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Valencia-Sanchez C, Knight AM, Hammami MB, Guo Y, Mills JR, Kryzer TJ, Piquet AL, Amin A, Heinzelmann M, Lucchinetti CF, Lennon VA, McKeon A, Pittock SJ, Dubey D. Characterisation of TRIM46 autoantibody-associated paraneoplastic neurological syndrome. J Neurol Neurosurg Psychiatry 2022; 93:196-200. [PMID: 34921120 PMCID: PMC9597704 DOI: 10.1136/jnnp-2021-326656] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 11/22/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To report the expanded neurological presentations and oncological associations of tripartite motif-containing protein 46 (TRIM46)-IgG seropositive patients. METHODS Archived sera/cerebrospinal fluid (CSF) were evaluated by tissue-based immunofluorescence assay to identify patients with identical axon initial segment (AIS)-specific staining pattern. Phage immunoprecipitation sequencing (PhIP-Seq) was used to identify the putative autoantigen. RESULTS IgG in serum (17) and/or CSF (16) from 25 patients yielded unique AIS-specific staining on murine central nervous system (CNS) tissue. An autoantibody specific for TRIM46 was identified by PhIP-Seq, and autoantigen specificity was confirmed by transfected COS7 cell-based assay. Clinical information was available for 22 TRIM46-IgG seropositive patients. Fifteen were female (68%). Median age was 67 years (range 25-87). Fifteen (68%) patients presented with subacute cerebellar syndrome (six isolated; nine with CNS accompaniments: encephalopathy (three), brainstem signs (two), myelopathy (two), parkinsonism (one)). Other phenotypes included limbic encephalitis (three), encephalopathy with/without seizures (two), myelopathy (two). Eighteen (82%) had cancer: neuroendocrine carcinomas (9; pancreatic (3), small-cell lung (4), oesophagus (1), endometrium (1)), adenocarcinomas (6; lung (2), ovarian (2), endometrial (1), breast (1)), sarcoma (2) and gastrointestinal tumour (1). Neurological symptoms in three followed immune checkpoint inhibitor (ICI) administration. CONCLUSIONS This study supports TRIM46-IgG being a biomarker of paraneoplastic CNS disorders and expands the neurological phenotypes, oncological and ICI-related adverse event associations.
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Affiliation(s)
| | - Andrew M Knight
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - M Bakri Hammami
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yong Guo
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas J Kryzer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Amanda L Piquet
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Anik Amin
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Morgan Heinzelmann
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Vanda A Lennon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Immunology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA .,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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Shelly S, Kryzer TJ, Komorowski L, Miske R, Anderson MD, Flanagan EP, Hinson SR, Lennon VA, Pittock SJ, McKeon A. Neurochondrin neurological autoimmunity. Neurol Neuroimmunol Neuroinflamm 2019; 6:6/6/e612. [PMID: 31511329 PMCID: PMC6745726 DOI: 10.1212/nxi.0000000000000612] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/30/2019] [Indexed: 11/19/2022]
Abstract
Objectives To describe the neurologic spectrum and treatment outcomes for neurochondrin-IgG positive cases identified serologically in the Mayo Clinic Neuroimmunology Laboratory. Methods Archived serum and CSF specimens previously scored positive for IgGs that stained mouse hippocampal tissue in a nonuniform synaptic pattern by immunofluorescence assay (89 among 616,025 screened, 1993–2019) were reevaluated. Antibody characterization experiments revealed specificity for neurochondrin, confirmed by recombinant protein assays. Results IgG in serum (9) or CSF (4) from 8 patients yielded identical neuron-restricted CNS patterns, most pronounced in hippocampus (stratum lucidum in particular), cerebellum (Purkinje cells and molecular layer), and amygdala. All were neurochondrin-IgG positive. Five were women; median symptom onset age was 43 years (range, 30–69). Of 7 with clinical data, 6 presented with rapidly progressive cerebellar ataxia, brainstem signs, or both; 1 had isolated unexplained psychosis 1 year prior. Five of 6 had cerebellar signs, 4 with additional brainstem symptoms or signs (eye movement abnormalities, 3; dysphagia, 2; nausea and vomiting, 1). One patient with brainstem signs (vocal cord paralysis and VII nerve palsy) had accompanying myelopathy (longitudinally extensive abnormality on MRI; aquaporin-4-IgG and myelin oligodendrocyte glycoprotein-IgG negative). The 7th patient had small fiber neuropathy only. Just 1 of 7 had contemporaneous cancer (uterine). Six patients with ataxia or brainstem signs received immunotherapy, but just 1 remained ambulatory. At last follow-up, 5 had MRI evidence of severe cerebellar atrophy. Conclusion In our series, neurochondrin autoimmunity was usually accompanied by a nonparaneoplastic rapidly progressive rhombencephalitis with poor neurologic outcomes. Other phenotypes and occasional paraneoplastic causes may occur.
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Affiliation(s)
- Shahar Shelly
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Thomas J Kryzer
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Lars Komorowski
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Ramona Miske
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Mark D Anderson
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Eoin P Flanagan
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Shannon R Hinson
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Vanda A Lennon
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Sean J Pittock
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS
| | - Andrew McKeon
- Department of Laboratory Medicine and Pathology (S.S., T.J.K., E.P.F., S.R.H., V.A.L., S.J.P., A.M.), Department of Neurology (E.P.F., V.A.L., S.J.P., A.M.), and Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic; Euroimmun AG (L.K., R.M.), Lubeck, Germany; and Department of Neurology (M.D.A.), University of Mississippi Medical Center, Jackson, MS.
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Honorat JA, Lopez-Chiriboga AS, Kryzer TJ, Komorowski L, Scharf M, Hinson SR, Lennon VA, Pittock SJ, Klein CJ, McKeon A. Autoimmune gait disturbance accompanying adaptor protein-3B2-IgG. Neurology 2019; 93:e954-e963. [PMID: 31371564 PMCID: PMC6745733 DOI: 10.1212/wnl.0000000000008061] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 04/08/2019] [Indexed: 01/03/2023] Open
Abstract
Objective To describe phenotypes, treatment response, and outcomes of autoimmunity targeting a synaptic vesicle coat protein, the neuronal (B2) form of adaptor protein–3 (AP3). Methods Archived serum and CSF specimens (from 616,025 screened) harboring unclassified synaptic antibodies mimicking amphiphysin–immunoglobulin G (IgG) on tissue-based indirect immunofluorescence assay (IFA) were re-evaluated for novel IgG staining patterns. Autoantigens were identified by western blot and mass spectrometry. Recombinant western blot and cell-binding assay (CBA) were used to confirm antigen specificity. Clinical data were obtained retrospectively. Results Serum (10) and CSF (6) specimens of 10 patients produced identical IFA staining patterns throughout mouse nervous system tissues, most prominently in cerebellum (Purkinje neuronal perikarya, granular layer synapses, and dentate regions), spinal cord gray matter, dorsal root ganglia, and sympathetic ganglia. The antigen revealed by mass spectrometry analysis and confirmed by recombinant assays (western blot and CBA) was AP3B2 in all. Of 10 seropositive patients, 6 were women; median symptom onset age was 42 years (range 24–58). Clinical information was available for 9 patients, all with subacute onset and rapidly progressive gait ataxia. Neurologic manifestations were myeloneuropathy (3), peripheral sensory neuropathy (2), cerebellar ataxia (2), and spinocerebellar ataxia (2). Five patients received immunotherapy; none improved, but they did not worsen over the follow-up period (median 36 months; range 3–94). Two patients (both with cancer) died. One of 50 control sera was positive by western blot only (but not by IFA or CBA). Conclusion AP3B2 (previously named β-neuronal adaptin-like protein) autoimmunity appears rare, is accompanied by ataxia (sensory or cerebellar), and is potentially treatable.
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Affiliation(s)
- Josephe A Honorat
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany
| | - A Sebastian Lopez-Chiriboga
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany
| | - Thomas J Kryzer
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany
| | - Lars Komorowski
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany
| | - Madeleine Scharf
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany
| | - Shannon R Hinson
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany
| | - Vanda A Lennon
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany
| | - Sean J Pittock
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany
| | - Christopher J Klein
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany
| | - Andrew McKeon
- From the Departments of Laboratory Medicine and Pathology (J.A.H., T.J.K., S.R.H., V.A.L., S.J.P., C.J.K., A.M.), Neurology (A.S.L.-C., V.A.L., S.J.P., C.J.K., A.M.), and Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Euroimmun, AG (L.K., M.S.), Lubeck, Germany.
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4
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Mandel-Brehm C, Dubey D, Kryzer TJ, O'Donovan BD, Tran B, Vazquez SE, Sample HA, Zorn KC, Khan LM, Bledsoe IO, McKeon A, Pleasure SJ, Lennon VA, DeRisi JL, Wilson MR, Pittock SJ. Kelch-like Protein 11 Antibodies in Seminoma-Associated Paraneoplastic Encephalitis. N Engl J Med 2019; 381:47-54. [PMID: 31269365 PMCID: PMC6800027 DOI: 10.1056/nejmoa1816721] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A 37-year-old man with a history of seminoma presented with vertigo, ataxia, and diplopia. An autoantibody specific for kelch-like protein 11 (KLHL11) was identified with the use of programmable phage display. Immunoassays were used to identify KLHL11 IgG in 12 other men with similar neurologic features and testicular disease. Immunostaining of the patient's IgG on mouse brain tissue showed sparse but distinctive points of staining in multiple brain regions, with enrichment in perivascular and perimeningeal tissues. The onset of the neurologic syndrome preceded the diagnosis of seminoma in 9 of the 13 patients. An age-adjusted estimate of the prevalence of autoimmune KLHL11 encephalitis in Olmsted County, Minnesota, was 2.79 cases per 100,000 men. (Funded by the Rochester Epidemiology Project and others.).
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Affiliation(s)
- Caleigh Mandel-Brehm
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Divyanshu Dubey
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Thomas J Kryzer
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Brian D O'Donovan
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Baouyen Tran
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Sara E Vazquez
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Hannah A Sample
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Kelsey C Zorn
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Lillian M Khan
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Ian O Bledsoe
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Andrew McKeon
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Samuel J Pleasure
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Vanda A Lennon
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Joseph L DeRisi
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Michael R Wilson
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Sean J Pittock
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
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Basal E, Zalewski N, Kryzer TJ, Hinson SR, Guo Y, Dubey D, Benarroch EE, Lucchinetti CF, Pittock SJ, Lennon VA, McKeon A. Paraneoplastic neuronal intermediate filament autoimmunity. Neurology 2018; 91:e1677-e1689. [PMID: 30282771 PMCID: PMC6207411 DOI: 10.1212/wnl.0000000000006435] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 07/23/2018] [Indexed: 12/13/2022] Open
Abstract
Objective To describe paraneoplastic neuronal intermediate filament (NIF) autoimmunity. Methods Archived patient and control serum and CSF specimens were evaluated by tissue-based indirect immunofluorescence assay (IFA). Autoantigens were identified by Western blot and mass spectrometry. NIF specificity was confirmed by dual tissue section staining and 5 recombinant NIF-specific HEK293 cell-based assays (CBAs, for α-internexin, neurofilament light [NfL], neurofilament medium, or neurofilament heavy chain, and peripherin). NIF–immunoglobulin Gs (IgGs) were correlated with neurologic syndromes and cancers. Results Among 65 patients, NIF-IgG-positive by IFA and CBAs, 33 were female (51%). Median symptom onset age was 62 years (range 18–88). Patients fell into 2 groups, defined by the presence of NfL-IgG (21 patients, who mostly had ≥4 NIF-IgGs detected) or its absence (44 patients, who mostly had ≤2 NIF-IgGs detected). Among NfL-IgG-positive patients, 19/21 had ≥1 subacute onset CNS disorders: cerebellar ataxia (11), encephalopathy (11), or myelopathy (2). Cancers were detected in 16 of 21 patients (77%): carcinomas of neuroendocrine lineage (10) being most common (small cell [5], Merkel cell [3], other neuroendocrine [2]). Two of 257 controls (0.8%, both with small cell carcinoma) were positive by both IFA and CBA. Five of 7 patients with immunotherapy data improved. By comparison, the 44 NfL-IgG-negative patients had findings of unclear significance: diverse nervous system disorders (p = 0.006), as well as limited (p = 0.003) and more diverse (p < 0.0001) cancer accompaniments. Conclusions NIF-IgG detection by IFA, with confirmatory CBA testing that yields a profile including NfL-IgG, defines a paraneoplastic CNS disorder (usually ataxia or encephalopathy) accompanying neuroendocrine lineage neoplasia.
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Affiliation(s)
- Eati Basal
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Nicholas Zalewski
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Thomas J Kryzer
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Shannon R Hinson
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Yong Guo
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Divyanshu Dubey
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Eduardo E Benarroch
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Claudia F Lucchinetti
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Sean J Pittock
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Vanda A Lennon
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Andrew McKeon
- From the Departments of Laboratory Medicine and Pathology (E.B., T.J.K., S.R.H., S.J.P., V.A.L., A.M.), Neurology (N.Z., Y.G., D.D., E.E.B., C.F.L., S.J.P., V.A.L., A.M.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN.
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Honorat JA, Lopez-Chiriboga AS, Kryzer TJ, Fryer JP, Devine M, Flores A, Lennon VA, Pittock SJ, McKeon A. Autoimmune septin-5 cerebellar ataxia. Neurol Neuroimmunol Neuroinflamm 2018; 5:e474. [PMID: 29998156 PMCID: PMC6039209 DOI: 10.1212/nxi.0000000000000474] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 05/21/2018] [Indexed: 01/08/2023]
Abstract
Objective To report a form of autoimmune cerebellar ataxia in which antibodies target septin-5, a guanosine triphosphate (GTP)-binding neural protein involved in neurotransmitter exocytosis. Methods Archived sera and CSF specimens with unclassified synaptic antibodies were re-evaluated by tissue-based indirect immunofluorescence assay. Autoantigens were identified by Western blot and mass spectrometry. Recombinant protein assays (Western blot, cell based, and protein screening array) confirmed antigen specificity. Results Serum and CSF from 6 patients produced identical synaptic immunoglobulin G (IgG) staining patterns of synaptic regions (neuropil) of the mouse cerebrum and cerebellum. The molecular layer of the cerebellum and the thalamus demonstrated stronger immunoreactivity than the midbrain, hippocampus, cortex, and basal ganglia. The antigen revealed by mass spectrometry analysis of immunoprecipitated cerebellar proteins and confirmed by recombinant protein assays was septin-5. All 4 patients with records available had subacute onset of cerebellar ataxia with prominent eye movement symptoms (oscillopsia or vertigo). None had cancer detected. Improvements occurred after immunotherapies (2) or spontaneously (1). One patient died. Conclusion Septin-5 IgG represents a biomarker for a potentially fatal but treatable autoimmune ataxia.
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Affiliation(s)
- Josephe A Honorat
- Department of Laboratory Medicine and Pathology (J.A.H., T.J.K., J.P.F., V.A.L., S.J.P., A.M.), the Department of Neurology (A.S.L.-C., V.A.L., S.J.P., A.M.), and the Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Department of Neurology (M.D., A.F.), University of Texas, Southwestern, Dallas
| | - A Sebastian Lopez-Chiriboga
- Department of Laboratory Medicine and Pathology (J.A.H., T.J.K., J.P.F., V.A.L., S.J.P., A.M.), the Department of Neurology (A.S.L.-C., V.A.L., S.J.P., A.M.), and the Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Department of Neurology (M.D., A.F.), University of Texas, Southwestern, Dallas
| | - Thomas J Kryzer
- Department of Laboratory Medicine and Pathology (J.A.H., T.J.K., J.P.F., V.A.L., S.J.P., A.M.), the Department of Neurology (A.S.L.-C., V.A.L., S.J.P., A.M.), and the Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Department of Neurology (M.D., A.F.), University of Texas, Southwestern, Dallas
| | - James P Fryer
- Department of Laboratory Medicine and Pathology (J.A.H., T.J.K., J.P.F., V.A.L., S.J.P., A.M.), the Department of Neurology (A.S.L.-C., V.A.L., S.J.P., A.M.), and the Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Department of Neurology (M.D., A.F.), University of Texas, Southwestern, Dallas
| | - Michelle Devine
- Department of Laboratory Medicine and Pathology (J.A.H., T.J.K., J.P.F., V.A.L., S.J.P., A.M.), the Department of Neurology (A.S.L.-C., V.A.L., S.J.P., A.M.), and the Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Department of Neurology (M.D., A.F.), University of Texas, Southwestern, Dallas
| | - Angela Flores
- Department of Laboratory Medicine and Pathology (J.A.H., T.J.K., J.P.F., V.A.L., S.J.P., A.M.), the Department of Neurology (A.S.L.-C., V.A.L., S.J.P., A.M.), and the Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Department of Neurology (M.D., A.F.), University of Texas, Southwestern, Dallas
| | - Vanda A Lennon
- Department of Laboratory Medicine and Pathology (J.A.H., T.J.K., J.P.F., V.A.L., S.J.P., A.M.), the Department of Neurology (A.S.L.-C., V.A.L., S.J.P., A.M.), and the Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Department of Neurology (M.D., A.F.), University of Texas, Southwestern, Dallas
| | - Sean J Pittock
- Department of Laboratory Medicine and Pathology (J.A.H., T.J.K., J.P.F., V.A.L., S.J.P., A.M.), the Department of Neurology (A.S.L.-C., V.A.L., S.J.P., A.M.), and the Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Department of Neurology (M.D., A.F.), University of Texas, Southwestern, Dallas
| | - Andrew McKeon
- Department of Laboratory Medicine and Pathology (J.A.H., T.J.K., J.P.F., V.A.L., S.J.P., A.M.), the Department of Neurology (A.S.L.-C., V.A.L., S.J.P., A.M.), and the Department of Immunology (V.A.L.), College of Medicine, Mayo Clinic, Rochester, MN; and Department of Neurology (M.D., A.F.), University of Texas, Southwestern, Dallas
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Shimizu F, Schaller KL, Owens GP, Cotleur AC, Kellner D, Takeshita Y, Obermeier B, Kryzer TJ, Sano Y, Kanda T, Lennon VA, Ransohoff RM, Bennett JL. Glucose-regulated protein 78 autoantibody associates with blood-brain barrier disruption in neuromyelitis optica. Sci Transl Med 2018; 9:9/397/eaai9111. [PMID: 28679661 DOI: 10.1126/scitranslmed.aai9111] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 05/19/2017] [Indexed: 12/15/2022]
Abstract
Neuromyelitis optica (NMO) is an inflammatory disorder mediated by antibodies to aquaporin-4 (AQP4) with prominent blood-brain barrier (BBB) breakdown in the acute phase of the disease. Anti-AQP4 antibodies are produced mainly in the periphery, yet they target the astrocyte perivascular end feet behind the BBB. We reasoned that an endothelial cell-targeted autoantibody might promote BBB transit of AQP4 antibodies and facilitate NMO attacks. Using monoclonal recombinant antibodies (rAbs) from patients with NMO, we identified two that strongly bound to the brain microvascular endothelial cells (BMECs). Exposure of BMECs to these rAbs resulted in nuclear translocation of nuclear factor κB p65, decreased claudin-5 protein expression, and enhanced transit of macromolecules. Unbiased membrane proteomics identified glucose-regulated protein 78 (GRP78) as the rAb target. Using immobilized GRP78 to deplete GRP78 antibodies from pooled total immunoglobulin G (IgG) of 50 NMO patients (NMO-IgG) reduced the biological effect of NMO-IgG on BMECs. GRP78 was expressed on the surface of murine BMECs in vivo, and repeated administration of a GRP78-specific rAb caused extravasation of serum albumin, IgG, and fibrinogen into mouse brains. Our results identify GRP78 antibodies as a potential component of NMO pathogenesis and GRP78 as a candidate target for promoting central nervous system transit of therapeutic antibodies.
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Affiliation(s)
- Fumitaka Shimizu
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Minamikogushi, Ube, Yamaguchi 7558505, Japan
| | - Kristin L Schaller
- Departments of Neurology and Ophthalmology, Program in Neuroscience, University of Colorado Denver School of Medicine, Aurora, CO 80045, USA
| | - Gregory P Owens
- Departments of Neurology and Ophthalmology, Program in Neuroscience, University of Colorado Denver School of Medicine, Aurora, CO 80045, USA
| | - Anne C Cotleur
- Neuroimmunology and Acute Neurology, Biogen, Cambridge, MA 02142, USA
| | - Debra Kellner
- Neuroimmunology and Acute Neurology, Biogen, Cambridge, MA 02142, USA
| | - Yukio Takeshita
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Minamikogushi, Ube, Yamaguchi 7558505, Japan
| | - Birgit Obermeier
- Neuroimmunology and Acute Neurology, Biogen, Cambridge, MA 02142, USA
| | - Thomas J Kryzer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Yasuteru Sano
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Minamikogushi, Ube, Yamaguchi 7558505, Japan
| | - Takashi Kanda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Minamikogushi, Ube, Yamaguchi 7558505, Japan
| | - Vanda A Lennon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Jeffrey L Bennett
- Departments of Neurology and Ophthalmology, Program in Neuroscience, University of Colorado Denver School of Medicine, Aurora, CO 80045, USA.
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Fang B, McKeon A, Hinson SR, Kryzer TJ, Pittock SJ, Aksamit AJ, Lennon VA. Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy: A Novel Meningoencephalomyelitis. JAMA Neurol 2017; 73:1297-1307. [PMID: 27618707 DOI: 10.1001/jamaneurol.2016.2549] [Citation(s) in RCA: 315] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance A novel astrocytic autoantibody has been identified as a biomarker of a relapsing autoimmune meningoencephalomyelitis that is immunotherapy responsive. Seropositivity distinguishes autoimmune glial fibrillary acidic protein (GFAP) meningoencephalomyelitis from disorders commonly considered in the differential diagnosis. Objective To describe a novel IgG autoantibody found in serum or cerebrospinal fluid that is specific for a cytosolic intermediate filament protein of astrocytes. Design, Setting, and Participants Retrospective review of the medical records of seropositive patients identified in the Mayo Clinic Neuroimmunology Laboratory from October 15, 1998, to April 1, 2016, in blinded comprehensive serologic evaluation for autoantibody profiles to aid the diagnosis of neurologic autoimmunity (and predict cancer likelihood). Main Outcomes and Measures Frequency and definition of novel autoantibody, the autoantigen's immunochemical identification, clinical and magnetic resonance imaging correlations of the autoantibody, and immunotherapy responsiveness. Results Of 103 patients whose medical records were available for review, the 16 initial patients identified as seropositive were the subject of this study. Median age at neurologic symptom onset was 42 years (range, 21-73 years); there was no sex predominance. The novel neural autoantibody, which we discovered to be GFAP-specific, is disease spectrum restricted but not rare (frequency equivalent to Purkinje cell antibody type 1 [anti-Yo]). Its filamentous pial, subventricular, and perivascular immunostaining pattern on mouse tissue resembles the characteristic magnetic resonance imaging findings of linear perivascular enhancement in patients. Prominent clinical manifestations are headache, subacute encephalopathy, optic papillitis, inflammatory myelitis, postural tremor, and cerebellar ataxia. Cerebrospinal fluid was inflammatory in 13 of 14 patients (93%) with data available. Neoplasia was diagnosed within 3 years of neurologic onset in 6 of 16 patients (38%): prostate and gastroesophageal adenocarcinomas, myeloma, melanoma, colonic carcinoid, parotid pleomorphic adenoma, and teratoma. Neurologic improvement followed treatment with high-dose corticosteroids, with a tendency of patients to relapse without long-term immunosuppression. Conclusions and Relevance Glial fibrillary acidic protein-specific IgG identifies a distinctive, corticosteroid-responsive, sometimes paraneoplastic autoimmune meningoencephalomyelitis. It has a lethal canine equivalent: necrotizing meningoencephalitis. Expression of GFAP has been reported in some of the tumor types identified in paraneoplastic cases. Glial fibrillary acidic protein peptide-specific cytotoxic CD8+ T cells are implicated as effectors in a transgenic mouse model of autoimmune GFAP meningoencephalitis.
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Affiliation(s)
- Boyan Fang
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Andrew McKeon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota2Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Shannon R Hinson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Thomas J Kryzer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Sean J Pittock
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota2Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | | | - Vanda A Lennon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota2Department of Neurology, Mayo Clinic, Rochester, Minnesota3Department of Immunology, Mayo Clinic, Rochester, Minnesota
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Gadoth A, Kryzer TJ, Fryer J, McKeon A, Lennon VA, Pittock SJ. Microtubule-associated protein 1B: Novel paraneoplastic biomarker. Ann Neurol 2017; 81:266-277. [DOI: 10.1002/ana.24872] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 01/03/2017] [Accepted: 01/04/2017] [Indexed: 02/04/2023]
Affiliation(s)
- Avi Gadoth
- Departments of Laboratory Medicine and Pathology
| | | | - Jim Fryer
- Departments of Laboratory Medicine and Pathology
| | - Andrew McKeon
- Departments of Laboratory Medicine and Pathology
- Neurology
| | - Vanda A. Lennon
- Departments of Laboratory Medicine and Pathology
- Neurology
- Immunology, Mayo Clinic; Rochester MN
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Takeshita Y, Obermeier B, Cotleur AC, Spampinato SF, Shimizu F, Yamamoto E, Sano Y, Kryzer TJ, Lennon VA, Kanda T, Ransohoff RM. Effects of neuromyelitis optica-IgG at the blood-brain barrier in vitro. Neurol Neuroimmunol Neuroinflamm 2016; 4:e311. [PMID: 28018943 PMCID: PMC5173350 DOI: 10.1212/nxi.0000000000000311] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 11/02/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To address the hypothesis that physiologic interactions between astrocytes and endothelial cells (EC) at the blood-brain barrier (BBB) are afflicted by pathogenic inflammatory signaling when astrocytes are exposed to aquaporin-4 (AQP4) antibodies present in the immunoglobulin G (IgG) fraction of serum from patients with neuromyelitis optica (NMO), referred to as NMO-IgG. METHODS We established static and flow-based in vitro BBB models incorporating co-cultures of conditionally immortalized human brain microvascular endothelial cells and human astrocyte cell lines with or without AQP4 expression. RESULTS In astrocyte-EC co-cultures, exposure of astrocytes to NMO-IgG decreased barrier function, induced CCL2 and CXCL8 expression by EC, and promoted leukocyte migration under flow, contingent on astrocyte expression of AQP4. NMO-IgG selectively induced interleukin (IL)-6 production by AQP4-positive astrocytes. When EC were exposed to IL-6, we observed decreased barrier function, increased CCL2 and CXCL8 expression, and enhanced leukocyte transmigration under flow. These effects were reversed after application of IL-6 neutralizing antibody. CONCLUSIONS Our results indicate that NMO-IgG induces IL-6 production by AQP4-positive astrocytes and that IL-6 signaling to EC decreases barrier function, increases chemokine production, and enhances leukocyte transmigration under flow.
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Affiliation(s)
- Yukio Takeshita
- Neuroinflammation Research Center (Y.T., B.O., A.C.C., S.F.S., F.S., E.Y., R.M.R.), Lerner Research Institute, Cleveland Clinic, OH; Department of Neurology and Clinical Neuroscience (Y.S., T.K.), Yamaguchi University Graduate School of Medicine, Japan; and Department of Laboratory Medicine and Pathology (T.J.K., V.A.L.), Mayo Clinic, Rochester, MN. Y.T. and F.S. are currently affiliated with the Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Japan. B.O., A.C.C., and R.M.R. are currently affiliated with Neuroimmunology Research, Biogen, Cambridge, MA. S.F.S. is currently affiliated with the Department of Biomedical and Biotechnological Sciences, Section of Pharmacology, University of Catania, Italy
| | - Birgit Obermeier
- Neuroinflammation Research Center (Y.T., B.O., A.C.C., S.F.S., F.S., E.Y., R.M.R.), Lerner Research Institute, Cleveland Clinic, OH; Department of Neurology and Clinical Neuroscience (Y.S., T.K.), Yamaguchi University Graduate School of Medicine, Japan; and Department of Laboratory Medicine and Pathology (T.J.K., V.A.L.), Mayo Clinic, Rochester, MN. Y.T. and F.S. are currently affiliated with the Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Japan. B.O., A.C.C., and R.M.R. are currently affiliated with Neuroimmunology Research, Biogen, Cambridge, MA. S.F.S. is currently affiliated with the Department of Biomedical and Biotechnological Sciences, Section of Pharmacology, University of Catania, Italy
| | - Anne C Cotleur
- Neuroinflammation Research Center (Y.T., B.O., A.C.C., S.F.S., F.S., E.Y., R.M.R.), Lerner Research Institute, Cleveland Clinic, OH; Department of Neurology and Clinical Neuroscience (Y.S., T.K.), Yamaguchi University Graduate School of Medicine, Japan; and Department of Laboratory Medicine and Pathology (T.J.K., V.A.L.), Mayo Clinic, Rochester, MN. Y.T. and F.S. are currently affiliated with the Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Japan. B.O., A.C.C., and R.M.R. are currently affiliated with Neuroimmunology Research, Biogen, Cambridge, MA. S.F.S. is currently affiliated with the Department of Biomedical and Biotechnological Sciences, Section of Pharmacology, University of Catania, Italy
| | - Simona F Spampinato
- Neuroinflammation Research Center (Y.T., B.O., A.C.C., S.F.S., F.S., E.Y., R.M.R.), Lerner Research Institute, Cleveland Clinic, OH; Department of Neurology and Clinical Neuroscience (Y.S., T.K.), Yamaguchi University Graduate School of Medicine, Japan; and Department of Laboratory Medicine and Pathology (T.J.K., V.A.L.), Mayo Clinic, Rochester, MN. Y.T. and F.S. are currently affiliated with the Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Japan. B.O., A.C.C., and R.M.R. are currently affiliated with Neuroimmunology Research, Biogen, Cambridge, MA. S.F.S. is currently affiliated with the Department of Biomedical and Biotechnological Sciences, Section of Pharmacology, University of Catania, Italy
| | - Fumitaka Shimizu
- Neuroinflammation Research Center (Y.T., B.O., A.C.C., S.F.S., F.S., E.Y., R.M.R.), Lerner Research Institute, Cleveland Clinic, OH; Department of Neurology and Clinical Neuroscience (Y.S., T.K.), Yamaguchi University Graduate School of Medicine, Japan; and Department of Laboratory Medicine and Pathology (T.J.K., V.A.L.), Mayo Clinic, Rochester, MN. Y.T. and F.S. are currently affiliated with the Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Japan. B.O., A.C.C., and R.M.R. are currently affiliated with Neuroimmunology Research, Biogen, Cambridge, MA. S.F.S. is currently affiliated with the Department of Biomedical and Biotechnological Sciences, Section of Pharmacology, University of Catania, Italy
| | - Erin Yamamoto
- Neuroinflammation Research Center (Y.T., B.O., A.C.C., S.F.S., F.S., E.Y., R.M.R.), Lerner Research Institute, Cleveland Clinic, OH; Department of Neurology and Clinical Neuroscience (Y.S., T.K.), Yamaguchi University Graduate School of Medicine, Japan; and Department of Laboratory Medicine and Pathology (T.J.K., V.A.L.), Mayo Clinic, Rochester, MN. Y.T. and F.S. are currently affiliated with the Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Japan. B.O., A.C.C., and R.M.R. are currently affiliated with Neuroimmunology Research, Biogen, Cambridge, MA. S.F.S. is currently affiliated with the Department of Biomedical and Biotechnological Sciences, Section of Pharmacology, University of Catania, Italy
| | - Yasuteru Sano
- Neuroinflammation Research Center (Y.T., B.O., A.C.C., S.F.S., F.S., E.Y., R.M.R.), Lerner Research Institute, Cleveland Clinic, OH; Department of Neurology and Clinical Neuroscience (Y.S., T.K.), Yamaguchi University Graduate School of Medicine, Japan; and Department of Laboratory Medicine and Pathology (T.J.K., V.A.L.), Mayo Clinic, Rochester, MN. Y.T. and F.S. are currently affiliated with the Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Japan. B.O., A.C.C., and R.M.R. are currently affiliated with Neuroimmunology Research, Biogen, Cambridge, MA. S.F.S. is currently affiliated with the Department of Biomedical and Biotechnological Sciences, Section of Pharmacology, University of Catania, Italy
| | - Thomas J Kryzer
- Neuroinflammation Research Center (Y.T., B.O., A.C.C., S.F.S., F.S., E.Y., R.M.R.), Lerner Research Institute, Cleveland Clinic, OH; Department of Neurology and Clinical Neuroscience (Y.S., T.K.), Yamaguchi University Graduate School of Medicine, Japan; and Department of Laboratory Medicine and Pathology (T.J.K., V.A.L.), Mayo Clinic, Rochester, MN. Y.T. and F.S. are currently affiliated with the Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Japan. B.O., A.C.C., and R.M.R. are currently affiliated with Neuroimmunology Research, Biogen, Cambridge, MA. S.F.S. is currently affiliated with the Department of Biomedical and Biotechnological Sciences, Section of Pharmacology, University of Catania, Italy
| | - Vanda A Lennon
- Neuroinflammation Research Center (Y.T., B.O., A.C.C., S.F.S., F.S., E.Y., R.M.R.), Lerner Research Institute, Cleveland Clinic, OH; Department of Neurology and Clinical Neuroscience (Y.S., T.K.), Yamaguchi University Graduate School of Medicine, Japan; and Department of Laboratory Medicine and Pathology (T.J.K., V.A.L.), Mayo Clinic, Rochester, MN. Y.T. and F.S. are currently affiliated with the Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Japan. B.O., A.C.C., and R.M.R. are currently affiliated with Neuroimmunology Research, Biogen, Cambridge, MA. S.F.S. is currently affiliated with the Department of Biomedical and Biotechnological Sciences, Section of Pharmacology, University of Catania, Italy
| | - Takashi Kanda
- Neuroinflammation Research Center (Y.T., B.O., A.C.C., S.F.S., F.S., E.Y., R.M.R.), Lerner Research Institute, Cleveland Clinic, OH; Department of Neurology and Clinical Neuroscience (Y.S., T.K.), Yamaguchi University Graduate School of Medicine, Japan; and Department of Laboratory Medicine and Pathology (T.J.K., V.A.L.), Mayo Clinic, Rochester, MN. Y.T. and F.S. are currently affiliated with the Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Japan. B.O., A.C.C., and R.M.R. are currently affiliated with Neuroimmunology Research, Biogen, Cambridge, MA. S.F.S. is currently affiliated with the Department of Biomedical and Biotechnological Sciences, Section of Pharmacology, University of Catania, Italy
| | - Richard M Ransohoff
- Neuroinflammation Research Center (Y.T., B.O., A.C.C., S.F.S., F.S., E.Y., R.M.R.), Lerner Research Institute, Cleveland Clinic, OH; Department of Neurology and Clinical Neuroscience (Y.S., T.K.), Yamaguchi University Graduate School of Medicine, Japan; and Department of Laboratory Medicine and Pathology (T.J.K., V.A.L.), Mayo Clinic, Rochester, MN. Y.T. and F.S. are currently affiliated with the Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Japan. B.O., A.C.C., and R.M.R. are currently affiliated with Neuroimmunology Research, Biogen, Cambridge, MA. S.F.S. is currently affiliated with the Department of Biomedical and Biotechnological Sciences, Section of Pharmacology, University of Catania, Italy
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11
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Apiwattanakul M, Milone M, Pittock SJ, Kryzer TJ, Fryer JP, O'toole O, Mckeon A, Lennon VA. Signal recognition particle immunoglobulin g detected incidentally associates with autoimmune myopathy. Muscle Nerve 2016; 53:925-32. [PMID: 26561982 PMCID: PMC5067628 DOI: 10.1002/mus.24970] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 10/16/2015] [Accepted: 11/09/2015] [Indexed: 12/03/2022]
Abstract
Introduction: Paraneoplastic autoantibody screening of 150,000 patient sera by tissue‐based immunofluorescence incidentally revealed 170 with unsuspected signal recognition particle (SRP) immunoglobulin G (IgG), which is a recognized biomarker of autoimmune myopathy. Of the 77 patients with available information, 54 had myopathy. We describe the clinical/laboratory associations. Methods: Distinctive cytoplasm‐binding IgG (mouse tissue substrate) prompted western blot, enzyme‐linked immunoassay, and immunoprecipitation analyses. Available histories were reviewed. Results: The immunostaining pattern resembled rough endoplasmic reticulum, and mimicked Purkinje‐cell cytoplasmic antibody type 1 IgG/anti‐Yo. Immunoblotting revealed ribonucleoprotein reactivity. Recombinant antigens confirmed the following: SRP54 IgG specificity alone (17); SRP72 IgG specificity alone (3); both (32); or neither (2). Coexisting neural autoantibodies were identified in 28% (low titer). Electromyography revealed myopathy with fibrillation potentials; 78% of biopsies had active necrotizing myopathy with minimal inflammation, and 17% had inflammatory myopathy. Immunotherapy responsiveness was typically slow and incomplete, and relapses were frequent on withdrawal. Histologically confirmed cancers (17%) were primarily breast and hematologic, with some others. Conclusions: Autoimmune necrotizing SRP myopathy, both idiopathic and paraneoplastic, is underdiagnosed in neurological practice. Serological screening aids early diagnosis. Cancer surveillance and appropriate immunosuppressant therapy may improve outcome. Muscle Nerve53: 925–932, 2016
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Affiliation(s)
- Metha Apiwattanakul
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA
| | | | - Sean J Pittock
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA.,Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas J Kryzer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA
| | - James P Fryer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA
| | - Orna O'toole
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew Mckeon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA.,Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vanda A Lennon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA.,Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Immunology, Mayo Clinic, Rochester, Minnesota, USA
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12
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Abstract
OBJECTIVE To report neurologic phenotypes and their etiologies determined among 68 patients with either (1) celiac disease (CD) or (2) no CD, but gliadin antibody positivity (2002-2012). METHODS Neurologic patients included both those with the CD-prerequisite major histocompatibility complex class II human leukocyte antigen (HLA)-DQ2/DQ8 haplotype, and those without. The 3 groups were as follows: group 1 (n = 44), CD or transglutaminase (Tg)-2/deamidated gliadin immunoglobulin (Ig)A/IgG detected; group 2 (n = 15), HLA-DQ2/DQ8 noncarriers, and gliadin IgA/IgG detected; and group 3 (n = 9), HLA-DQ2/DQ8 carriers, and gliadin IgA/IgG detected. Neurologic patients and 21 nonneurologic CD patients were evaluated for neural and Tg6 antibodies. RESULTS In group 1, 42 of 44 patients had CD. Neurologic phenotypes (cerebellar ataxia, 13; neuropathy, 11; dementia, 8; myeloneuropathy, 5; other, 7) and causes (autoimmune, 9; deficiencies of vitamin E, folate, or copper, 6; genetic, 6; toxic or metabolic, 4; unknown, 19) were diverse. In groups 2 and 3, 21 of 24 patients had cerebellar ataxia; none had CD. Causes of neurologic disorders in groups 2 and 3 were diverse (autoimmune, 4; degenerative, 4; toxic, 3; nutritional deficiency, 1; other, 2; unknown, 10). One or more neural-reactive autoantibodies were detected in 10 of 68 patients, all with autoimmune neurologic diagnoses (glutamic acid decarboxylase 65 IgG, 4; voltage-gated potassium channel complex IgG, 3; others, 5). Tg6-IgA/IgG was detected in 7 of 68 patients (cerebellar ataxia, 3; myelopathy, 2; ataxia and parkinsonism, 1; neuropathy, 1); the 2 patients with myelopathy had neurologic disorders explained by malabsorption of copper, vitamin E, and folate rather than by neurologic autoimmunity. CONCLUSIONS Our data support causes alternative to gluten exposure for neurologic dysfunction among most gliadin antibody-positive patients without CD. Nutritional deficiency and coexisting autoimmunity may cause neurologic dysfunction in CD.
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Affiliation(s)
- Andrew McKeon
- From the Departments of Laboratory Medicine and Pathology (A.M., V.A.L., S.J.P., T.J.K.), Neurology (A.M., V.A.L., S.J.P.), Immunology (V.A.L., J.M.), and Gastroenterology (J.M.), College of Medicine, Mayo Clinic, Rochester, MN.
| | - Vanda A Lennon
- From the Departments of Laboratory Medicine and Pathology (A.M., V.A.L., S.J.P., T.J.K.), Neurology (A.M., V.A.L., S.J.P.), Immunology (V.A.L., J.M.), and Gastroenterology (J.M.), College of Medicine, Mayo Clinic, Rochester, MN
| | - Sean J Pittock
- From the Departments of Laboratory Medicine and Pathology (A.M., V.A.L., S.J.P., T.J.K.), Neurology (A.M., V.A.L., S.J.P.), Immunology (V.A.L., J.M.), and Gastroenterology (J.M.), College of Medicine, Mayo Clinic, Rochester, MN
| | - Thomas J Kryzer
- From the Departments of Laboratory Medicine and Pathology (A.M., V.A.L., S.J.P., T.J.K.), Neurology (A.M., V.A.L., S.J.P.), Immunology (V.A.L., J.M.), and Gastroenterology (J.M.), College of Medicine, Mayo Clinic, Rochester, MN
| | - Joseph Murray
- From the Departments of Laboratory Medicine and Pathology (A.M., V.A.L., S.J.P., T.J.K.), Neurology (A.M., V.A.L., S.J.P.), Immunology (V.A.L., J.M.), and Gastroenterology (J.M.), College of Medicine, Mayo Clinic, Rochester, MN
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13
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Brickshawana A, Hinson SR, Romero MF, Lucchinetti CF, Guo Y, Buttmann M, McKeon A, Pittock SJ, Chang MH, Chen AP, Kryzer TJ, Fryer JP, Jenkins SM, Cabre P, Lennon VA. Investigation of the KIR4.1 potassium channel as a putative antigen in patients with multiple sclerosis: a comparative study. Lancet Neurol 2014; 13:795-806. [PMID: 25008548 DOI: 10.1016/s1474-4422(14)70141-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Antibodies have been implicated in the pathogenicity of multiple sclerosis by findings of immunoglobulins in patients' CSF and often IgG and complement in lesions, and by a 2012 report that nearly half of patients' serum samples contain IgG specific for a glial potassium-channel, KIR4.1. We aimed to establish the frequency of KIR4.1-binding IgG in serum and CSF of patients with multiple sclerosis, and whether KIR4.1 immunoreactivity is retained or lost in demyelinating lesions. METHODS Using ELISA with a KIR4.1 peptide, we tested archival serum from 229 population-based and 57 clinic-based patients with multiple sclerosis, 99 healthy controls, and 109 disease controls, and CSF from 25 patients with multiple sclerosis and 22 disease controls. We tested all CSF and serum samples from 50 of the clinic-based patients with multiple sclerosis on cells expressing functional KIR4.1, using cell-based immunofluorescence and immunoprecipitation (solubilised recombinant human KIR4.1). We assessed KIR4.1 immunoreactivity in archival brain samples from 15 patients with histopathologically confirmed multiple sclerosis (22 plaques [eight early active, eight inactive, and six remyelinated], 13 periplaque regions and eight normal-appearing white-matter and grey-matter regions) and from three controls with non-neurological diseases. FINDINGS Three of 286 serum samples from patients with multiple sclerosis and two of 208 serum samples from controls showed KIR4.1 reactivity on ELISA; none of the CSF samples from patients or controls showed KIR4.1 reactivity. IgG in none of the 50 serum samples from clinic-based patients immunoprecipitated KIR4.1, but a commercial KIR4.1-specific control IgG did. By immunofluorescence, one of 50 serum samples from patients with multiple sclerosis yielded faint plasmalemmal staining on both KIR4.1-expressing and non-expressing cells; 16 bound faintly to intracellular components. In all cases, IgG binding was quenched by absorption with liver powder or lysates from non-transfected cells. Binding by the KIR4.1-specific control IgG was quenched only by lysates containing KIR4.1. IgG in none of the 25 CSF samples from patients with multiple sclerosis bound to KIR4.1-transfected cells. Glial KIR4.1 immunoreactivity was increased relative to expression in healthy control brain in all active demyelinating lesions, remyelinated lesions, and periplaque white matter regions. INTERPRETATION We did not detect KIR4.1-specific IgG in serum or CSF from patients with multiple sclerosis or KIR4.1 loss from glia in multiple sclerosis lesions. Serological testing for KIR4.1-specific IgG is unlikely to aid diagnosis of multiple sclerosis. The target antigen of multiple sclerosis remains elusive. FUNDING The National Institutes of Health, the National Multiple Sclerosis Society, and the Mayo Clinic Robert and Arlene Kogod Center on Aging.
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Affiliation(s)
- Adipong Brickshawana
- Department of Immunology, Mayo Clinic, Rochester, MN, USA; Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Shannon R Hinson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Michael F Romero
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
| | | | - Yong Guo
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Andrew McKeon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Sean J Pittock
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Min-Hwang Chang
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
| | - An-Ping Chen
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
| | - Thomas J Kryzer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - James P Fryer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Sarah M Jenkins
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Philippe Cabre
- Pierre Zobda Quitman Hospital, CHRU de Fort de France, Martinique
| | - Vanda A Lennon
- Department of Immunology, Mayo Clinic, Rochester, MN, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Neurology, Mayo Clinic, Rochester, MN, USA.
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Meeusen JW, Haselkorn KE, Fryer JP, Kryzer TJ, Gibbons SJ, Xiao Y, Lennon VA. Gastrointestinal hypomotility with loss of enteric nicotinic acetylcholine receptors: active immunization model in mice. Neurogastroenterol Motil 2013; 25:84-8.e10. [PMID: 23072523 PMCID: PMC3535544 DOI: 10.1111/nmo.12030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Autoimmune gastrointestinal dysmotility (AGID) is a limited form of dysautonomia. The only proven effector to date is IgG specific for ganglionic nicotinic-acetylcholine receptors containing α3 subunits [α3*- nicotinic acetylcholine receptor (nAChR)]. Rabbits immunized with recombinant α3-polypeptide produce α3*-nAChR autoantibodies, and profound AGID ensues. Human and rabbit α3*-nAChR-specific-IgGs induce transient hypomotility when injected into mice. Here, we describe success and problems encountered inducing gastrointestinal hypomotility in mice by active immunization. METHODS We repeatedly injected young adult mice of seven different strains susceptible to autoimmunity (spontaneous diabetes or neural antigen immunization-induced myasthenia gravis or encephalomyelitis) with: (i) α3-polypeptide, intradermally or (ii) live α3*-nAChR-expressing xenogeneic cells, intraperitoneally. We measured serum α3*-nAChR-IgG twice monthly, and terminally assessed blue dye gastrointestinal transit, total small intestinal α3*-nAChR content (radiochemically) and myenteric plexus neuron numbers (immunohistochemically, ileal-jejunal whole-mount preparations). KEY RESULTS Standard cutaneous inoculation with α3-polypeptide was minimally immunogenic, regardless of dose. Intraperitoneally injected live cells were potently immunogenic. Self-reactive α3*-nAChR-IgG was induced only by rodent immunogen; small intestinal transit slowing and enteric α3*-nAChR loss required high serum levels. Ganglionic neurons were not lost. CONCLUSIONS & INFERENCES Autoimmune gastrointestinal dysmotility is inducible in mice by active immunization. Accompanying enteric α3*-nAChR reduction without neuronal death is consistent with an IgG-mediated rather than T cell-mediated pathogenesis, as is improvement of symptoms in patients receiving antibody-depleting therapies.
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Affiliation(s)
- Jeffrey W. Meeusen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - James P. Fryer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Thomas J. Kryzer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Simon J. Gibbons
- Department of Enteric Neuroscience Program, Mayo Clinic, Rochester, MN
| | - Yingxian Xiao
- Department of Pharmacology and Physiology, Georgetown University School of Medicine, Washington, DC
| | - Vanda A. Lennon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN,Department of Immunology, Mayo Clinic, Rochester, MN,Department of Neurology, Mayo Clinic, Rochester, MN
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15
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Meeusen JW, Klein CJ, Pirko I, Haselkorn KE, Kryzer TJ, Pittock SJ, Lachance DH, Dyck PJ, Lennon VA. Potassium channel complex autoimmunity induced by inhaled brain tissue aerosol. Ann Neurol 2012; 71:417-26. [PMID: 22451206 PMCID: PMC3315155 DOI: 10.1002/ana.22674] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To test the hypothesis that autoimmunity induced by inhalation of aerosolized brain tissue caused outbreaks of sensory-predominant polyradiculoneuropathy among swine abattoir employees in the Midwestern United States. METHODS Mice were exposed intranasally, 5 days per week, to liquefied brain tissue. Serum from exposed mice, patients, and unaffected abattoir employees were analyzed for clinically pertinent neural autoantibodies. RESULTS Patients, coworkers, and mice exposed to liquefied brain tissue had an autoantibody profile dominated by neural cation channel immunoglobulin Gs (IgGs). The most compelling link between patients and exposed mice was magnetic resonance imaging (MRI) evidence of grossly swollen spinal nerve roots. Autoantibody responses in patients and mice were dose-dependent and declined after antigen exposure ceased. Autoantibodies detected most frequently, and at high levels, bound to detergent-solubilized macromolecular complexes containing neuronal voltage-gated potassium channels ligated with a high affinity Kv1 channel antagonist, 125I-α-dendrotoxin. Exposed mice exhibited a behavioral phenotype consistent with potassium channel dysfunction recognized in drosophila with mutant ("shaker") channels: reduced sensitivity to isoflurane-induced anesthesia. Pathological and electrophysiological findings in patients supported peripheral nerve hyperexcitability over destructive axonal loss. The pain-predominant symptoms were consistent with sensory nerve hyperexcitability. INTERPRETATION Our observations establish that inhaled neural antigens readily induce neurological autoimmunity and identify voltage-gated potassium channel complexes as a major immunogen.
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Affiliation(s)
- Jeffrey W. Meeusen
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Christopher J. Klein
- Department of Laboratory Neurology and College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Istvan Pirko
- Department of Laboratory Neurology and College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Keegan E. Haselkorn
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Thomas J. Kryzer
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Sean J. Pittock
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
- Department of Laboratory Neurology and College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Daniel H. Lachance
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
- Department of Laboratory Neurology and College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - P. James Dyck
- Department of Laboratory Neurology and College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Vanda A. Lennon
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
- Department of Laboratory Neurology and College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
- Department of Immunology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
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Chamberlain JL, Pittock SJ, Oprescu AM, Dege C, Apiwattanakul M, Kryzer TJ, Lennon VA. Peripherin-IgG association with neurologic and endocrine autoimmunity. J Autoimmun 2010; 34:469-77. [PMID: 20061119 PMCID: PMC2902873 DOI: 10.1016/j.jaut.2009.12.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Revised: 11/12/2009] [Accepted: 12/06/2009] [Indexed: 11/17/2022]
Abstract
Peripherin-IgG has been reported a pertinent autoantibody in non-obese type 1 diabetic (NOD) mice. However, it has not previously been recognized in any human disease. In blinded evaluation of serum for markers of neurological autoimmunity in a high-volume diagnostic laboratory, we incidentally identified 26 patients (61% female) with an IgG that bound selectively to neural elements in enteric ganglia, sympathetic nerve trunks and discrete nerve tracts in mid-brain and hind-brain. The target antigen was identified as peripherin, a 55kDa - type III intermediate filament protein. Review of clinical histories revealed that 54% of seropositive patients had dysautonomia (predominantly gastrointestinal dysmotility), 30% had neuropathies with varied sensory symptoms and 35% had clinical or serological evidence of endocrinopathy (type 1 diabetes, thyroiditis or premature ovarian failure). Collectively, 73% had autonomic dysfunction or endocrinopathy. None of 173 healthy subjects was seropositive. Subsequent western blot evaluation of archival sera from patients with small fiber/autonomic neuropathies (with or without endocrinopathy) revealed a 33% seropositivity rate for peripherin-IgG. Our further demonstration that peripherin-immunoreactive autonomic fibers in pancreas, thyroid and ovary are juxtaposed to endocrine epithelium, complement our clinical observations in suggesting that neuronal elements may be a pertinent initial target for immune attack in multiple forms of endocrine autoimmunity (intermolecular epitope spreading). It remains to be determined whether or not peripherin-IgG is predictive for development of small fiber neuropathy (autonomic or somatic).
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Affiliation(s)
- Jayne L. Chamberlain
- Department of Immunology, Mayo Clinic College of Medicine, Rochester, MN 55905, U.S.A
| | - Sean J. Pittock
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN 55905, U.S.A
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN 55905, U.S.A
| | - Anna-Maria Oprescu
- Department of Immunology, Mayo Clinic College of Medicine, Rochester, MN 55905, U.S.A
| | - Carissa Dege
- Department of Immunology, Mayo Clinic College of Medicine, Rochester, MN 55905, U.S.A
| | - Metha Apiwattanakul
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN 55905, U.S.A
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN 55905, U.S.A
| | - Thomas J. Kryzer
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN 55905, U.S.A
| | - Vanda A. Lennon
- Department of Immunology, Mayo Clinic College of Medicine, Rochester, MN 55905, U.S.A
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN 55905, U.S.A
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN 55905, U.S.A
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Apiwattanakul M, Mckeon A, Pittock SJ, Kryzer TJ, Lennon VA. Eliminating false-positive results in serum tests for neuromuscular autoimmunity. Muscle Nerve 2010; 41:702-4. [DOI: 10.1002/mus.21653] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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McKeon A, Fryer JP, Apiwattanakul M, Lennon VA, Hinson SR, Kryzer TJ, Lucchinetti CF, Weinshenker BG, Wingerchuk DM, Shuster EA, Pittock SJ. Diagnosis of Neuromyelitis Spectrum Disorders. ACTA ACUST UNITED AC 2009; 66:1134-8. [DOI: 10.1001/archneurol.2009.178] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Hinson SR, Roemer SF, Lucchinetti CF, Fryer JP, Kryzer TJ, Chamberlain JL, Howe CL, Pittock SJ, Lennon VA. Aquaporin-4-binding autoantibodies in patients with neuromyelitis optica impair glutamate transport by down-regulating EAAT2. ACTA ACUST UNITED AC 2008; 205:2473-81. [PMID: 18838545 PMCID: PMC2571922 DOI: 10.1084/jem.20081241] [Citation(s) in RCA: 272] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neuromyelitis optica (NMO)-immunoglobulin G (IgG) is a clinically validated serum biomarker that distinguishes relapsing central nervous system (CNS) inflammatory demyelinating disorders related to NMO from multiple sclerosis. This autoantibody targets astrocytic aquaporin-4 (AQP4) water channels. Clinical, radiological, and immunopathological data suggest that NMO-IgG might be pathogenic. Characteristic CNS lesions exhibit selective depletion of AQP4, with and without associated myelin loss; focal vasculocentric deposits of IgG, IgM, and complement; prominent edema; and inflammation. The effect of NMO-IgG on astrocytes has not been studied. In this study, we demonstrate that exposure to NMO patient serum and active complement compromises the membrane integrity of CNS-derived astrocytes. Without complement, astrocytic membranes remain intact, but AQP4 is endocytosed with concomitant loss of Na+-dependent glutamate transport and loss of the excitatory amino acid transporter 2 (EAAT2) . Our data suggest that EAAT2 and AQP4 exist in astrocytic membranes as a macromolecular complex. Transport-competent EAAT2 protein is up-regulated in differentiating astrocyte progenitors and in nonneural cells expressing AQP4 transgenically. Marked reduction of EAAT2 in AQP4-deficient regions of NMO patient spinal cord lesions supports our immunocytochemical and immunoprecipitation data. Thus, binding of NMO-IgG to astrocytic AQP4 initiates several potentially neuropathogenic mechanisms: complement activation, AQP4 and EAAT2 down-regulation, and disruption of glutamate homeostasis.
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Affiliation(s)
- Shannon R Hinson
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Hinson SR, Pittock SJ, Lucchinetti CF, Roemer SF, Fryer JP, Kryzer TJ, Lennon VA. Pathogenic potential of IgG binding to water channel extracellular domain in neuromyelitis optica. Neurology 2007; 69:2221-31. [PMID: 17928579 DOI: 10.1212/01.wnl.0000289761.64862.ce] [Citation(s) in RCA: 356] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Autoantibody specific for the aquaporin-4 astrocytic water channel is restricted to serum and CSF of patients with neuromyelitis optica (NMO) and related CNS inflammatory demyelinating disorders (relapsing optic neuritis and longitudinally extensive transverse myelitis). NMO-typical lesions are distinct from MS-typical lesions. Aquaporin-4 is lost selectively at vasculocentric sites of edema/inflammation coinciding with focal deposits of immunoglobulins (Ig) G, M, and terminal complement products, with and without myelin loss. Evidence for antigen-specific autoantibody pathogenicity is lacking. METHODS We used confocal microscopy and flow cytometry to evaluate the selectivity and immunopathological consequences of Ig binding to surface epitopes of living target cells expressing aquaporin-4 fused at its cytoplasmic N-terminus with GFP. We tested serum, IgG-enriched and IgG-depleted serum fractions, and CSF from patients with NMO, neurologic control patients, and healthy subjects. We also analyzed aquaporin-4 immunoreactivity in myelinated adult mouse optic nerves and spinal cord, and plasma cell Ig isotypes in archived brain tissue from an NMO patient. RESULTS Serum IgG from patients with NMO binds to the extracellular domain of aquaporin-4; it is predominantly IgG(1), and it initiates two potentially competing outcomes, aquaporin-4 endocytosis/degradation and complement activation. Serum and CSF lack aquaporin-4-specific IgM, and plasma cells in CNS lesions of NMO contain only IgG. Paranodal astrocytic endfeet highly express aquaporin-4. CONCLUSIONS NMO patients' serum IgG has a selective pathologic effect on cell membranes expressing aquaporin-4. IgG targeting astrocytic processes around nodes of Ranvier could initiate demyelination.
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Affiliation(s)
- S R Hinson
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Pittock SJ, Yoshikawa H, Ahlskog JE, Tisch SH, Benarroch EE, Kryzer TJ, Lennon VA. Glutamic acid decarboxylase autoimmunity with brainstem, extrapyramidal, and spinal cord dysfunction. Mayo Clin Proc 2006; 81:1207-14. [PMID: 16970217 DOI: 10.4065/81.9.1207] [Citation(s) in RCA: 144] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe novel neurological manifestations associated with glutamic acid decarboxylase (GAD65) autoimmunity. PATIENTS AND METHODS This retrospective study (1987-2003) describes 62 patients Incidentally found to have a serum autoantibody that bound selectively to synapse-rich central nervous system tissues. The immunostaining pattern was determined to be GAD65-specific by radiolmmunoprecipitation assay. These cases were identified among samples submitted for paraneoplastic autoantibody evaluation using indirect immunofluorescence. In no case had GAD65 or any other islet cell antibody testing been requested. RESULTS In most cases, the patients' presentations were initially considered neurodegenerative or inflammatory (multiple sclerosis or paraneoplastic). Median age at onset was 50 years, and 77% were women. Of the 44 patients seen at the Mayo Clinic, 23% were African American; in contrast, less than 10% of Mayo Clinic's neurology patients are African American. Median follow-up was 24 months. The radioimmunoprecipitation assay values for GAD65 antibody were extremely high (median, 1429 nmol/L; Interquartile range, 643-3078 nmol/L) and correlated significantly with immunofluorescence titers (median, 3840; interquartile range, 1920-15,360; r = 0.81; P < .001). Neurological manifestations were multifocal in 41 patients and included cerebellar ataxia (63%), brainstem involvement (29%), seizures (27%), stiff-man phenomena (26%), extrapyramidal signs (16%), and myelopathy (8%). One third of the patients had type 1 diabetes mellitus, 53% had thyroid autoantibodies, and 16% had vitiligo. Eleven of 20 patients identified as African American had brainstem involvement. Some patients appeared to benefit from short-term immunosuppression (none received long-term therapy). CONCLUSIONS The neurological spectrum of GAD65 autoimmunity includes brainstem, extrapyramidal, and spinal cord syndromes. In our experience, African American patients were disproportionately affected. A patient with a presumed neurodegenerative disorder of new onset, with high levels of GAD65 antibody (>20 nmol/L), merits consideration of immunotherapy.
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Affiliation(s)
- Sean J Pittock
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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Lennon VA, Kryzer TJ, Pittock SJ, Verkman AS, Hinson SR. IgG marker of optic-spinal multiple sclerosis binds to the aquaporin-4 water channel. ACTA ACUST UNITED AC 2005; 202:473-7. [PMID: 16087714 PMCID: PMC2212860 DOI: 10.1084/jem.20050304] [Citation(s) in RCA: 1570] [Impact Index Per Article: 82.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Neuromyelitis optica (NMO) is an inflammatory demyelinating disease that selectively affects optic nerves and spinal cord. It is considered a severe variant of multiple sclerosis (MS), and frequently is misdiagnosed as MS, but prognosis and optimal treatments differ. A serum immunoglobulin G autoantibody (NMO-IgG) serves as a specific marker for NMO. Here we show that NMO-IgG binds selectively to the aquaporin-4 water channel, a component of the dystroglycan protein complex located in astrocytic foot processes at the blood-brain barrier. NMO may represent the first example of a novel class of autoimmune channelopathy.
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Affiliation(s)
- Vanda A Lennon
- Department of Immunology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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Lennon VA, Wingerchuk DM, Kryzer TJ, Pittock SJ, Lucchinetti CF, Fujihara K, Nakashima I, Weinshenker BG. A serum autoantibody marker of neuromyelitis optica: distinction from multiple sclerosis. Lancet 2004; 364:2106-12. [PMID: 15589308 DOI: 10.1016/s0140-6736(04)17551-x] [Citation(s) in RCA: 2191] [Impact Index Per Article: 109.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neuromyelitis optica is an inflammatory demyelinating disease with generally poor prognosis that selectively targets optic nerves and spinal cord. It is commonly misdiagnosed as multiple sclerosis. Neither disease has a distinguishing biomarker, but optimum treatments differ. The relation of neuromyelitis optica to optic-spinal multiple sclerosis in Asia is uncertain. We assessed the capacity of a putative marker for neuromyelitis optica (NMO-IgG) to distinguish neuromyelitis optica and related disorders from multiple sclerosis. METHODS Indirect immunofluorescence with a composite substrate of mouse tissues identified a distinctive NMO-IgG staining pattern, which we characterised further by dual immunostaining. We tested masked serum samples from 102 North American patients with neuromyelitis optica or with syndromes that suggest high risk of the disorder, and 12 Japanese patients with optic-spinal multiple sclerosis. Control patients had multiple sclerosis, other myelopathies, optic neuropathies, and miscellaneous disorders. We also established clinical diagnoses for 14 patients incidentally shown to have NMO-IgG among 85000 tested for suspected paraneoplastic autoimmunity. FINDINGS NMO-IgG outlines CNS microvessels, pia, subpia, and Virchow-Robin space. It partly colocalises with laminin. Sensitivity and specificity were 73% (95% CI 60-86) and 91% (79-100) for neuromyelitis optica and 58% (30-86) and 100% (66-100) for optic-spinal multiple sclerosis. NMO-IgG was detected in half of patients with high-risk syndromes. Of 14 seropositive cases identified incidentally, 12 had neuromyelitis optica or a high-risk syndrome for the disease. INTERPRETATION NMO-IgG is a specific marker autoantibody of neuromyelitis optica and binds at or near the blood-brain barrier. It distinguishes neuromyelitis optica from multiple sclerosis. Asian optic-spinal multiple sclerosis seems to be the same as neuromyelitis optica.
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Affiliation(s)
- Vanda A Lennon
- Department of Neurology, Mayo Clinic Rochester, Rochester, MN 55905, USA.
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Abstract
We investigated coexisting autoantibodies in sera of 553 patients with a neurological presentation and one or more paraneoplastic neuronal nuclear or cytoplasmic autoantibodies: antineuronal nuclear autoantibody type 1 (ANNA-1), ANNA-2, ANNA-3; Purkinje cell cytoplasmic autoantibody type 1 (PCA-1), PCA-2; and CRMP-5-immunoglobulin G or amphiphysin-immunoglobulin G. Except for PCA-1, which occurred alone, 31% of sera had more than one of these autoantibodies. In addition, 25% of sera had neuronal calcium channel (P/Q-type or N-type), potassium channel, ganglionic acetylcholine receptor, muscle acetylcholine receptor, or striational antibodies. The autoantibody profiles observed in patients with paraneoplastic disorders imply the targeting of multiple onconeural antigens and predict the patient's neoplasm, but not a specific neurological syndrome.
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Cross SA, Salomao DR, Parisi JE, Kryzer TJ, Bradley EA, Mines JA, Lam BL, Lennon VA. Paraneoplastic autoimmune optic neuritis with retinitis defined by CRMP-5-IgG. Ann Neurol 2003; 54:38-50. [PMID: 12838519 DOI: 10.1002/ana.10587] [Citation(s) in RCA: 162] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Autoantibodies have defined two paraneoplastic visual disorders related to small-cell lung carcinoma: retinopathy ("CAR"-IgG [23kDa, recoverin]) and optic neuritis collapsin response-mediated protein 5 (CRMP-5-IgG [62kDa]). Among 16 patients with CRMP-5-IgG and optic neuritis (aged 52-74 years; all smokers, 9 women), we documented coexisting retinitis in 5. None had CAR-IgG. Fifteen had subacute vision loss, swollen optic discs, and field defects. Vascular leakage was evident at and remote from the disc; 5/5 tested had abnormal electroretinograms. Nine had striking vitreous cells. Vitrectomy showed reactive lymphocytosis (4/4), predominantly CD4(+) (1/1). Most patients had multifocal neurological accompaniments. Cerebrospinal fluid contained lymphocytes (7-32), elevated protein, multiple oligoclonal immunoglobulin bands, and CRMP-5-IgG. Three patients superficially resembled Devic's disease at presentation. One autopsied patient had predominantly CD8(+) T lymphocytes infiltrating optic nerve and spinal cord. Eleven patients had confirmed small-cell carcinoma; 1 had imaging evidence of lung cancer; 3 had renal or thyroid carcinoma. Full-length CRMP-5 protein was identified in normal retina and optic nerve by Western blot analyses. Photoreceptor cells, retinal ganglion cells, and nerve fibers exhibited CRMP-5-specific immunoreactivity. In summary, CRMP-5-IgG defines a paraneoplastic ophthalmological entity of combined optic neuritis and retinitis with vitreous inflammatory cells. Positive serology obviates the need for vitreous biopsy and expedites the search for cancer.
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Affiliation(s)
- Shelley A Cross
- Department of Neurology, Mayo Graduate and Medical Schools, Mayo Clinic, Rochester, MN 55905, USA
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Yu Z, Kryzer TJ, Griesmann GE, Kim K, Benarroch EE, Lennon VA. CRMP-5 neuronal autoantibody: marker of lung cancer and thymoma-related autoimmunity. Ann Neurol 2001; 49:146-54. [PMID: 11220734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
We have defined a new paraneoplastic immunoglobulin G (IgG) autoantibody specific for CRMP-5, a previously unknown 62-kd neuronal cytoplasmic protein of the collapsin response-mediator family. CRMP-5 is in adult central and peripheral neurons, including synapses, and in small-cell lung carcinomas. Since 1993, our Clinical Neuroimmunology Laboratory has detected CRMP-5-IgG in 121 patients among approximately 68,000 whose sera were submitted for standardized immunofluorescence screening because a subacute neurological presentation was suspected to be paraneoplastic. This makes CRMP-5 autoantibody as frequent as PCA-1 (anti-Yo) autoantibody, second only to ANNA-1 (anti-Hu). Clinical information, obtained for 116 patients, revealed multifocal neurological signs. Most remarkable were the high frequencies of chorea (11%) and cranial neuropathy (17%, including 10% loss of olfaction/taste, 7% optic neuropathy). Other common signs were peripheral neuropathy (47%), autonomic neuropathy (31%), cerebellar ataxia (26%), subacute dementia (25%), and neuromuscular junction disorders (12%). Spinal fluid was inflammatory in 86%, and CRMP-5-IgG in 37% equaled or significantly exceeded serum titers. Lung carcinoma (mostly limited small-cell) was found in 77% of patients; thymoma was in 6%. Half of those remaining had miscellaneous neoplasms; all but two were smokers. Serum IgG in all cases bound to recombinant CRMP-5 (predominantly N-terminal epitopes), but not to human CRMP-2 or CRMP-3.
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Affiliation(s)
- Z Yu
- Department of Immunology, Mayo Clinic, Rochester, MN 55905, USA
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Lennon VA, Kryzer TJ. Neuronal calcium channel autoantibodies coexisting with type 1 Purkinje cell cytoplasmic autoantibodies (PCA-1 or "anti-Yo"). Neurology 1998; 51:327-9. [PMID: 9674845 DOI: 10.1212/wnl.51.1.327] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Vernino S, Adamski J, Kryzer TJ, Fealey RD, Lennon VA. Neuronal nicotinic ACh receptor antibody in subacute autonomic neuropathy and cancer-related syndromes. Neurology 1998; 50:1806-13. [PMID: 9633732 DOI: 10.1212/wnl.50.6.1806] [Citation(s) in RCA: 148] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Autoantibodies specific for the acetylcholine receptor (AChR) of skeletal muscle (containing the alpha1 subunit) impair neuromuscular transmission in myasthenia gravis (MG). AChRs mediating fast synaptic transmission through autonomic ganglia are structurally similar to muscle AChR, but contain the alpha3 subunit. We propose that ganglionic AChR autoimmunity may cause dysautonomia. OBJECTIVE To test serum of patients with autonomic neuropathy for autoantibodies of neuronal ganglionic AChR specificity. METHODS We developed an immunoprecipitation radioassay by complexing epibatidine (125I-labeled high affinity agonist) to a Triton X-100-solubilized AChR antigen from peripheral neuroblastoma membranes. Monoclonal rat immunoglobulins (IgG) specific for muscle or neuronal AChRs validated the assay's specificity. We tested serum from 52 healthy subjects, 12 patients with subacute autonomic neuropathy, and 248 patients with other neurologic disorders. RESULTS Twelve patients had antibodies that bound unequivocally to ganglionic AChR. Five had subacute autonomic neuropathy, and three (of six tested) had Isaacs' syndrome; four of these eight had a carcinoma (lung, bladder, rectum, thyroid). The remaining four seropositive patients (two Lambert-Eaton syndrome, one dementia, one sensory neuronopathy) all had Ca2+ channel antibodies and three had small cell lung carcinoma. No healthy subject had ganglionic AChR antibodies, nor did 62 patients with MG and muscle AChR antibodies. CONCLUSION Neuronal AChR antibodies are a novel serologic marker of neurologic autoimmunity. The pathogenicity of neuronal AChR autoantibodies in autonomic neuropathy, Isaacs' syndrome, or other neurologic disorders remains to be shown, as has been demonstrated for muscle AChR antibodies in MG. An autoimmune and potentially paraneoplastic etiology is implicated in seropositive patients.
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Affiliation(s)
- S Vernino
- Department of Immunology, Mayo Clinic, Rochester, MN 55905, USA
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Black JL, Griesmann GE, Erickson J, Kryzer TJ, Lamke GT, Lennon VA. Lambert-Eaton myasthenic syndrome. Antigenicity of recombinant human P/Q-type calcium channel alpha 1 subunit putative ion pore region (domain IV, S5-S6). Ann N Y Acad Sci 1998; 841:691-5. [PMID: 9668316 DOI: 10.1111/j.1749-6632.1998.tb11004.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- J L Black
- Department of Psychiatry, Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Lennon VA, Kryzer TJ, Griesmann GE, O'Suilleabhain PE, Windebank AJ, Woppmann A, Miljanich GP, Lambert EH. Calcium-channel antibodies in the Lambert-Eaton syndrome and other paraneoplastic syndromes. N Engl J Med 1995; 332:1467-74. [PMID: 7739683 DOI: 10.1056/nejm199506013322203] [Citation(s) in RCA: 446] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Voltage-gated calcium channels in small-cell lung carcinomas may initiate autoimmunity in the paraneoplastic neuromuscular disorder Lambert-Eaton syndrome. The calcium-channel subtype that is responsible is not known. METHODS We compared the effects of antagonists of L-type, N-type, and P/Q-type neuronal calcium channels on the depolarization-dependent influx of calcium-45 in cultured carcinoma cells. Serum samples from patients with various disorders were tested for reactivity with P/Q-type channels solubilized from carcinoma and cerebellar membranes and N-type channels from cerebral cortex. RESULTS P/Q-type calcium-channel antagonists were the most potent inhibitors of depolarization-induced 45Ca influx in cultured small-cell carcinoma cell lines. Anti-P/Q-type calcium-channel antibodies were found in serum from all 32 patients with Lambert-Eaton syndrome and a diagnosis of cancer and in 91 percent of the 33 patients with Lambert-Eaton syndrome without cancer. Anti-N-type calcium-channel antibodies were found in 49 percent of the 65 patients with the Lambert-Eaton Syndrome. Lower titers of anti-P/Q-type and anti-N-type calcium-channel antibodies were found in 54 percent of 70 patients with a paraneoplastic encephalomyeloneuropathic complication of lung, ovarian, or breast carcinoma, 24 percent of 90 patients with cancer but no evident neurologic complications, 23 percent of 78 patients with sporadic amyotrophic lateral sclerosis, and less than 3 percent of 69 patients with myasthenia gravis, epilepsy, or scleroderma. CONCLUSIONS The high frequency of P/Q-type calcium-channel antibodies found in patients with Lambert-Eaton syndrome implies that antibodies of this specificity have a role in the presynaptic pathophysiology of this disorder.
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Affiliation(s)
- V A Lennon
- Department of Immunology, Mayo Clinic, Rochester, MN 55905, USA
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