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Guasp M, Martín-Aguilar L, Sabater L, Bioque M, Armangué T, Martínez-Hernández E, Landa J, Maudes E, Borràs R, Muñoz-Lopetegi A, Saiz A, Castro-Fornieles J, Graus F, Parellada E, Querol L, Dalmau J. Neurofilament Light Chain Levels in Anti-NMDAR Encephalitis and Primary Psychiatric Psychosis. Neurology 2022; 98:e1489-e1498. [PMID: 35145006 DOI: 10.1212/wnl.0000000000200021] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 01/03/2022] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION An important challenge in diagnosing anti-NMDAR encephalitis (NMDARe) is differentiating it from a first episode of psychosis (FEP) caused by a psychiatric disease (pFEP). CSF antibody testing distinguishes these diseases, but spinal taps are difficult to obtain in psychiatric facilities. A separate problem is the lack of biomarkers of NMDARe severity and outcome. Here we assessed the performance of neurofilament light chain (NfL) testing in these settings. METHODS In this observational study, NfL were determined with Single molecule array (SiMoA) in patients with NMDARe, pFEP, herpes simplex encephalitis (HSE), and healthy subjects (HC), the latter two groups used as controls. Receiver operating characteristic (ROC) analyses were performed to assess the prediction accuracy of serum NfL (sNfL) levels for NMDARe and pFEP, and to obtain clinically useful cutoffs. RESULTS 118 patients with NMDARe (33 with isolated psychosis at presentation), 45 pFEP, 36 HSE, and 36 HC were studied. NMDARe patients with seizures/status epilepticus, ICU admission, CSF pleocytosis (>20 WBC/µL), and without early immunotherapy were more likely to have higher sNfL than NMDARe without these features. NfL levels at diagnosis of NMDARe did not correlate with outcome at 1 year follow-up assessed with the modified Ranking Scale (mRS). NMDARe patients had significantly higher NfL than pFEP and HC, and lower than HSE patients. ROC analysis of sNfL between NMDARe with isolated psychosis and pFEP provided an AUC of 0.93 (95% CI 0.87-0.99) and a sNfL cutoff ≥15 pg/mL to distinguish these disorders (sensitivity 85%, specificity 96%, positive likelihood ratio 19.3). Forty-three/45 (96%) pFEP had sNfL<15pg/mL whereas only 5/33 (15%) NMDARe with isolated psychosis were below this cutoff (risk estimation NMDARe vs pFEP: odds ratio 120.4 [95% CI 21.8-664], p<0.001). None of the HSE and 35/36 (97%) HC had sNfL<15pg/mL. DISCUSSION NfL measured at diagnosis of NMDARe associated with features of disease severity but not with long-term outcome. Young patients with FEP and sNfL≥15pg/mL had 120 times higher chance of having NMDARe than pFEP. This cutoff correctly classified 96% of pFEP and 85% of NMDARe with isolated psychosis. Patients with FEP of unclear etiology and sNfL≥15pg/mL should undergo CSF NMDAR-antibody testing.
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Affiliation(s)
- Mar Guasp
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Neurology Department, Institute of Neuroscience, Hospital Clínic, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Spain
| | - Lorena Martín-Aguilar
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain
| | - Lidia Sabater
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Spain
| | - Miquel Bioque
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Barcelona Clínic Schizophrenia Unit (BCSU), Institute of Neuroscience, Hospital Clínic, Barcelona, Spain.,Department of Medicine, University of Barcelona, Spain.,Centro de Investigación Biomédica en Red, Salud Mental (CIBERSAM), Spain
| | - Thaís Armangué
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Pediatric Neuroimmunology Unit, Department of Neurology, Sant Joan de Déu (SJD) Children's Hospital, University of Barcelona, Barcelona, Spain.,Department of Child and Adolescent Psychiatry and Psychology, Institute of Neuroscience, Hospital Clínic, Barcelona, Spain
| | - Eugenia Martínez-Hernández
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Neurology Department, Institute of Neuroscience, Hospital Clínic, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Spain
| | - Jon Landa
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Estíbaliz Maudes
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Roger Borràs
- Medical Statistics Core Facility, Hospital Clínic, Barcelona, Spain
| | - Amaia Muñoz-Lopetegi
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Neurology Department, Institute of Neuroscience, Hospital Clínic, Barcelona, Spain
| | - Albert Saiz
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Neurology Department, Institute of Neuroscience, Hospital Clínic, Barcelona, Spain.,Department of Medicine, University of Barcelona, Spain
| | - Josefina Castro-Fornieles
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Department of Medicine, University of Barcelona, Spain.,Centro de Investigación Biomédica en Red, Salud Mental (CIBERSAM), Spain.,Department of Child and Adolescent Psychiatry and Psychology, Institute of Neuroscience, Hospital Clínic, Barcelona, Spain
| | - Francesc Graus
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Eduard Parellada
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Barcelona Clínic Schizophrenia Unit (BCSU), Institute of Neuroscience, Hospital Clínic, Barcelona, Spain.,Department of Medicine, University of Barcelona, Spain.,Centro de Investigación Biomédica en Red, Salud Mental (CIBERSAM), Spain
| | - Luis Querol
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Spain.,Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain
| | - Josep Dalmau
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Neurology Department, Institute of Neuroscience, Hospital Clínic, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Spain.,Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Catalan Institute for Research and Advanced Studies (ICREA), Barcelona, Spain
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