIII autoantibodies. J Neuroimmunol 2020; 344:577242. [PMID: 32325285 DOI: 10.1016/j.jneuroim.2020.577242] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 04/13/2020] [Indexed: 11/22/2022]
Abstract
Paraneoplastic cerebellar degeneration is a neurological syndrome resulting from immune-mediated dysfunction of Purkinje cells and commonly is associated with a tumor. In most cases, well-characterized onconeural antibodies are detected, such as anti-Yo and anti-Ri antibodies. Carbonic anhydrase-related protein VIII (CARP VIII) antibodies associated with paraneoplastic cerebellar degeneration have been previously described in only two cases. Herein, we present a 75-year-old female who developed progressive cerebellar ataxia. Anti-CARP VIII autoantibodies were found at high titres and screening for underlying malignancies revealed a breast cancer. Intravenous immunoglobulin was administered with poor results. Our report further confirms the role of CARP VIII antibodies in cerebellar degeneration.
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48
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Gandini J, Manto M. How does editing the genome improve targeting DNA and RNA for cerebellar ataxias? FUTURE NEUROLOGY 2020. [DOI: 10.2217/fnl-2019-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Jordi Gandini
- Cerebellar Ataxia Unit, Department of Neurology, CHU-Charleroi, Charleroi, Belgium
| | - Mario Manto
- Cerebellar Ataxia Unit, Department of Neurology, CHU-Charleroi, Charleroi, Belgium
- Department of Neuroscience, University of Mons, Mons, Belgium
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49
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The neurological update: therapies for cerebellar ataxias in 2020. J Neurol 2020; 267:1211-1220. [DOI: 10.1007/s00415-020-09717-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/12/2020] [Accepted: 01/18/2020] [Indexed: 12/28/2022]
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50
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Dudova I, Horackova K, Hrdlicka M, Balastik M. Can Maternal Autoantibodies Play an Etiological Role in ASD Development? Neuropsychiatr Dis Treat 2020; 16:1391-1398. [PMID: 32581542 PMCID: PMC7276202 DOI: 10.2147/ndt.s239504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 04/10/2020] [Indexed: 12/20/2022] Open
Abstract
Autism spectrum disorder (ASD) is a heterogeneous condition with multiple etiologies and risk factors - both genetic and environmental. Recent data demonstrate that the immune system plays an important role in prenatal brain development. Deregulation of the immune system during embryonic development can lead to neurodevelopmental changes resulting in ASD. One of the potential etiologic factors in the development of ASD has been identified as the presence of maternal autoantibodies targeting fetal brain proteins. The type of ASD associated with the presence of maternal autoantibodies has been referred to as maternal antibodies related to ASD (MAR ASD). The link between maternal autoantibodies and ASD has been demonstrated in both clinical studies and animal models, but the exact mechanism of their action in the pathogenesis of ASD has not been clarified yet. Several protein targets of ASD-related maternal autoantibodies have been identified. Here, we discuss the role of microtubule-associated proteins of the collapsin response mediator protein (CRMP) family in neurodevelopment and ASD. CRMPs have been shown to integrate multiple signaling cascades regulating neuron growth, guidance or migration. Their targeting by maternal autoantibodies could change CRMP levels or distribution in the developing nervous system, leading to defects in axon growth/guidance, cortical migration, or dendritic projection, which could play an etiological role in ASD development. In addition, we discuss the future possibilities of MAR ASD treatment.
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Affiliation(s)
- Iva Dudova
- Department of Child Psychiatry, Charles University Second Faculty of Medicine, Prague, Czech Republic
| | - Klara Horackova
- Department of Psychiatry, Charles University First Faculty of Medicine, Prague, Czech Republic
| | - Michal Hrdlicka
- Department of Child Psychiatry, Charles University Second Faculty of Medicine, Prague, Czech Republic
| | - Martin Balastik
- Laboratory of Molecular Neurobiology, Institute of Physiology of the Czech Academy of Sciences, Prague, Czech Republic
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