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Quaak MSW, Buijze MSJS, Verhoeven VJM, Vermont C, Buddingh EP, Heredia M, Samsom JN, Titulaer MJ, van Rossum AM, Kamphuis S, Neuteboom RF. Management of Autoimmune Encephalitis in a 7-Year-Old Child With CTLA-4 Haploinsufficiency and AMPA Receptor Antibodies: A Case Report. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200254. [PMID: 38728609 PMCID: PMC11089537 DOI: 10.1212/nxi.0000000000200254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/19/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVES We report on the therapeutic management of early-onset severe neurologic symptoms in cytotoxic T lymphocyte antigen-4 haploinsufficiency (CTLA-4h) and the presence of antibodies to the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) as an important finding. METHODS This is a case report from a Dutch academic hospital. Repeated clinical examinations, repeated brain MRI and extended diagnostics on serum and CSF were performed. We used the CARE checklist. RESULTS A 7-year-old boy was diagnosed with CTLA-4h based on family screening. On diagnosis, he had mild chronic diarrhea and autism spectrum disorder, but no abnormalities in extensive laboratory screening. Six months later, he presented with sudden-onset autoimmune encephalitis. Repeated brain MRI revealed no abnormalities, but immunohistochemistry analysis on serum and CSF showed the presence of AMPAR antibodies. Treatment was initially focused on immunomodulation and targeted CTLA-4 replacement therapy. Because of the persistent fluctuating cerebellar and neuropsychiatric symptoms and the potential clinical significance of the AMPAR antibodies, treatment was intensified with repetition of first-line immunomodulation and rituximab. This combined therapy resulted in sustained clinical improvement and served as a bridge to curative hematopoietic stem cell transplantation. DISCUSSION This case illustrates the rare early onset of autoimmune encephalitis and presence of AMPAR antibodies in CTLA-4h. Targeted CTLA-4 replacement therapy resulted in a partial response. However, awaiting its optimal therapeutic effect, refractory CNS symptoms required intensification of immunomodulation. The identification of AMPAR antibodies guided our treatment decisions. CLASSIFICATION OF EVIDENCE This provides Class IV evidence. It is a single observational study without controls.
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Affiliation(s)
- Marjolijn S W Quaak
- From the Division of Infectious Diseases and Immunology (M.S.W.Q., C.V., A.M.C.R.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital; Department of Neurology (M.S.J.B., M.J.T., R.F.N.); Department of Clinical Genetics (V.J.M.V.), Erasmus MC University Medical Center, Rotterdam; Pediatric Stem Cell Transplantation Program (E.P.B.), Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center; Division Gastroenterology and Nutrition (M.H., J.N.S.), Department of Pediatrics/Laboratory of Pediatrics, Erasmus MC University Medical Center; and Division of Rheumatology (S.K.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Michiel S J S Buijze
- From the Division of Infectious Diseases and Immunology (M.S.W.Q., C.V., A.M.C.R.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital; Department of Neurology (M.S.J.B., M.J.T., R.F.N.); Department of Clinical Genetics (V.J.M.V.), Erasmus MC University Medical Center, Rotterdam; Pediatric Stem Cell Transplantation Program (E.P.B.), Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center; Division Gastroenterology and Nutrition (M.H., J.N.S.), Department of Pediatrics/Laboratory of Pediatrics, Erasmus MC University Medical Center; and Division of Rheumatology (S.K.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Virginie J M Verhoeven
- From the Division of Infectious Diseases and Immunology (M.S.W.Q., C.V., A.M.C.R.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital; Department of Neurology (M.S.J.B., M.J.T., R.F.N.); Department of Clinical Genetics (V.J.M.V.), Erasmus MC University Medical Center, Rotterdam; Pediatric Stem Cell Transplantation Program (E.P.B.), Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center; Division Gastroenterology and Nutrition (M.H., J.N.S.), Department of Pediatrics/Laboratory of Pediatrics, Erasmus MC University Medical Center; and Division of Rheumatology (S.K.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Clementien Vermont
- From the Division of Infectious Diseases and Immunology (M.S.W.Q., C.V., A.M.C.R.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital; Department of Neurology (M.S.J.B., M.J.T., R.F.N.); Department of Clinical Genetics (V.J.M.V.), Erasmus MC University Medical Center, Rotterdam; Pediatric Stem Cell Transplantation Program (E.P.B.), Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center; Division Gastroenterology and Nutrition (M.H., J.N.S.), Department of Pediatrics/Laboratory of Pediatrics, Erasmus MC University Medical Center; and Division of Rheumatology (S.K.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Emmeline P Buddingh
- From the Division of Infectious Diseases and Immunology (M.S.W.Q., C.V., A.M.C.R.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital; Department of Neurology (M.S.J.B., M.J.T., R.F.N.); Department of Clinical Genetics (V.J.M.V.), Erasmus MC University Medical Center, Rotterdam; Pediatric Stem Cell Transplantation Program (E.P.B.), Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center; Division Gastroenterology and Nutrition (M.H., J.N.S.), Department of Pediatrics/Laboratory of Pediatrics, Erasmus MC University Medical Center; and Division of Rheumatology (S.K.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Maud Heredia
- From the Division of Infectious Diseases and Immunology (M.S.W.Q., C.V., A.M.C.R.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital; Department of Neurology (M.S.J.B., M.J.T., R.F.N.); Department of Clinical Genetics (V.J.M.V.), Erasmus MC University Medical Center, Rotterdam; Pediatric Stem Cell Transplantation Program (E.P.B.), Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center; Division Gastroenterology and Nutrition (M.H., J.N.S.), Department of Pediatrics/Laboratory of Pediatrics, Erasmus MC University Medical Center; and Division of Rheumatology (S.K.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Janneke N Samsom
- From the Division of Infectious Diseases and Immunology (M.S.W.Q., C.V., A.M.C.R.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital; Department of Neurology (M.S.J.B., M.J.T., R.F.N.); Department of Clinical Genetics (V.J.M.V.), Erasmus MC University Medical Center, Rotterdam; Pediatric Stem Cell Transplantation Program (E.P.B.), Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center; Division Gastroenterology and Nutrition (M.H., J.N.S.), Department of Pediatrics/Laboratory of Pediatrics, Erasmus MC University Medical Center; and Division of Rheumatology (S.K.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Maarten J Titulaer
- From the Division of Infectious Diseases and Immunology (M.S.W.Q., C.V., A.M.C.R.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital; Department of Neurology (M.S.J.B., M.J.T., R.F.N.); Department of Clinical Genetics (V.J.M.V.), Erasmus MC University Medical Center, Rotterdam; Pediatric Stem Cell Transplantation Program (E.P.B.), Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center; Division Gastroenterology and Nutrition (M.H., J.N.S.), Department of Pediatrics/Laboratory of Pediatrics, Erasmus MC University Medical Center; and Division of Rheumatology (S.K.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Annemarie M van Rossum
- From the Division of Infectious Diseases and Immunology (M.S.W.Q., C.V., A.M.C.R.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital; Department of Neurology (M.S.J.B., M.J.T., R.F.N.); Department of Clinical Genetics (V.J.M.V.), Erasmus MC University Medical Center, Rotterdam; Pediatric Stem Cell Transplantation Program (E.P.B.), Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center; Division Gastroenterology and Nutrition (M.H., J.N.S.), Department of Pediatrics/Laboratory of Pediatrics, Erasmus MC University Medical Center; and Division of Rheumatology (S.K.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sylvia Kamphuis
- From the Division of Infectious Diseases and Immunology (M.S.W.Q., C.V., A.M.C.R.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital; Department of Neurology (M.S.J.B., M.J.T., R.F.N.); Department of Clinical Genetics (V.J.M.V.), Erasmus MC University Medical Center, Rotterdam; Pediatric Stem Cell Transplantation Program (E.P.B.), Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center; Division Gastroenterology and Nutrition (M.H., J.N.S.), Department of Pediatrics/Laboratory of Pediatrics, Erasmus MC University Medical Center; and Division of Rheumatology (S.K.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Rinze F Neuteboom
- From the Division of Infectious Diseases and Immunology (M.S.W.Q., C.V., A.M.C.R.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital; Department of Neurology (M.S.J.B., M.J.T., R.F.N.); Department of Clinical Genetics (V.J.M.V.), Erasmus MC University Medical Center, Rotterdam; Pediatric Stem Cell Transplantation Program (E.P.B.), Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center; Division Gastroenterology and Nutrition (M.H., J.N.S.), Department of Pediatrics/Laboratory of Pediatrics, Erasmus MC University Medical Center; and Division of Rheumatology (S.K.), Department of Pediatrics, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
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Yan W, Mengke W, Zhiqiang S, Jiaao G, Fulin G. Clinical features, cerebrospinal fluid changes, and prognosis in Chinese patients with autoimmune encephalitis. Acta Neurol Belg 2024:10.1007/s13760-024-02537-6. [PMID: 38635129 DOI: 10.1007/s13760-024-02537-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/13/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Autoimmune encephalitis (AE) is a rare, treatable disease of the central nervous system (CNS) caused by an antibody-related immune response. This study is to investigate the correlation of clinical features, cerebrospinal fluid (CSF) characteristics, and prognosis in patients with AE. METHODS A total of 71 patients diagnosed with antibody-positive AE were retrospectively analyzed. The patients were divided into three groups: anti-NMDAR group, anti-LGI1 group, and other types. Clinical data were collected to analyze clinical features and CSF results, and prognosis was determined by modified Rankin Scale (mRS). RESULTS There was statistical difference in the incidences of decreased consciousness level (P < 0.001), memory loss (P = 0.017), speech disorders (P = 0.035), and dyskinesia (P = 0.001) in different antibodies groups. Younger age (P = 0.018), elevated CSF chloride content (P = 0.006), and white blood cells > 50/mm3 (P = 0.026) were highly correlated with ICU admission. Anti-LGI1 encephalitis had a relatively small risk for ICU admission (P = 0.034), and a lower risk of poor functional recovery (P = 0.048) and recurrence (P = 0.041). Patients with first-line treatment failure (P = 0.021) had an increased risk of poor functional recovery. Delayed treatment (P = 0.011) would increase the risk of recurrence. CONCLUSION There are differences in age, gender, clinical characteristics, and CSF results in different subtypes of AE. First-line therapy failure would have poor functional recovery, and delayed therapy would increase the risk of relapse. Chloride ion content and white blood cell count in cerebrospinal fluid are positively correlated with the patient's exacerbation and admission to ICU. These indicators have certain clinical value for the prognosis of AE patients.
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Affiliation(s)
- Wu Yan
- First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
- Xinqiao Hospital and Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Wang Mengke
- First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Su Zhiqiang
- First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Gu Jiaao
- First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China.
| | - Guan Fulin
- First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China.
- Dushu Lake Hospital Affiliated to Soochow University, Soochow, Jiangsu, China.
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Legouy C, Cervantes A, Sonneville R, Thakur KT. Autoimmune and inflammatory neurological disorders in the intensive care unit. Curr Opin Crit Care 2024; 30:142-150. [PMID: 38441114 DOI: 10.1097/mcc.0000000000001139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW The present review summarizes the diagnostic approach to autoimmune encephalitis (AE) in the intensive care unit (ICU) and provides practical guidance on therapeutic management. RECENT FINDINGS Autoimmune encephalitis represents a group of immune-mediated brain diseases associated with antibodies that are pathogenic against central nervous system proteins. Recent findings suggests that the diagnosis of AE requires a multidisciplinary approach including appropriate recognition of common clinical syndromes, brain imaging and electroencephalography to confirm focal pathology, and cerebrospinal fluid and serum tests to rule out common brain infections, and to detect autoantibodies. ICU admission may be necessary at AE onset because of altered mental status, refractory seizures, and/or dysautonomia. Early management in ICU includes prompt initiation of immunotherapy, detection and treatment of seizures, and supportive care with neuromonitoring. In parallel, screening for neoplasm should be systematically performed. Despite severe presentation, epidemiological studies suggest that functional recovery is likely under appropriate therapy, even after prolonged ICU stays. CONCLUSION AE and related disorders are increasingly recognized in the ICU population. Critical care physicians should be aware of these conditions and consider them early in the differential diagnosis of patients presenting with unexplained encephalopathy. A multidisciplinary approach is mandatory for diagnosis, ICU management, specific therapy, and prognostication.
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Affiliation(s)
- Camille Legouy
- GHU Paris Psychiatrie & Neurosciences, Department of Intensive Care Medicine, Paris, France
| | - Anna Cervantes
- Divisions of Neurocritical Care and Neuroinfectious Disease, Boston Medical Center, Boston, Massachusetts, USA
| | - Romain Sonneville
- Université Paris Cité, IAME, INSERM UMR1137
- AP-HP, Hôpital Bichat - Claude Bernard, Department of Intensive Care Medicine, Paris, France
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, New York, USA
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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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Alkhayat D, Khawaji ZY, Sunyur AM, Sanyour OA, Badawi AS. Overview of Paraneoplastic Autoantibody-Mediated Cognitive Impairment and Behavioral Changes: A Narrative Review. Cureus 2024; 16:e51787. [PMID: 38322089 PMCID: PMC10846349 DOI: 10.7759/cureus.51787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2024] [Indexed: 02/08/2024] Open
Abstract
Cognitive dysfunction and behavioral change can be some of the manifestations of cancer, occurring as a part of paraneoplastic neurological syndrome, most commonly in small cell lung cancer. Paraneoplastic limbic encephalitis is the leading cause of cognitive disturbance and abnormal behavior in paraneoplastic syndromes, which is usually autoantibody-mediated. Autoantibodies are the main contributors to the development of cognitive dysfunction and behavioral change in cancer patients, with studies suggesting a higher liability for antibody-positive cancer patients to be affected. Anti-NMDAR and anti-AMPAR are antibodies targeted against surface antigens, manifesting predominantly as memory disturbance, abnormal behavior, psychiatric symptoms, and seizures. Other surface antigen-targeted antibodies include anti-GABA, anti-CASPR2, and anti-LGI1, which were shown to have cognitive function impairment and abnormal behavior as some of the main presentations, predominantly affecting memory. Cognitive deterioration and changes in behavior were also relatively common with some of the intracellular antigen-targeted antibodies, including anti-Hu, anti-SOX1, anti-PCA2, and anti-Zic2. Affected behavior and cognition, however, were reported less commonly in other paraneoplastic antibodies against intracellular antigens (anti-Yo, anti-GAD, anti-Ma2, anti-Ri, anti-CV2, and anti-KLHL11). Our article will provide a comprehensive review of the clinical manifestations of cognitive impairment and behavioral changes among cancer patients who develop paraneoplastic syndrome. Additionally, this review will discuss the role of specific paraneoplastic autoantibodies and the clinical spectrum linked to each separately.
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Affiliation(s)
| | | | - Amal M Sunyur
- Medicine and Surgery, Taibah University, Medina, SAU
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Graber JJ. Paraneoplastic Neurologic Syndromes. Continuum (Minneap Minn) 2023; 29:1779-1808. [PMID: 38085898 DOI: 10.1212/con.0000000000001357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
OBJECTIVE Progress is ongoing in understanding paraneoplastic neurologic disorders, with new syndromes and antibodies being described and more detailed evidence available to guide workup for diagnosis and treatment to improve outcomes. Many excellent reviews have summarized the molecular features of different antibodies, but this article emphasizes the clinical features of each syndrome that may help guide initial diagnosis and treatment, which often should occur before an antibody or cancer is found to confirm the diagnosis. LATEST DEVELOPMENTS Recent findings include updated diagnostic criteria with validated sensitivity and specificity, discovery of novel antibodies, and clinical findings that increase the likelihood of an underlying paraneoplastic disorder. Suggestive syndromes that have been recently identified include faciobrachial dystonic seizures and pilomotor auras in anti-leucine-rich glioma inactivated protein 1 encephalitis, extreme delta brush on EEG in N-methyl-d-aspartate (NMDA)-receptor encephalitis, déjà vu aura in anti-glutamic acid decarboxylase 65 (GAD65) encephalitis, and sleep disturbances in several disorders. In addition, there is confirmed utility of brain positron emission tomography (PET) and CSF markers, including carcinoembryonic antigen and oligoclonal bands, as well as improved tests for the presence of leptomeningeal cancer cells in CSF. Associations of cancer immunotherapies with paraneoplastic syndromes and herpes simplex virus encephalitis (and COVID-19) with NMDA-receptor encephalitis have been described. ESSENTIAL POINTS All neurologists should be aware of advances regarding paraneoplastic neurologic syndromes, as patients can present with a wide variety of neurologic symptoms and earlier diagnosis and treatment can improve outcomes.
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Li EC, Lai QL, Cai MT, Fang GL, Shen CH, Ding MP, Zhang YX. Anti-adenylate kinase 5 encephalitis: Clinical characteristics, diagnosis, and management of this rare entity. J Transl Autoimmun 2023; 7:100218. [PMID: 37859804 PMCID: PMC10582738 DOI: 10.1016/j.jtauto.2023.100218] [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: 06/06/2023] [Revised: 09/08/2023] [Accepted: 10/06/2023] [Indexed: 10/21/2023] Open
Abstract
The spectrum and understanding of antibody-positive autoimmune encephalitis (AE) have expanded over the past few decades. In 2007, a rare subtype of AE known as anti-adenylate kinase 5 (AK5) encephalitis, was first reported. This disease is more common in elderly males, with limbic encephalitis as the core phenotype (characterized by subacute anterograde amnesia, sometimes with psychiatric symptoms, and rarely with seizures). Brain magnetic resonance imaging typically demonstrated initial temporal lobe T2/fluid-attenuated inversion recovery hyperintensities, and subsequent atrophy. No concomitant tumors have been found yet. AK5 antibody, targeting the intracellular antigen, is a biomarker for a non-paraneoplastic T-cell autoimmunity response, and can be detected in serum and cerebrospinal fluid using tissue-based and cell-based assays. Cytotoxic T-cell-mediating neuronal injury and loss play a pivotal role in the immunopathogenesis of anti-AK5 encephalitis. Patients mostly show poor response to immunotherapy and thus a poor prognosis in the long run. Herein, we review the literature and provide updated knowledge of this less-known entity, focusing on clinical characteristics, paraclinical findings, diagnosis process, and therapeutic approaches.
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Affiliation(s)
- Er-Chuang Li
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
- Department of Neurology, Taikang Ningbo Hospital, Ningbo, 315042, China
| | - Qi-Lun Lai
- Department of Neurology, Zhejiang Hospital, Hangzhou, 310013, China
| | - Meng-Ting Cai
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Gao-Li Fang
- Department of Neurology, Zhejiang Chinese Medicine and Western Medicine Integrated Hospital, Hangzhou, 310003, China
| | - Chun-Hong Shen
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Mei-Ping Ding
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Yin-Xi Zhang
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
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Akkus S, Elkhooly M, Amatya S, Shrestha K, Sharma K, Kagzi Y, Khan E, Gupta R, Piquet AL, Jaiswal S, Wen S, Tapia M, Samant R, Sista SR, Sriwastava S. Autoimmune and paraneoplastic neurological disorders: A review of relevant neuroimaging findings. J Neurol Sci 2023; 454:120830. [PMID: 37856996 DOI: 10.1016/j.jns.2023.120830] [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: 08/21/2023] [Revised: 09/28/2023] [Accepted: 10/04/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Paraneoplastic neurologic syndromes (PNS) and autoimmune encephalitis (AIE) are immune-mediated disorders. PNS is linked to cancer, while AIE may not Their clinical manifestations and imaging patterns need further elucidation. OBJECTIVE/AIMS To investigate the clinical profiles, antibody associations, neuroimaging patterns, treatments, and outcomes of PNS and AIE. METHODS A systematic review of 379 articles published between 2014 and 2023 was conducted. Of the 55 studies screened, 333 patients were diagnosed with either PNS or AIE and tested positive for novel antibodies. Data on demographics, symptoms, imaging, antibodies, cancer associations, treatment, and outcomes were extracted. RESULTS The study included 333 patients (mean age 54 years, 67% males) with PNS and AIE positive for various novel antibodies. 84% had central nervous system issues like cognitive impairment (53%), rhombencephalitis (17%), and cerebellar disorders (24%). Neuroimaging revealed distinct patterns with high-risk antibodies associated with brainstem lesions in 98%, cerebellar in 91%, hippocampal in 98%, basal ganglia in 75%, and spinal cord in 91%, while low/intermediate-risk antibodies were associated with medial temporal lobe lesions in 71% and other cortical/subcortical lesions in 55%. High-risk antibodies were associated with younger males, deep brain lesions, and increased mortality of 61%, while low/intermediate-risk antibodies were associated with females, cortical/subcortical lesions, and better outcomes with 39% mortality. Associated cancers included seminomas (23%), lung (19%), ovarian (2%), and breast (2%). Treatments included IVIG, chemotherapy, and plasmapheresis. Overall mortality was 25% in this cohort. CONCLUSION PNS and AIE have distinct clinical and radiological patterns based on antibody profiles. High-risk antibodies are associated with increased mortality while low/intermediate-risk antibodies are associated with improved outcomes. Appropriate imaging and antibody testing are critical for accurate diagnosis.
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Affiliation(s)
- Sema Akkus
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mahmoud Elkhooly
- Department of Neurology, Wayne state University, Detroit, MI, USA; Department of Neurology, Southern Illinois university, Springfield, IL, USA; Department of Neuropsychiatry, Minia University, Egypt
| | - Suban Amatya
- Department of Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Kriti Shrestha
- Department of Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Kanika Sharma
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA
| | - Yusuf Kagzi
- Mahatma Gandhi Memorial Medical College, Indore, India
| | - Erum Khan
- Department of Neurology, University of Alabama at Birmingham, Al, USA
| | - Rajesh Gupta
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA
| | - Amanda L Piquet
- Neuroimmunology, Neuroinfectious Disease and Neurohospitalist Sections, University of Colorado School of Medicine, CO, USA
| | - Shruti Jaiswal
- Department of Neuro-oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Sijin Wen
- West Virginia Clinical Transitional Science, Morgantown, WV, USA
| | - Michaela Tapia
- West Virginia Clinical Transitional Science, Morgantown, WV, USA
| | - Rohan Samant
- Department of Neuroradiology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sri Raghav Sista
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA
| | - Shitiz Sriwastava
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA.
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Huang Y, Zhou M, Zhou J, Wu B, Yang X, Min W, Li Z. Anti-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor encephalitis developed after ovarian cancer cytoreduction surgery: a case report and literature review. BMC Womens Health 2023; 23:507. [PMID: 37735388 PMCID: PMC10512534 DOI: 10.1186/s12905-023-02636-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 09/06/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Anti-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) encephalitis, a rare subtype of autoimmune encephalitis (AE), is often found associated with tumors such as thymoma, lung cancer, ovarian tumors, and breast cancer, and the tumors were generally detected during the screening process after the encephalitis initiated. The tumor is considered a trigger of AE, but the mechanism remains unclear. CASE PRESENTATION A 53-year-old woman presented short-term memory loss two days after the primary cytoreduction for high-grade serous ovarian cancer (HGSOC, FIGO stage IC3). Cell-based assay found AMPAR CluA2 IgG positive in both serum (1:3.2) and cerebrospinal fluid (1:32). Moreover, mild AMPAR GluA1 and strong GluA2 expressions were also found positive in the paraffin sections of ovarian tumor tissue, indicating the ovarian cytoreduction surgery might stimulate the release of receptor antigens into the circulation system. The patient's condition deteriorated within two weeks, developing consciousness and autonomic dysfunction, leading to ICU admission. With oral steroids, intravenous immunoglobulin, plasmapheresis, and rituximab treatment, the patient's consciousness markedly improved after three months. CONCLUSION We presented the first case of anti-AMPAR encephalitis developed right after the primary cytoreduction of a patient with HGSOC and retrieved paraneoplastic anti-AMPAR encephalitis cases (n = 66). Gynecologists should pay attention to patients who develop cognitive dysfunction or psychiatric symptoms shortly after the ovarian tumor resection and always include AE in the differentiation diagnosis.
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Affiliation(s)
- Yue Huang
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, 610041, People's Republic of China
| | - Muke Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Jing Zhou
- Department of Gynecology and Obstetrics, Chengdu Fifth People's Hospital, Chengdu, 610041, People's Republic of China
| | - Bo Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Xi Yang
- Department of Anesthesiology, West China Hospital, Sichuan university, Chengdu, 610041, People's Republic of China
| | - Wenjiao Min
- Department of Psychosomatic Medicine, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, Chengdu, 610041, People's Republic of China
| | - Zhengyu Li
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, 610041, People's Republic of China.
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10
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He S, Sun C, Zhu Q, Li L, Huang J, Wu G, Cao Y, Liao J, Lu Y, Su Q, Lin S, Ma X, Zhong C. A juvenile mouse model of anti-N-methyl-D-aspartate receptor encephalitis by active immunization. Front Mol Neurosci 2023; 16:1211119. [PMID: 37790883 PMCID: PMC10544982 DOI: 10.3389/fnmol.2023.1211119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/25/2023] [Indexed: 10/05/2023] Open
Abstract
Introduction Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a common autoimmune encephalitis, and it is associated with psychosis, dyskinesia, and seizures. Anti-NMDAR encephalitis (NMDARE) in juveniles and adults presents different clinical charactreistics. However, the pathogenesis of juvenile anti-NMDAR encephalitis remains unclear, partly because of a lack of suitable animal models. Methods We developed a model of juvenile anti-NMDAR encephalitis using active immunization with an amino terminal domain peptide from the GluN1 subunit (GluN1356 - 385) against NMDARs in 3-week-old female C57BL/6J mice. Results Immunofluorescence staining suggested that autoantibody levels in the hippocampus increased, and HEK-293T cells staining identified the target of the autoantibodies as GluN1, suggesting that GluN1-specific immunoglobulin G was successfully induced. Behavior assessment showed that the mice suffered significant cognition impairment and sociability reduction, which is similar to what is observed in patients affected by anti-NMDAR encephalitis. The mice also exhibited impaired long-term potentiation in hippocampal CA1. Pilocarpine-induced epilepsy was more severe and had a longer duration, while no spontaneous seizures were observed. Conclusion The juvenile mouse model for anti-NMDAR encephalitis is of great importance to investigate the pathological mechanism and therapeutic strategies for the disease, and could accelerate the study of autoimmune encephalitis.
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Affiliation(s)
- Shuyu He
- Shenzhen Key Laboratory of Precision Diagnosis and Treatment of Depression, CAS Key Laboratory of Brain Connectome and Manipulation, The Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institution, Shenzhen, China
- Department of Clinical Research, Department of Neurology, Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, China
- Shenzhen Children's Hospital of China Medical University, Shenzhen, China
| | - Chongyang Sun
- Shenzhen Key Laboratory of Precision Diagnosis and Treatment of Depression, CAS Key Laboratory of Brain Connectome and Manipulation, The Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institution, Shenzhen, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Qian Zhu
- Shenzhen Key Laboratory of Precision Diagnosis and Treatment of Depression, CAS Key Laboratory of Brain Connectome and Manipulation, The Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institution, Shenzhen, China
- Department of Clinical Research, Department of Neurology, Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, China
| | - Lin Li
- Department of Clinical Research, Department of Neurology, Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, China
| | - Jianyu Huang
- Shenzhen Key Laboratory of Precision Diagnosis and Treatment of Depression, CAS Key Laboratory of Brain Connectome and Manipulation, The Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institution, Shenzhen, China
| | - Ge Wu
- Shenzhen Key Laboratory of Precision Diagnosis and Treatment of Depression, CAS Key Laboratory of Brain Connectome and Manipulation, The Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institution, Shenzhen, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Yi Cao
- Shenzhen Key Laboratory of Precision Diagnosis and Treatment of Depression, CAS Key Laboratory of Brain Connectome and Manipulation, The Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institution, Shenzhen, China
| | - Jianxiang Liao
- Department of Clinical Research, Department of Neurology, Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, China
| | - Yi Lu
- Shenzhen Key Laboratory of Precision Diagnosis and Treatment of Depression, CAS Key Laboratory of Brain Connectome and Manipulation, The Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institution, Shenzhen, China
| | - Qiru Su
- Department of Clinical Research, Department of Neurology, Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, China
| | - Sufang Lin
- Department of Clinical Research, Department of Neurology, Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, China
| | - Xiaopeng Ma
- Department of Clinical Research, Department of Neurology, Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, China
| | - Cheng Zhong
- Shenzhen Key Laboratory of Precision Diagnosis and Treatment of Depression, CAS Key Laboratory of Brain Connectome and Manipulation, The Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institution, Shenzhen, China
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11
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Lin J, Wang J, Li J. Patient characteristics and outcome in patients with anti-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) encephalitis. Neurol Sci 2023; 44:3253-3259. [PMID: 37010671 DOI: 10.1007/s10072-023-06769-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 03/21/2023] [Indexed: 04/04/2023]
Abstract
OBJECTIVE Anti-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) encephalitis is a rare subtype of autoimmune encephalitis. We report patients diagnosed with anti-AMPAR encephalitis in western China, focusing on their clinical presentations, imaging results, treatment strategies, and prognosis. METHODS Data from patients diagnosed with anti-AMPAR encephalitis in the neurology center of West China Hospital from August 2018 to July 2021 were retrospectively collected and analyzed. Based on the diagnostic criteria of autoimmune encephalitis, nine cases were included. RESULTS Four patients (44%) were males, and the median age at presentation was 54 years (range, 25-85). Short-term memory loss was the most common initial symptom. Additional types of autoantibodies were identified in three patients. After presentation, four patients were found to have tumors: two with small cell lung cancer, one with ovarian teratoma, and one with thymoma. All patients accepted first-line immune therapy, and follow-up was available from 8 patients (median 20 weeks, range 4-78). At the last follow-up, three patients showed good outcomes (modified Rankin scale [mRS] 0-2; 37.5%). Five patients showed poor outcomes (mRS 3-6; 62.5%): two had minimal changes and remained hospitalized, two had residual severe cognitive impairments, and one patient died during follow-up. Outcomes were worse among patients with tumors. Finally, only one patient experienced relapse during follow-up. CONCLUSION Anti-AMPAR encephalitis should be considered in the differential diagnosis for middle- and senior-aged patients who present with predominantly acute or subacute short-term memory impairment. The long-term prognosis is correlated with the presence of a tumor.
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Affiliation(s)
- Jingfang Lin
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, China
| | - Jierui Wang
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, China
| | - Jinmei Li
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, China.
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Braczkowski M, Soszyński D, Sierakowska A, Braczkowski R, Kufel K, Łabuz-Roszak B. Autoimmune Encephalitis with Antibodies: Anti-NMDAR, Anti-AMPAR, Anti-GQ1b, Anti-DPPX, Anti-CASPR2, Anti-LGI1, Anti-RI, Anti-Yo, Anti-Hu, Anti-CV2 and Anti-GABAAR, in the Course of Psychoses, Neoplastic Diseases, and Paraneoplastic Syndromes. Diagnostics (Basel) 2023; 13:2589. [PMID: 37568953 PMCID: PMC10417199 DOI: 10.3390/diagnostics13152589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/25/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023] Open
Abstract
Encephalitis is a condition with a variety of etiologies, clinical presentations, and degrees of severity. The causes of these disorders include both neuroinfections and autoimmune diseases in which host antibodies are pathologically directed against self-antigens. In autoimmune encephalitis, autoantibodies are expressed in the central nervous system. The incidence of this disease is approximately 4% of all reported cases of encephalitis. Autoimmune encephalitis can be induced by antibodies against neuronal surface antigens such as N-methyl-D-aspartate-activated glutamate receptors (NMDAR), α-amino-3-hydroxy-5-methyl-4-isoxazole propionate receptors (AMPAR) or gangliosides GQ1b, DPPX, CASPR2, LGI1, as well as by antibodies against neuronal intracellular antigens. The paper presents a number of both mental and neurological symptoms of autoimmune encephalitis. Moreover, the coexistence of psychoses, neoplastic diseases, and the methods of diagnosing autoimmune encephalitis are discussed. Attention was also drawn to the fact that early diagnosis, as well as early initiation of targeted treatment, increases the chance of a successful course of the therapeutic process. Strategy and Methodology: The articles on which the following paper was based were searched using search engines such as PubMed and Medline. Considering that anti-NMDAR antibodies were first described in 2007, the articles were from 2007 to 2023. The selection of papers was made by entering the phrases "autoimmune encephalitis and psychosis/paraneplastic syndromes or cancer". The total number of articles that could be searched was 747, of which 100 items were selected, the most recent reports illustrating the presented topic. Thirty-four of them were rejected in connection with case reports or papers that could not be accessed.
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Affiliation(s)
- Michał Braczkowski
- Department of Physiology, Institute of Medical Sciences, University of Opole, 45040 Opole, Poland
| | - Dariusz Soszyński
- Department of Physiology, Institute of Medical Sciences, University of Opole, 45040 Opole, Poland
- Department of Human Physiology, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, 87100 Torun, Poland
| | - Alicja Sierakowska
- Student Scientific Society of Physiology, Department of Physiology, Institute of Medical Sciences, University of Opole, 45040 Opole, Poland; (A.S.)
- Student Association of Neurology, Department of Neurology, Institute of Medical Sciences, University of Opole, 45040 Opole, Poland
| | | | - Klaudia Kufel
- Student Scientific Society of Physiology, Department of Physiology, Institute of Medical Sciences, University of Opole, 45040 Opole, Poland; (A.S.)
| | - Beata Łabuz-Roszak
- Department of Neurology, Institute of Medical Sciences, University of Opole, 45040 Opole, Poland
- Department of Neurology, ST Jadwiga Regional Specialized Hospital, 45040 Opole, Poland
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13
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Song W, Li K, Li J, Liu X, Wu X, Xu X, Xiong K, Chen X, Zhang Y. Thymoma-associated autoimmune encephalitis: Analysis of factors determining prognosis. CNS Neurosci Ther 2023; 29:1213-1221. [PMID: 36914970 PMCID: PMC10068466 DOI: 10.1111/cns.14166] [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: 07/21/2022] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 03/16/2023] Open
Abstract
INTRODUCTION Autoimmune encephalitis (AE) is a heterogeneous group of inflammatory central nervous system disorders caused by a misdirected immune response against self-antigens expressed in the central nervous system. The thymus is a central organ in the immune system and thymic tumors are thought to be possible initiators of many neurological disorders. Recently, there is growing evidence that thymomas are associated with autoimmune encephalitis. AIMS Our study initially explored the characteristics of patients with autoimmune encephalitis combined with thymoma. METHODS We used patient data from January 1, 2011 to October 1, 2021 from the PubMed, Web of Science, Ovid, and CNKI platforms to analyze overall demographics, frequency of symptoms and associations, and treatment prognosis outcomes. RESULTS A total of 68 patients were included. There were 39 female cases (57.4%). The mean age was 50 years (IQR 40-66 years). All had acute and subacute onset. The clinical manifestations were mostly cognitive changes (70.6%), mental disorders (57.4%), and epilepsy (50.0%). The most common neuronal antibody was alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA). Magnetic resonance imaging (MRI) abnormalities were present in 81.0% of patients, mostly in the hippocampus, temporal lobe, and some in cortical and subcortical areas. Abnormalities in the electroencephalogram (EEG) in 69.8% of patients. Treatment involved immunotherapy and thymoma treatment, with 79.7% of patients improving after treatment. While 20.3% of patients had a poor prognosis. Further, 14.8% of patients relapsed. Mental disorders, autonomic dysfunction, sleep disturbances, anti-Ma2, and thymoma untreated were more frequent in patients with poor prognosis. CONCLUSION Thymoma-associated autoimmune encephalitis is a unique disease entity. Long-term follow-up of chest CT findings is recommended for patients with autoimmune encephalitis.
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Affiliation(s)
- Wenli Song
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Keru Li
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiao Li
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoni Liu
- Department of Neurology, Huashan Hospital and Institute of Neurology, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Fudan University, Shanghai, China
| | - Xiaoke Wu
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaodong Xu
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Kangping Xiong
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiangjun Chen
- Department of Neurology, Huashan Hospital and Institute of Neurology, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Fudan University, Shanghai, China.,Human Phenome Institute, Fudan University, Shanghai, China
| | - Yanlin Zhang
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
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Li KR, Wu AG, Tang Y, He XP, Yu CL, Wu JM, Hu GQ, Yu L. The Key Role of Magnetic Resonance Imaging in the Detection of Neurodegenerative Diseases-Associated Biomarkers: A Review. Mol Neurobiol 2022; 59:5935-5954. [PMID: 35829831 DOI: 10.1007/s12035-022-02944-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 06/28/2022] [Indexed: 11/30/2022]
Abstract
Neurodegenerative diseases (NDs), including chronic disease such as Alzheimer's disease, Parkinson's disease, Huntington's disease, and multiple sclerosis, and acute diseases like traumatic brain injury and ischemic stroke are characterized by progressive degeneration, brain tissue damage and loss of neurons, accompanied by behavioral and cognitive dysfunctions. So far, there are no complete cures for NDs; thus, early and timely diagnoses are essential and beneficial to patients' treatment. Magnetic resonance imaging (MRI) has become one of the advanced medical imaging techniques widely used in the clinical examination of NDs due to its non-invasive diagnostic value. In this review, research published in English in current decade from PubMed electronic database on the use of MRI to detect specific biomarkers of NDs was collected, summarized, and discussed, which provides valuable suggestions for the early diagnosis, prevention, and treatment of NDs in the clinic.
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Affiliation(s)
- Ke-Ru Li
- Department of Human Anatomy, School of Preclinical Medicine, Southwest Medical University, Luzhou, 646000, Sichuan, China
- Sichuan Key Medical Laboratory of New Drug Discovery and Druggability Evaluation, Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica, Southwest Medical University, Luzhou, 646000, China
- Department of Radiology, Chongqing University Fuling Hospital, Chongqing, 408000, China
| | - An-Guo Wu
- Sichuan Key Medical Laboratory of New Drug Discovery and Druggability Evaluation, Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica, Southwest Medical University, Luzhou, 646000, China
- School of Pharmacy, Southwest Medical University, Luzhou, 646000, China
| | - Yong Tang
- Sichuan Key Medical Laboratory of New Drug Discovery and Druggability Evaluation, Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica, Southwest Medical University, Luzhou, 646000, China
| | - Xiao-Peng He
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, the Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Chong-Lin Yu
- Department of Human Anatomy, School of Preclinical Medicine, Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Jian-Ming Wu
- Sichuan Key Medical Laboratory of New Drug Discovery and Druggability Evaluation, Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica, Southwest Medical University, Luzhou, 646000, China
- School of Pharmacy, Southwest Medical University, Luzhou, 646000, China
| | - Guang-Qiang Hu
- Department of Human Anatomy, School of Preclinical Medicine, Southwest Medical University, Luzhou, 646000, Sichuan, China.
| | - Lu Yu
- Sichuan Key Medical Laboratory of New Drug Discovery and Druggability Evaluation, Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica, Southwest Medical University, Luzhou, 646000, China.
- School of Pharmacy, Southwest Medical University, Luzhou, 646000, China.
- Department of Chemistry, School of Preclinical Medicine, Southwest Medical University, Luzhou, 646000, Sichuan, China.
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15
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Abstract
PURPOSE OF REVIEW Autoimmune encephalitis (AE) refers to immune-mediated neurological syndromes often characterised by the detection of pathogenic autoantibodies in serum and/or cerebrospinal fluid which target extracellular epitopes of neuroglial antigens. There is increasing evidence these autoantibodies directly modulate function of their antigens in vivo. Early treatment with immunotherapy improves outcomes. Yet, these patients commonly exhibit chronic disability. Importantly, optimal therapeutic strategies at onset and during escalation remain poorly understood. In this review of a rapidly emerging field, we evaluate recent studies on larger cohorts, registries, and meta-analyses to highlight existing evidence for contemporary therapeutic approaches in AE. RECENT FINDINGS We highlight acute and long-term treatments used in specific AE syndromes, exemplify how understanding disease pathogenesis can inform precision therapy and outline challenges of defining disability outcomes in AE. SUMMARY Early first-line immunotherapies, including corticosteroids and plasma exchange, improve outcomes, with emerging evidence showing second-line immunotherapies (especially rituximab) reduce relapse rates. Optimal timing of immunotherapy escalation remains unclear. Routine reporting of outcome measures which incorporate cognitive impairment, fatigue, pain, and mental health will permit more accurate quantification of residual disability and comprehensive comparisons between international multicentre cohorts, and enable future meta-analyses with the aim of developing evidence-based therapeutic guidelines.
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Affiliation(s)
- Benjamin P Trewin
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead; Sydney Medical School and Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Isaak Freeman
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Sudarshini Ramanathan
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead; Sydney Medical School and Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Neurology, Concord Hospital, Sydney, Australia
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
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Han W, Ma J, Jiang L, Cheng M. Fulminant anti-α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor GluR1 antibodies encephalitis in a Chinese boy: a case report. BMC Pediatr 2022; 22:287. [PMID: 35581601 PMCID: PMC9110937 DOI: 10.1186/s12887-022-03356-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 05/11/2022] [Indexed: 11/22/2022] Open
Abstract
Background Anti-α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) encephalitis is a rare autoimmune synaptic encephalitis associated with autoantibodies that cause a selective decrease in surface expression and changes in receptor localization. Anti-AMPAR encephalitis is poorly recognized, especially in children, and its clinical phenotype is incompletely described. Case presentation We report a case of anti-AMPAR GluR1 antibody-mediated autoimmune encephalitis in a 12-year-old male. The patient manifested as a fulminant course, with ataxia, cerebellar degeneration at the onset, and rapidly evolved into hyperthermia, coma and rhabdomyolysis. Antibodies against AMPAR GluR1 receptors were detected in the cerebrospinal fluid by cell-based assay. Diffuse slow waves were found by electroencephalograph, and the left cerebellar vermis and hemisphere were affected on brain magnetic resonance imaging (MRI). The patient was treated with intravenous immunoglobulin (IVIG), methylprednisolone combined with plasma exchange. Symptoms were alleviated after immunotherapy and the patient sustained clinical improvement. This is the first time that acute rhabdomyolysis symptom has been identified in a pediatric patient with anti-AMPAR encephalitis. Conclusions This case expands the clinical spectrum of anti-AMPAR encephalitis and highlights that despite poor clinical manifestation at the outset, recovery remains possible. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03356-5.
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Affiliation(s)
- Wei Han
- Department of Neurology Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, No.136 Zhongshan 2nd Road, Chongqing, 400014, China
| | - Jiannan Ma
- Department of Neurology Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, No.136 Zhongshan 2nd Road, Chongqing, 400014, China
| | - Li Jiang
- Department of Neurology Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, No.136 Zhongshan 2nd Road, Chongqing, 400014, China
| | - Min Cheng
- Department of Neurology Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, No.136 Zhongshan 2nd Road, Chongqing, 400014, China.
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Yang J, Wu P, Liu X, Xia H, Lai Z. Autoimmune Encephalitis With Multiple Auto-Antibodies With Concomitant Human Herpesvirus-7 and Ovarian Teratoma: A Case Report. Front Med (Lausanne) 2022; 8:759559. [PMID: 35237615 PMCID: PMC8882612 DOI: 10.3389/fmed.2021.759559] [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: 08/16/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Abstract
Infectious etiologies and tumors are common triggers of autoimmune encephalitis. We herein reported a rare case of autoimmune encephalitis with multiple autoantibodies in cerebrospinal fluid (CSF) and serum, with concomitant human herpesvirus 7 (HHV-7) infection and ovarian teratoma. A 36-year-old woman presented with mental and behavioral changes and gibberish for 13 days, followed by fever for 1 day. Her brain MRI indicated limbic encephalitis. Metagenomic next-generation sequencing (mNGS) of CSF revealed HHV-7. Antibody testing showed positive anti-N-methyl-D-aspartate receptor (NMDAR) and anti-α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) antibodies in CSF and serum. Ovarian teratoma was considered after pelvic MRI, which was then pathologically confirmed after laparoscopic ovariectomy. Her conditions improved after laparoscopic surgery, intravenous steroids, immunoglobulin, and rituximab therapy. Our findings suggested that the combination of multiple therapies including antiviral, immunotherapy, and resection of tumors were appropriate and improved the prognosis, when HHV-7 infection and ovarian teratoma were concomitant with multiple anti-neuronal antibodies of autoimmune encephalitis.
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Affiliation(s)
- Jianhua Yang
- Department of Neurology, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
| | - Pengcheng Wu
- Department of Neurology, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
| | - Xianghong Liu
- Department of Neurology, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
| | - Han Xia
- Department of Scientific Affairs, Hugobiotech Co., Ltd., Beijing, China
| | - Zhaohui Lai
- Department of Neurology, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
- *Correspondence: Zhaohui Lai
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Baudin P, Cousyn L, Navarro V. The LGI1 protein: molecular structure, physiological functions and disruption-related seizures. Cell Mol Life Sci 2021; 79:16. [PMID: 34967933 PMCID: PMC11072701 DOI: 10.1007/s00018-021-04088-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 01/16/2023]
Abstract
Leucine-rich, glioma inactivated 1 (LGI1) is a secreted glycoprotein, mainly expressed in the brain, and involved in central nervous system development and physiology. Mutations of LGI1 have been linked to autosomal dominant lateral temporal lobe epilepsy (ADLTE). Recently auto-antibodies against LGI1 have been described as the basis for an autoimmune encephalitis, associated with specific motor and limbic epileptic seizures. It is the second most common cause of autoimmune encephalitis. This review presents details on the molecular structure, expression and physiological functions of LGI1, and examines how their disruption underlies human pathologies. Knock-down of LGI1 in rodents reveals that this protein is necessary for normal brain development. In mature brains, LGI1 is associated with Kv1 channels and AMPA receptors, via domain-specific interaction with membrane anchoring proteins and contributes to regulation of the expression and function of these channels. Loss of function, due to mutations or autoantibodies, of this key protein in the control of neuronal activity is a common feature in the genesis of epileptic seizures in ADLTE and anti-LGI1 autoimmune encephalitis.
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Affiliation(s)
- Paul Baudin
- Sorbonne Université, Paris Brain Institute - Institut du Cerveau, ICM, INSERM, CNRS, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Louis Cousyn
- Sorbonne Université, Paris Brain Institute - Institut du Cerveau, ICM, INSERM, CNRS, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
- AP-HP, Epilepsy Unit, Pitié-Salpêtrière Hospital, DMU Neurosciences, Paris, France
| | - Vincent Navarro
- Sorbonne Université, Paris Brain Institute - Institut du Cerveau, ICM, INSERM, CNRS, AP-HP, Pitié-Salpêtrière Hospital, Paris, France.
- AP-HP, Epilepsy Unit, Pitié-Salpêtrière Hospital, DMU Neurosciences, Paris, France.
- AP-HP, Center of Reference for Rare Epilepsies, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.
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Hansen N, Krasiuk I, Titsch T. Neural autoantibodies in delirium. J Autoimmun 2021; 125:102740. [PMID: 34757245 DOI: 10.1016/j.jaut.2021.102740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Delirium in hospitalized and intensive care unit patients is an emerging condition due to its rapid-onset requiring fast action to mitigate a worse clinical outcome. Although several causes and conditions are known, the association between delirium and neural autoantibodies has often been neglected in cohort studies and reviews as causing delirium. The aim of our review is to delineate the occurrence and type of neural autoantibodies and to depict other biological markers of autoimmunity in relationship to delirium. METHODS For this narrative review Pubmed research was done to select articles about delirium and neural autoantibodies. RESULTS We can report on several cell-surface autoantibodies such as anti-α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors, anti-contactin associated protein 2, anti-Leucin rich glioma inactivated protein 1, anti-dipeptidyl-peptidase-like 6 protein, anti-glycine receptor and anti-myelin autoantibodies, as well as intracellular autoantibodies such as anti-glutamic acid decarboxylase 65 (GAD65), anti-CV2 and anti-Hu associated with delirium in patients. Our case reports and case series screening revealed that 20 of 63 patients with delirium presented neural autoantibodies, thus revealing a 32% frequency of autoantibody-associated delirium in delirium patients. Our main finding is that delirium's hyperactive form is associated with neural autoantibodies. Diagnosing delirium differentially is difficult, as in patients with delirium and GAD65 autoantibodies, as it must be distinguished from other psychopathological excitation states such as mania. We also describe autoimmune delirium's potential pathophysiologic pathways. CONCLUSIONS The existence of neural autoantibodies in delirious patients is scientifically and clinically highly relevant in its diagnosis, therapy, and pathogenesis. More large-scale studies should be conducted to evaluate their significance and prevalence in delirium.
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Affiliation(s)
- Niels Hansen
- Department of Psychiatry and Psychotherapy, University of Goettingen, Von-Siebold-Str. 5, 37075, Goettingen, Germany; Autoimmunity and Translational Neuropsychiatry, University of Goettingen, Von-Siebold-Str. 5, 37075, Goettingen, Germany.
| | - Iryna Krasiuk
- Department of Psychiatry and Psychotherapy, University of Goettingen, Von-Siebold-Str. 5, 37075, Goettingen, Germany; Autoimmunity and Translational Neuropsychiatry, University of Goettingen, Von-Siebold-Str. 5, 37075, Goettingen, Germany
| | - Tobias Titsch
- Department of Psychiatry and Psychotherapy, University of Goettingen, Von-Siebold-Str. 5, 37075, Goettingen, Germany; Autoimmunity and Translational Neuropsychiatry, University of Goettingen, Von-Siebold-Str. 5, 37075, Goettingen, Germany
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