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Morishima Y, Hata T, Nakajima S, Shindo K, Tsuchiya M, Watanabe T, Tahara I, Kondo T, Kimura A, Shimohata T, Ueno Y. Case report: Atypical case of autoimmune glial fibrillary acidic protein astrocytopathy following COVID-19 vaccination refractory to immunosuppressive treatments. Front Immunol 2024; 15:1361685. [PMID: 38665914 PMCID: PMC11043467 DOI: 10.3389/fimmu.2024.1361685] [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: 12/26/2023] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
A 54-year-old Japanese man presented with headache and fever the day after SARS-CoV-2 vaccination. He became deeply unconscious within a week. Brain MRI showed periventricular linear enhancements and a few spotty lesions in the cerebral white matter. Cerebrospinal fluid (CSF) testing showed mild pleocytosis. He was treated with intravenous methylprednisolone and plasma exchange. However, the white matter lesions enlarged to involve the brainstem and cerebellum, and long cord spinal lesions appeared. Anti-glial fibrillary acidic protein (GFAP) antibody was positive in the CSF and serum, and he was therefore diagnosed as autoimmune GFAP-astrocytopathy (GFAP-A). In addition, high-dose immunoglobulin therapy was administered twice, but his symptoms did not improve; the white matter lesions enlarged further, and modified Rankin Scale score increased to 5. A brain biopsy specimen showed infiltration of macrophages and CD4 + lymphocytes together with neuron and oligodendrocytic injuries and glial scar. Although GFAP-A generally responds well to steroids, the present case developed GFAP-A following SARS-CoV-2 vaccination, with refractory to intensive immunosuppressive therapy and atypical pathologic findings of infiltration of CD4 + lymphocytes and demyelination.
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Affiliation(s)
- Yuto Morishima
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | - Takanori Hata
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | - Sho Nakajima
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | - Kazumasa Shindo
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | - Mai Tsuchiya
- Department of Neurology, University of Yamanashi, Chuo, Japan
| | | | - Ippei Tahara
- Department of Pathology, University of Yamanashi, Chuo, Japan
| | - Tetsuo Kondo
- Department of Pathology, University of Yamanashi, Chuo, Japan
| | - Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yuji Ueno
- Department of Neurology, University of Yamanashi, Chuo, Japan
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Kimura A. [Clinical features and pathogenesis of Glial fibrillary acidic protein (GFAP) antibody-associated disorders]. Rinsho Shinkeigaku 2024; 64:75-84. [PMID: 38281748 DOI: 10.5692/clinicalneurol.cn-001925] [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: 01/30/2024]
Abstract
Glial fibrillary acidic protein (GFAP) antibody-associated disorders (AD) were recently proposed to be immune-mediated neurological disorders. The pathogenesis of GFAP antibody-AD is poorly understood. Pathologically, there is a marked infiltration of large numbers of lymphocytes, including CD8+ and CD4+ T cells, into the meningeal and brain parenchyma, especially around the perivascular areas. GFAP-specific cytotoxic T cells are considered to be the effector cells of GFAP antibody-AD. The common phenotype of GFAP antibody-AD includes meningoencephalitis with or without myelitis. During the clinical disease course, patients present with consciousness disturbances, urinary dysfunction, movement disorders, meningeal irritation, and cognitive dysfunction. The detection of GFAP antibodies in the cerebrospinal fluid (CSF) by cell-based assay is essential for a diagnosis of GFAP antibody-AD. The CSF can be examined for lymphocyte-predominant pleocytosis and elevated protein levels. Brain linear perivascular radial enhancement patterns are observed in about half of GFAP antibody-AD patients. Spinal cord magnetic resonance imaging is used to detect longitudinal extensive spinal cord lesions. Although corticosteroid therapy is generally effective, some patients have a poor prognosis and relapse.
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Affiliation(s)
- Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine
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Guo Y, Endmayr V, Zekeridou A, McKeon A, Leypoldt F, Hess K, Kalinowska-Lyszczarz A, Klang A, Pakozdy A, Höftberger E, Hametner S, Haider C, De Simoni D, Peters S, Gelpi E, Röcken C, Oberndorfer S, Lassmann H, Lucchinetti CF, Höftberger R. New insights into neuropathology and pathogenesis of autoimmune glial fibrillary acidic protein meningoencephalomyelitis. Acta Neuropathol 2024; 147:31. [PMID: 38310187 PMCID: PMC10838242 DOI: 10.1007/s00401-023-02678-7] [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: 09/05/2023] [Revised: 12/06/2023] [Accepted: 12/24/2023] [Indexed: 02/05/2024]
Abstract
Anti-glial fibrillary acidic protein (GFAP) meningoencephalomyelitis (autoimmune GFAP astrocytopathy) is a new autoimmune central nervous system (CNS) disease diagnosable by the presence of anti-GFAP autoantibodies in the cerebrospinal fluid and presents as meningoencephalomyelitis in the majority of patients. Only few neuropathological reports are available and little is known about the pathogenic mechanisms. We performed a histopathological study of two autopsies and nine CNS biopsies of patients with anti-GFAP autoantibodies and found predominantly a lymphocytic and in one autopsy case a granulomatous inflammatory phenotype. Inflammatory infiltrates were composed of B and T cells, including tissue-resident memory T cells. Although obvious astrocytic damage was absent in the GFAP-staining, we found cytotoxic T cell-mediated reactions reflected by the presence of CD8+/perforin+/granzyme A/B+ cells, polarized towards astrocytes. MHC-class-I was upregulated in reactive astrocytes of all biopsies and two autopsies but not in healthy controls. Importantly, we observed a prominent immunoreactivity of astrocytes with the complement factor C4d. Finally, we provided insight into an early phase of GFAP autoimmunity in an autopsy of a pug dog encephalitis that was characterized by marked meningoencephalitis with selective astrocytic damage with loss of GFAP and AQP4 in the lesions.Our histopathological findings indicate that a cytotoxic T cell-mediated immune reaction is present in GFAP autoimmunity. Complement C4d deposition on astrocytes could either represent the cause or consequence of astrocytic reactivity. Selective astrocytic damage is prominent in the early phase of GFAP autoimmunity in a canine autopsy case, but mild or absent in subacute and chronic stages in human disease, probably due to the high regeneration potential of astrocytes. The lymphocytic and granulomatous phenotypes might reflect different stages of lesion development or patient-specific modifications of the immune response. Future studies will be necessary to investigate possible implications of pathological subtypes for clinical disease course and therapeutic strategies.
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Affiliation(s)
- Yong Guo
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Verena Endmayr
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
- Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
- Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Frank Leypoldt
- Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein Kiel, Lübeck, Germany
- Department of Neurology, University Medical Center Schleswig-Holstein and Kiel University, Kiel, Germany
| | - Katharina Hess
- Institute of Neuropathology, University Hospital Muenster, Muenster, North Rhine Westphalia, Germany
- Department of Pathology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Alicja Kalinowska-Lyszczarz
- Department of Neurology, Division of Neurochemistry and Neuropathology, Poznan University of Medical Sciences, Poznań, Poland
| | - Andrea Klang
- Institute of Pathology, University of Veterinary Medicine, Vienna, Austria
| | - Akos Pakozdy
- Internal Medicine, University Clinic for Small Animals, University of Veterinary Medicine, Vienna, Austria
| | - Elisabeth Höftberger
- Internal Medicine, University Clinic for Small Animals, University of Veterinary Medicine, Vienna, Austria
| | - Simon Hametner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Carmen Haider
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Désirée De Simoni
- Division of Neurology, Karl Landsteiner University of Health Sciences, University Hospital, St. Pölten, Austria
| | - Sönke Peters
- Clinic for Radiology and Neuroradiology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Ellen Gelpi
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christoph Röcken
- Department of Pathology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Stefan Oberndorfer
- Division of Neurology, Karl Landsteiner University of Health Sciences, University Hospital, St. Pölten, Austria
| | - Hans Lassmann
- Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | | | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Budhram A, Flanagan EP. Optimizing the diagnostic performance of neural antibody testing for paraneoplastic and autoimmune encephalitis in clinical practice. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:365-382. [PMID: 38494290 DOI: 10.1016/b978-0-12-823912-4.00002-5] [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
The detection of neural antibodies in patients with paraneoplastic and autoimmune encephalitis has majorly advanced the diagnosis and management of neural antibody-associated diseases. Although testing for these antibodies has historically been restricted to specialized centers, assay commercialization has made this testing available to clinical chemistry laboratories worldwide. This improved test accessibility has led to reduced turnaround time and expedited diagnosis, which are beneficial to patient care. However, as the utilization of these assays has increased, so too has the need to evaluate how they perform in the clinical setting. In this chapter, we discuss assays for neural antibody detection that are in routine use, draw attention to their limitations and provide strategies to help clinicians and laboratorians overcome them, all with the aim of optimizing neural antibody testing for paraneoplastic and autoimmune encephalitis in clinical practice.
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Affiliation(s)
- Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, ON, Canada; Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada.
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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Lowe MC, Money KM, Matthews E, Pastula DM, Piquet AL. case of autoimmune GFAP astrocytopathy with eosinophils in the cerebrospinal fluid. J Neuroimmunol 2023; 385:578249. [PMID: 37992587 DOI: 10.1016/j.jneuroim.2023.578249] [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: 09/29/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 11/24/2023]
Abstract
Cerebrospinal fluid (CSF) eosinophilia is associated with a narrow differential, primarily including parasitic and fungal infections, neoplasm, and chemical meningitis. It has rarely been reported in neuroinflammatory conditions including as a finding of CSF cytology in two autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy cases. Here we describe a case of autoimmune GFAP astrocytopathy with classic clinical and radiographic features as well as presence of eosinophils in the CSF. This case highlights a potential association of eosinophils in the CSF with autoimmune GFAP astrocytopathy, which may suggest its inclusion in the differential diagnosis of eosinophilic meningitis, encephalitis, or myelitis.
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Affiliation(s)
- Mallory C Lowe
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Kelli M Money
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Elizabeth Matthews
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Daniel M Pastula
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States of America; Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, United States of America; Department of Epidemiology, Colorado School of Public Health, Aurora, CO, United States of America
| | - Amanda L Piquet
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States of America.
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Yue J, Lin P, Lian C, Yao H, Jiang L, Liao S, Xu L, Zhang J, Tan J, Chen Z, Yang J, Gao C, Huang L, Yang X, Long Y. Brain radial enhancement pattern in patients with negative glial fibrillary acidic protein-IgG: A cases series study. J Neurol Sci 2023; 453:120782. [PMID: 37683309 DOI: 10.1016/j.jns.2023.120782] [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: 07/18/2023] [Revised: 08/27/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Brain radial enhancement pattern on magnetic resonance imaging (MRI) has been identified as typical lesions in autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A). However, the authors encountered several patients without GFAP-IgG showing that such specific imaging. In the present study, we reported the clinical pictures of 5 GFAP-IgG-negative patients with GFAP-A specific imaging pattern. METHODS Data was retrospectively obtained from June 2013 through April 2023, and five GFAP-IgG-negative patients with valid data were recruited. Clinical information was either obtained by the investigators or retrieved from the referring clinicians and included prodromal symptoms, neurologic manifestations, comorbidities, results of ancillary studies. RESULTS Altogether five GFAP-IgG-negative patients with "meningoencephalitis/encephalitis" manifestations and brain radial perivascular enhancement were confirmed. One patient had peripheral lymphoma. Four patients had other autoimmune antibody in serum and/or cerebrospinal fluid, of which one patient had positive aquaporin IgG. Clinical features of the five patients included headache, fever, epilepsy and abnormal behavioral symptoms. MRI of patients revealed radial perivascular gadolinium enhancement extending from the lateral ventricles to the white matter suggestive of autoimmune GFAP-A. CONCLUSION GFAP-A-like disorders with radial perivascular enhancement could be found in GFAP-IgG-negative patients with or without neoplasm, which could provide new insight into the differential diagnosis of GFAP-A.
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Affiliation(s)
- Jiajia Yue
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Peihao Lin
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Chun Lian
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Haiyan Yao
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Lihong Jiang
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Sha Liao
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Lufen Xu
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Jiayuan Zhang
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Jie Tan
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Zixuan Chen
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Jie Yang
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Cong Gao
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Li Huang
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China
| | - Xinguang Yang
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Sun Yat-sen Memorial Hospital, the Second Affiliated Hospital of Sun Yat-sen University, 107#Yan Jiang West Road, Guangzhou, China
| | - Youming Long
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and The Ministry of Education of China, Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, 250# Changgang east Road, Guangzhou, 510260, Guangdong Province, China.
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Wang S, Yuan J, Liu J. Autoimmune Glial Fibrillary Acidic Protein (Gfap) Astrocytopa-Thy Accompanied with Reversible Splenial Lesion Syndrome (RESLES): A Case Report and Literature Review. Brain Sci 2023; 13:brainsci13040659. [PMID: 37190624 DOI: 10.3390/brainsci13040659] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 03/21/2023] [Accepted: 03/31/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy usually presents as meningoencephalomyelitis. Many patients developed flu-like symptoms preceding the neurologic symptoms. Reversible lesion in the splenium of the corpus callosum (SCC) is a clinical and radiological syndrome secondary to many kinds of etiologies, including infections, which is termed RESLES. CASE PRESENTATION we reported a case developing irregularly high fever, both temporal pain, low limbs fatigue with frequent urination admitted to our neurology department. CSF test showed GFAP-IgG positive, elevated WBC counts and protein, with low glucose and chlorine, while MRI showed a reversible lesion on SCC, leading us to diagnose autoimmune GFAP autocytopathy accompanied with RESLES. The boy had significantly improved after anti-virus and steroids therapy. DISCUSSION Autoimmune GFAP autocytopathy accompanied with RESLES is rarely seen, and pathogenesis for the co-existence has not been clarified. Autoimmune GFAP autocytopathy and RESLES are both related to viral infection. Our case covered infectious symptoms and improved after antiviral treatment, suggesting virus infection may perform a key role in pathogenesis.
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Affiliation(s)
- Siting Wang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Jianlan Yuan
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Jingli Liu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
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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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Liu L, Fang B, Qiao Z, Di X, Ma Q, Zhang J, Wang J. Clinical Manifestation, Auxiliary Examination Features, and Prognosis of GFAP Autoimmunity: A Chinese Cohort Study. Brain Sci 2022; 12:brainsci12121662. [PMID: 36552122 PMCID: PMC9775969 DOI: 10.3390/brainsci12121662] [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: 09/04/2022] [Revised: 11/16/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE This paper reports the clinical manifestation and auxiliary examination features of 15 Chinese patients with glial fibrillary acidic protein (GFAP) autoimmunity. METHODS From June 2016 to December 2019, patients suspected to have neurological autoimmune disease after having their serum and cerebrospinal fluid (CSF) tested for conventional neural antibodies were scanned for additional autoantibodies by immunohistochemistry. Samples that showed a characteristic immunoreactive pattern reminiscent of the GFAP of astrocytes were selected and confirmed by cell-based assay using cells-expressing human GFAPα. RESULTS A total of 15 patients (eight male and seven female) with a median age at onset of 53 years (range 28-72) were identified as GFAP-IgG-positive. Fourteen cases had GFAP-IgG detected in the CSF, while serum GFAP-IgG was detected in 11 cases. Eleven of the fifteen patients (73.3%) presented with an acute monophasic course, of which 10 (90.9%) had antecedent flu-like symptoms. The predominant phenotype was meningoencephalitis (46.7%), followed by meningoencephalomyelitis in 40% of the cases. The most common clinical features included long tract signs, brainstem symptoms, tremors, headaches, and psychiatric symptoms. Magnetic resonance imaging (MRI) revealed the enhancement of the meninges, the surface of the brainstem, the cerebellum, and the spinal cord as predominant. Inflammatory CSF showed mild lymphocyte-predominant pleocytosis with a median of 51/μL and elevated protein with a median of 87.5 mg/dL. Five patients had coexisting antibodies, including NMDAR-IgG in three patients and Yo and MOG-IgG in one patient each. One patient underwent a stereotactic brain biopsy, and the neuropathology diagnosis was diffuse large B-cell lymphoma. One patient had ovarian teratoma. Eleven of the fifteen (73.3%) patients received both intravenous immunoglobulin and steroids. Among them, three patients also received immunosuppressive agents later. During a two-year follow-up, 9 of the 15 (60%) patients achieved complete clinical remission. CONCLUSIONS The clinical presentation of GFAP astrocytopathy is heterogeneous. It can be characterized by an acute monophasic course and a chronic relapsing course. Tremors are a prominent clinical manifestation in patients with an acute monophasic course with GFAP-IgG antibodies only. Most patients responded well to immunotherapy. In patients with GFAP autoimmunity, presenting with a chronic relapsing course, one should actively search for immunogenic factors and the culprit antibodies. In the case of primary central nervous system lymphoma, GFAP autoimmunity does not always equate to autoimmune GFAP astrocytopathy.
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Affiliation(s)
- Lei Liu
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100176, China
| | - Boyan Fang
- Neurological Rehabilitation Center, Beijing Rehabilitation Hospital, Capital Medical University, Beijing 100144, China
- Correspondence: (B.F.); (J.W.); Tel.: +86-010-56981223 (B.F.); +86-010-58266168 (J.W.)
| | - Zhixin Qiao
- Medical Research Center, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Xiaomeng Di
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100176, China
| | - Qiuying Ma
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100176, China
| | - Jingxiao Zhang
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100176, China
| | - Jiawei Wang
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100176, China
- Correspondence: (B.F.); (J.W.); Tel.: +86-010-56981223 (B.F.); +86-010-58266168 (J.W.)
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Cerebrospinal fluid glial fibrillary acidic protein-antibody in idiopathic intracranial hypertension: a case report. Acta Neurol Belg 2022:10.1007/s13760-022-02024-w. [PMID: 35794295 DOI: 10.1007/s13760-022-02024-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 06/26/2022] [Indexed: 11/01/2022]
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