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Ibenyahia A, Adnor S, Bigi S, Bazi I, Elmekkaoui A, Othmane B, Hicham N, Wakrim S. Neuroimaging insights into poor prognosis paraneoplastic encephalomyelitis: A case report on a challenging diagnosis revealed by MR imaging in a patient with Hodgkin's lymphoma. Radiol Case Rep 2024; 19:4992-4999. [PMID: 39247480 PMCID: PMC11378097 DOI: 10.1016/j.radcr.2024.07.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 07/26/2024] [Accepted: 07/27/2024] [Indexed: 09/10/2024] Open
Abstract
Paraneoplastic encephalomyelitis (PEM) is a rare complication associated with malignancies, often presenting before the cancer diagnosis. A 42-year-old male with a history of chronic smoking presented with acute urinary retention and neurological deficits, all evolving in a febrile context with general deterioration. Laboratory tests were conducted, followed by a cerebral MRI which revealed multiple T2 and FLAIR hyperintense lesions in the periventricular and periaqueductal regions, medial temporal lobes, and bilateral postero-medial thalamus. Enhanced CT scans of the chest and abdomen identified multiple cervical, axillary, and inguinal lymphadenopathies. Subsequently, an ultrasound-guided biopsy of a cervical node was performed. His condition deteriorated rapidly, requiring intubation and sedation. A subsequent MRI revealed worsening cerebral and spinal cord lesions with new contrast enhancement in the brainstem. The differential diagnosis included toxic/metabolic and paraneoplastic causes. Biopsy results confirmed Hodgkin's lymphoma, leading to a diagnosis of progressive paraneoplastic encephalomyelitis (PEM). Despite adequate treatment, the patient's condition worsened, leading to death from pneumonitis and metabolic complications. This case underscores the importance of considering PEM in patients with neurological deficits and malignancy, with MRI playing a crucial role in diagnosis. Early detection and treatment are essential to improving outcomes.
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Affiliation(s)
- Abderrahmane Ibenyahia
- Radiology Department, Faculty of Medicine and Pharmacy, University Hospital Center of Souss Massa, Ibn Zohr Agadir University, Agadir, Morocco
| | - Said Adnor
- Radiology Department, Faculty of Medicine and Pharmacy, University Hospital Center of Souss Massa, Ibn Zohr Agadir University, Agadir, Morocco
| | - Soufiane Bigi
- Radiology Department, Faculty of Medicine and Pharmacy, University Hospital Center of Souss Massa, Ibn Zohr Agadir University, Agadir, Morocco
| | - Imane Bazi
- Radiology Department, Faculty of Medicine and Pharmacy, University Hospital Center of Souss Massa, Ibn Zohr Agadir University, Agadir, Morocco
| | - Adel Elmekkaoui
- Department of Anesthesia Reanimation, Faculty of Medicine and Pharmacy, University Hospital Center of Souss Massa, Ibn Zohr Agadir University, Agadir, Morocco
| | - Benlenda Othmane
- Department of Anesthesia Reanimation, Faculty of Medicine and Pharmacy, University Hospital Center of Souss Massa, Ibn Zohr Agadir University, Agadir, Morocco
| | - Nassik Hicham
- Department of Anesthesia Reanimation, Faculty of Medicine and Pharmacy, University Hospital Center of Souss Massa, Ibn Zohr Agadir University, Agadir, Morocco
| | - Soukaina Wakrim
- Radiology Department, Faculty of Medicine and Pharmacy, University Hospital Center of Souss Massa, Ibn Zohr Agadir University, Agadir, Morocco
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Ohira K, Kanai D, Inoue Y. Myelitis preceding anti-N-terminal of α-enolase antibody-positive Hashimoto's encephalopathy. Radiol Case Rep 2024; 19:4392-4396. [PMID: 39165314 PMCID: PMC11334564 DOI: 10.1016/j.radcr.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 06/27/2024] [Accepted: 07/01/2024] [Indexed: 08/22/2024] Open
Abstract
Hashimoto's encephalopathy is an autoimmune disease characterized by diverse clinical and imaging manifestations, often presenting considerable challenges in its diagnosis, especially when myelitis occurs before the onset of encephalopathy. Anti-N-terminal of α-enolase antibodies targeting the N-terminal of α-enolase are specific serum markers of Hashimoto's encephalopathy; however, studies analyzing their association with myelitis are lacking. Herein, we describe the case of a patient with myelitis who later developed encephalopathy. Owing to positivity for anti-N-terminal of α-enolase antibodies in the serum, a diagnosis of Hashimoto's encephalopathy was made. Detecting anti-NAE antibodies can be useful in diagnosing myelitis of unknown etiology.
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Affiliation(s)
- Kenji Ohira
- Department of Radiology, Japanese Red Cross Society Shizuoka Hospital, 8-2 Otemachi, Aoi Ward, Shizuoka City, Shizuoka Prefecture, 420-0853, Japan
| | - Daisuke Kanai
- Department of Radiology, Japanese Red Cross Society Shizuoka Hospital, 8-2 Otemachi, Aoi Ward, Shizuoka City, Shizuoka Prefecture, 420-0853, Japan
| | - Yukio Inoue
- Department of Radiology, Japanese Red Cross Society Shizuoka Hospital, 8-2 Otemachi, Aoi Ward, Shizuoka City, Shizuoka Prefecture, 420-0853, Japan
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Bali AS, Dumitrascu A. 70-Year-Old Woman With Altered Mental Status. Mayo Clin Proc 2024; 99:1488-1493. [PMID: 38912990 DOI: 10.1016/j.mayocp.2023.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/17/2023] [Accepted: 10/24/2023] [Indexed: 06/25/2024]
Affiliation(s)
- Aman S Bali
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL, USA
| | - Adrian Dumitrascu
- Advisor to resident and Consultant in Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL, USA.
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Pai V, Kang H, Suthiphosuwan S, Gao A, Mandell D, Shroff M. Autoimmune Encephalitis: Insights Into Immune-Mediated Central Nervous System Injury. Korean J Radiol 2024; 25:807-823. [PMID: 39197826 PMCID: PMC11361799 DOI: 10.3348/kjr.2023.1307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 04/23/2024] [Accepted: 06/10/2024] [Indexed: 09/01/2024] Open
Abstract
Autoimmune encephalitis (AE) is a category of immune-mediated disorders of the central nervous system (CNS) affecting children and adults. It is characterized by the subacute onset of altered mentation, neurocognitive issues, refractory seizures/drug-resistant epilepsy, movement disorders, and/or autonomic dysfunction. AE is mediated by autoantibodies targeting specific surface components or intracytoplasmic antigens in the CNS, leading to functional or structural alterations. Multiple triggers that induce autoimmunity have been described, which are mainly parainfectious and paraneoplastic. The imaging features of AE often overlap with each other and with other common causes of encephalitis/encephalopathy (infections and toxic-metabolic etiologies). Limbic encephalitis is the most common imaging finding shared by most of these entities. Cortical, basal ganglia, diencephalon, and brainstem involvement may also be present. Cerebellar involvement is rare and is often a part of paraneoplastic degeneration. Owing to an improved understanding of AE, their incidence and detection have increased. Hence, in an appropriate setting, a high degree of suspicion is crucial when reporting clinical MRIs to ensure prompt treatment and better patient outcomes. In this review, we discuss the pathophysiology of AE and common etiologies encountered in clinical practice.
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Affiliation(s)
- Vivek Pai
- Division of Neuroradiology, Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Toronto, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Heejun Kang
- Department of Medical Imaging, University of Toronto, Toronto, Canada
- Division of Neuroradiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Suradech Suthiphosuwan
- Department of Medical Imaging, University of Toronto, Toronto, Canada
- Division of Neuroradiology, St. Michael's Hospital-Unity Health Toronto, Toronto, Canada
| | - Andrew Gao
- Laboratory Medicine Program, University Health Network, Toronto, Canada
| | - Daniel Mandell
- Department of Medical Imaging, University of Toronto, Toronto, Canada
- Joint Department of Medical Imaging (JDMI), Toronto Western Hospital, Toronto, Canada
| | - Manohar Shroff
- Division of Neuroradiology, Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Toronto, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Canada.
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Lee ST, Abboud H, Irani SR, Nakajima H, Piquet AL, Pittock SJ, Yeh EA, Wang J, Rajan S, Overell J, Smith J, St Lambert J, El-Khairi M, Gafarova M, Gelfand JM. Innovation and optimization in autoimmune encephalitis trials: the design and rationale for the Phase 3, randomized study of satralizumab in patients with NMDAR-IgG-antibody-positive or LGI1-IgG-antibody-positive autoimmune encephalitis (CIELO). Front Neurol 2024; 15:1437913. [PMID: 39193150 PMCID: PMC11348855 DOI: 10.3389/fneur.2024.1437913] [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: 05/24/2024] [Accepted: 07/15/2024] [Indexed: 08/29/2024] Open
Abstract
Background Autoimmune encephalitis (AIE) encompasses a spectrum of rare autoimmune-mediated neurological disorders, which are characterized by brain inflammation and dysfunction. Autoantibodies targeting the N-methyl-d-aspartic acid receptor (NMDAR) and leucine-rich glioma-inactivated 1 (LGI1) are the most common subtypes of antibody-positive AIE. Currently, there are no approved therapies for AIE. Interleukin-6 (IL-6) signaling plays a role in the pathophysiology of AIE. Satralizumab, a humanized, monoclonal recycling antibody that specifically targets the IL-6 receptor and inhibits IL-6 signaling, has demonstrated efficacy and safety in another autoantibody-mediated neuroinflammatory disease, aquaporin-4 immunoglobulin G antibody-positive neuromyelitis optica spectrum disorder, and has the potential to be an evidence-based disease modifying treatment in AIE. Objectives CIELO will evaluate the efficacy, safety, pharmacodynamics, and pharmacokinetics of satralizumab compared with placebo in patients with NMDAR-immunoglobulin G antibody-positive (IgG+) or LGI1-IgG+ AIE. Study design CIELO (NCT05503264) is a prospective, Phase 3, randomized, double-blind, multicenter, basket study that will enroll approximately 152 participants with NMDAR-IgG+ or LGI1-IgG+ AIE. Prior to enrollment, participants will have received acute first-line therapy. Part 1 of the study will consist of a 52-week primary treatment period, where participants will receive subcutaneous placebo or satralizumab at Weeks 0, 2, 4, and every 4 weeks thereafter. Participants may continue to receive background immunosuppressive therapy, symptomatic treatment, and rescue therapy throughout the study. Following Part 1, participants can enter an optional extension period (Part 2) to continue the randomized, double-blind study drug, start open-label satralizumab, or stop study treatment and continue with follow-up assessments. Endpoints The primary efficacy endpoint is the proportion of participants with a ≥1-point improvement in the modified Rankin Scale (mRS) score from study baseline and no use of rescue therapy at Week 24. Secondary efficacy assessments include mRS, Clinical Assessment Scale of Autoimmune Encephalitis (CASE), time to rescue therapy, sustained seizure cessation and no rescue therapy, Montreal Cognitive Assessment, and Rey Auditory Verbal Learning Test (RAVLT) measures. Safety, pharmacokinetics, pharmacodynamics, exploratory efficacy, and biomarker endpoints will be captured. Conclusion The innovative basket study design of CIELO offers the opportunity to yield prospective, robust evidence, which may contribute to the development of evidence-based treatment recommendations for satralizumab in AIE.
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Affiliation(s)
- Soon-Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hesham Abboud
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Sarosh R. Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- Departments of Neurology and Neurosciences, Mayo Clinic, Jacksonville, FL, United States
| | - Hideto Nakajima
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Amanda L. Piquet
- Department of Neurology, University of Colorado, Aurora, CO, United States
| | - Sean J. Pittock
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, United States
| | - E. Ann Yeh
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Jiawei Wang
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Sharmila Rajan
- Product Development Neuroscience, Genentech, Inc., South San Francisco, CA, United States
| | - James Overell
- Product Development Neuroscience, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Jillian Smith
- Roche Products Ltd., Welwyn Garden City, United Kingdom
| | | | | | - Marina Gafarova
- Product Development Neuroscience, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Jeffrey M. Gelfand
- Department of Neurology, UCSF Weill Institute for Neurosciences, San Francisco, CA, United States
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Almeida FC, Pereira AI, Mendes-Pinto C, Lopes J, Moura J, Sousa JM, Videira G, Samões R, Oliveira TG. MR Imaging Findings in Anti-Leucine-Rich Glioma Inactivated Protein 1 Encephalitis: A Systematic Review and Meta-analysis. AJNR Am J Neuroradiol 2024; 45:977-986. [PMID: 38871367 DOI: 10.3174/ajnr.a8256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/14/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Antibodies against leucine-rich glioma inactivated protein 1 (LGI1) constitute a common form of autoimmune encephalitis. On MR imaging, it may show T2 FLAIR hyperintensities of the medial temporal lobe (T2 FLAIR-MTL), involve the basal ganglia, or be unremarkable. PURPOSE We performed a systematic review and meta-analysis to obtain prevalence estimates of abnormal findings on MR imaging in anti-LGI1 encephalitis. A human brain map of the LGI1 microarray gene expression was derived from the Allen Human Brain Atlas. DATA SOURCES PubMed and Web of Science were searched with the terms "LGI1" and "encephalitis" from inception to April 7, 2022. STUDY SELECTION Thirty-one research publications, encompassing case series and retrospective cohort and case-control studies, with >10 patients with anti-LGI1 encephalitis and MR imaging data were included. DATA ANALYSIS Pooled prevalence estimates were calculated using Freeman-Tukey double-arcsine transformation. Meta-analysis used DerSimonian and Laird random effects models. DATA SYNTHESIS Of 1318 patients in 30 studies, T2 FLAIR-MTL hyperintensities were present in 54% (95% CI, 0.48-0.60; I2 = 76%). Of 394 patients in 13 studies, 27% showed bilateral (95% CI, 0.19-0.36; I2 = 71%) and 24% unilateral T2 FLAIR-MTL abnormalities (95% CI, 0.17-0.32; I2 = 61%). Of 612 patients in 15 studies, basal ganglia abnormalities were present in 10% (95% CI, 0.06-0.15; I2 = 67%). LGI1 expression was highest in the amygdala, hippocampus, and caudate nucleus. LIMITATIONS Only part of the spectrum of MR imaging abnormalities in anti-LGI1 encephalitis could be included in a meta-analysis. MR imaging findings were not the main outcomes in most studies, limiting available information. I2 values ranged from 62% to 76%, representing moderate-to-large heterogeneity. CONCLUSIONS T2 FLAIR-MTL hyperintensities were present in around one-half of patients with anti-LGI1. The prevalence of unilateral and bilateral presentations was similar, suggesting unilaterality should raise the suspicion of this disease in the appropriate clinical context. Around 10% of patients showed basal ganglia abnormalities, indicating that special attention should be given to this region. LGI1 regional expression coincided with the most frequently reported abnormal findings on MR imaging. Regional specificity might be partially determined by expression levels of the target protein.
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Affiliation(s)
- Francisco C Almeida
- From the Department of Neuroradiology (F.C.A., A.I.P., C.M.-P.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Life and Health Sciences Research Institute (F.C.A., T.G.O.), School of Medicine, University of Minho, Braga, Portugal
- Life and Health Sciences Research Institute/3B's-PT Government Associate Laboratory (F.C.A., T.G.O.), Braga/Guimarães, Portugal
| | - Ana I Pereira
- From the Department of Neuroradiology (F.C.A., A.I.P., C.M.-P.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Catarina Mendes-Pinto
- From the Department of Neuroradiology (F.C.A., A.I.P., C.M.-P.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Joana Lopes
- Department of Neurology (J.L., J.M., G.V., R.S.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - João Moura
- Department of Neurology (J.L., J.M., G.V., R.S.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - José Maria Sousa
- Department of Neuroradiology (J.M.S.), Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Gonçalo Videira
- Department of Neurology (J.L., J.M., G.V., R.S.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Raquel Samões
- Department of Neurology (J.L., J.M., G.V., R.S.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Unit for Multidisciplinary Research in Biomedicine (R.S.), Instituto de Ciências Biomédicas de Abel Salazar da Universidade do Porto, Porto, Portugal
| | - Tiago Gil Oliveira
- Life and Health Sciences Research Institute (F.C.A., T.G.O.), School of Medicine, University of Minho, Braga, Portugal
- Life and Health Sciences Research Institute/3B's-PT Government Associate Laboratory (F.C.A., T.G.O.), Braga/Guimarães, Portugal
- Department of Neuroradiology (T.G.O.), Hospital de Braga, Braga, Portugal
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Santoro JD, Demakakos P, He S, Kumar S, Murton M, Tennigkeit F, Hemingway C. A systematic review of the epidemiology of pediatric autoimmune encephalitis: disease burden and clinical decision-making. Front Neurol 2024; 15:1408606. [PMID: 39040538 PMCID: PMC11262030 DOI: 10.3389/fneur.2024.1408606] [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: 03/28/2024] [Accepted: 06/19/2024] [Indexed: 07/24/2024] Open
Abstract
Background Autoimmune encephalitis (AIE) comprises a group of rare, immune system-mediated conditions. Clinical manifestations among children are not well-characterized, and there are challenges in testing and diagnosis. This can result in treatment delays, which has been found to correlate with poorer long-term outcomes. This challenge is exacerbated by the scarcity of epidemiological reporting of AIE. The objective of this systematic literature review (SLR) was to identify studies reporting epidemiological data on AIE in children. Methods MEDLINE, Embase, the Cochrane Library, and the University of York Centre for Reviews and Dissemination (CRD) were searched in May 2023 for studies reporting on the epidemiology of AIE in children. These were supplemented with additional searches of conference proceedings, gray literature, and the reference lists of identified SLRs. Quality of studies was assessed using a modified version of the Joanna Briggs Institute (JBI) Checklist for Prevalence Studies. Results Forty-three publications reporting on 41 unique studies were included. Nine studies reported incidence estimates of different subtypes of AIE, with only one reporting the incidence of overall AIE in children ≤ 18 years, estimated at 1.54 per million children per year in the Netherlands. Three studies reported the incidence of pediatric N-methyl-D-aspartate receptor (NMDAR)-AIE [in United Kingdom (UK), Hong Kong, and Denmark]. The other studies reported incidence data for selected populations. Conclusion This SLR highlights a paucity of epidemiology data for AIE in children, which is likely reflective of difficulties in testing and diagnosis. There is a clear need for further research and awareness of these challenges in clinical practice to avoid treatment delays and improve patient outcomes. A deeper understanding of the epidemiology of AIE will help determine the worldwide burden of disease and inform research, health policies and clinical decision-making.
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Affiliation(s)
- Jonathan D. Santoro
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | | | - Shiying He
- Costello Medical Singapore Ltd., Singapore, Singapore
| | - Swati Kumar
- Costello Medical Consulting Ltd., Cambridge, United Kingdom
| | - Molly Murton
- Costello Medical Consulting Ltd., Cambridge, United Kingdom
| | | | - Cheryl Hemingway
- Department of Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
- UCL Queen Square Institute of Neurology, London, United Kingdom
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Balaji N, Ignatowicz A, Kalra A, Mansour R, Jadhav V. Anti-CASPR2 Antibody-Associated Autoimmune Encephalitis Presenting as Refractory Seizures. Cureus 2024; 16:e64317. [PMID: 39131008 PMCID: PMC11316415 DOI: 10.7759/cureus.64317] [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] [Accepted: 07/11/2024] [Indexed: 08/13/2024] Open
Abstract
Autoimmune encephalitis (AE) is a rare immune-mediated disorder comprised of non-infectious neuroinflammatory disease processes. Clinical presentation overlaps with a broad range of neurodegenerative disorders and infectious encephalitis; therefore, AE remains a diagnosis of exclusion. Patients may present with nonspecific symptoms such as psychiatric disturbances, cognitive deficits, seizures, movement disorders, and confusion. Prompt diagnosis and management are necessary for patients with AE to decrease mortality and improve quality of life. First-line therapy includes immunosuppression with corticosteroids, intravenous immunoglobulin, and plasmapheresis. We report the case of an 86-year-old female with a medical history of Parkinson's disease who presented with nonspecific seizure-like activity and was diagnosed with AE.
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Affiliation(s)
- Nivedha Balaji
- Internal Medicine, Northeast Georgia Medical Center Gainsville, Gainesville, USA
| | | | - Aarushi Kalra
- Internal Medicine, Northeast Georgia Medical Center Gainsville, Gainesville, USA
| | - Rami Mansour
- Internal Medicine, Philadelphia College of Osteopathic Medicine, Suwanee, USA
| | - Vaishali Jadhav
- Internal Medicine, Northeast Georgia Medical Center Gainsville, Gainesville, USA
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Gagnon MH, Derenoncourt PR, Rayamahi S, Taylor S, Parikh AK, Ponisio MR, Khanna G. Unusual imaging findings associated with abdominal pediatric germ cell tumors. Pediatr Radiol 2024; 54:1093-1104. [PMID: 38462578 DOI: 10.1007/s00247-024-05894-9] [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: 11/15/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/12/2024]
Abstract
Germ cell tumors of childhood are tumors arising from germline cells in gonadal or extragonadal locations. Extragonadal germ cell tumors are characteristically located in the midline, arising intracranially or in the mediastinum, retroperitoneum, or pelvis. These tumors are generally easily diagnosed due to typical sites of origin, characteristic imaging findings, and laboratory markers. However, germ cell tumors can be associated with unusual clinical syndromes or imaging features that can perplex the radiologist. This review will illustrate atypical imaging/clinical manifestations and complications of abdominal germ cell tumors in childhood. These features include unusual primary tumors such as multifocal primaries; local complications such as ovarian torsion or ruptured dermoid; atypical presentations of metastatic disease associated with burned-out primary tumor, growing teratoma syndrome, and gliomatosis peritonei; endocrine manifestations such as precocious puberty and hyperthyroidism; and antibody mediated paraneoplastic syndrome such as anti-N-methyl-D-aspartate-receptor antibody-mediated encephalitis. This review aims to illustrate unusual imaging features associated with the primary tumor, metastatic disease, or distant complications of abdominal germ cell tumors of childhood.
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Affiliation(s)
- Marie-Helene Gagnon
- Department of Radiology & Imaging Sciences, Emory University and Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA, 30322, USA.
| | - Paul-Robert Derenoncourt
- Mallinckrodt Institute of Radiology, Washington University in Saint Louis, 510 S Kingshighway Blvd, St. Louis, MO, 63110, USA
| | - Sampanna Rayamahi
- Mallinckrodt Institute of Radiology, Washington University in Saint Louis, 510 S Kingshighway Blvd, St. Louis, MO, 63110, USA
| | - Susan Taylor
- Department of Radiology & Imaging Sciences, Emory University and Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Ashishkumar K Parikh
- Department of Radiology & Imaging Sciences, Emory University and Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Maria R Ponisio
- Mallinckrodt Institute of Radiology, Washington University in Saint Louis, 510 S Kingshighway Blvd, St. Louis, MO, 63110, USA
| | - Geetika Khanna
- Department of Radiology & Imaging Sciences, Emory University and Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA, 30322, USA
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Abunada M, Nierobisch N, Ludovichetti R, Simmen C, Terziev R, Togni C, Michels L, Kulcsar Z, Hainc N. Autoimmune encephalitis: Early and late findings on serial MR imaging and correlation to treatment timepoints. Eur J Radiol Open 2024; 12:100552. [PMID: 38327544 PMCID: PMC10847996 DOI: 10.1016/j.ejro.2024.100552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/09/2024] Open
Abstract
Introduction MRI is negative in a large percentage of autoimmune encephalitis cases or lacks findings specific to an antibody. Even rarer is literature correlating the evolution of imaging findings with treatment timepoints. We aim to characterize imaging findings in autoimmune encephalitis at presentation and on follow up correlated with treatment timepoints for this rare disease. Methods A full-text radiological information system search was performed for "autoimmune encephalitis" between January 2012 and June 2022. Patients with laboratory-identified autoantibodies were included. MRI findings were assessed in correlation to treatment timepoints by two readers in consensus. For statistical analysis, cell-surface vs intracellular antibody groups were assessed for the presence of early limbic, early extralimbic, late limbic, and late extralimbic findings using the χ2 test. Results Thirty-seven patients (female n = 18, median age 58.8 years; range 25.7 to 82.7 years) with 15 different autoantibodies were included in the study. Twenty-three (62%) patients were MRI-negative at time of presentation; 5 of these developed MRI findings on short-term follow up. Of the 19 patients with early MRI findings, 9 (47%) demonstrated improvement upon treatment initiation (7/9 cell-surface group). There was a significant difference (p = 0.046) between the MRI spectrum of cell-surface vs intracellular antibody syndromes as cell-surface antibody syndromes demonstrated more early classic findings of limbic encephalitis and intracellular antibody syndromes demonstrated more late extralimbic abnormalities. Conclusion MRI can be used to help narrow the differential diagnosis in autoimmune encephalitis and can be used as a monitoring tool for certain subtypes of this rare disease.
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Affiliation(s)
- Mahmoud Abunada
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Nathalie Nierobisch
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Riccardo Ludovichetti
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Cyril Simmen
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Robert Terziev
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Claudio Togni
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Lars Michels
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Nicolin Hainc
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
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11
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Sakharova T, Aringazina R, Lilyanov N, Monov D. Features of the clinical course of Autoimmune Encephalitis Associated with various antibodies. Neurol Sci 2024:10.1007/s10072-024-07604-7. [PMID: 38806881 DOI: 10.1007/s10072-024-07604-7] [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: 04/18/2024] [Accepted: 05/16/2024] [Indexed: 05/30/2024]
Abstract
Despite the increasing incidence of autoimmune encephalitis and the incomplete recovery observed in patients post-affliction, the issue of timely diagnosis remains unresolved. The primary objective of this study is identification the distinctive clinical presentation features evaluation the management strategies, and assess the outcomes of the disease in patients with various forms of autoimmune encephalitis. The research aims to contribute in a better understanding of the disease progression and facilitate the selection of optimal therapeutic interventions. A retrospective observational study enrolled 68 patients aged 18 years and older with verified autoimmune encephalitis who underwent treatment in state hospitals in Sofia, Bulgaria, from the beginning of 2014 to the end of 2022. The number of patients with pathology linked to antibodies against glycine receptors (Gly-R) was half as much, with 32 and 17 patients, respectively. The primary manifestations of autoimmune encephalitis included cognitive impairments observed in 51 patients, seizures occurring in 44 patients, and mood disorders observed in 22 patients. While the findings of imaging studies were nonspecific, hospitalizations for patients with this pathology, especially those with antibodies to CASPR2 and DPPX, were prolonged (114 and 232 days, respectively). In the vast majority of cases, incomplete recovery with residual symptoms was noted. Among the diverse forms of autoimmune encephalitis, the most prevalent is NMDA-R. Cognitive impairments predominate in the autoimmune encephalitis clinical presentation. Prolonged hospitalization periods and incomplete recovery of patients are characteristic features of autoimmune encephalitis, despite combined therapy involving intravenous administration of methylprednisolone and immunoglobulins.
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Affiliation(s)
- Tatyana Sakharova
- Department of Biology and General Genetics, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Raisa Aringazina
- Department of Internal Diseases № 1, Non-Commercial Joint-Stock Society «West Kazakhstan Marat Ospanov Medical University», Aktobe, Kazakhstan
| | - Nikolay Lilyanov
- Department of Anesthesiology and Intensive Care, Medical University of Sofia, Sofia, Bulgaria.
| | - Dimitar Monov
- Department of Anesthesiology and Intensive Care, Medical University of Sofia, Sofia, Bulgaria
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12
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Comer JD, Capizzano AA. Uncommon and Miscellaneous Inflammatory Disorders of the Brain and Spine. Magn Reson Imaging Clin N Am 2024; 32:277-287. [PMID: 38555141 DOI: 10.1016/j.mric.2024.01.006] [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: 04/02/2024]
Abstract
Inflammatory disorders of the brain and spine have a highly variable MRI appearance, often demonstrating significant overlap in imaging features. The resulting diagnostic dilemma is particularly challenging when considering the more uncommon neuroinflammatory entities. Diligent examination of the salient clinical presentation and signal alteration on imaging examination is necessary when considering neuroinflammation as a diagnostic possibility and may aid in raising suspicion for a particular neuroinflammatory entity. This article reviews a selection of uncommon and miscellaneous inflammatory disorders of the brain and spine to raise awareness of the clinical and imaging features that may assist in this challenging diagnostic task.
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Affiliation(s)
- John D Comer
- Division of Neuroradiology, Department of Radiology, University of Michigan Health System, 1500 East Medical Center Drive, B2-A209 UH, Ann Arbor, MI 48109, USA.
| | - Aristides A Capizzano
- Division of Neuroradiology, Department of Radiology, University of Michigan Health System, 1500 East Medical Center Drive, B2-A209 UH, Ann Arbor, MI 48109, USA
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13
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Sanvito F, Pichiecchio A, Paoletti M, Rebella G, Resaz M, Benedetti L, Massa F, Morbelli S, Caverzasi E, Asteggiano C, Businaro P, Masciocchi S, Castellan L, Franciotta D, Gastaldi M, Roccatagliata L. Autoimmune encephalitis: what the radiologist needs to know. Neuroradiology 2024; 66:653-675. [PMID: 38507081 PMCID: PMC11031487 DOI: 10.1007/s00234-024-03318-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/20/2024] [Indexed: 03/22/2024]
Abstract
Autoimmune encephalitis is a relatively novel nosological entity characterized by an immune-mediated damage of the central nervous system. While originally described as a paraneoplastic inflammatory phenomenon affecting limbic structures, numerous instances of non-paraneoplastic pathogenesis, as well as extra-limbic involvement, have been characterized. Given the wide spectrum of insidious clinical presentations ranging from cognitive impairment to psychiatric symptoms or seizures, it is crucial to raise awareness about this disease category. In fact, an early diagnosis can be dramatically beneficial for the prognosis both to achieve an early therapeutic intervention and to detect a potential underlying malignancy. In this scenario, the radiologist can be the first to pose the hypothesis of autoimmune encephalitis and refer the patient to a comprehensive diagnostic work-up - including clinical, serological, and neurophysiological assessments.In this article, we illustrate the main radiological characteristics of autoimmune encephalitis and its subtypes, including the typical limbic presentation, the features of extra-limbic involvement, and also peculiar imaging findings. In addition, we review the most relevant alternative diagnoses that should be considered, ranging from other encephalitides to neoplasms, vascular conditions, and post-seizure alterations. Finally, we discuss the most appropriate imaging diagnostic work-up, also proposing a suggested MRI protocol.
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Affiliation(s)
- Francesco Sanvito
- Unit of Radiology, Department of Clinical, Surgical, Diagnostic, and Paediatric Sciences, University of Pavia, Viale Camillo Golgi, 19, 27100, Pavia, Italy.
- UCLA Brain Tumor Imaging Laboratory (BTIL), Center for Computer Vision and Imaging Biomarkers, University of California Los Angeles, Los Angeles, CA, USA.
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | - Anna Pichiecchio
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Matteo Paoletti
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Giacomo Rebella
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Martina Resaz
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Luana Benedetti
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Federico Massa
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Largo Daneo 3, 16132, Genoa, Italy
| | - Silvia Morbelli
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Via Antonio Pastore 1, 16132, Genoa, Italy
| | - Eduardo Caverzasi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Carlo Asteggiano
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Pietro Businaro
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Stefano Masciocchi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Lucio Castellan
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Diego Franciotta
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Luca Roccatagliata
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Via Antonio Pastore 1, 16132, Genoa, Italy
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14
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Ludovichetti R, Nierobisch N, Achangwa NR, De Vere-Tyndall A, Fierstra J, Reimann R, Togni C, Terziev R, Galovic M, Kulcsar Z, Hainc N. The split apparent diffusion coefficient sign: A novel magnetic resonance imaging biomarker for cortical pathology with possible implications in autoimmune encephalitis. Neuroradiol J 2024; 37:206-213. [PMID: 38146643 DOI: 10.1177/19714009231224416] [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: 12/27/2023] Open
Abstract
INTRODUCTION MRI is the imaging modality of choice for assessing patients with encephalopathy. In this context, we discuss a novel biomarker, the "split ADC sign," where the cerebral cortex demonstrates restricted diffusion (high DWI signal and low ADC) and the underlying white matter demonstrates facilitated diffusion (high or low DWI signal and high ADC). We hypothesize that this sign can be used as a biomarker to suggest either acute encephalitis onset or to raise the possibility of an autoimmune etiology. MATERIALS AND METHODS A full-text radiological information system search of radiological reports was performed for all entities known to produce restricted diffusion in the cortex excluding stroke between January 2012 and June 2022. Initial MRI studies performed upon onset of clinical symptoms were screened for the split ADC sign. RESULTS 25 subjects were encountered with a positive split ADC sign (15 female; median age = 57 years, range 18-82). Diagnosis included six herpes simplex encephalitis, three peri-ictal MRI changes, eight PRES, two MELAS, and six autoimmune (3 anti-GABAAR, two seronegative, and one anti-Ma2/Ta). Subjects were imaged at a mean 1.8 days after the onset of symptoms (range 0-8). DISCUSSION We present a novel visual MRI biomarker, the split ADC sign, and highlight its potential usefulness in subjects with encephalopathy to suggest acute disease onset or to raise the possibility of an autoimmune etiology when location-based criteria are applied. When positive, the sign was present on the initial MRI and can therefore be used to help focus further clinical and laboratory workup.
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Affiliation(s)
- Riccardo Ludovichetti
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Nathalie Nierobisch
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Ngwe Rawlings Achangwa
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Anthony De Vere-Tyndall
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Jorn Fierstra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Regina Reimann
- Institute of Neuropathology, University Hospital of Zurich, University of Zurich, Switzerland
| | - Claudio Togni
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Robert Terziev
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Marian Galovic
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Nicolin Hainc
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
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15
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Lin Z, Zhou F, Ni L, Dong S, Fu G, Zhao J. Case report: Successful treatment of an anti-D2R and DPPX antibody-associated autoimmune encephalitis patient with high-dose methylprednisolone and intravenous immunoglobulin. Front Immunol 2024; 15:1338714. [PMID: 38469308 PMCID: PMC10925708 DOI: 10.3389/fimmu.2024.1338714] [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: 11/15/2023] [Accepted: 02/02/2024] [Indexed: 03/13/2024] Open
Abstract
Background Autoimmune encephalitis is a neurological condition caused by abnormal immune responses, manifesting as cognitive impairments, behavioral abnormalities, and seizures. Its diagnosis depends on the detecting neuronal surface antibodies in serum or cerebrospinal fluid. Despite recent advances in understanding, clinical recognition remains challenging, especially with rare antibodies such as anti-dopamine D2 receptor (D2R) and anti-dipeptidyl-peptidase-like protein 6 (DPPX) antibodies. Delayed diagnosis can lead to severe complications. This case presentation emphasizes the diagnostic intricacies and effective treatment of the anti-D2R and DPPX antibody-associated autoimmune encephalitis. Case description The patient presented with a 3-day history of fatigue and limb soreness followed by a 3-h episode of confusion and limb convulsions. Upon admission to our facility, the initial diagnosis included status epilepticus, aspiration pneumonia, metabolic acidosis, respiratory alkalosis, and suspected encephalitis. Despite receiving antiepileptic, anti-infection, and antivirus therapy, the patient's condition deteriorated. Both computed tomography (CT) scan and magnetic resonance imaging (MRI) of the brain showed no significant abnormalities. No pathogen was identified in the cerebrospinal fluid (CSF). However, further CSF and serum examination revealed positive results of anti-D2R and anti-DPPX antibodies, confirming a diagnosis of anti-D2R and DPPX antibody-associated autoimmune encephalitis. The patient underwent a comprehensive treatment regimen, including high-dose methylprednisolone pulse therapy combined with intravenous immunoglobulin (IVIG), antiviral and anti-infection treatments, and antiepileptic medications. Significant clinical improvement was observed, and by the 18th day of admission, the patient was stable and coherent. Conclusions The current patient represents the first reported case of double-positive autoimmune encephalitis for anti-D2R and DPPX antibodies, with epilepsy as a prominent feature. High-dose methylprednisolone pulse therapy combined with IVIG has shown significant safety and efficacy in treating anti-D2R and DPPX antibody-positive autoimmune encephalitis-associated epilepsy.
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Affiliation(s)
- Zhangliang Lin
- Neurology Department, Shaoxing No.2 Hospital Meical Community General Hospital, Shaoxing, China
| | - Feng Zhou
- Neurology Department, Shaoxing No.2 Hospital Meical Community General Hospital, Shaoxing, China
| | - Lili Ni
- Neurology Department, Shaoxing No.2 Hospital Meical Community General Hospital, Shaoxing, China
| | - Shiye Dong
- Department of Medicine, Shanghai Biotecan Pharmaceuticals Co., Ltd., Shanghai Zhangjiang Institute of Medical Innovation, Shanghai, China
| | - Guoping Fu
- Neurology Department, Shaoxing No.2 Hospital Meical Community General Hospital, Shaoxing, China
| | - Jiangman Zhao
- Department of Medicine, Shanghai Biotecan Pharmaceuticals Co., Ltd., Shanghai Zhangjiang Institute of Medical Innovation, Shanghai, China
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16
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Voit A, Graziano A, Schomer A, Theodore D. Ovarian teratoma-associated anti-NMDA receptor encephalitis with severe features. BMJ Case Rep 2024; 17:e258038. [PMID: 38355204 PMCID: PMC10868323 DOI: 10.1136/bcr-2023-258038] [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: 02/16/2024] Open
Abstract
Anti-N-methyl-D-aspartame receptor (NMDAR) encephalitis is an uncommon clinical entity for the general intensivist or neurologist. Diagnosis can be made by the presence of cerebrospinal fluid IgG antibody against the GluNR1 and GluNR2 subunits of the NMDAR. We present a case of anti-NMDAR encephalitis in a young woman with an ovarian teratoma treated with surgical resection and multiple immunomodulatory therapies.
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Affiliation(s)
- Antanina Voit
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ashley Graziano
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Andrew Schomer
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Danny Theodore
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
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17
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Hahn C, Budhram A, Alikhani K, AlOhaly N, Beecher G, Blevins G, Brooks J, Carruthers R, Comtois J, Cowan J, de Robles P, Hébert J, Kapadia RK, Lapointe S, Mackie A, Mason W, McLane B, Muccilli A, Poliakov I, Smyth P, Williams KG, Uy C, McCombe JA. Canadian Consensus Guidelines for the Diagnosis and Treatment of Autoimmune Encephalitis in Adults. Can J Neurol Sci 2024:1-21. [PMID: 38312020 DOI: 10.1017/cjn.2024.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Abstract
Autoimmune encephalitis is increasingly recognized as a neurologic cause of acute mental status changes with similar prevalence to infectious encephalitis. Despite rising awareness, approaches to diagnosis remain inconsistent and evidence for optimal treatment is limited. The following Canadian guidelines represent a consensus and evidence (where available) based approach to both the diagnosis and treatment of adult patients with autoimmune encephalitis. The guidelines were developed using a modified RAND process and included input from specialists in autoimmune neurology, neuropsychiatry and infectious diseases. These guidelines are targeted at front line clinicians and were created to provide a pragmatic and practical approach to managing such patients in the acute setting.
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Affiliation(s)
- Christopher Hahn
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Adrian Budhram
- Clinical Neurological Sciences, London Health Sciences Centre, London, ON, Canada
- Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada
| | - Katayoun Alikhani
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Nasser AlOhaly
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Grayson Beecher
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - Gregg Blevins
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - John Brooks
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Robert Carruthers
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Jacynthe Comtois
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Juthaporn Cowan
- Division of Infectious Diseases, Department of Medicine Ottawa Hospital, Ottawa, ON, Canada
| | - Paula de Robles
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Julien Hébert
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Ronak K Kapadia
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Sarah Lapointe
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Aaron Mackie
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Warren Mason
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Brienne McLane
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | | | - Ilia Poliakov
- Division of Neurology, University of Saskatchewan College of Medicine, Saskatoon, SK, Canada
| | - Penelope Smyth
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | | | - Christopher Uy
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
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18
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Dhabalia R, Kashikar SV, Parihar PS, Mishra GV. Unveiling the Intricacies: A Comprehensive Review of Magnetic Resonance Imaging (MRI) Assessment of T2-Weighted Hyperintensities in the Neuroimaging Landscape. Cureus 2024; 16:e54808. [PMID: 38529430 PMCID: PMC10961652 DOI: 10.7759/cureus.54808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 02/24/2024] [Indexed: 03/27/2024] Open
Abstract
T2-weighted hyperintensities in neuroimaging represent areas of heightened signal intensity on magnetic resonance imaging (MRI) scans, holding crucial importance in neuroimaging. This comprehensive review explores the T2-weighted hyperintensities, providing insights into their definition, characteristics, clinical relevance, and underlying causes. It highlights the significance of these hyperintensities as sensitive markers for neurological disorders, including multiple sclerosis, vascular dementia, and brain tumors. The review also delves into advanced neuroimaging techniques, such as susceptibility-weighted and diffusion tensor imaging, and the application of artificial intelligence and machine learning in hyperintensities analysis. Furthermore, it outlines the challenges and pitfalls associated with their assessment and emphasizes the importance of standardized protocols and a multidisciplinary approach. The review discusses future directions for research and clinical practice, including the development of biomarkers, personalized medicine, and enhanced imaging techniques. Ultimately, the review underscores the profound impact of T2-weighted hyperintensities in shaping the landscape of neurological diagnosis, prognosis, and treatment, contributing to a deeper understanding of complex neurological conditions and guiding more informed and effective patient care.
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Affiliation(s)
- Rishabh Dhabalia
- 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
| | - Pratap S Parihar
- Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Gaurav V Mishra
- Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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19
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Lang M, Colby S, Ashby-Padial C, Bapna M, Jaimes C, Rincon SP, Buch K. An imaging review of the hippocampus and its common pathologies. J Neuroimaging 2024; 34:5-25. [PMID: 37872430 DOI: 10.1111/jon.13165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/07/2023] [Accepted: 10/12/2023] [Indexed: 10/25/2023] Open
Abstract
The hippocampus is a complex structure located in the mesial temporal lobe that plays a critical role in cognitive and memory-related processes. The hippocampal formation consists of the dentate gyrus, hippocampus proper, and subiculum, and its importance in the neural circuitry makes it a key anatomic structure to evaluate in neuroimaging studies. Advancements in imaging techniques now allow detailed assessment of hippocampus internal architecture and signal features that has improved identification and characterization of hippocampal abnormalities. This review aims to summarize the neuroimaging features of the hippocampus and its common pathologies. It provides an overview of the hippocampal anatomy on magnetic resonance imaging and discusses how various imaging techniques can be used to assess the hippocampus. The review explores neuroimaging findings related to hippocampal variants (incomplete hippocampal inversion, sulcal remnant and choroidal fissure cysts), and pathologies of neoplastic (astrocytoma and glioma, ganglioglioma, dysembryoplastic neuroepithelial tumor, multinodular and vacuolating neuronal tumor, and metastasis), epileptic (mesial temporal sclerosis and focal cortical dysplasia), neurodegenerative (Alzheimer's disease, progressive primary aphasia, and frontotemporal dementia), infectious (Herpes simplex virus and limbic encephalitis), vascular (ischemic stroke, arteriovenous malformation, and cerebral cavernous malformations), and toxic-metabolic (transient global amnesia and opioid-associated amnestic syndrome) etiologies.
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Affiliation(s)
- Min Lang
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Samantha Colby
- Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA
| | | | - Monika Bapna
- School of Medicine, Georgetown University, Washington, DC, USA
| | - Camilo Jaimes
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Sandra P Rincon
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Karen Buch
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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20
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Hammami MB, Rezk M, Dubey D. Paraneoplastic neurologic syndrome and autoantibody accompaniments of germ cell tumors. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:431-445. [PMID: 38494295 DOI: 10.1016/b978-0-12-823912-4.00001-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes (PNSs) are a group of diseases affecting the central and/or peripheral nervous system caused by immune-mediated processes directed toward antigens with shared expression in tumor and neural tissue. Germ cell tumors (GCTs) are associated with PNSs with varied clinical phenotypes. Early diagnosis of PNS is vital to potentially uncover and treat underlying tumors, improving the chances of recovery, and preventing permanent neurologic complications. In this chapter, we outline the pathophysiology and epidemiology of PNS. We briefly provide a summary of GCTs in males and females. We review the neural-specific autoantibodies and PNSs associated with GCTs and their clinical and radiologic accompaniments. We also provide an overview of the treatment and prognosis of these disorders.
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Affiliation(s)
- M Bakri Hammami
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States
| | - Mohamed Rezk
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Divyanshu Dubey
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Neurology, Mayo Clinic, Rochester, MN, United States.
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21
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Masciocchi S, Businaro P, Scaranzin S, Morandi C, Franciotta D, Gastaldi M. General features, pathogenesis, and laboratory diagnostics of autoimmune encephalitis. Crit Rev Clin Lab Sci 2024; 61:45-69. [PMID: 37777038 DOI: 10.1080/10408363.2023.2247482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/09/2023] [Indexed: 10/02/2023]
Abstract
Autoimmune encephalitis (AE) is a group of inflammatory conditions that can associate with the presence of antibodies directed to neuronal intracellular, or cell surface antigens. These disorders are increasingly recognized as an important differential diagnosis of infectious encephalitis and of other common neuropsychiatric conditions. Autoantibody diagnostics plays a pivotal role for accurate diagnosis of AE, which is of utmost importance for the prompt recognition and early treatment. Several AE subgroups can be identified, either according to the prominent clinical phenotype, presence of a concomitant tumor, or type of neuronal autoantibody, and recent diagnostic criteria have provided important insights into AE classification. Antibodies to neuronal intracellular antigens typically associate with paraneoplastic neurological syndromes and poor prognosis, whereas antibodies to synaptic/neuronal cell surface antigens characterize many AE subtypes that associate with tumors less frequently, and that are often immunotherapy-responsive. In addition to the general features of AE, we review current knowledge on the pathogenic mechanisms underlying these disorders, focusing mainly on the potential role of neuronal antibodies in the most frequent conditions, and highlight current theories and controversies. Then, we dissect the crucial aspects of the laboratory diagnostics of neuronal antibodies, which represents an actual challenge for both pathologists and neurologists. Indeed, this diagnostics entails technical difficulties, along with particularly interesting novel features and pitfalls. The novelties especially apply to the wide range of assays used, including specific tissue-based and cell-based assays. These assays can be developed in-house, usually in specialized laboratories, or are commercially available. They are widely used in clinical immunology and in clinical chemistry laboratories, with relevant differences in analytic performance. Indeed, several data indicate that in-house assays could perform better than commercial kits, notwithstanding that the former are based on non-standardized protocols. Moreover, they need expertise and laboratory facilities usually unavailable in clinical chemistry laboratories. Together with the data of the literature, we critically evaluate the analytical performance of the in-house vs commercial kit-based approach. Finally, we propose an algorithm aimed at integrating the present strategies of the laboratory diagnostics in AE for the best clinical management of patients with these disorders.
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Affiliation(s)
- Stefano Masciocchi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, Università degli Studi di Pavia, Pavia, Italy
| | - Pietro Businaro
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, Università degli Studi di Pavia, Pavia, Italy
| | - Silvia Scaranzin
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Chiara Morandi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Diego Franciotta
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Matteo Gastaldi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
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22
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Lee E, Kim M, Kyoung KH, Jun JY. A Near-Fatal Encounter with Acute Suicidal Behavior in Anti-N-methyl-D-aspartate Autoimmune Encephalitis. J Clin Med 2023; 13:206. [PMID: 38202213 PMCID: PMC10779752 DOI: 10.3390/jcm13010206] [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: 11/22/2023] [Revised: 12/25/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
Anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDARE) is a complex neuropsychiatric syndrome known for its diverse neurological manifestations, often involving psychiatric symptoms and seizures that elevate the risk of suicidal ideation and behavior. We present a case illustrating the potentially lethal nature of anti-NMDARE, wherein an unexpected suicide attempt occurred 10 days after the onset of seizures in a 21-year-old man. Upon arrival at the emergency room, immediate interventions addressed hypovolemic shock, followed by subsequent neurosurgical and orthopedic procedures. Six days after cessation of sedation, the patient exhibited atypical focal seizures, behavioral arrest, psychotic responses, and delusions. Despite normal brain magnetic resonance imaging and cerebrospinal fluid (CSF) analysis results, a high CSF immunoglobulin G index and posterior hypometabolism on brain F-fluorodeoxyglucose positron emission tomography raised suspicion of autoimmune encephalitis. Steroids and intravenous immunoglobulins were administered. A comprehensive evaluation ruled out other conditions. Serum and CSF tests confirmed the presence of anti-NMDAR antibodies. This case highlights the potential lethality of the acute stage of anti-NMDARE, emphasizing the absence of apparent psychiatric symptoms before a suicide attempt. Further studies on suicidality associated with anti-NMDARE are crucial, underscoring the importance of vigilance in cases involving newly diagnosed seizures or psychoses.
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Affiliation(s)
- Eunmi Lee
- Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Republic of Korea;
| | - Minjee Kim
- Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Republic of Korea;
| | - Kyu-Hyouck Kyoung
- Department of Trauma Surgery, Trauma Center, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Republic of Korea;
| | - Jin Yong Jun
- Department of Psychiatry, Ulsan University Hospital, Ulsan 44033, Republic of Korea;
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23
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Huang T, Liu F, Wang B, Wang C, Hao M, Guo S. Clinical characteristics and prognosis in patients with neuronal surface antibody-mediated autoimmune encephalitis: a single-center cohort study in China. Front Immunol 2023; 14:1213532. [PMID: 38152405 PMCID: PMC10751914 DOI: 10.3389/fimmu.2023.1213532] [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: 05/03/2023] [Accepted: 11/22/2023] [Indexed: 12/29/2023] Open
Abstract
Objective This retrospective observational study primarily aimed to analyse the clinical characteristics of patients with neuronal surface antibody-mediated autoimmune encephalitis (AE) in China and report their prognosis after immunotherapy. Methods Clinical characteristics, laboratory or imaging examinations, and treatment outcomes of 103 patients diagnosed with AE between 1 September 2014 and 31 December 2020 were collected. Univariate and multivariate logistic regression analyses were performed to determine the predictors of poor prognosis. Results Overall, 103 patients were enrolled in the study. The main clinical symptoms included seizures (74.8%), psychiatric and behavior disorders (66.0%), cognitive deficits (51.5%), disturbances of consciousness (45.6%), and movement disorders/involuntary movements (26.2%). The distribution of clinical syndromes also differed for different AE subtypes. The efficacy rates of first-line immunotherapy for anti-NMDAR, anti-LGI1, anti-GABABR, and anti-CASPR2 encephalitis were 70.2%, 92.3%, 70%, and 83.3%, respectively, and rituximab was administered to 21 patients as second-line immunotherapy, including 14 patients with anti-NMDAR encephalitis, 4 with anti-LGI1 encephalitis, 2 with anti-GABABR encephalitis, and 1 with anti-CASPR2 encephalitis. Five patients with poor effect of the second-line treatment received bortezomib. According to the results of the last follow-up, 78 patients had a good prognosis (mRS 0-2), and 21 patients had a poor prognosis (mRS 3-6). The proportion of patients with a poor prognosis was significantly higher in anti-GABABR encephalitis compared to the other AE subtypes (p<0.001). Multivariate analysis indicated that elevated neutrophil-to-lymphocyte ratio (NLR) and tumour presence were independent risk factors for poor prognosis. The regression equation of the model was logit(P)=-3.480 + 0.318 NLR+2.434 with or without tumour (with assignment =1, without assignment =0). The prediction probability generated by the regression model equation was used as the independent variable for receiver operating curve (ROC) analysis. The results showed that the area under the curve (AUC) of the prediction probability was 0.847 (95% CI, 0.733-0.961; p < 0.001). Conclusions Different AE subtypes demonstrated different clinical symptom spectra throughout the disease stage. Anti-LGI1 encephalitis and anti-CASPR2 encephalitis were more sensitive to first-line and second-line treatments. Anti-GABABR encephalitis had the worst prognosis among the abovementioned subtypes. The regression equation constructed using NLR and tumour presence effectively predicted the poor prognosis.
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Affiliation(s)
- Teng Huang
- Department of Neurology, Shandong Provincial Hospital, Shandong University, Jinan, China
- Department of Neurology, Shandong Second Provincial General Hospital, Jinan, China
| | - Fei Liu
- Department of Neurology, Shandong Second Provincial General Hospital, Jinan, China
| | - Baojie Wang
- Department of Neurology, Shandong Second Provincial General Hospital, Jinan, China
| | - Chunjuan Wang
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Maolin Hao
- Department of Neurology, Shandong Second Provincial General Hospital, Jinan, China
| | - Shougang Guo
- Department of Neurology, Shandong Provincial Hospital, Shandong University, Jinan, China
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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Esechie A, Thottempudi N, Patel C, Shanina E, Li X. A Devastating Neurological Disorder: Anti-Dipeptidyl-Peptidase-Like Protein 6 (DPPX) Encephalitis Causing Rapidly Progressive Dementia. Cureus 2023; 15:e51123. [PMID: 38274926 PMCID: PMC10810258 DOI: 10.7759/cureus.51123] [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] [Accepted: 12/21/2023] [Indexed: 01/27/2024] Open
Abstract
Rapidly progressive dementia (RPD) is caused by a heterogeneous group of neurological disorders, and the prototype is Creutzfeldt-Jakob disease (CJD). However, treatable causes including autoimmune encephalitis are often underrecognized and undertreated. A 72-year-old female patient was admitted with a 10-month history of rapidly progressive cognitive decline, visual hallucinations, paranoid behavior, diarrhea, and an 18-kg unintentional weight loss. On the physical exam, she was only oriented to the person and demonstrated an exaggerated startle response with diffuse rigidity. The initial clinical suspicion included CJD versus autoimmune encephalitis. Comprehensive laboratory testing, thyroid peroxidase, thyroglobulin antibodies, and autoimmune encephalitis panel were negative. The EEG showed mild to moderate diffuse slowing without any epileptiform abnormalities. An MRI brain revealed mild hippocampal atrophy. CSF testing revealed mild lymphocytic pleocytosis; RT-QuIC analysis and 14-3-3 protein were negative. There was no clinical improvement after treatment with IV steroids and IVIG. Repeated autoimmune encephalitis panel testing performed on a research basis was positive for dipeptidyl-peptidase-like protein 6 (DPPX) antibodies in serum and CSF. Unfortunately, our patient passed away before additional treatment could be attempted. Anti-DPPX encephalitis is a rare autoimmune disorder and an unrecognized cause of RPD. Early diagnosis and rapid escalation of treatment are imperative to avoid devastating neurological consequences.
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Affiliation(s)
| | | | - Chilvana Patel
- Neurology, University of Texas Medical Branch, Galveston, USA
| | - Elena Shanina
- Neurology, University of Texas Medical Branch, Galveston, USA
| | - Xiangping Li
- Neurology, University of Texas Medical Branch, Galveston, USA
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25
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Goertzen A, Altawashi AK, Rieck J, Veh RW. Autoimmune processes in neurological patients are much more common than presently suspected. J Neurol 2023; 270:5866-5877. [PMID: 37603074 PMCID: PMC10632246 DOI: 10.1007/s00415-023-11901-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 07/23/2023] [Accepted: 07/25/2023] [Indexed: 08/22/2023]
Abstract
Autoimmune encephalitides are seldom diseases. How rare they actually are, however, is not known. The low incidence combined with the problematic identification may dampen efforts of neurologists, to identify patients with unclear symptoms as suffering from autoimmune encephalitis. Here, we aim to obtain a better estimate, how many patients with autoimmune disorders should be expected among 100 inpatients in a conventional neurological department. From a total number of 2603 non-stroke patients attended in a 2-year period (2018-2019) 460 CSFs were obtained. From this collection 187 samples (40.7%, > 500 sections) could be analyzed with our immunocytochemical technique. Autoreactive antibodies were detected in 102 (55%) of these 187 CSF samples. Certainly, the presence of autoreactive antibodies does not necessarily indicate that the patient suffers from an autoimmune disease. Our data indicate that from roughly 2000 patients during 1 year about 125 patients with autoreactive CSF antibodies should be expected in a conventional neurological department. This represents the about 35-fold value of what is generally expected at present. Being aware of this high incidence may intensify the efforts of neurologist to identify patients with any type of autoimmune encephalitis. This will be beneficial for patients, because they often profit from immunomodulatory therapy. Interestingly, some CFSs from our patients react with the CA2 subdivision of the hippocampus. While long neglected, recent research places this area into an important position to influence hippocampal network physiology. Autoreactive antibodies in the CSF may disturb the function of CA2 neurons, thereby explaining some neuropsychiatric symptoms in patients with autoimmune encephalitides.
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Affiliation(s)
- Angelika Goertzen
- AMEOS Klinikum St. Clemens Oberhausen, Wilhelmstrasse 34, D-46145, Oberhausen, Germany
| | | | - Julian Rieck
- Institut für Zell- und Neurobiologie, Centrum 2, Charité - Universitätsmedizin Berlin, Charitéplatz 1, D-10117, Berlin, Germany
| | - Rüdiger W Veh
- Institut für Zell- und Neurobiologie, Centrum 2, Charité - Universitätsmedizin Berlin, Charitéplatz 1, D-10117, Berlin, Germany.
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26
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Van Steenhoven RW, de Vries JM, Bruijstens AL, Paunovic M, Nagtzaam MM, Franken SC, Bastiaansen AE, De Bruijn MA, Van Sonderen A, Schreurs MWJ, Gardeniers M, Verdijk RM, Balvers RK, Sillevis Smitt PA, Neuteboom RF, Titulaer MJ. Mimics of Autoimmune Encephalitis: Validation of the 2016 Clinical Autoimmune Encephalitis Criteria. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200148. [PMID: 37582614 PMCID: PMC10427145 DOI: 10.1212/nxi.0000000000200148] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/27/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND AND OBJECTIVES The clinical criteria for autoimmune encephalitis (AE) were proposed by Graus et al. in 2016. In this study, the AE criteria were validated in the real world, and common AE mimics were described. In addition, criteria for probable anti-LGI1 encephalitis were proposed and validated. METHODS In this retrospective cohort study, patients referred to our national referral center with suspicion of AE and specific neuroinflammatory disorders with similar clinical presentations were included from July 2016 to December 2019. Exclusion criteria were pure cerebellar or peripheral nerve system disorders. All patients were evaluated according to the AE criteria. RESULTS In total, 239 patients were included (56% female; median age 42 years, range 1-85). AE was diagnosed in 104 patients (44%) and AE mimics in 109 patients (46%). The most common AE mimics and misdiagnoses were neuroinflammatory CNS disorders (26%), psychiatric disorders (19%), epilepsy with a noninflammatory cause (13%), CNS infections (7%), neurodegenerative diseases (7%), and CNS neoplasms (6%). Common confounding factors were mesiotemporal lesions on brain MRI (17%) and false-positive antibodies in serum (12%). Additional mesiotemporal features (involvement extralimbic structures, enhancement, diffusion restriction) were observed more frequently in AE mimics compared with AE (61% vs 24%; p = 0.005). AE criteria showed the following sensitivity and specificity: possible AE, 83% (95% CI 74-89) and 27% (95% CI 20-36); definite autoimmune limbic encephalitis (LE), 10% (95% CI 5-17) and 98% (95% CI 94-100); and probable anti-NMDAR encephalitis, 50% (95% CI 26-74) and 96% (95% CI 92-98), respectively. Specificity of the criteria for probable seronegative AE was 99% (95% CI 96-100). The newly proposed criteria for probable anti-LGI1 encephalitis showed a sensitivity of 66% (95% CI 47-81) and specificity of 96% (95% CI 93-98). DISCUSSION AE mimics occur frequently. Common pitfalls in AE misdiagnosis are mesiotemporal lesions (predominantly with atypical features) and false-positive serum antibodies. As expected, the specificity of the criteria for possible AE is low because these criteria represent the minimal requirements for entry in the diagnostic algorithm for AE. Criteria for probable AE (-LGI1, -NMDAR, seronegative) and definite autoimmune LE are applicable for decisions on immunotherapy in early disease stage, as specificity is high.
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Affiliation(s)
- Robin W Van Steenhoven
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Juna M de Vries
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Arlette L Bruijstens
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Manuela Paunovic
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Mariska M Nagtzaam
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Suzanne C Franken
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Anna E Bastiaansen
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marienke A De Bruijn
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Agnes Van Sonderen
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marco W J Schreurs
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Mayke Gardeniers
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Robert M Verdijk
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Rutger K Balvers
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Peter A Sillevis Smitt
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Rinze F Neuteboom
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Maarten J Titulaer
- From the Department of Neurology (R.W.V.S., J.M.V., A.L.B., M.P., M.M.N., S.C.F., A.E.B., M.A.D.B., P.A.S.S., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology (A.V.S.), Haaglanden Medical Center, The Hague; Departments of Immunology (M.W.J.S.), Radiology (M.G.), Neuropathology (R.M.V.), and Neurosurgery (R.K.B.), Erasmus MC University Medical Center; and Department of Pediatric Neurology (R.F.N.), Sophia Childrens Hospital, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
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Pathak A, Patel J, Tran G, Mrlik M, Zhong N, Lui F. An Unusual Case of LGI1 (Leucine-Rich Glioma-Inactivated Protein 1) Limbic Encephalitis With Anti-acetylcholine Receptor and Anti-striational Autoantibodies. Cureus 2023; 15:e46491. [PMID: 37927656 PMCID: PMC10624515 DOI: 10.7759/cureus.46491] [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] [Accepted: 10/03/2023] [Indexed: 11/07/2023] Open
Abstract
Autoimmune encephalitis (AE) results from immune-mediated damage to the central nervous system (CNS) with varying clinical manifestations depending on autoimmune antibodies present and the antigens they target. Leucine-rich glioma-inactivated protein 1 (LGI1) has been recognized as one of the leading causes of limbic encephalitis (LE), presenting with seizures, memory loss, and faciobrachial dystonic seizures. A better understanding of the unique presentations of these AE allows for quick and effective diagnosis and treatment. We are presenting a very unusual case of LGI1 autoimmune LE with two additional autoantibodies, anti-acetylcholine receptor (AChR) and anti-striational, in a patient with an underlying thymoma. We will discuss the pathophysiology and common clinical presentation of anti-LGI1 autoimmune LE.
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Affiliation(s)
- Akash Pathak
- Neurology, California Northstate University College of Medicine, Elk Grove, USA
| | - Jay Patel
- Neurology, California Northstate University College of Medicine, Elk Grove, USA
| | - Giselle Tran
- Neurology, California Northstate University College of Medicine, Elk Grove, USA
| | - Matthew Mrlik
- Neurology, California Northstate University College of Medicine, Elk Grove, USA
| | - Ning Zhong
- Neurology, Kaiser Permanente Sacramento Medical Center, Sacramento, USA
| | - Forshing Lui
- Clinical Sciences, California Northstate University College of Medicine, Elk Grove, USA
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Yoon SJ, Kim KK, Kim HR, Lee EJ. A case of hyperacute postvaccinal encephalopathy after BNT162b2 nCoV-19 vaccine. ENCEPHALITIS 2023; 3:109-113. [PMID: 37621190 PMCID: PMC10598283 DOI: 10.47936/encephalitis.2023.00066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 08/02/2023] [Accepted: 08/10/2023] [Indexed: 08/26/2023] Open
Abstract
The global severe acute respiratory syndrome coronavirus 2 pandemic contributed to the development of a large variety of vaccines, of which postvaccinal hyperacute encephalopathy is a very rare complication. Despite its rarity, if diagnosed properly, appropriate treatment can be rapidly applied. A healthy 53-year-old woman was admitted for a seizure on the day she received the second dose of the BNT 162b2 nCoV-19 vaccine. She subsequently developed irritability, which gradually worsened over several days. Cerebrospinal fluid analysis revealed mild pleocytosis and normal protein levels. Brain magnetic resonance imaging (MRI) revealed diffuse sulcal hyperintensity on the entire brain surface on fluid-attenuated inversion recovery images with meningeal enhancement. The patient was diagnosed with hyperacute postvaccinal encephalopathy and received immunosuppressive therapy with corticosteroids and therapeutic plasmapheresis. Fortunately, the patient responded to therapy, achieving almost complete recovery from the neurological symptoms, with only mild memory impairment remaining after 3 weeks. Based on the clinical presentation, electroencephalogram findings, and MRI, our patient developed hyperacute encephalopathy within 24 hours of vaccine administration, which we surmised from the temporal course of symptoms and brain imaging findings. Further studies are required to elucidate the pathogenesis of coronavirus disease 2019 vaccination-related encephalopathy.
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Affiliation(s)
- Soo Ji Yoon
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
- Institute of Interdisciplinary Brain Science, Dongguk University College of Medicine, Goyang, Korea
| | - Kwang Ki Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
- Institute of Interdisciplinary Brain Science, Dongguk University College of Medicine, Goyang, Korea
| | - Hang-Rai Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
- Institute of Interdisciplinary Brain Science, Dongguk University College of Medicine, Goyang, Korea
| | - Eun Ja Lee
- Department of Radiology, Dongguk University Ilsan Hospital, Goyang, Korea
- Institute of Interdisciplinary Brain Science, Dongguk University College of Medicine, Goyang, Korea
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Dumrikarnlert C, Thakolwiboon S, Senanarong V. Clinical presentations and treatment outcomes of Hashimoto encephalopathy at Siriraj Hospital - Thailand's largest national tertiary referral center. BMC Neurol 2023; 23:334. [PMID: 37737161 PMCID: PMC10514970 DOI: 10.1186/s12883-023-03305-4] [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: 11/24/2022] [Accepted: 06/24/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Hashimoto encephalopathy has multiple clinical presentations, and other than the presence of thyroid antibody, laboratory and imaging investigations are all non-specific. Data specific to the clinical presentations and treatment outcomes of patients with Hashimoto encephalopathy in Thailand remain scarce. OBJECTIVES To retrospectively investigate the clinical presentations and treatment outcomes of patients with Hashimoto encephalopathy at Siriraj Hospital. METHODS Patients who presented with acute encephalopathy at our center during July 2012-March 2017 were evaluated for eligibility. The inclusion criteria were positive anti-thyroperoxidase (anti-TPO) or anti-thyroglobulin (anti-Tg) in serum with negative neuronal antibody in serum or cerebral spinal fluid (CSF). Clinical presentations, symptom duration, laboratory results of thyroid status and thyroid autoantibody, CSF study, and clinical outcomes were collected. RESULTS Of the 204 patients who presented with encephalopathy, 31 (15.2%) were positive for the anti-TPO or anti-Tg antibody. Of those, 13 patients met the diagnostic criteria for Hashimoto encephalopathy. Clinical presentations included cognitive impairment (76.9%), clouding of consciousness (46.2%), and behavior change (30.8%). The neuropsychiatric presentations were visual hallucination (30.8%), auditory hallucination (15.4%), delusion (7.7%), and mood disturbance (23.1%). Other clinical presentations included seizure (38.5%), abnormal movement (23.1%), sleep disturbance (38.5%), ataxia (46.2%), stroke-like episode (15.4%), and fever (15.4%). Most patients (76.9%) had onset within < 3 months. Regarding outcomes, 1 patient who did not receive corticosteroid died from status epilepticus and septic shock. Among the 12 patients who received corticosteroid, 9 (75%) had marked improvement, 1 (8.3%) had slight improvement, and 2 (16.6%) had no clinical improvement. Seven patients (53.9%) had normal thyroid function, 4 patients (30.8%) had subclinical hypothyroidism, and 2 patients (15.4%) had subclinical hyperthyroidism. CONCLUSIONS The results of this study revealed cognitive impairment, neuropsychiatric symptoms, seizure, ataxia, and sleep disturbance to be common manifestations of Hashimoto encephalopathy. This condition should always be considered in individuals with subacute onset of unexplained cognitive impairment or cerebellar ataxia. Laboratory and neuroimaging investigations were all found to be nonspecific in Hashimoto encephalopathy. Most patients responded well to treatment, so clinical suspicion and early diagnosis and treatment will lead to improved patient outcomes.
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Affiliation(s)
- Chaisak Dumrikarnlert
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Neuroscience Center, Bangkok International Hospital, Bangkok, Thailand
| | - Smathorn Thakolwiboon
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Vorapun Senanarong
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Bai S, Zhang C, Yao X, Shao H, Huang G, Liu J, Hao Y, Guan Y. A novel classification model based on cerebral 18F-FDG uptake pattern facilitates the diagnosis of acute/subacute seropositive autoimmune encephalitis. J Neuroradiol 2023; 50:492-501. [PMID: 37142216 DOI: 10.1016/j.neurad.2023.05.001] [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: 11/14/2022] [Revised: 05/01/2023] [Accepted: 05/01/2023] [Indexed: 05/06/2023]
Abstract
PURPOSE To explore the intrinsic alteration of cerebral 18F-FDG metabolism in acute/subacute seropositive autoimmune encephalitis (AE) and to propose a universal classification model based on 18F-FDG metabolic patterns to predict AE. METHODS Cerebral 18F-FDG PET images of 42 acute/subacute seropositive AE patients and 45 healthy controls (HCs) were compared using voxelwise and region of interest (ROI)-based schemes. The mean standardized uptake value ratios (SUVRs) of 59 subregions according to a modified Automated Anatomical Labeling (AAL) atlas were compared using a t-test. Subjects were randomly divided into a training set (70%) and a testing set (30%). Logistic regression models were built based on the SUVRs and the models were evaluated by determining their predictive value in the training and testing sets. RESULTS The 18F-FDG uptake pattern in the AE group was characterized by increased SUVRs in the brainstem, cerebellum, basal ganglia, and temporal lobe, and decreased SUVRs in the occipital, and frontal regions with voxelwise analysis (false discovery rate [FDR] p<0.05). Utilizing ROI-based analysis, we identified 15 subareas that exhibited statistically significant changes in SUVRs among AE patients compared to HC (FDR p<0.05). Further, a logistic regression model incorporating SUVRs from the calcarine cortex, putamen, supramarginal gyrus, cerebelum_10, and hippocampus successfully enhanced the positive predictive value from 0.76 to 0.86 when compared to visual assessments. This model also demonstrated potent predictive ability, with AUC values of 0.94 and 0.91 observed for the training and testing sets, respectively. CONCLUSIONS During the acute/subacute stages of seropositive AE, alterations in SUVRs appear to be concentrated within physiologically significant regions, ultimately defining the general cerebral metabolic pattern. By incorporating these key regions into a new classification model, we have improved the overall diagnostic efficiency of AE.
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Affiliation(s)
- Shuwei Bai
- Department of Neurology, The Second Affiliated Hospital of Xinjiang Medical University, Urumqi 830063, China; Department of Neurology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chenpeng Zhang
- Department of Nuclear Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoying Yao
- Department of Neurology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongda Shao
- Department of Nuclear Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Gan Huang
- Department of Nuclear Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianjun Liu
- Department of Nuclear Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Yong Hao
- Department of Neurology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Yangtai Guan
- Department of Neurology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Gillon S, Chan M, Chen J, Guterman EL, Wu X, Glastonbury CM, Li Y. MR Imaging Findings in a Large Population of Autoimmune Encephalitis. AJNR Am J Neuroradiol 2023; 44:799-806. [PMID: 37385678 PMCID: PMC10337613 DOI: 10.3174/ajnr.a7907] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 05/24/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND AND PURPOSE Autoimmune encephalitis is a rare condition in which autoantibodies attack neuronal tissue, causing neuropsychiatric disturbances. This study sought to evaluate MR imaging findings associated with subtypes and categories of autoimmune encephalitis. MATERIALS AND METHODS Cases of autoimmune encephalitis with specific autoantibodies were identified from the medical record (2009-2019). Cases were excluded if no MR imaging of the brain was available, antibodies were associated with demyelinating disease, or >1 concurrent antibody was present. Demographics, CSF profile, antibody subtype and group (group 1 intracellular antigen or group 2 extracellular antigen), and MR imaging features at symptom onset were reviewed. Imaging and clinical features were compared across antibody groups using χ2 and Wilcoxon rank-sum tests. RESULTS Eighty-five cases of autoimmune encephalitis constituting 16 distinct antibodies were reviewed. The most common antibodies were anti-N-methyl-D-aspartate (n = 41), anti-glutamic acid decarboxylase (n = 7), and anti-voltage-gated potassium channel (n = 6). Eighteen of 85 (21%) were group 1; and 67/85 (79%) were group 2. The median time between MR imaging and antibody diagnosis was 14 days (interquartile range, 4-26 days). MR imaging had normal findings in 33/85 (39%), and 20/33 (61%) patients with normal MRIs had anti-N-methyl-D-aspartate receptor antibodies. Signal abnormality was most common in the limbic system (28/85, 33%); 1/68 (1.5%) had susceptibility artifacts. Brainstem and cerebellar involvement were more common in group 1, while leptomeningeal enhancement was more common in group 2. CONCLUSIONS Sixty-one percent of patients with autoimmune encephalitis had abnormal brain MR imaging findings at symptom onset, most commonly involving the limbic system. Susceptibility artifact is rare and makes autoimmune encephalitis less likely as a diagnosis. Brainstem and cerebellar involvement were more common in group 1, while leptomeningeal enhancement was more common in group 2.
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Affiliation(s)
- S Gillon
- From the School of Medicine (S.G., J.C.)
| | - M Chan
- Department of Radiology (M.C.), University of Toronto, Toronto, Ontario, Canada
| | - J Chen
- From the School of Medicine (S.G., J.C.)
| | | | - X Wu
- Department of Radiology and Biomedical Imaging (X.W., C.M.G., Y.L.), University of California San Francisco, San Francisco, California
| | - C M Glastonbury
- Department of Radiology and Biomedical Imaging (X.W., C.M.G., Y.L.), University of California San Francisco, San Francisco, California
| | - Y Li
- Department of Radiology and Biomedical Imaging (X.W., C.M.G., Y.L.), University of California San Francisco, San Francisco, California
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Tirado-García LA, Piña-Ballantyne SA, Cienfuegos-Meza J, Tena-Suck ML. Anti-N-Methyl-D-Aspartate Receptor Encephalitis With Diffuse Demyelinating Plaques: A Case Report of an Atypical Presentation. Cureus 2023; 15:e41595. [PMID: 37559837 PMCID: PMC10408726 DOI: 10.7759/cureus.41595] [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] [Accepted: 07/09/2023] [Indexed: 08/11/2023] Open
Abstract
Anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis is an autoimmune disease triggered by antibodies against the NR1 subunit of this receptor. It has a wide variety of presentations, including abnormal behavior, psychosis, seizures, abnormal movement, insomnia, and irritability. The diagnosis is confirmed by the presence of one of the six main symptoms and anti-NR1 immunoglobulin G (IgG)-positive antibodies in the cerebrospinal fluid (CSF) after the exclusion of other disorders. We present a case of an 18-year-old female with progressive paresthesia and muscle weakness that compromised walking and psychiatric symptoms. She was admitted to a private institution where magnetic resonance imaging (MRI) revealed pseudotumoral lesions, which led to surgical intervention. The original histopathological diagnosis was of a pleomorphic xanthoastrocytoma (PXA) WHO grade 2. As symptoms persisted, she was referred to our institution where a new MRI was performed, and a biopsy was re-evaluated. It showed perivascular inflammatory infiltrates composed of T cells, intense peripheral gliosis, nodules of macrophages, and reactive astrocytes in the white matter with fragmentation and vacuolation of myelin sheets, suggesting a demyelinating process in contrast to neoplasia. CSF analysis was performed, and it was positive for anti-NMDA antibodies. Immunohistochemical positivity for N-methyl-D-aspartate (NMDA) was observed in the neuronal nuclei, which led to the diagnosis.
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Affiliation(s)
- Luis-Angel Tirado-García
- Neuropathology, Instituto Nacional de Neurologia y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | | | - Jesús Cienfuegos-Meza
- Neuropathology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | - Martha-Lilia Tena-Suck
- Neuropathology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
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Yu X, Gao Z, Gao M, Qiao M. Bibliometric Analysis on GABA-A Receptors Research Based on CiteSpace and VOSviewer. J Pain Res 2023; 16:2101-2114. [PMID: 37361426 PMCID: PMC10289248 DOI: 10.2147/jpr.s409380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/11/2023] [Indexed: 06/28/2023] Open
Abstract
Background GABA-A receptors are the primary mediators of brain inhibitory neurotransmission. In the past years, many studies focused on this channel to decipher the pathogenesis of related diseases but lacked bibliometric analysis research. This study aims to explore the research status and identify the research trends of GABA-A receptor channels. Methods Publications related to GABA-A receptor channels were retrieved from the Web of Science Core Collection from 2012 to 2022. After screening, the VOSviewer 1.6.18 and Citespace 5.8 R3 were used for bibliometric analysis from journals, countries, institutions, authors, co-cited references and keywords. Results We included 12,124 publications in the field of GABA-A receptor channels for analysis. The data shows that although there was a slight decrease in annual publications from 2012 to 2021, it remained at a relatively high level. Most publications were in the domain of neuroscience. Additionally, the United States was the most prolific country, followed by China. Univ Toronto was the most productive institution, and James M Cook led essential findings in this field. Furthermore, brain activation, GABAAR subunits expression, modulation mechanism in pain and anxiety behaviors and GABA and dopamine were paid attention to by researchers. And top research frontiers were molecular docking, autoimmune encephalitic series, obesity, sex difference, diagnosis and management, EEG and KCC2. Conclusion Taken together, academic attention on GABA-A receptor channels was never neglected since 2012. Our analysis identified key information, such as core countries, institutions and authors in this field. Molecular docking, autoimmune encephalitic series, obesity, sex difference, diagnosis and management, EEG and KCC2 will be the future research direction.
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Affiliation(s)
- Xufeng Yu
- College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, People’s Republic of China
| | - Zhan Gao
- College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, People’s Republic of China
| | - Mingzhou Gao
- Innovation Research Institute of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, People’s Republic of China
| | - Mingqi Qiao
- College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, People’s Republic of China
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Pedersen C, Aboian M, Messina SA, Daldrup-Link H, Franceschi AM. PET/MRI Applications in Pediatric Epilepsy. World J Nucl Med 2023; 22:78-86. [PMID: 37223623 PMCID: PMC10202574 DOI: 10.1055/s-0043-1764303] [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] [Indexed: 05/25/2023] Open
Abstract
Epilepsy neuroimaging assessment requires exceptional anatomic detail, physiologic and metabolic information. Magnetic resonance (MR) protocols are often time-consuming necessitating sedation and positron emission tomography (PET)/computed tomography (CT) comes with a significant radiation dose. Hybrid PET/MRI protocols allow for exquisite assessment of brain anatomy and structural abnormalities, in addition to metabolic information in a single, convenient imaging session, which limits radiation dose, sedation time, and sedation events. Brain PET/MRI has proven especially useful for accurate localization of epileptogenic zones in pediatric seizure cases, providing critical additional information and guiding surgical decision making in medically refractory cases. Accurate localization of seizure focus is necessary to limit the extent of the surgical resection, preserve healthy brain tissue, and achieve seizure control. This review provides a systematic overview with illustrative examples demonstrating the applications and diagnostic utility of PET/MRI in pediatric epilepsy.
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Affiliation(s)
- Christian Pedersen
- Department of Radiology, Yale School of Medicine, New Haven, Connecticut, United States
| | - Mariam Aboian
- Department of Radiology, Yale School of Medicine, New Haven, Connecticut, United States
| | - Steven A. Messina
- Neuroradiology Division, Department of Radiology, Mayo Clinic Radiology, Rochester, Minnesota, United States
| | - Heike Daldrup-Link
- Department of Radiology and Pediatrics, Stanford University School of Medicine, Palo Alto, California, United States
| | - Ana M. Franceschi
- Neuroradiology Division, Department of Radiology, Northwell Health/Donald and Barbara Zucker School of Medicine, Lenox Hill Hospital, New York, New York, United States
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Safan AS, Al-Termanini M, Abdelhady M, Osman Y, Awad Elzouki ANY, Abdussalam AL. Claustrum sparing sign in seronegative limbic encephalitis. eNeurologicalSci 2023; 31:100465. [PMID: 37250109 PMCID: PMC10212785 DOI: 10.1016/j.ensci.2023.100465] [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: 02/23/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/31/2023] Open
Abstract
Background Limbic encephalitis (LE) is a rare variant of autoimmune encephalitis. It often manifests with subacute neuropsychiatric symptoms of agitation, delusions, variable seizure semiology, and short-term memory loss. Seronegative limbic encephalitis can pose a diagnostic conundrum owing to its inadequately understood pathophysiology. Case presentation We report a rare case of a young male with subacute neuropsychiatric manifestations of delusions, agitations and seizures. He was diagnosed with seronegative limbic encephalitis (SNLE). Brain MRI demonstrated bilateral Claustrum sparing sign. An EEG showed continuous left-sided epileptiform discharges in periodic to predominantly left middle temporal. Patient condition gradually improved with pulsed methylprednisolone, intravenous immunoglobulins and anti-seizure medications. Conclusion Claustrum remains one of the least understood neuroanatomical structures. Claustrum sign has been reported in febrile infection-related epilepsy syndrome (FIRES), LE, and autoimmune refractory epilepsy. To the best of our knowledge, we report the first case in literature with Claustrum sparing sign in seronegative Limbic Encephalitis. Further experimental models and researches are warranted to better understand the unique function of the claustrum and unravel possible other attributable auto-antibodies, which could alter treatment and prognosis.
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Affiliation(s)
- Abeer Sabry Safan
- Department of Neurology, Neurosciences Institute, Hamad Medical Corporation, Doha, Qatar
| | | | - Mohamed Abdelhady
- Department of Neuroradiology, Neurosciences Institute, Hamad Medical Corporation, Doha, Qatar
| | - Yasir Osman
- Department of Neurology, Neurosciences Institute, Hamad Medical Corporation, Doha, Qatar
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Hu W, Wang E, Fang H, Li L, Yi J, Liu Q, Qing W, Guo D, Tan Q, Liao H. Clinical spectrum of contactin-associated protein 2 autoimmune encephalitis in children. Front Neurosci 2023; 17:1106214. [PMID: 37274200 PMCID: PMC10232858 DOI: 10.3389/fnins.2023.1106214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 04/03/2023] [Indexed: 06/06/2023] Open
Abstract
Objective Anti-contactin-associated protein 2 (CASPR2)-related autoimmune encephalitis (AE) is more common in adults than in children. Clinical understanding of anti-CASPR2-antibody (Ab)-related AE, diagnosis and treatment standards are lacking in children. Therefore, this retrospective study on clinical symptoms and treatment outcomes in children with anti-CASPR2-Ab-related AE was conducted, to improve the clinical understanding of the disease, its diagnosis and treatment. Methods This study retrospectively assessed children with anti-CASPR2-Ab-related AE from January 1, 2020, to June 30, 2022, in the Department of Neurology at Hunan Children's Hospital. Data regarding demographics, clinical symptoms, laboratory examinations, electroencephalography (EEG), imaging, and curative were collected. Results Thirteen patients were positive for serum anti-CASPR2-Ab (age at manifestation, 25 months to 13 years old; median, 8.1 years old; male-to-female ratio, 8/5). One patient (P1) had dual Abs, including anti-CASPR2 and anti-N-methyl-D-aspartate receptor Abs; his symptoms were more severe than those of children with anti-CASPR2 Abs alone. The clinical symptoms of the 13 patients with anti-CASPR2 Ab were movement disorders (9/13), consciousness disorders (9/13), abnormal demeanor (8/13), seizures (7/13), language disorders (6/13), fever (6/13), pain (4/13), involuntary exercise (4/13), poor diet (4/13), vomiting (3/13), sleep disorders (3/13), mood disorders (3/13), eczema/itching/redness (2/13), sweating (P8), urinary disorders (P13), and cognitive disorders (P9). No tumors were found in any patient. Additionally, EEG results of six patients were abnormal and imaging findings such as abnormal signals were found in 10 patients. Moreover, all except one patient recovered well after treatment; P1 with overlapping syndrome underwent recovery for more than 2 years. None of the patients who recovered have had a relapse. Discussion and conclusion Anti-CASPR2-Ab-related AE has several clinical manifestations. Anti-CASPR2-Ab levels were higher in male patients than in female patients. Moreover, related tumors are relatively rare. Most patients benefit from immunotherapy and have a lower chance of recurrence in the short term. Furthermore, different from patients who had anti-CASPR2-Ab AE alone, those with overlapping syndrome had a severe and complex condition requiring lengthy treatment and rehabilitation. Additional studies are needed to evaluate the long-term prognosis of these patients.
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Affiliation(s)
- Wenjing Hu
- Department of Neurology, Hunan Children’s Hospital, Changsha, Hunan, China
| | - Enhui Wang
- Department of Neurology, Hunan Children’s Hospital, Changsha, Hunan, China
| | - Hongjun Fang
- Department of Neurology, Hunan Children’s Hospital, Changsha, Hunan, China
| | - Li Li
- Department of Radiology, Hunan Children’s Hospital, Changsha, Hunan, China
| | - Jurong Yi
- Department of Neurology, Hunan Children’s Hospital, Changsha, Hunan, China
| | - Qingqing Liu
- Department of Neurology, Hunan Children’s Hospital, Changsha, Hunan, China
| | - Wei Qing
- Department of Neurology, Hunan Children’s Hospital, Changsha, Hunan, China
| | - Danni Guo
- Department of Neurology, Hunan Children’s Hospital, Changsha, Hunan, China
| | - Qianqian Tan
- Department of Neurology, Hunan Children’s Hospital, Changsha, Hunan, China
| | - Hongmei Liao
- Department of Neurology, Hunan Children’s Hospital, Changsha, Hunan, China
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Zhang F, Gao X, Liu J, Zhang C. Biomarkers in autoimmune diseases of the central nervous system. Front Immunol 2023; 14:1111719. [PMID: 37090723 PMCID: PMC10113662 DOI: 10.3389/fimmu.2023.1111719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/16/2023] [Indexed: 04/09/2023] Open
Abstract
The autoimmune diseases of the central nervous system (CNS) represent individual heterogeneity with different disease entities. Although clinical and imaging features make it possible to characterize larger patient cohorts, they may not provide sufficient evidence to detect disease activity and response to disease modifying drugs. Biomarkers are becoming a powerful tool due to their objectivity and easy access. Biomarkers may indicate various aspects of biological processes in healthy and/or pathological states, or as a response to drug therapy. According to the clinical features described, biomarkers are usually classified into predictive, diagnostic, monitoring and safety biomarkers. Some nerve injury markers, humoral markers, cytokines and immune cells in serum or cerebrospinal fluid have potential roles in disease severity and prognosis in autoimmune diseases occurring in the CNS, which provides a promising approach for clinicians to early intervention and prevention of future disability. Therefore, this review mainly summarizes the potential biomarkers indicated in autoimmune disorders of the CNS.
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Affiliation(s)
- Fenghe Zhang
- Department of Neurology and Institute of Neuroimmunology, Tianjin Medical University General Hospital, Tianjin, China
| | - Xue Gao
- Department of Neurology and Institute of Neuroimmunology, Tianjin Medical University General Hospital, Tianjin, China
| | - Jia Liu
- Department of Neurology and Institute of Neuroimmunology, Tianjin Medical University General Hospital, Tianjin, China
| | - Chao Zhang
- Department of Neurology and Institute of Neuroimmunology, Tianjin Medical University General Hospital, Tianjin, China
- Centers of Neuroimmunology and Neurological Diseases, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- *Correspondence: Chao Zhang,
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Hiesgen J, Schutte CM. Autoimmune encephalitis: Epidemiology, pathophysiology and clinical spectrum (part 2). S Afr Med J 2023. [DOI: 10.7196/samj.2023.v113i4.875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
Autoimmune encephalitis (AE) represents a growing number of severe autoimmune-inflammatory diseases affecting both the white and grey matter of the brain. In part 1 of this series we focused on the epidemiology, pathophysiology and clinical presentation of this condition, with two illustrative cases. In this part, we will introduce the clinical criteria for AE, particularly for the diagnosis of anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, which were developed to facilitate immune treatment in suspected cases before antibody results are available. We subsequently discuss the work up, differential diagnosis and treatment options for patients with this disease.
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Cipriano L, Miele G, Ugga L, Abbadessa G, Caranci F, Bonavita S. MRI and steroid-responsive encephalopathy associated with autoimmune thyroiditis: first report of conus medullaris involvement and literature review of the known neuroimaging profiles. Neurol Sci 2023; 44:1773-1776. [PMID: 36809420 DOI: 10.1007/s10072-023-06642-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/22/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT) is a rare but potentially reversible autoimmune encephalopathy. The most frequent neuroimaging correlates are normal brain MRI or non-specific white matter hyperintensities. METHODS We present the first description of conus medullaris involvement, also providing an extensive review of MRI patterns described so far. RESULTS Our results show that in less than 30% of cases, it is possible to find focal SREAT neuroanatomical correlates. Among these, T2w/FLAIR temporal hyperintensities are the most frequent, followed by basal ganglia/thalamic and brainstem involvement, respectively. CONCLUSIONS Unfortunately, spinal cord investigation is an uncommon practice in the diagnostic approach of encephalopathies, thus neglecting potential pathological lesions of the medulla spinalis. In our opinion, the extension of the MRI study to the cervical, thoracic, and lumbosacral regions may allow finding new, and hopefully specific, anatomical correlates.
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Affiliation(s)
- Lorenzo Cipriano
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy.
| | - Giuseppina Miele
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Lorenzo Ugga
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Gianmarco Abbadessa
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Ferdinando Caranci
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Simona Bonavita
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
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Liu Y, Mo X, Feng Y, Willoughby RE, Weng X, Wang Y, Li X, Gao J, Tian J, Peng J. Metagenomic next-generation sequencing for the etiological diagnosis of rabies virus in cerebrospinal fluid. Front Med (Lausanne) 2023; 10:982290. [PMID: 36844226 PMCID: PMC9947348 DOI: 10.3389/fmed.2023.982290] [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: 07/09/2022] [Accepted: 01/02/2023] [Indexed: 02/11/2023] Open
Abstract
Background Rabies is a highly fatal disease. Once symptoms develop, death usually occurs within days. Survivors were occasionally reported in the literatures. Ante-mortem diagnosis remains a challenge in most rabies endemic countries. A novel, accurate diagnostic assay is highly desirable. Methods We used metagenomic next-generation sequencing (mNGS) to examine the cerebrospinal fluid (CSF) samples of a 49-year-old patient with rabies and validated the results by TaqMan PCR and RT-PCR/Sanger sequencing. Results Metagenomic next-generation sequencing identified sequence reads uniquely aligned to the rabies virus (RABV). PCR confirmed the presence of the partial RABV N gene in the CSF. Phylogenetic analysis showed that the RABV grouped as an Asian clade, which is the most broadly distributed clade in China. Conclusion Metagenomic next-generation sequencing may be a useful screening tool for the etiological diagnosis of rabies, especially in the absence of timely rabies laboratory testing or in patients with no exposure history.
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Affiliation(s)
- Yong Liu
- Intensive Care Unit, Shenzhen Hospital, Southern Medical University, Shenzhen, Guangdong, China
| | - Xichao Mo
- Department of Infectious Diseases, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Ye Feng
- Changchun Veterinary Research Institute, Chinese Academy of Agricultural Sciences, Changchun, Jilin, China
| | - Rodney E. Willoughby
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, MI, United States
| | - Xing Weng
- Department of Infectious Disease, BGI-Shenzhen, Shenzhen, Guangdong, China
| | - Yuyang Wang
- Changchun Veterinary Research Institute, Chinese Academy of Agricultural Sciences, Changchun, Jilin, China
| | - Xing Li
- Department of Infectious Disease, BGI-Shenzhen, Shenzhen, Guangdong, China
| | - Junling Gao
- Centre of Buddhists Studies, The University of Hong Kong, Hong Kong, Hong Kong SAR, China,Department of Medicine, LKS Medical Faculty, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Jinfei Tian
- Intensive Care Unit, Shenzhen Hospital, Southern Medical University, Shenzhen, Guangdong, China
| | - Jie Peng
- Department of Infectious Diseases, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong, China,*Correspondence: Jie Peng,
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Liu X, Guo K, Lu L, Luo R, Liu J, Zhou D, Hong Z. Safety of inactivated COVID-19 vaccines in autoimmune encephalitis: A real-world cross-sectional survey. Mult Scler Relat Disord 2023; 70:104495. [PMID: 36603293 PMCID: PMC9801688 DOI: 10.1016/j.msard.2022.104495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 12/26/2022] [Accepted: 12/29/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To assess safety data of the inactivated COVID-19 vaccines in a real-world sample of people with autoimmune encephalitis (pwAE). METHODS A cross-sectional study was performed between 1 March and 30 April 2022. We invited pwAE from our previous ONE-WC (Outcome of Autoimmune Encephalitis Study in Western China) registration study database, to attend neurological clinics, at West China Hospital to participate in a face-to-face survey using a custom-designed questionnaire for this study. The ONE-WC study began in October 2011 and prospectively enrolled pwAE from four large comprehensive neurological centers in Sichuan province, China. RESULTS Of the 387 pwAE, 240 (62.0%) completed the questionnaire. Half the 240 participants (121, 50.4%) reported receiving at least one dose of COVID-19 vaccine, which in all but two patients received inactivated COVID-19 vaccine. Among vaccinated pwAE, the median age was 35 years (range 15-69) and 57.8% of them were women. The most frequent reasons that unvaccinated individuals reported for not receiving the COVID-19 vaccine were concern about vaccine-induced relapse of AE (50.4%) and advice from a physician to delay vaccination (21.0%). Small proportions of vaccinated individuals reported adverse events after the first dose (11.5%) or the second dose (10.2%), and none of the adverse events was serious. Across the entire sample, one individual reported relapsing within 30 days after the first dose and three individuals reported relapsing more than 120 days after the first dose. CONCLUSIONS This real-world survey indicates an overall favorable safety profile of the inactivated COVID-19 vaccine for pwAE.
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Affiliation(s)
- Xu Liu
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan 610041, China
| | - Kundian Guo
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan 610041, China
| | - Lu Lu
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan 610041, China
| | - Rong Luo
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Jie Liu
- Department of Neurology, Sichuan Provincial Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan 610041, China
| | - Zhen Hong
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan 610041, China; Department of Neurology, Chengdu Shangjin Nanfu Hospital, Chengdu, Sichuan 611730, China.
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Arai Y, Okanishi T, Kumasaki K, Kanai S, Nishimura Y, Takahashi Y, Maegaki Y. A pediatric case of autoimmune encephalitis with chronologically moving seizure foci and cortical lesions: A case report. Brain Dev 2023; 45:146-151. [PMID: 36335005 DOI: 10.1016/j.braindev.2022.10.002] [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] [Received: 08/09/2022] [Revised: 09/28/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Autoimmune encephalitis (AIE) is a relatively newly described category of immune-mediated diseases involving the central nervous system with a wide spectrum of clinical presentations, ranging from relatively mild or insidious onset of cognitive impairment to more complex forms of encephalopathy with medically refractory seizures. Single or multifocal seizures accompanied by neuropsychiatric symptoms and cognitive or memory impairments are suggestive of clinical features at AIE onset. CASE REPORT A six-year-old boy presented with repetitive focal seizures, slowly progressive emotional liability, and attention-deficit/hyperactivity disorder-like symptoms. Seizure types varied during the clinical course, sometimes emerging as clusters or statuses. MRI performed during seizure clustering/status revealed moving signal abnormalities. We successfully treated the patient with high-dose intravenous methylprednisolone. Cerebrospinal fluid analysis revealed pleocytosis and marked elevation of antibodies against N-terminals of N-methyl-d-aspartate type glutamate receptor subunits and granzyme B. CONCLUSION We report a case of moving seizure foci with abnormal MRI findings. Although the onset of psychiatric symptoms slowly progressed to those atypical for AIE, responsiveness to immunotherapy, cerebrospinal fluid pleocytosis, and autoantibodies all indicated AIE. We thus suggest that moving seizure foci and abnormal MRI signals may be findings of AIE.
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Affiliation(s)
- Yuto Arai
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Tohru Okanishi
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan.
| | - Kensuke Kumasaki
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan; Department of Pediatrics, Tottori Prefectural Kosei Hospital, Kurayoshi, Japan
| | - Sotaro Kanai
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Yoko Nishimura
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan; Department of Pediatrics, Tokyo Metropolitan Tobu Medical Center, Tokyo, Japan
| | - Yukitoshi Takahashi
- National Epilepsy Center, NHO Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Yoshihiro Maegaki
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
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Liang C, Chu E, Kuoy E, Soun JE. Autoimmune-mediated encephalitis and mimics: A neuroimaging review. J Neuroimaging 2023; 33:19-34. [PMID: 36217010 DOI: 10.1111/jon.13060] [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: 06/15/2022] [Revised: 09/10/2022] [Accepted: 09/20/2022] [Indexed: 02/01/2023] Open
Abstract
Autoimmune encephalitis is a category of autoantibody-mediated neurological disorders that often presents a diagnostic challenge due to its variable clinical and imaging findings. The purpose of this image-based review is to provide an overview of the major subtypes of autoimmune encephalitis and their associated autoantibodies, discuss their characteristic clinical and imaging features, and highlight several disease processes that may mimic imaging findings of autoimmune encephalitis. A literature search on autoimmune encephalitis was performed and publications from neuroradiology, neurology, and nuclear medicine literature were included. Cases from our institutional database that best exemplify major imaging features were presented.
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Affiliation(s)
- Conan Liang
- Department of Radiological Sciences, University of California, Irvine Medical Center, Orange, California, USA
| | - Eleanor Chu
- Department of Radiological Sciences, University of California, Irvine Medical Center, Orange, California, USA
| | - Edward Kuoy
- Department of Radiological Sciences, University of California, Irvine Medical Center, Orange, California, USA
| | - Jennifer E Soun
- Department of Radiological Sciences, University of California, Irvine Medical Center, Orange, California, USA
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Ackerman A, Igawa T, Singla A, Kosack A. A Perplexing Case of Confusion. Clin Pediatr (Phila) 2022:99228221145301. [PMID: 36539962 DOI: 10.1177/00099228221145301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Anouk Ackerman
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Teryn Igawa
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ankit Singla
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA, USA
| | - Amanda Kosack
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA, USA
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Chen AY, Wang DS, Sawlani K. Teaching NeuroImage: Atypical Unilateral Cortical Ribboning in Anti-NMDA Receptor Encephalitis. Neurology 2022; 99:1062-1063. [PMID: 36127147 DOI: 10.1212/wnl.0000000000201368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 08/22/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Alex Y Chen
- From the Department of Neurology at Case Western Reserve University (A.Y.C., D.S.W., K.S.), Cleveland, OH; and University Hospitals (A.Y.C., D.S.W., K.S.), Cleveland Medical Center, Cleveland, OH.
| | - David S Wang
- From the Department of Neurology at Case Western Reserve University (A.Y.C., D.S.W., K.S.), Cleveland, OH; and University Hospitals (A.Y.C., D.S.W., K.S.), Cleveland Medical Center, Cleveland, OH
| | - Komal Sawlani
- From the Department of Neurology at Case Western Reserve University (A.Y.C., D.S.W., K.S.), Cleveland, OH; and University Hospitals (A.Y.C., D.S.W., K.S.), Cleveland Medical Center, Cleveland, OH
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Muacevic A, Adler JR, Gonçalves F, Duro J, Aguiar P. Neurosyphilis: The Great Imitator. Cureus 2022; 14:e32747. [PMID: 36686118 PMCID: PMC9851570 DOI: 10.7759/cureus.32747] [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] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
Syphilis is a sexually transmitted disease caused by spirochete Treponema pallidum, with a growing incidence documented in recent years. Its clinical course is divided into three phases - primary, secondary, and tertiary syphilis - and virtually any organ can be affected, resulting in diverse clinical manifestations, making the diagnosis challenging. Neurosyphilis is a progressive, destructive disease of the central nervous system (CNS) that can develop at any stage of the infection, leading to meningeal involvement, meningovascular disease, or parenchymal syphilis (including tabes dorsalis and general paresis). Its clinical manifestations are heterogeneous and vary from focal neurologic signs to neuropsychiatric manifestations. The diagnosis is based mainly on the clinical picture and study of cerebrospinal fluid. Neuroimaging is helpful and sometimes essential, with magnetic resonance imaging being the most sensitive radiologic method, although there are no pathognomonic radiologic signs. Treatment of all forms of neurosyphilis is based on parenteral penicillin. We present a case of neurosyphilis in a patient presenting with a subacute confusional state and initial imaging findings suggestive of metastatic CNS lesions.
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Binks S, Lamquet S, Crawford AH, Meurs A, Irani SR, Pakozdy A. Parallel roles of neuroinflammation in feline and human epilepsies. Vet J 2022; 290:105912. [PMID: 36209994 PMCID: PMC10912827 DOI: 10.1016/j.tvjl.2022.105912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
Autoimmune encephalitis refers to a group of disorders characterised by a non-infectious encephalitis, often with prominent seizures and surface neuronal autoantibodies. AE is an important cause of new-onset refractory status epilepticus in humans and is frequently responsive to immunotherapies including corticosteroids, plasma exchange, intravenous immunoglobulin G and rituximab. Recent research suggests that parallel autoantibodies can be detected in non-human mammalian species. The best documented example is leucine-rich glioma-inactivated 1 (LGI1)-antibodies in domestic cats with limbic encephalitis (LE). In this review, we discuss the role of neuroinflammation and autoantibodies in human and feline epilepsy and LE.
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Affiliation(s)
- Sophie Binks
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, OX3 9DU, UK; Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals Foundation Trust, Oxford OX3 9DU, UK.
| | - Simon Lamquet
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Abbe H Crawford
- Clinical Science and Services, The Royal Veterinary College, Hertfordshire AL9 7TA, UK
| | - Alfred Meurs
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, OX3 9DU, UK; Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals Foundation Trust, Oxford OX3 9DU, UK
| | - Akos Pakozdy
- University Clinic for Small Animals, University of Veterinary Medicine Vienna, Austria
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Extracellular Vesicles in Chronic Demyelinating Diseases: Prospects in Treatment and Diagnosis of Autoimmune Neurological Disorders. LIFE (BASEL, SWITZERLAND) 2022; 12:life12111943. [PMID: 36431078 PMCID: PMC9693249 DOI: 10.3390/life12111943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/15/2022] [Accepted: 11/17/2022] [Indexed: 11/23/2022]
Abstract
Extracellular vesicles (EVs) represent membrane-enclosed structures that are likely to be secreted by all living cell types in the animal organism, including cells of peripheral (PNS) and central nervous systems (CNS). The ability to cross the blood-brain barrier (BBB) provides the possibility not only for various EV-loaded molecules to be delivered to the brain tissues but also for the CNS-to-periphery transmission of these molecules. Since neural EVs transfer proteins and RNAs are both responsible for functional intercellular communication and involved in the pathogenesis of neurodegenerative diseases, they represent attractive diagnostic and therapeutic targets. Here, we discuss EVs' role in maintaining the living organisms' function and describe deviations in EVs' structure and malfunctioning during various neurodegenerative diseases.
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Jha S, Nagaraj C, Mundlamuri RC, Alladi S, Nashi S, Kenchaiah R, Mahadevan A, Bhat M, Saini J, Netravathi M. FDG-PET in Autoimmune Encephalitis: Utility, Pattern of Abnormalities, and Correlation with Autoantibodies. Ann Indian Acad Neurol 2022; 25:1122-1129. [PMID: 36911487 PMCID: PMC9996532 DOI: 10.4103/aian.aian_645_22] [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: 07/27/2022] [Revised: 10/04/2022] [Accepted: 10/14/2022] [Indexed: 03/14/2023] Open
Abstract
Background Fluorodeoxyglucose-positron emission tomography (FDG-PET) in autoimmune encephalitis (AE) as an adjunctive investigation helps in characterizing the type of AE based on characteristic metabolic patterns. Objectives We aimed to study the following: (i) the sensitivity of FDG-PET in the diagnosis of AE, (ii) describe abnormal patterns of metabolism of various subtypes of AE, and (iii) correlate serum serology with FDG-PET abnormalities. Materials and Methods This study was conducted at a tertiary university hospital in South India. The demographic profile, clinical features, and investigations (FDG-PET, magnetic resonance imaging (MRI) brain, electroencephalography (EEG), cerebrospinal fluid (CSF)) were reviewed. The nuclear medicine physician performed blinded qualitative visual and semi-quantitative analysis of the 18-FDG-PET (fluorine 18-FDG-PET) findings of these patients. Results Twenty-nine (M:F: 11:18) patients were recruited; among them, 22 (75.8%) patients had autoimmune antibodies; the rest seven (24.1%) patients were seronegative. Among the 22 seropositive patients, 9 (31%) patients were positive for anti-N-methyl-D-aspartate receptor (NMDAR), 8 (28%) for anti-leucine-rich glioma inactivated 1 (LGI-1), 4 (14%) for anti-contactin-associated protein 2 (CASPR2), 1 (3%) for anti-glutamic acid decarboxylase (GAD)-65, and rest 7 (24%) patients were seronegative. The patterns most commonly observed were isolated hypermetabolism (41%), isolated hypometabolism (41%), and combined hypermetabolism with hypometabolism (18%). The fraction of abnormalities was lower for MRI (17/22; 73.9%) than for FDG-PET (27/29; 93.1%). FDG-PET correlated with serology in 10 (34%) cases [NMDAR: 6 (60%) and LGI-1: 4 (40%)]. The sensitivity of FDG-PET was 94.1% when compared with MRI. Discussion and Conclusion FDG-PET correlated with serology in only one-third of patients. The most consistent pattern in both seropositive and seronegative AE is characterized by parieto-occipital hypometabolism and fronto-temporal with basal ganglia hypermetabolism.
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Affiliation(s)
- Shreyashi Jha
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Chandana Nagaraj
- Department of Neuroimaging and Interventional Neuroradiology (NIIR), National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - R. C. Mundlamuri
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Suvarna Alladi
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Saraswati Nashi
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Raghavendra Kenchaiah
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Anita Mahadevan
- Department of Neuropathology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Maya Bhat
- Department of Neuroimaging and Interventional Neuroradiology (NIIR), National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Jitender Saini
- Department of Neuroimaging and Interventional Neuroradiology (NIIR), National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - M. Netravathi
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
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Zhao Y, Han B, Qin C, Shi X, Yun W, Wang M, Yuan B, Sun T, Wang H. Brain magnetic resonance imaging predictors in anti-N-methyl-D-aspartate receptor encephalitis. Ann Clin Transl Neurol 2022; 9:1974-1984. [PMID: 36314483 PMCID: PMC9735371 DOI: 10.1002/acn3.51690] [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: 06/23/2022] [Revised: 09/18/2022] [Accepted: 10/20/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Brain magnetic resonance imaging (MRI) findings in anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis are nonspecific and rarely have obvious associations with clinical characteristics and outcomes. This study aimed to comprehensively describe the MRI features of patients with NMDAR encephalitis, examine their associations with clinical characteristics, and evaluate their predictive power for disease recurrence and prognosis. METHODS We retrospectively extracted the clinical data and brain MRI findings of 144 patients with NMDAR encephalitis. Patients underwent a 2-year follow-up to assess disease outcomes. We evaluated the associations of brain MRI findings at the onset with clinical characteristics, recurrence, and prognosis. RESULTS Initial MRI showed typical abnormalities in 65 patients (45.1%); of these, 34 (29.3%) developed recurrence and 10 (9.4%) had poor prognosis (mRS ≥3). Binary logistic regression analyses revealed that insula abnormalities were associated with acute seizure (odds ratio [OR] = 3.048, 95% confidence interval [CI]: 1.026-9.060) and white matter lesions were associated with cognitive impairment (OR = 2.730, 95% CI: 1.096-6.799). Risk factors for a poor 2-year prognosis included a higher number of brain MRI abnormalities (OR = 1.573, 95% CI: 1.129-2.192) and intensive care unit (ICU) admissions (OR = 15.312, 95% CI: 1.684-139.198). The risk factors for 2-year recurrence included abnormalities of the thalamus (HR = 3.780, 95% CI: 1.642-8.699). INTERPRETATIONS Brain MRI features of patients with NMDAR encephalitis were associated with clinical manifestations, prognosis, and recurrence. Higher numbers of MRI abnormalities and ICU admissions were predictive of poor prognosis. Abnormalities of the thalamus constituted a recurrence-related risk factor.
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Affiliation(s)
- Ying‐Ying Zhao
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Bing Han
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Cui‐Hong Qin
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Xue‐Xiu Shi
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Wen‐Jing Yun
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Meng Wang
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Bo Yuan
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Tong‐Wen Sun
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Hai‐Xu Wang
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
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