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Peng Y, Yang H, Xue YH, Chen Q, Jin H, Liu S, Yao SY, Du MQ. An update on malignant tumor-related stiff person syndrome spectrum disorders: clinical mechanism, treatment, and outcomes. Front Neurol 2023; 14:1209302. [PMID: 37859648 PMCID: PMC10582361 DOI: 10.3389/fneur.2023.1209302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/01/2023] [Indexed: 10/21/2023] Open
Abstract
Stiff person syndrome (SPS) is a rare central nervous system disorder associated with malignancies. In this review, we retrieved information from PubMed, up until August 2023, using various search terms and their combinations, including SPS, stiff person syndrome spectrum disorders (SPSSDs), paraneoplastic, cancer, and malignant tumor. Data from peer-reviewed journals printed in English were organized to explain the possible relationships between different carcinomas and SPSSD subtypes, as well as related autoantigens. From literature searching, it was revealed that breast cancer was the most prevalent carcinoma linked to SPSSDs, followed by lung cancer and lymphoma. Furthermore, classic SPS was the most common SPSSD subtype, followed by stiff limb syndrome and progressive encephalomyelitis with rigidity and myoclonus. GAD65 was the most common autoantigen in patients with cancer and SPSSDs, followed by amphiphysin and GlyR. Patients with cancer subtypes might have multiple SPSSD subtypes, and conversely, patients with SPSSD subtypes might have multiple carcinoma subtypes. The first aim of this review was to highlight the complex nature of the relationships among cancers, autoantigens, and SPSSDs as new information in this field continues to be generated globally. The adoption of an open-minded approach to updating information on new cancer subtypes, autoantigens, and SPSSDs is recommended to renew our database. The second aim of this review was to discuss SPS animal models, which will help us to understand the mechanisms underlying the pathogenesis of SPS. In future, elucidating the relationship among cancers, autoantigens, and SPSSDs is critical for the early prediction of cancer and discovery of new therapeutic modalities.
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Affiliation(s)
- Yong Peng
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ya-hui Xue
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Quan Chen
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Hong Jin
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Shu Liu
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Shun-yu Yao
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Miao-qiao Du
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
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2
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Vlad B, Wang Y, Newsome SD, Balint B. Stiff Person Spectrum Disorders-An Update and Outlook on Clinical, Pathophysiological and Treatment Perspectives. Biomedicines 2023; 11:2500. [PMID: 37760941 PMCID: PMC10525659 DOI: 10.3390/biomedicines11092500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Stiff person spectrum disorders (SPSD) are paradigm autoimmune movement disorders characterized by stiffness, spasms and hyperekplexia. Though rare, SPSD represent a not-to-miss diagnosis because of the associated disease burden and treatment implications. After decades as an enigmatic orphan disease, major advances in our understanding of the evolving spectrum of diseases have been made along with the identification of multiple associated autoantibodies. However, the most important recent developments relate to the recognition of a wider affection, beyond the classic core motor symptoms, and to further insights into immunomodulatory and symptomatic therapies. In this review, we summarize the recent literature on the clinical and paraclinical spectrum, current pathophysiological understanding, as well as current and possibly future therapeutic strategies.
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Affiliation(s)
- Benjamin Vlad
- Department of Neurology, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Yujie Wang
- Department of Neurology, University of Washington, Seattle, WA 98195, USA
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Scott D. Newsome
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Bettina Balint
- Department of Neurology, University Hospital Zurich, 8091 Zurich, Switzerland;
- Faculty of Medicine, University of Zurich, 8091 Zurich, Switzerland
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3
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Zong S, Vinke AM, Du P, Hoffmann C, Mané-Damas M, Molenaar PC, Damoiseaux JGMC, Losen M, Rouhl RPW, Martinez-Martinez P. Anti-GAD65 autoantibody levels measured by ELISA and alternative types of immunoassays in relation to neuropsychiatric diseases versus diabetes mellitus type 1. Front Neurol 2023; 14:1111063. [PMID: 37305746 PMCID: PMC10248002 DOI: 10.3389/fneur.2023.1111063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 05/10/2023] [Indexed: 06/13/2023] Open
Abstract
Background Anti-GAD65 autoantibodies (GAD65-Abs) may occur in patients with epilepsy and other neurological disorders, but the clinical significance is not clear-cut. Whereas high levels of GAD65-Abs are considered pathogenic in neuropsychiatric disorders, low or moderate levels are only considered as mere bystanders in, e.g., diabetes mellitus type 1 (DM1). The value of cell-based assays (CBA) and immunohistochemistry (IHC) for GAD65-Abs detection has not been clearly evaluated in this context. Objective To re-evaluate the assumption that high levels of GAD65-Abs are related to neuropsychiatric disorders and lower levels only to DM1 and to compare ELISA results with CBA and IHC to determine the additional value of these tests. Methods 111 sera previously assessed for GAD65-Abs by ELISA in routine clinical practice were studied. Clinical indications for testing were, e.g., suspected autoimmune encephalitis or epilepsy (neuropsychiatric cohort; n = 71, 7 cases were initially tested positive for GAD65-Abs by ELISA), and DM1 or latent autoimmune diabetes in adults (DM1/LADA cohort (n = 40, all were initially tested positive)). Sera were re-tested for GAD65-Abs by ELISA, CBA, and IHC. Also, we examined the possible presence of GAD67-Abs by CBA and of other neuronal autoantibodies by IHC. Samples that showed IHC patterns different from GAD65 were further tested by selected CBAs. Results ELISA retested GAD65-Abs level in patients with neuropsychiatric diseases was higher than in patients with DM1/LADA (only retested positive samples were compared; 6 vs. 38; median 47,092 U/mL vs. 581 U/mL; p = 0.02). GAD-Abs showed positive both by CBA and IHC only if antibody levels were above 10,000 U/mL, without a difference in prevalence between the studied cohorts. We found other neuronal antibodies in one patient with epilepsy (mGluR1-Abs, GAD-Abs negative), and in a patient with encephalitis, and two patients with LADA. Conclusion GAD65-Abs levels are significantly higher in patients with neuropsychiatric disease than in patients with DM1/LADA, however, positivity in CBA and IHC only correlates with high levels of GAD65-Abs, and not with the underlying diseases.
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Affiliation(s)
- Shenghua Zong
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
| | - Anita M. Vinke
- Department of Neurology, Maastricht University Medical Center (MUMC +), Maastricht, Netherlands
| | - Peng Du
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
| | - Carolin Hoffmann
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
- Algarve Biomedical Center, Algarve Biomedical Center Research Institute, Faro, Portugal
| | - Marina Mané-Damas
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
| | - Peter C. Molenaar
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
| | | | - Mario Losen
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
| | - Rob P. W. Rouhl
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
- Department of Neurology, Maastricht University Medical Center (MUMC +), Maastricht, Netherlands
- Academic Centre for Epileptology Kempenhaeghe/MUMC+, Maastricht, Netherlands
| | - Pilar Martinez-Martinez
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
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4
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Hou JY, Liu HU, Kuo CY, Liu YH, Lin JJ, Hsieh MY, Hung PC, Cheng YT, Su IC, Wang HS, Chou IJ, Lin KL. The clinical relevance of anti-glutamic acid decarboxylase antibodies in children with encephalitis/encephalopathy. Front Neurosci 2023; 16:1081580. [PMID: 36817097 PMCID: PMC9932768 DOI: 10.3389/fnins.2022.1081580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/31/2022] [Indexed: 02/05/2023] Open
Abstract
Anti-glutamic acid decarboxylase (anti-GAD) antibodies are associated with different types of syndromes. However, few studies have investigated the correlation between anti-GAD antibody titers with clinical severity and outcomes in children with encephalitis/encephalopathy. In this single-center retrospective cohort study, we consecutively enrolled hospitalized children who had encephalitis and/or encephalopathy with positive anti-GAD antibodies in serum and/or cerebrospinal fluid (CSF) from February 2010 to October 2021. Thirty-seven patients were included and divided into high-titer and low-titer groups. The patients with high anti-GAD antibody titers were associated with initial symptoms of language difficulty and ataxia. The level of titers was not associated with severity or outcomes. Anti-GAD antibody titers decreased after immunotherapy, however, the clinical response to immunotherapy was variable. A transient elevation in anti-GAD antibody titers during immunotherapy was noted. Further studies are warranted to investigate the role of anti-GAD antibodies in the pathogenesis and immune mechanisms of encephalitis/encephalopathy.
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Affiliation(s)
- Ju-Yin Hou
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Hsin-Uei Liu
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Cheng-Yen Kuo
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Yi-Hsuan Liu
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Jainn-Jim Lin
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan,Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Meng-Ying Hsieh
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Po-Cheng Hung
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Yi-Ting Cheng
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - I-Chen Su
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Huei-Shyong Wang
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - I-Jun Chou
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan,College of Medicine, Chang Gung University, Taoyuan City, Taiwan,I-Jun Chou,
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Department of Pediatric, Chang Gung Children’s Hospital and Chang Gung Memorial Hospital, Taoyuan City, Taiwan,College of Medicine, Chang Gung University, Taoyuan City, Taiwan,*Correspondence: Kuang-Lin Lin,
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5
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Newsome SD, Johnson T. Stiff person syndrome spectrum disorders; more than meets the eye. J Neuroimmunol 2022; 369:577915. [PMID: 35717735 PMCID: PMC9274902 DOI: 10.1016/j.jneuroim.2022.577915] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 05/21/2022] [Accepted: 06/07/2022] [Indexed: 10/18/2022]
Abstract
Stiff person syndrome spectrum disorders (SPSD) are a group of rare neuroimmunological disorders that often include painful spasms and rigidity. However, patients have highly heterogeneous signs and symptoms which may reflect different mechanistic disease processes. Understanding subsets of patients based on clinical phenotype may be important for prognosis and guiding treatment. The goal of this review is to provide updates on SPSD and its expanding clinical spectrum, prognostic markers, and treatment considerations. Further, we describe the current understanding in immunopathogenesis and highlight gaps in our knowledge appropriate for future research directions. Examples of revised diagnostic criteria for SPSD based on phenotype are also presented.
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Affiliation(s)
- Scott D Newsome
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Tory Johnson
- Johns Hopkins University School of Medicine, Baltimore, MD, USA; Section of Infections of the Nervous System, NINDS, NIH, Bethesda, MD, USA
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6
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Li Y, Gao J, Xue L, Shang Y, Cai W, Xie X, Jiang T, Chen H, Zhang J, Wang J, Chen M, Ding Y, Wu Q. Determination of Antiviral Mechanism of Centenarian Gut-Derived Limosilactobacillus fermentum Against Norovirus. Front Nutr 2022; 9:812623. [PMID: 35419394 PMCID: PMC8997286 DOI: 10.3389/fnut.2022.812623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/11/2022] [Indexed: 01/03/2023] Open
Abstract
Although noroviruses are the causative agents of most non-bacterial foodborne disease outbreaks, effective antivirals are currently unavailable. Certain probiotic strains have been reported as active antivirals for norovirus infections, but their mechanisms have not been fully elucidated. Herein, we examined the antiviral potential of 122 lactic acid bacteria isolates against murine norovirus (MNV), a human norovirus surrogate. A centenarian gut-derived strain, Limosilactobacillus fermentum PV22, exhibited the strongest MNV antagonism and reduced the viral titer by 2.23 ± 0.38 (log-value) in 5 min with stable activity at 25°C (P < 0.01). Genome mining revealed that its antiviral activity can be attributed to the synthesis of γ-aminobutyric acid, and this finding was experimentally verified. Furthermore, we demonstrated the safety of the isolate and its high intestinal colonization ability. In conclusion, we discovered a centenarian gut-derived L. fermentum strain with strong anti-norovirus activity and identified its antiviral metabolite. Our results will offer new solutions for the prevention and treatment of food-related norovirus infections.
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Affiliation(s)
- Ying Li
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, State Key Laboratory of Applied Microbiology Southern China, Ministry of Agriculture and Rural Affairs, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou, China
| | - Junshan Gao
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, State Key Laboratory of Applied Microbiology Southern China, Ministry of Agriculture and Rural Affairs, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou, China
| | - Liang Xue
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, State Key Laboratory of Applied Microbiology Southern China, Ministry of Agriculture and Rural Affairs, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou, China
| | - Yanyan Shang
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, State Key Laboratory of Applied Microbiology Southern China, Ministry of Agriculture and Rural Affairs, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou, China
| | - Weicheng Cai
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, State Key Laboratory of Applied Microbiology Southern China, Ministry of Agriculture and Rural Affairs, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou, China
| | - Xinqiang Xie
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, State Key Laboratory of Applied Microbiology Southern China, Ministry of Agriculture and Rural Affairs, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou, China
| | - Tong Jiang
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, State Key Laboratory of Applied Microbiology Southern China, Ministry of Agriculture and Rural Affairs, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou, China
| | - Huizhen Chen
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, State Key Laboratory of Applied Microbiology Southern China, Ministry of Agriculture and Rural Affairs, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou, China
| | - Jumei Zhang
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, State Key Laboratory of Applied Microbiology Southern China, Ministry of Agriculture and Rural Affairs, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou, China
| | - Juan Wang
- College of Food Science, South China Agricultural University, Guangzhou, China
| | - Moutong Chen
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, State Key Laboratory of Applied Microbiology Southern China, Ministry of Agriculture and Rural Affairs, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou, China
| | - Yu Ding
- Department of Food Science and Technology, Institute of Food Safety and Nutrition, Jinan University, Guangzhou, China
| | - Qingping Wu
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, State Key Laboratory of Applied Microbiology Southern China, Ministry of Agriculture and Rural Affairs, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou, China
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7
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Khan A, Bellio MA, Schulman IH, Levi AD, Longsomboon B, Brooks A, Valasaki K, DiFede DL, Pujol MV, Yavagal DR, Bates KE, Si MS, Kaushal S, Green BA, Anderson KD, Guest JD, Burks SS, Silvera R, Santamaria AJ, Lalwani A, Dietrich WD, Hare JM. The Interdisciplinary Stem Cell Institute's Use of Food and Drug Administration-Expanded Access Guidelines to Provide Experimental Cell Therapy to Patients With Rare Serious Diseases. Front Cell Dev Biol 2021; 9:675738. [PMID: 34169074 PMCID: PMC8217825 DOI: 10.3389/fcell.2021.675738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/04/2021] [Indexed: 11/15/2022] Open
Abstract
The U.S. Food and Drug Administration (FDA) provides guidance for expanded access to experimental therapies, which in turn plays an important role in the Twenty-first Century Cures Act mandate to advance cell-based therapy. In cases of incurable diseases where there is a lack of alternative treatment options, many patients seek access to cell-based therapies for the possibility of treatment responses demonstrated in clinical trials. Here, we describe the use of the FDA’s expanded access to investigational new drug (IND) to address rare and emergency conditions that include stiff-person syndrome, spinal cord injury, traumatic brain stem injury, complex congenital heart disease, ischemic stroke, and peripheral nerve injury. We have administered both allogeneic bone marrow-derived mesenchymal stem cell (MSC) and autologous Schwann cell (SC) therapy to patients upon emergency request using Single Patient Expanded Access (SPEA) INDs approved by the FDA. In this report, we present our experience with 10 completed SPEA protocols.
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Affiliation(s)
- Aisha Khan
- Leonard M. Miller School of Medicine, The Interdisciplinary Stem Cell Institute, University of Miami, Miami, FL, United States.,The Miami Project to Cure Paralysis, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Michael A Bellio
- Leonard M. Miller School of Medicine, The Interdisciplinary Stem Cell Institute, University of Miami, Miami, FL, United States
| | - Ivonne H Schulman
- Leonard M. Miller School of Medicine, The Interdisciplinary Stem Cell Institute, University of Miami, Miami, FL, United States.,Katz Family Division of Nephrology and Hypertension, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Allan D Levi
- The Miami Project to Cure Paralysis, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Bangon Longsomboon
- Leonard M. Miller School of Medicine, The Interdisciplinary Stem Cell Institute, University of Miami, Miami, FL, United States
| | - Adriana Brooks
- Leonard M. Miller School of Medicine, The Interdisciplinary Stem Cell Institute, University of Miami, Miami, FL, United States.,The Miami Project to Cure Paralysis, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Krystalenia Valasaki
- Leonard M. Miller School of Medicine, The Interdisciplinary Stem Cell Institute, University of Miami, Miami, FL, United States
| | - Darcy L DiFede
- Leonard M. Miller School of Medicine, The Interdisciplinary Stem Cell Institute, University of Miami, Miami, FL, United States
| | - Marietsy V Pujol
- Leonard M. Miller School of Medicine, The Interdisciplinary Stem Cell Institute, University of Miami, Miami, FL, United States
| | - Dileep R Yavagal
- Leonard M. Miller School of Medicine, The Interdisciplinary Stem Cell Institute, University of Miami, Miami, FL, United States.,The Department of Clinical Neurology and Neurosurgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Karen E Bates
- The Department of Clinical Neurology and Neurosurgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Ming-Sing Si
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, MI, United States
| | - Sunjay Kaushal
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Barth A Green
- The Miami Project to Cure Paralysis, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | | | - James D Guest
- The Miami Project to Cure Paralysis, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Stephen Shelby Burks
- The Department of Neurological Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Risset Silvera
- Leonard M. Miller School of Medicine, The Interdisciplinary Stem Cell Institute, University of Miami, Miami, FL, United States.,The Miami Project to Cure Paralysis, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Andrea J Santamaria
- The Miami Project to Cure Paralysis, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Anil Lalwani
- Medtronic ST Neurosurgery, Louisville, CO, United States
| | - W Dalton Dietrich
- The Miami Project to Cure Paralysis, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Joshua M Hare
- Leonard M. Miller School of Medicine, The Interdisciplinary Stem Cell Institute, University of Miami, Miami, FL, United States.,Division of Cardiology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
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8
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Tsiortou P, Alexopoulos H, Dalakas MC. GAD antibody-spectrum disorders: progress in clinical phenotypes, immunopathogenesis and therapeutic interventions. Ther Adv Neurol Disord 2021; 14:17562864211003486. [PMID: 33854562 PMCID: PMC8013924 DOI: 10.1177/17562864211003486] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 02/27/2021] [Indexed: 12/14/2022] Open
Abstract
Antibodies against glutamic acid decarboxylase (GAD), originally linked to stiff person syndrome (SPS), now denote the "GAD antibody-spectrum disorders" (GAD-SD) that also include autoimmune epilepsy, limbic encephalitis, cerebellar ataxia and nystagmus with overlapping symptomatology highlighting autoimmune neuronal excitability disorders. The reasons for the clinical heterogeneity among GAD-antibody associated syndromes remain still unsettled, implicating variable susceptibility of GABAergic neurons to anti-GAD or other still unidentified autoantibodies. Although anti-GAD antibody titers do not correlate with clinical severity, very high serum titers, often associated with intrathecal synthesis of anti-GAD-specific IgG, point to in-situ effects of GAD or related autoantibodies within the central nervous system. It remains, however, uncertain what drives these antibodies, why they persist and whether they are disease markers or have pathogenic potential. The review, focused on these concerns, describes the widened clinical manifestations and overlapping features of all GAD-SD; addresses the importance of GAD antibody titers and potential significance of GAD epitopes; summarizes the biologic basis of autoimmune hyperexcitability; highlights the electrophysiological basis of reciprocal inhibition in muscle stiffness; and provides practical guidelines on symptomatic therapies with gamma-aminobutyric acid-enhancing drugs or various immunotherapies.
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Affiliation(s)
- Popianna Tsiortou
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Philadelphia, PA 19107, USA; Neuroimmunology Unit, National and Kapodistrian University of Athens, Athens, Greece
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9
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Glutamic acid decarboxylase antibodies in neurocritical patients: a culprit or a bystander? Neurol Sci 2020; 41:3691-3696. [PMID: 32514855 PMCID: PMC7278224 DOI: 10.1007/s10072-020-04466-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/09/2020] [Indexed: 11/21/2022]
Abstract
Background Glutamic acid decarboxylase (GAD) is an intracellular enzyme, which is widely expressed in central nervous system (CNS), pancreas, and other organs. GAD antibodies (GAD-Abs) are linked to various neurological disorders. However, the significance of GAD-Abs in neurocritical patients is undetermined. Materials and methods Patients with serologically positive GAD-Abs and requiring neurocritical care were included. The clinical, laboratory, and outcome data were retrospectively collected. Results We included 9 patients with serologically positive GAD-Abs. Clinical manifestations involved both CNS and peripheral nervous system (PNS). Six (66.7%) patients had other specific autoimmune antibodies. Non-specific autoimmune responses were observed in 8 (88.9%) patients. All patients clinically responded well to immunotherapy. The titers of GAD-Abs decreased in 7 (77.8%) patients but remained unchanged in the other 2 patients. One (11.1%) patient awoke before the negative conversion of GAD-Abs, and 3 (33.3%) patients remained unconscious and/or under mechanical ventilation for several weeks after the vanishing of GAD-Abs. Conclusions Most neurocritical patients with serologically positive GAD-Abs had other specific autoimmune antibodies. All patients responded well to immunotherapy, but not parallel to the titers of GAD-Abs. These results indicated that GAD-Abs might be more a bystander than a culprit in neurocritical patients, suggesting that an underlying autoimmune disease should be explored.
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Graus F, Saiz A, Dalmau J. GAD antibodies in neurological disorders — insights and challenges. Nat Rev Neurol 2020; 16:353-365. [DOI: 10.1038/s41582-020-0359-x] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2020] [Indexed: 01/07/2023]
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11
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Immune-mediated epilepsy with GAD65 antibodies. J Neuroimmunol 2020; 341:577189. [PMID: 32087461 DOI: 10.1016/j.jneuroim.2020.577189] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 02/11/2020] [Accepted: 02/11/2020] [Indexed: 12/18/2022]
Abstract
Anti-GAD65 antibodies have been identified in both acute/subacute seizures (limbic encephalitis and extralimbic encephalitis) and chronic isolated epilepsy. The evidence of high serum titers and intrathecal synthesis play a fundamental role in diagnosis but poorly correlate with disease severity or response to therapies. It remains controversial whether anti-GAD65 Abs are the pathogenic entity or only serve as a surrogate marker for autoimmune disorders mediated by cytotoxic T cells. Unlike other immune-mediated epilepsy, although multiple combinations of therapeutics are used, the efficacy and prognosis of patients with GAD65-epilepsy patients are poor. Besides, GAD65-epilepsy is more prone to relapse and potentially evolve into a more widespread CNS inflammatory disorder. This article reviews the recent advances of GAD65-epilepsy, focusing on the diagnosis, epidemiology, pathophysiology, clinical features, and treatment, to better promote the recognition and provide proper therapy for this condition.
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12
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El-Abassi R, Soliman MY, Villemarette-Pittman N, England JD. SPS: Understanding the complexity. J Neurol Sci 2019; 404:137-149. [PMID: 31377632 DOI: 10.1016/j.jns.2019.06.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 05/31/2019] [Accepted: 06/17/2019] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Stiff-person syndrome (SPS), first described in 1956 by Moersch and Woltman, is a progressive autoimmune disorder with core features of chronic fluctuating progressive truncal and limb rigidity and painful muscle spasms leading to gait difficulties, falls and an appearance that resembles tin soldiers. The syndrome is a rare, highly disabling disorder of the central nervous and frequently results in significant disability. Understanding of the etiology, clinical spectrum, diagnostic workup and therapeutic modalities for this painful and disabling disorder has vastly evolved over the past few years with more confidence in classifying and treating the patients. The purpose of this review is to increase the awareness, early detection, and treatment of this disabling disease. METHOD PubMed was searched, all date inclusive, using the following phrases: stiff person syndrome,anti-Glutamic acid decarboxylase (Anti-GAD) antibody syndrome, Progressive encephalomyelitis with rigidity and myoclonus (PERM), and Paraneoplastic Stiff Person syndrome. No filters or restrictions were used. A total of 888 articles were identified. RESULTS The results were narrowed to 190 citations after excluding non-English and duplicate reports. Clinical presentation, laboratory testing, treatment, and prognosis were categorized and summarized. DISCUSSION In this article we will discuss the epidemiology, presentation and classification. Explain the pathophysiology of SPS and the autoimmune mechanisms involved. Discuss the diagnostic approach and treatments available, as well as, the prognosis and outcome.
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Affiliation(s)
- Rima El-Abassi
- Department of Neurology, Louisiana State University School of medicine, New Orleans, USA.
| | - Michael Y Soliman
- Department of Neurology, Louisiana State University School of medicine, New Orleans, USA
| | | | - John D England
- Department of Neurology, Louisiana State University School of medicine, New Orleans, USA
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Baizabal-Carvallo JF. The neurological syndromes associated with glutamic acid decarboxylase antibodies. J Autoimmun 2019; 101:35-47. [DOI: 10.1016/j.jaut.2019.04.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/07/2019] [Accepted: 04/08/2019] [Indexed: 12/12/2022]
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14
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Giannoccaro MP, Menassa DA, Jacobson L, Coutinho E, Prota G, Lang B, Leite MI, Cerundolo V, Liguori R, Vincent A. Behaviour and neuropathology in mice injected with human contactin-associated protein 2 antibodies. Brain 2019; 142:2000-2012. [PMID: 31079141 DOI: 10.1093/brain/awz119] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 01/21/2019] [Accepted: 03/05/2019] [Indexed: 12/31/2022] Open
Abstract
Serum antibodies that bind to the surface of neurons or glia are associated with a wide range of rare but treatable CNS diseases. In many, if not most instances, the serum levels are higher than CSF levels yet most of the reported attempts to reproduce the human disease in mice have used infusion of antibodies into the mouse cerebral ventricle(s) or intrathecal space. We used the intraperitoneal route and injected purified plasma IgG from either a CASPR2-antibody-positive patient (n = 10 mice) or healthy individual (n = 9 mice) daily for 8 days. Lipopolysaccharide was injected intraperitoneally on Day 3 to cause a temporary breach in the blood brain barrier. A wide range of baseline behaviours, including tests of locomotion, coordination, memory, anxiety and social interactions, were established before the injections and tested from Day 5 until Day 11. At termination, brain tissue was analysed for human IgG, CASPR2 and c-fos expression, lymphocyte infiltration, and neuronal, astrocytic and microglial markers. Mice exposed to CASPR2-IgG, compared with control-IgG injected mice, displayed reduced working memory during the continuous spontaneous alternation test with trends towards reduced short-term and long-term memories. In the open field tests, activities were not different from controls, but in the reciprocal social interaction test, CASPR2-IgG injected mice showed longer latency to start interacting, associated with more freezing behaviour and reduced non-social activities of rearing and grooming. At termination, neuropathology showed more IgG deposited in the brains of CASPR2-IgG injected mice, but a trend towards increased CASPR2 expression; these results were mirrored in short-term in vitro experiments where CASPR2-IgG binding to hippocampal neurons and to CASPR2-transfected HEK cells led to some internalization of the IgG, but with a trend towards higher surface CASPR2 expression. Despite these limited results, in the CASPR2-IgG injected mouse brains there was increased c-fos expression in the piriform-entorhinal cortex and hypothalamus, and a modest loss of Purkinje cells. There was also increased microglia density, morphological changes in both microglia and astrocytes and raised complement C3 expression on astrocytes, all consistent with glial activation. Patients with CASPR2 antibodies can present with a range of clinical features reflecting central, autonomic and peripheral dysfunction. Although the behavioural changes in mice were limited to social interactions and mild working-memory defects, the neuropathological features indicate potentially widespread effects of the antibodies on different brain regions.
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Affiliation(s)
- Maria Pia Giannoccaro
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - David A Menassa
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Biological Sciences, University of Southampton, Southampton, UK
| | - Leslie Jacobson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Ester Coutinho
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Gennaro Prota
- MRC Human Immunology Unit, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Bethan Lang
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - M Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Vincenzo Cerundolo
- MRC Human Immunology Unit, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Rocco Liguori
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- IRCSS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Rogers JP, Pollak TA, Blackman G, David AS. Catatonia and the immune system: a review. Lancet Psychiatry 2019; 6:620-630. [PMID: 31196793 PMCID: PMC7185541 DOI: 10.1016/s2215-0366(19)30190-7] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 03/27/2019] [Accepted: 04/04/2019] [Indexed: 12/13/2022]
Abstract
Catatonia is a psychomotor disorder featuring stupor, posturing, and echophenomena. This Series paper examines the evidence for immune dysregulation in catatonia. Activation of the innate immune system is associated with mutism, withdrawal, and psychomotor retardation, which constitute the neurovegetative features of catatonia. Evidence is sparse and conflicting for acute-phase activation in catatonia, and whether this feature is secondary to immobility is unclear. Various viral, bacterial, and parasitic infections have been associated with catatonia, but it is primarily linked to CNS infections. The most common cause of autoimmune catatonia is N-methyl-D-aspartate receptor (NMDAR) encephalitis, which can account for the full spectrum of catatonic features. Autoimmunity appears to cause catatonia less by systemic inflammation than by the downstream effects of specific actions on extracellular antigens. The specific association with NMDAR encephalitis supports a hypothesis of glutamatergic hypofunction in catatonia.
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Affiliation(s)
- Jonathan P Rogers
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; South London and Maudsley National Health Service Foundation Trust, Bethlem Royal Hospital, UK.
| | - Thomas A Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; South London and Maudsley National Health Service Foundation Trust, Bethlem Royal Hospital, UK
| | - Graham Blackman
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; South London and Maudsley National Health Service Foundation Trust, Bethlem Royal Hospital, UK
| | - Anthony S David
- Institute of Mental Health, University College London, London, UK
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16
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Rakocevic G, Alexopoulos H, Dalakas MC. Quantitative clinical and autoimmune assessments in stiff person syndrome: evidence for a progressive disorder. BMC Neurol 2019; 19:1. [PMID: 30606131 PMCID: PMC6317182 DOI: 10.1186/s12883-018-1232-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 12/19/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Stiff Person Syndrome (SPS) is an under-diagnosed disorder that affects mobility and the quality of life of affected patients. The aim of the study is to describe the natural history of SPS, the extent of accumulated disability and the associated clinical and immunological features in patients followed for up to 8 years in a single center. METHODS Our collective cohort included 57 SPS patients. Additionally, 32 of these patients were examined every 6 months for a two-year period in a longitudinal study protocol, to assess disease progression using quantitative measures of stiffness and heightened sensitivity. RESULTS The most frequent initial symptom was leg stiffness, followed by paraspinal muscle rigidity and painful spasms in 95% of the patients. Although none of the patients required assistance for ambulation during the first 2 years of disease onset, 46 patients (80%) lost the ability to walk independently during our follow-up, despite symptomatic medications. In the longitudinal cohort, the number of stiff areas increased (p < 0.0001), consistent with worsening functional status and quality of life. High-titer anti-GAD antibodies were present in serum and CSF with elevated intrathecal GAD-specific IgG synthesis, but they did not correlate with clinical severity or progression. CONCLUSIONS This large study on SPS patients, combining an eight-year follow-up at a single center by the same leading neurologist and his team, is the first to provide longitudinal data in a large patient subgroup using objective clinical measures. One of the main findings is that SPS is a progressive disease leading to physical disability over time.
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Affiliation(s)
- Goran Rakocevic
- Department of Neurology, Thomas Jefferson University, Philadelphia, USA
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C. Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, USA
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Huang J, Li H, Zhou R, Huang W, Lin W, Chen T, Long Y. Clinical Heterogeneity in Patients with Glutamate Decarboxylase Antibody. Neuroimmunomodulation 2019; 26:234-238. [PMID: 31661704 DOI: 10.1159/000502695] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 08/08/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To explore the diversity and clinical features of anti-glutamate decarboxylase (GAD) antibody-associated neurological diseases. METHODS Clinical data of a series of 5 patients positive for anti-GAD antibodies were retrospectively analyzed. RESULTS All 5 patients were female, with a median age of 41.5 years (range 19-60 years). Their neurological symptoms included stiff-person syndrome (SPS), encephalitis, myelitis, cramp, visual loss, and paresthesia. Three patients (60%) were diagnosed with tumors, 2 cases of thymic tumor and 1 of breast cancer. On immunohistochemistry for tumor pathology, expression of GAD65 was found only in 1 patient. Four patients (80%) had abnormal brain MRI findings. All patients received immunotherapy and improved significantly after treatment, but 4 (80%) then experienced a relapse. CONCLUSIONS Neurological manifestations in anti-GAD-positive patients are diverse and include SPS, encephalitis, myelitis, cramp, visual loss, and paresthesia.
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Affiliation(s)
- Jiehong Huang
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Guangzhou, China
- Second Clinical College, Guangzhou Medical University, Xinzao, Panyu District, Guangzhou, China
| | - Huilu Li
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Guangzhou, China
- Second Clinical College, Guangzhou Medical University, Xinzao, Panyu District, Guangzhou, China
| | - Ruisi Zhou
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Guangzhou, China
- Second Clinical College, Guangzhou Medical University, Xinzao, Panyu District, Guangzhou, China
| | - Wenyao Huang
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Guangzhou, China
- Second Clinical College, Guangzhou Medical University, Xinzao, Panyu District, Guangzhou, China
| | - Wenhui Lin
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Guangzhou, China
- Second Clinical College, Guangzhou Medical University, Xinzao, Panyu District, Guangzhou, China
| | - Ting Chen
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Guangzhou, China
- Second Clinical College, Guangzhou Medical University, Xinzao, Panyu District, Guangzhou, China
| | - Youming Long
- Department of Neurology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China,
- Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Guangzhou, China,
- Second Clinical College, Guangzhou Medical University, Xinzao, Panyu District, Guangzhou, China,
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18
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Prüss H, Kirmse K. Pathogenic role of autoantibodies against inhibitory synapses. Brain Res 2018; 1701:146-152. [DOI: 10.1016/j.brainres.2018.09.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/20/2018] [Accepted: 09/07/2018] [Indexed: 12/13/2022]
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19
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Damato V, Balint B, Kienzler AK, Irani SR. The clinical features, underlying immunology, and treatment of autoantibody-mediated movement disorders. Mov Disord 2018; 33:1376-1389. [PMID: 30218501 PMCID: PMC6221172 DOI: 10.1002/mds.27446] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 04/28/2018] [Accepted: 05/02/2018] [Indexed: 12/30/2022] Open
Abstract
An increasing number of movement disorders are associated with autoantibodies. Many of these autoantibodies target the extracellular domain of neuronal surface proteins and associate with highly specific phenotypes, suggesting they have pathogenic potential. Below, we describe the phenotypes associated with some of these commoner autoantibody‐mediated movement disorders, and outline increasingly well‐established mechanisms of autoantibody pathogenicity which include antigen downregulation and complement fixation. Despite these advances, and the increasingly robust evidence for improved clinical outcomes with early escalation of immunotherapies, the underlying cellular immunology of these conditions has received little attention. Therefore, here, we outline the likely roles of T cells and B cells in the generation of autoantibodies, and reflect on how these may guide both current immunotherapy regimes and our future understanding of precision medicine in the field. In addition, we summarise potential mechanisms by which these peripherally‐driven immune responses may reach the central nervous system. We integrate this with the immunologically‐relevant clinical observations of preceding infections, tumours and human leucocyte antigen‐associations to provide an overview of the therapeutically‐relevant underlying adaptive immunology in the autoantibody‐mediated movement disorders. © 2018 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Valentina Damato
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Institute of Neurology, Department of Neuroscience, Catholic University, Rome, Italy
| | - Bettina Balint
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Department of Neurology, University Hospital, Heidelberg, Germany.,Oxford University Hospitals, John Radcliffe Hospital, Oxford, UK
| | - Anne-Kathrin Kienzler
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Oxford University Hospitals, John Radcliffe Hospital, Oxford, UK
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20
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Vinke AM, Schaper FLWVJ, Vlooswijk MCG, Nicolai J, Majoie MHJM, Martinez Martinez P, Hoffmann C, Damoiseaux JGMC, Rouhl RPW. Anti-GAD antibodies in a cohort of neuropsychiatric patients. Epilepsy Behav 2018; 82:25-28. [PMID: 29579551 DOI: 10.1016/j.yebeh.2018.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 02/27/2018] [Accepted: 03/01/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Antiglutamate decarboxylase (anti-GAD) antibodies are associated with several neurological manifestations, like epilepsy and movement disorders. However, in daily neurological practice, it remains hard to define when to test for anti-GAD antibodies in patients with neurologic and/or psychiatric symptoms. Therefore, here, we report the patient characteristics of a large retrospective cohort of patients tested for anti-GAD antibodies in clinical practice and compare the characteristics of anti-GAD positive and anti-GAD negative patients. METHODS We blindly assessed relevant clinical symptoms and comorbidities and functional outcome with the modified Rankin Scale (mRS) in a retrospective observational cohort of all patients in which the decision to assess anti-GAD levels had been made based solely on the presence of possible associated neurological and/or psychiatric symptoms (N=119). RESULTS Out of 119 patients, 17 (14.3%) were anti-GAD positive. The anti-GAD positive patients had a median age of 30years (range: 3-64; 2 children). They all had epilepsy, with 8 (47%) patients reporting cognitive complaints. Psychiatric symptoms were less prevalent in anti-GAD positive patients, only 1 anti-GAD positive patient (6%) versus 34 anti-GAD negative patients (33%) reported psychiatric symptoms (p=0.021). The most frequent comorbidity of anti-GAD positive patients was diabetes mellitus type 1 (n=8). Twelve (71%) and 13 (78%) of the anti-GAD positive patients were functionally independent at the time of diagnosis and after one year, respectively (mRS score: 0 to 2). There was no significant difference in functional status at any time during follow-up compared with the anti-GAD negative group. CONCLUSION Antiglutamate decarboxylase (anti-GAD) antibodies relate to epilepsy with or without cognitive complaints. However, psychiatric symptoms were almost absent in anti-GAD positive patients, and the presence of anti-GAD antibodies contributed little to the prognosis in our cohort.
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Affiliation(s)
- Anita M Vinke
- Department of Neurology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Frédéric L W V J Schaper
- Department of Neurology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands; Department of Neuroscience, Maastricht University, The Netherlands
| | - Mariëlle C G Vlooswijk
- Department of Neurology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands; Academic Center for Epileptology (ACE) Kempenhaeghe/MUMC+, Heeze and Maastricht, The Netherlands; School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
| | - Joost Nicolai
- Department of Neurology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands; Academic Center for Epileptology (ACE) Kempenhaeghe/MUMC+, Heeze and Maastricht, The Netherlands; School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
| | - Marian H J M Majoie
- Academic Center for Epileptology (ACE) Kempenhaeghe/MUMC+, Heeze and Maastricht, The Netherlands; School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands;; School of Health Professions Education, Maastricht University, The Netherlands
| | - Pilar Martinez Martinez
- Department of Neuroscience, Maastricht University, The Netherlands; School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
| | - Carolin Hoffmann
- Department of Neuroscience, Maastricht University, The Netherlands; School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
| | - Jan G M C Damoiseaux
- Department of Central Diagnostic Laboratory, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Rob P W Rouhl
- Department of Neurology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands; Academic Center for Epileptology (ACE) Kempenhaeghe/MUMC+, Heeze and Maastricht, The Netherlands; School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands;.
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21
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Autoimmune encephalitis and psychiatric disorders. Rev Neurol (Paris) 2018; 174:228-236. [DOI: 10.1016/j.neurol.2017.11.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/15/2017] [Accepted: 11/29/2017] [Indexed: 12/20/2022]
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22
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Balint B, Vincent A, Meinck HM, Irani SR, Bhatia KP. Movement disorders with neuronal antibodies: syndromic approach, genetic parallels and pathophysiology. Brain 2018; 141:13-36. [PMID: 29053777 PMCID: PMC5888977 DOI: 10.1093/brain/awx189] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/10/2017] [Accepted: 06/13/2017] [Indexed: 01/17/2023] Open
Abstract
Movement disorders are a prominent and common feature in many autoantibody-associated neurological diseases, a group of potentially treatable conditions that can mimic infectious, metabolic or neurodegenerative disease. Certain movement disorders are likely to associate with certain autoantibodies; for example, the characteristic dyskinesias, chorea and dystonia associated with NMDAR antibodies, stiff person spectrum disorders with GAD, glycine receptor, amphiphysin or DPPX antibodies, specific paroxysmal dystonias with LGI1 antibodies, and cerebellar ataxia with various anti-neuronal antibodies. There are also less-recognized movement disorder presentations of antibody-related disease, and a considerable overlap between the clinical phenotypes and the associated antibody spectra. In this review, we first describe the antibodies associated with each syndrome, highlight distinctive clinical or radiological 'red flags', and suggest a syndromic approach based on the predominant movement disorder presentation, age, and associated features. We then examine the underlying immunopathophysiology, which may guide treatment decisions in these neuroimmunological disorders, and highlight the exceptional interface between neuronal antibodies and neurodegeneration, such as the tauopathy associated with IgLON5 antibodies. Moreover, we elaborate the emerging pathophysiological parallels between genetic movement disorders and immunological conditions, with proteins being either affected by mutations or targeted by autoantibodies. Hereditary hyperekplexia, for example, is caused by mutations of the alpha subunit of the glycine receptor leading to an infantile-onset disorder with exaggerated startle and stiffness, whereas antibodies targeting glycine receptors can induce acquired hyperekplexia. The spectrum of such immunological and genetic analogies also includes cerebellar ataxias and some encephalopathies. Lastly, we discuss how these pathophysiological considerations could reflect on possible future directions regarding antigen-specific immunotherapies or targeting the pathophysiological cascades downstream of the antibody effects.
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Affiliation(s)
- Bettina Balint
- Sobell Department of Motor Neuroscience and Movement Disorders UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
- Department of Neurology, University Hospital, Heidelberg, Germany
- Neuroimmunology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Angela Vincent
- Neuroimmunology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | | | - Sarosh R Irani
- Neuroimmunology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Kailash P Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
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Why It Is Not Always Anxiety: A Tough Diagnosis of Stiff Person Syndrome. Case Rep Neurol Med 2017; 2017:7431092. [PMID: 28890837 PMCID: PMC5584351 DOI: 10.1155/2017/7431092] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 06/20/2017] [Accepted: 07/02/2017] [Indexed: 02/06/2023] Open
Abstract
Anxiety disorder is a commonly used diagnosis that may mask underlying conditions. Stiff person syndrome (SPS) is a rare neuroimmunological disorder characterized by progressive rigidity and painful muscle spasms affecting axial and lower extremity musculature. These episodes can be triggered by sudden movement, noise, or emotional stress, which may present as a psychiatric condition. We report the case of a 30-year-old female who presented with recurrent panic attacks with multiple prior hospital admissions for anxiety, rigidity, and difficulty in walking. Previous electroencephalogram (EEG) and brain and cervical spine magnetic resonance imaging (MRI) were unremarkable. She was empirically treated with diazepam and beta-blockers for SPS, which was confirmed by positive glutamic acid decarboxylase (GAD) antibodies. The patient's symptoms became refractory to benzodiazepines and required steroids with intravenous immunoglobulin (IVIG). Her rigidity subsequently responded to plasmapheresis. In SPS, antibodies in the cerebrospinal fluid (CSF) most commonly target the GAD antigen on gamma-aminobutyric acid (GABA) neurons. The goal of treatment is to ameliorate symptoms and improve quality of life. Our case of SPS was masked as generalized anxiety disorder for at least six years since onset of symptoms. The criteria for both diagnoses may overlap as seen in this patient.
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Tohid H. Anti-glutamic acid decarboxylase antibody positive neurological syndromes. ACTA ACUST UNITED AC 2017; 21:215-22. [PMID: 27356651 PMCID: PMC5107286 DOI: 10.17712/nsj.2016.3.20150596] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
A rare kind of antibody, known as anti-glutamic acid decarboxylase (GAD) autoantibody, is found in some patients. The antibody works against the GAD enzyme, which is essential in the formation of gamma aminobutyric acid (GABA), an inhibitory neurotransmitter found in the brain. Patients found with this antibody present with motor and cognitive problems due to low levels or lack of GABA, because in the absence or low levels of GABA patients exhibit motor and cognitive symptoms. The anti-GAD antibody is found in some neurological syndromes, including stiff-person syndrome, paraneoplastic stiff-person syndrome, Miller Fisher syndrome (MFS), limbic encephalopathy, cerebellar ataxia, eye movement disorders, and epilepsy. Previously, excluding MFS, these conditions were calledhyperexcitability disorders. However, collectively, these syndromes should be known as "anti-GAD positive neurological syndromes." An important limitation of this study is that the literature is lacking on the subject, and why patients with the above mentioned neurological problems present with different symptoms has not been studied in detail. Therefore, it is recommended that more research is conducted on this subject to obtain a better and deeper understanding of these anti-GAD antibody induced neurological syndromes.
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Affiliation(s)
- Hassaan Tohid
- Valley View Court, Fairfield, California, United States of America. E-mail:
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Redefining progressive encephalomyelitis with rigidity and myoclonus after the discovery of antibodies to glycine receptors. Curr Opin Neurol 2017; 30:310-316. [DOI: 10.1097/wco.0000000000000450] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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26
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McKeon A, Tracy JA. GAD65 neurological autoimmunity. Muscle Nerve 2017; 56:15-27. [PMID: 28063151 DOI: 10.1002/mus.25565] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 01/04/2017] [Indexed: 12/11/2022]
Abstract
The glutamic acid decarboxylase 65-kilodalton isoform (GAD65) antibody is a biomarker of autoimmune central nervous system (CNS) disorders and, more commonly, nonneurological autoimmune diseases. Type 1 diabetes, autoimmune thyroid disease, and pernicious anemia are the most frequent GAD65 autoimmune associations. One or more of these disorders coexists in approximately 70% of patients with GAD65 neurological autoimmunity. Neurological phenotypes have CNS localization and include limbic encephalitis, epilepsy, cerebellar ataxia, and stiff-person syndrome (SPS), among others. Classic SPS is a disorder on the spectrum of CNS hyperexcitability which also includes phenotypes that are either more restricted (stiff-limb syndrome) or more widespread (progressive encephalomyelitis with rigidity and myoclonus). GAD65 antibody is not highly predictive of a paraneoplastic cause for neurological disorders, but diverse cancer types have been occasionally reported. For all phenotypes, responses to immunotherapy are variable (approximately 50% improve). GAD65 autoimmunity is important to recognize for both coexisting nonneurological autoimmune associations and potential immunotherapy-response. Muscle Nerve 56: 15-27, 2017.
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Affiliation(s)
- Andrew McKeon
- Department of Neurology, College of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota, 55905, USA.,Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jennifer A Tracy
- Department of Neurology, College of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota, 55905, USA
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Abstract
PURPOSE OF REVIEW This review highlights the recent developments in immune-mediated movement disorders and how they reflect on clinical practice and our understanding of the underlying pathophysiological mechanisms. RECENT FINDINGS The antibody spectrum associated with stiff person syndrome and related disorders (SPSD) has broadened and, apart from the classic glutamic acid decarboxylase (GAD)- and amphiphysin-antibodies, includes now also antibodies against dipeptidyl-peptidase-like protein-6 (DPPX), gamma-aminobutyric acid type A receptor (GABAAR), glycine receptor (GlyR) and glycine transporter 2 (GlyT2). The field of movement disorders with neuronal antibodies keeps expanding with the discovery for example of antibodies against leucine rich glioma inactivated protein 1 (LGI1) and contactin associated protein 2 (Caspr2) in chorea, or antibodies targeting ARHGAP26- or Na/K ATPase alpha 3 subunit (ATP1A3) in cerebellar ataxia. Moreover, neuronal antibodies may partly account for movement disorders attributed for example to Sydenham's chorea, coeliac disease, or steroid responsive encephalopathy with thyroid antibodies. Lastly, there is an interface of immunology, genetics and neurodegeneration, e.g. in Aicardi-Goutières syndrome or the tauopathy with IgLON5-antibodies. SUMMARY Clinicians should be aware of new antibodies such as dipeptidyl-peptidase-like protein-6, gamma-aminobutyric acid type A receptor and glycine transporter 2 in stiff person syndrome and related disorders, as well as of the expanding spectrum of immune-mediated movement disorders.
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Chang T, Lang B, Vincent A. Stiff person syndrome in South Asia. BMC Res Notes 2016; 9:468. [PMID: 27756410 PMCID: PMC5070143 DOI: 10.1186/s13104-016-2276-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/11/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stiff person syndrome is a highly disabling, progressive autoimmune disorder of the central nervous system characterized by muscle rigidity and spasms. Stiff person syndrome is rare, but is believed to be under diagnosed with only 14 cases been reported among a 1.7 billion population in South Asia. We report the first authenticated case from Sri Lanka. CASE PRESENTATION A 55-year-old Sri Lankan female presented with difficulty in walking and recurrent falls due to progressive muscular rigidity in her lower limbs and trunk with superimposed muscle spasms that occurred in response to unexpected noise, startle or emotional upset. She had anxiety and specific phobias to open spaces, walking unaided and being among crowds of people. She had insulin-dependent diabetes mellitus and was on thyroxine replacement. On examination, she had hyperlordosis combined with board-like rigidity of her anterior abdomen and rigidity of her lower limbs bilaterally. Upper limbs were normal. Magnetic resonance imaging of her neuraxis was normal. Electromyography showed continuous motor unit activity at rest. Glutamic acid decarboxylase antibodies were detected in her serum at a titre of 15,500 IU/ml (normal <5). She showed a remarkable and sustained improvement to treatment with intravenous immunoglobulins, immunosuppressive and muscle relaxant medications, regaining independent ambulation. CONCLUSIONS Diagnosis of stiff person syndrome remains clinical, supported by electromyography and serology for glutamic acid decarboxylase antibodies, facilitated by a high index of clinical suspicion. An autoimmune basis lends stiff person syndrome amenable to treatment highlighting the importance of diagnosis. This case adds to map the worldwide distribution of stiff person syndrome.
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Affiliation(s)
- Thashi Chang
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, 25, Kynsey Road, Colombo, 00800, Sri Lanka.
| | - Bethan Lang
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Level 5/6 West Wing, Oxford, OX3 9DU, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Level 5/6 West Wing, Oxford, OX3 9DU, UK
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Dubey D, Blackburn K, Greenberg B, Stuve O, Vernino S. Diagnostic and therapeutic strategies for management of autoimmune encephalopathies. Expert Rev Neurother 2016; 16:937-49. [PMID: 27171736 DOI: 10.1080/14737175.2016.1189328] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION The understanding of the etio-pathogenesis of autoimmune encephalopathy syndromes has grown significantly in recent years. These are potentially reversible conditions, with variable clinical presentation and potential dramatic response to immunotherapy. AREAS COVERED In this article we review various diagnostic techniques and therapeutic options for management of autoimmune encephalopathy. We also review medication adverse effects and monitoring strategies. Expert commentary: Early diagnosis and immunomodulatory treatment remains the cornerstone of management, to halt the underlying neuro-inflammatory process and prevent permanent neuronal injury. The availability of serological testing and various imaging modalities has further improved detection of these immune-mediated neurological disorders. Understanding the mechanisms and potential adverse effects of immunomodulatory therapies will help physicians to choose the most favorable therapeutic strategy for each patient.
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Affiliation(s)
- Divyanshu Dubey
- a Department of Neurology and Neurotherapeutics , UT Southwestern Medical Center , Dallas , TX , USA
| | - Kyle Blackburn
- a Department of Neurology and Neurotherapeutics , UT Southwestern Medical Center , Dallas , TX , USA
| | - Benjamin Greenberg
- a Department of Neurology and Neurotherapeutics , UT Southwestern Medical Center , Dallas , TX , USA
| | - Olaf Stuve
- a Department of Neurology and Neurotherapeutics , UT Southwestern Medical Center , Dallas , TX , USA.,b Neurology Section , VA North Texas Health Care System, Medical Service , Dallas , TX , USA
| | - Steven Vernino
- a Department of Neurology and Neurotherapeutics , UT Southwestern Medical Center , Dallas , TX , USA
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Abstract
Autoimmune movement disorders encapsulate a large and diverse group of neurologic disorders occurring either in isolation or accompanying more diffuse autoimmune encephalitic illnesses. The full range of movement phenomena has been described and, as they often occur in adults, many of the presentations can mimic neurodegenerative disorders, such as Huntington disease. Disorders may be ataxic, hypokinetic (parkinsonism), or hyperkinetic (myoclonus, chorea, tics, and other dyskinetic disorders). The autoantibody targets are diverse and include neuronal surface proteins such as leucine-rich, glioma-inactivated 1 (LGI1) and glycine receptors, as well as antibodies (such as intracellular antigens) that are markers of a central nervous system process mediated by CD8+ cytotoxic T cells. However, there are two conditions, stiff-person syndrome (also known as stiff-man syndrome) and progressive encephalomyelitis with rigidity and myoclonus (PERM), that are always autoimmune movement disorders. In some instances (such as Purkinje cell cytoplasmic antibody-1 (PCA-1) autoimmunity), antibodies detected in serum and cerebrospinal fluid can be indicative of a paraneoplastic cause, and may direct the cancer search. In other instances (such as 65kDa isoform of glutamic acid decarboxylase (GAD65) autoimmunity), a paraneoplastic cause is very unlikely, and early treatment with immunotherapy may promote improvement or recovery. Here we describe the different types of movement disorder and the clinical features and antibodies associated with them, and discuss treatment.
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Affiliation(s)
- Andrew Mckeon
- Departments of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
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Sunwoo JS, Chu K, Byun JI, Moon J, Lim JA, Kim TJ, Lee ST, Jung KH, Park KI, Jeon D, Jung KY, Kim M, Lee SK. Intrathecal-specific glutamic acid decarboxylase antibodies at low titers in autoimmune neurological disorders. J Neuroimmunol 2015; 290:15-21. [PMID: 26711563 DOI: 10.1016/j.jneuroim.2015.11.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Revised: 11/13/2015] [Accepted: 11/15/2015] [Indexed: 01/07/2023]
Abstract
Autoantibodies to glutamic acid decarboxylase (Gad-Abs) are implicated in various neurological syndromes. The present study aims to identify intrathecal-specific GAD-Abs and to determine clinical manifestations and treatment outcomes. Nineteen patients had GAD-Abs in cerebrospinal fluid but not in paired serum samples. Neurological syndromes included limbic encephalitis, temporal lobe epilepsy, cerebellar ataxia, autonomic dysfunction, and stiff-person syndrome. Immunotherapy had beneficial effects in 57.1% of patients, and the patients with limbic encephalitis responded especially well to immunotherapy. Intrathecal-specific antibodies to GAD at low titers may appear as nonspecific markers of immune activation within the central nervous system rather than pathogenic antibodies causing neuronal dysfunction.
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Affiliation(s)
- Jun-Sang Sunwoo
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Kon Chu
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea.
| | - Jung-Ick Byun
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Jangsup Moon
- Department of Neurology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, South Korea
| | - Jung-Ah Lim
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Tae-Joon Kim
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Soon-Tae Lee
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Keun-Hwa Jung
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung-Il Park
- Department of Neurology, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, South Korea
| | - Daejong Jeon
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Ki-Young Jung
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Manho Kim
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea; Protein Metabolism Medical Research Center, Seoul National University College of Medicine, Seoul, South Korea
| | - Sang Kun Lee
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea.
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33
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Prud'homme GJ, Glinka Y, Wang Q. Immunological GABAergic interactions and therapeutic applications in autoimmune diseases. Autoimmun Rev 2015; 14:1048-56. [DOI: 10.1016/j.autrev.2015.07.011] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 07/17/2015] [Indexed: 12/20/2022]
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Baizabal-Carvallo JF, Jankovic J. Stiff-person syndrome: insights into a complex autoimmune disorder. J Neurol Neurosurg Psychiatry 2015; 86:840-8. [PMID: 25511790 DOI: 10.1136/jnnp-2014-309201] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 11/21/2014] [Indexed: 02/06/2023]
Abstract
Stiff-person syndrome (SPS) is characterised by progressive rigidity and muscle spasms affecting the axial and limb muscles. Since its initial description in 1956, marked progress has been made in the clinical characterisation, understanding of pathogenesis and therapy of this disorder. SPS can be classified according to the clinical presentation into classic SPS and SPS variants: focal or segmental-SPS, jerking-SPS and progressive encephalomyelitis with rigidity and myoclonus. Most patients with SPS have antibodies directed against the glutamic acid decarboxylase, the rate-limiting enzyme for the production of the inhibitory neurotransmitter γ-aminobutyric acid (GABA). Antibodies directed against GABA(A) receptor-associated protein, and the glycine-α1 receptor can also be observed. Paraneoplastic SPS is commonly associated with antiamphiphysin antibodies and breast cancer. Treatment of SPS with drugs that increase the GABAergic tone combined with immunotherapy can improve the neurological manifestations of these patients. The prognosis, however, is unpredictable and spontaneous remissions are unlikely.
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Affiliation(s)
- José Fidel Baizabal-Carvallo
- Department of Neurology, Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph Jankovic
- Department of Neurology, Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, Houston, Texas, USA
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Abstract
PURPOSE Temporal lobe epilepsy with antibodies (abs) against the glutamic acid decarboxylase 65 isoform (GAD-TLE) is known as an immune-mediated neurological syndrome. Here we evaluate the therapy response to various immunotherapies and epilepsy surgery in this syndrome. METHOD All patients with GAD-TLE and follow-up data and stored serum and CSF samples, identified and treated at the Bonn centre from 2002 to 2010, were studied retrospectively. Seizure freedom for ≥1 year and reduction of ≥50%, i.e. therapy response, were assessed. GAD-ab titres and neuropsychological performances were documented prior and after individual interventions. RESULTS Thirteen patients with GAD-TLE were identified with the following seizure responses: corticosteroids (5 responders out of 11 treated patients); i.v. immunoglobulins (1/5), apheresis therapy (1/8); and natalizumab (1/1), selective amygdala-hippocampectomy (2/3). None of the patients achieved sustained seizure freedom apart from one patient. This patient was on antiepileptic drug treatment after discontinuation of immunotherapy. CONCLUSION The seizure response to immunotherapies in patients with GAD-TLE was poor. Corticosteroids were the most effective regarding seizure response. Especially the poor effects of apheresis therapies support the idea that GAD-abs are not directly pathogenic. None of three patients was seizure-free after temporal lobe surgery suggesting that GAD-TLE patients respond worse than others to this type of intervention. Our results reflect the chronic course of the disease with low likelihood for patients with GAD-TLE to attain long-term seizure freedom.
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36
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Millet C, van Pesch V, Sindic CJM. Idiopathic limbic encephalitis associated with antibodies to glutamic acid decarboxylase. Acta Neurol Belg 2015; 115:165-7. [PMID: 25038738 DOI: 10.1007/s13760-014-0332-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 07/02/2014] [Indexed: 01/02/2023]
Affiliation(s)
- Claire Millet
- Service de Neurologie, Cliniques universitaires Saint-Luc, Avenue Hippocrate, 10, 1200, Bruxelles, Belgium ,
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Gresa-Arribas N, Ariño H, Martínez-Hernández E, Petit-Pedrol M, Sabater L, Saiz A, Dalmau J, Graus F. Antibodies to inhibitory synaptic proteins in neurological syndromes associated with glutamic acid decarboxylase autoimmunity. PLoS One 2015; 10:e0121364. [PMID: 25774787 PMCID: PMC4361655 DOI: 10.1371/journal.pone.0121364] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 01/31/2015] [Indexed: 12/12/2022] Open
Abstract
Antibodies to glutamic acid decarboxylase (GAD-ab) associate to different neurological syndromes. It is unknown if the diversity in syndrome association represents epitopes in different immunodominant domains or co-existence of antibodies to other proteins of the inhibitory synapsis. We examined the serum and CSF of 106 patients with anti-GAD related syndromes (39 cerebellar ataxia, 32 stiff-person syndrome [SPS], 18 epilepsy, and 17 limbic encephalitis [LE]). GAD65-ab titres were quantified by ELISA. Immunoblot was used to determine if the antibody-targeted epitopes of GAD65 and GAD67 were linear. A cell-based assay (CBA) with HEK293 cells expressing the GAD65 N-terminal, central catalytic domain, or C-terminal was used to investigate the immunodominant domains. Antibodies to GAD67, gamma-aminobutyric acid A receptor (GABAaR), glycine receptor (GlyR), GABAaR-associated protein (GABARAP), and gephyrin were determined with CBA. GAD-ab internalization was investigated using cultured rat hippocampal neurons. CSF GAD65-ab titres were higher in patients with cerebellar ataxia and LE compared to those with SPS (p = 0.02). GAD67-ab were identified in 81% of sera and 100% of CSF. GAD65-ab recognized linear epitopes in 98% of the patients and GAD67-ab in 42% (p<0.001). The GAD65 catalytic domain was recognized by 93% of sera, and the three domains by 22% of sera and 74% of CSF (p<0.001). Six patients had GABAaR-ab and another 6 had GlyR-ab without association to distinctive symptoms. None of the patients had gephyrin- or GABARAP-ab. GAD65-ab were not internalized by live neurons. Overall, these findings show that regardless of the neurological syndrome, the CSF immune response against GAD is more widespread than that of the serum and that there is no specific association between clinical phenotype and the presence of antibodies against other proteins of the inhibitory synapsis.
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Affiliation(s)
- Nuria Gresa-Arribas
- Neuroimmunology Program, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Helena Ariño
- Neuroimmunology Program, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Service of Neurology, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Eugenia Martínez-Hernández
- Neuroimmunology Program, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Service of Neurology, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Mar Petit-Pedrol
- Neuroimmunology Program, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Lidia Sabater
- Neuroimmunology Program, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Albert Saiz
- Neuroimmunology Program, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Service of Neurology, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Josep Dalmau
- Neuroimmunology Program, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Francesc Graus
- Neuroimmunology Program, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Service of Neurology, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
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Fouka P, Alexopoulos H, Akrivou S, Trohatou O, Politis PK, Dalakas MC. GAD65 epitope mapping and search for novel autoantibodies in GAD-associated neurological disorders. J Neuroimmunol 2015; 281:73-7. [PMID: 25867471 DOI: 10.1016/j.jneuroim.2015.03.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 03/06/2015] [Accepted: 03/07/2015] [Indexed: 10/23/2022]
Abstract
Antibodies against Glutamic-acid-decarboxylase (GAD65) are seen in various CNS excitability disorders including stiff-person syndrome, cerebellar ataxia, encephalitis and epilepsy. To explore pathogenicity, we examined whether distinct epitope specificities or other co-existing antibodies may account for each disorder. The epitope recognized by all 27 tested patients, irrespective of clinical phenotype, corresponded to the catalytic core of GAD. No autoantibodies against known GABAergic antigens were found. In a screen for novel specificities using live hippocampal neurons, three epilepsy patients, but no other, were positive. We conclude that no GAD-specific epitope defines any neurological syndrome but other antibody specificities may account for certain phenotypes.
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Affiliation(s)
- P Fouka
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Greece; Center for Basic Research, Biomedical Research Foundation of the Academy of Athens, Greece
| | - H Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Greece
| | - S Akrivou
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Greece
| | - O Trohatou
- Center for Basic Research, Biomedical Research Foundation of the Academy of Athens, Greece
| | - P K Politis
- Center for Basic Research, Biomedical Research Foundation of the Academy of Athens, Greece
| | - M C Dalakas
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Greece.
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Koike Y, Suwabe T, Konno T, Umeda Y, Oyake M, Fujita N. [A case of progressive encephalomyelitis with rigidity and myoclonus associated with anti-GAD, anti-glycine receptor and anti-GM1 antibodies]. Rinsho Shinkeigaku 2015; 55:111-114. [PMID: 25746075 DOI: 10.5692/clinicalneurol.55.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
A 62-year-old woman with one-year history of type 1 diabetes mellitus was admitted to our hospital with progressive weakness in the lower extremities and urinary dysfunction following high fever. On admission, she had rigidity and myoclonus in the upper extremities with sensory ataxia. Cerebrospinal fluid examination revealed mild pleocytosis and oligoclonal band. Glutamic acid decarboxylase (GAD) antibodies were detected at high titer in serum, but antibodies to glycine receptor (GlyR), thyroid peroxidase, mitochondrial M2, and GM1 were also detected. She was diagnosed with progressive encephalomyelitis with rigidity and myoclonus (PERM), which probably developed on the basis of polyglandular autoimmune syndromes. The clinical symptoms began to improve after initiation of intravenous high-dose methylprednisolone. Muscle weakness might be related to GM1 antibodies. This is the first report of PERM, in which GM1 antibodies were detected with GAD and GlyR antibodies.
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Affiliation(s)
- Yuka Koike
- Department of Neurology, Nagaoka Red Cross Hospital
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Ariño H, Gresa-Arribas N, Blanco Y, Martínez-Hernández E, Sabater L, Petit-Pedrol M, Rouco I, Bataller L, Dalmau JO, Saiz A, Graus F. Cerebellar ataxia and glutamic acid decarboxylase antibodies: immunologic profile and long-term effect of immunotherapy. JAMA Neurol 2014; 71:1009-16. [PMID: 24934144 DOI: 10.1001/jamaneurol.2014.1011] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Current clinical and immunologic knowledge on cerebellar ataxia (CA) with glutamic acid decarboxylase 65 antibodies (GAD65-Abs) is based on case reports and small series with short-term follow-up data. OBJECTIVE To report the symptoms, additional antibodies, prognostic factors, and long-term outcomes in a cohort of patients with CA and GAD65-Abs. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study and laboratory investigations at a center for autoimmune neurologic disorders among 34 patients with CA and GAD65-Abs, including 25 with long-term follow-up data (median, 5.4 years; interquartile range, 3.1-10.3 years). MAIN OUTCOMES AND MEASURES Analysis of clinicoimmunologic features and predictors of response to immunotherapy. Immunochemistry on rat brain, cultured neurons, and human embryonic kidney cells expressing GAD65, GAD67, α1-subunit of the glycine receptor, and a repertoire of known cell surface autoantigens were used to identify additional antibodies. Twenty-eight patients with stiff person syndrome and GAD65-Abs served as controls. RESULTS The median age of patients was 58 years (range, 33-80 years); 28 of 34 patients (82%) were women. Nine patients (26%) reported episodes of brainstem and cerebellar dysfunction or persistent vertigo several months before developing CA. The clinical presentation was subacute during a period of weeks in 13 patients (38%). Nine patients (26%) had coexisting stiff person syndrome symptoms. Systemic organ-specific autoimmunities (type 1 diabetes mellitus and others) were present in 29 patients (85%). Twenty of 25 patients with long-term follow-up data received immunotherapy (intravenous immunoglobulin in 10 and corticosteroids and intravenous immunoglobulin or other immunosuppressors in 10), and 7 of them (35%) improved. Predictors of clinical response included subacute onset of CA (odds ratio [OR], 0.50; 95% CI, 0.25-0.99; P = .047) and prompt immunotherapy (OR, 0.98; 95% CI, 0.96-0.99; P = .01). Similar frequencies of serum GAD67-Abs were found in patients with CA (24 of 34 patients [71%]) and in patients with stiff person syndrome (20 of 28 patients [71%]). However, GAD67-Abs were found in all of the cerebrospinal fluid samples examined (22 samples from patients with CA and 17 samples from patients with stiff person syndrome). Glycine receptor antibodies but not other cell surface antibodies were identified in 4 patients with CA. The presence of glycine receptor antibodies did not correlate with any specific clinical feature. CONCLUSIONS AND RELEVANCE In patients with CA and GAD65-Abs, subacute onset of symptoms and prompt immunotherapy are associated with good outcome. Persistent vertigo or brainstem and cerebellar episodes can herald CA and should lead to GAD65-Ab testing, particularly in patients with systemic organ-specific autoimmunities.
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Affiliation(s)
- Helena Ariño
- Neurology Service, Hospital Clínic, Barcelona, Spain2Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Nuria Gresa-Arribas
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Yolanda Blanco
- Neurology Service, Hospital Clínic, Barcelona, Spain2Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Eugenia Martínez-Hernández
- Neurology Service, Hospital Clínic, Barcelona, Spain2Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Lidia Sabater
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Mar Petit-Pedrol
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Idoia Rouco
- Neurology Service, Department of Neurosciences, Cruces University Hospital, University of the Basque Country, Bizkaia, Spain
| | - Luis Bataller
- Neurology Service, University Hospital Politècnic La Fe, Valencia, Spain
| | - Josep O Dalmau
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain5Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain6Department of Neurology, University of Pennsylvania, Philadelp
| | - Albert Saiz
- Neurology Service, Hospital Clínic, Barcelona, Spain2Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Francesc Graus
- Neurology Service, Hospital Clínic, Barcelona, Spain2Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
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Varley J, Vincent A, Irani SR. Clinical and experimental studies of potentially pathogenic brain-directed autoantibodies: current knowledge and future directions. J Neurol 2014; 262:1081-95. [PMID: 25491076 PMCID: PMC4412383 DOI: 10.1007/s00415-014-7600-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 11/27/2014] [Indexed: 02/06/2023]
Abstract
The field of neuronal surface-directed antibody-mediated diseases of the central nervous system has dramatically expanded in the last few years and now forms an important cluster of treatable neurological conditions. In this review, we focus on three areas. First, we review the demographics, clinical features and treatment responses of these conditions. Second, we consider their pathophysiology and compare autoantibody mechanisms and their effects to genetic or pharmacological disruptions of the target antigens. Third, we discuss areas of controversy within the field, propose possible resolutions, and explore new directions for neuronal surface antibody-mediated diseases.
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Affiliation(s)
- James Varley
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, West Wing, Level 6, Oxford, OX3 9DU UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, West Wing, Level 6, Oxford, OX3 9DU UK
| | - Sarosh R. Irani
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, West Wing, Level 6, Oxford, OX3 9DU UK
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Needham E, Zandi MS. Recent advances in the neuroimmunology of cell-surface CNS autoantibody syndromes, Alzheimer’s disease, traumatic brain injury and schizophrenia. J Neurol 2014; 261:2037-42. [DOI: 10.1007/s00415-014-7473-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 08/15/2014] [Indexed: 12/17/2022]
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Irani SR, Gelfand JM, Al-Diwani A, Vincent A. Cell-surface central nervous system autoantibodies: clinical relevance and emerging paradigms. Ann Neurol 2014; 76:168-84. [PMID: 24930434 PMCID: PMC4141019 DOI: 10.1002/ana.24200] [Citation(s) in RCA: 139] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 06/13/2014] [Accepted: 06/13/2014] [Indexed: 01/17/2023]
Abstract
The recent discovery of several potentially pathogenic autoantibodies has helped identify patients with clinically distinctive central nervous system diseases that appear to benefit from immunotherapy. The associated autoantibodies are directed against the extracellular domains of cell-surface-expressed neuronal or glial proteins such as LGI1, N-methyl-D-aspartate receptor, and aquaporin-4. The original descriptions of the associated clinical syndromes were phenotypically well circumscribed. However, as availability of antibody testing has increased, the range of associated patient phenotypes and demographics has expanded. This in turn has led to the recognition of more immunotherapy-responsive syndromes in patients presenting with cognitive and behavioral problems, seizures, movement disorders, psychiatric features, and demyelinating disease. Although antibody detection remains diagnostically important, clinical recognition of these distinctive syndromes should ensure early and appropriate immunotherapy administration. We review the emerging paradigm of cell-surface-directed antibody-mediated neurological diseases, describe how the associated disease spectrums have broadened since the original descriptions, discuss some of the methodological issues regarding techniques for antibody detection and emphasize considerations surrounding immunotherapy administration. As these disorders continue to reach mainstream neurology and even psychiatry, more cell-surface-directed antibodies will be discovered, and their possible relevance to other more common disease presentations should become more clearly defined.
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Affiliation(s)
- Sarosh R Irani
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom; Multiple Sclerosis and Neuroinflammation Center, Department of Neurology, University of California, San Francisco, San Francisco, CA
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Pollak TA, Nicholson TR, Mellers JDC, Vincent A, David AS. Epilepsy-related psychosis: a role for autoimmunity? Epilepsy Behav 2014; 36:33-8. [PMID: 24840753 DOI: 10.1016/j.yebeh.2014.04.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 04/22/2014] [Accepted: 04/23/2014] [Indexed: 12/20/2022]
Abstract
Postictal psychosis (PIP) is a serious psychiatric complication of epilepsy that occurs in approximately 6% of patients following multiple complex partial or generalized seizures. The psychosis is classically described as having a pleomorphic phenomenology, including paranoid, grandiose, and religious delusions as well as multimodal hallucinations with prominent affective changes and agitation. Little is understood about the pathophysiology of the condition. There has been a recent increase in interest in the relevance of autoimmunity to the pathogenesis of both epilepsy and psychosis. Studies have demonstrated the presence of antibodies directed against synaptic autoantigens (such as the N-methyl-d-aspartate receptor or the voltage-gated potassium channel complex) in approximately 10% of cases of sporadic epilepsy. These same autoantibodies are known to cause encephalopathy syndromes which feature psychiatric symptoms, usually psychosis, as a prominent part of the phenotype as well as other neurological features such as seizures, movement disorders, and autonomic dysfunction. It is beginning to be asked if these antibodies can be associated with a purely psychiatric phenotype. Here, we hypothesize that PIP may be an autoimmune phenomenon mediated by autoantibodies against synaptic antigens. More specifically, we outline a potential mechanism whereby long or repeated seizures cause short-lived blood-brain barrier (BBB) dysfunction during which the brain becomes exposed to pathogenic autoantibodies. In essence, we propose that PIP is a time-limited, seizure-dependent, autoantibody-mediated encephalopathy syndrome. We highlight a number of features of PIP that may be explained by this mechanism, such as the lucid interval between seizures and onset of psychosis and the progression in some cases to a chronic, interictal psychosis.
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Affiliation(s)
- T A Pollak
- National Institute for Health Research (NIHR) Biomedical Research Centre, South London and Maudsley NHS Foundation Trust and Institute of Psychiatry, King's College London, UK; Section of Cognitive Neuropsychiatry, Department of Psychosis Studies, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK
| | - T R Nicholson
- National Institute for Health Research (NIHR) Biomedical Research Centre, South London and Maudsley NHS Foundation Trust and Institute of Psychiatry, King's College London, UK; Section of Cognitive Neuropsychiatry, Department of Psychosis Studies, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK
| | | | - A Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - A S David
- Section of Cognitive Neuropsychiatry, Department of Psychosis Studies, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK
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Carvajal-González A, Leite MI, Waters P, Woodhall M, Coutinho E, Balint B, Lang B, Pettingill P, Carr A, Sheerin UM, Press R, Press R, Lunn MP, Lim M, Maddison P, Meinck HM, Vandenberghe W, Vincent A. Glycine receptor antibodies in PERM and related syndromes: characteristics, clinical features and outcomes. ACTA ACUST UNITED AC 2014; 137:2178-92. [PMID: 24951641 PMCID: PMC4107739 DOI: 10.1093/brain/awu142] [Citation(s) in RCA: 315] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
See Martinez-Martinez et al. (doi:10.1093/brain/awu153) for a scientific commentary on this article. Carvajal-González et al. describe the first prospective cohort of patients with glycine receptor antibodies. The majority have progressive encephalomyelitis with rigidity and myoclonus. The antibodies bind to extracellular determinants on glycine receptor-α1 and to glycine receptors on spinal cord and brainstem neurons. The patients make a good recovery with immunotherapies. The clinical associations of glycine receptor antibodies have not yet been described fully. We identified prospectively 52 antibody-positive patients and collated their clinical features, investigations and immunotherapy responses. Serum glycine receptor antibody endpoint titres ranged from 1:20 to 1:60 000. In 11 paired samples, serum levels were higher than (n = 10) or equal to (n = 1) cerebrospinal fluid levels; there was intrathecal synthesis of glycine receptor antibodies in each of the six pairs available for detailed study. Four patients also had high glutamic acid decarboxylase antibodies (>1000 U/ml), and one had high voltage-gated potassium channel-complex antibody (2442 pM). Seven patients with very low titres (<1:50) and unknown or alternative diagnoses were excluded from further study. Three of the remaining 45 patients had newly-identified thymomas and one had a lymphoma. Thirty-three patients were classified as progressive encephalomyelitis with rigidity and myoclonus, and two as stiff person syndrome; five had a limbic encephalitis or epileptic encephalopathy, two had brainstem features mainly, two had demyelinating optic neuropathies and one had an unclear diagnosis. Four patients (9%) died during the acute disease, but most showed marked improvement with immunotherapies. At most recent follow-up, (2–7 years, median 3 years, since first antibody detection), the median modified Rankin scale scores (excluding the four deaths) decreased from 5 at maximal severity to 1 (P < 0.0001), but relapses have occurred in five patients and a proportion are on reducing steroids or other maintenance immunotherapies as well as symptomatic treatments. The glycine receptor antibodies activated complement on glycine receptor-transfected human embryonic kidney cells at room temperature, and caused internalization and lysosomal degradation of the glycine receptors at 37°C. Immunoglobulin G antibodies bound to rodent spinal cord and brainstem co-localizing with monoclonal antibodies to glycine receptor-α1. Ten glycine receptor antibody positive samples were also identified in a retrospective cohort of 56 patients with stiff person syndrome and related syndromes. Glycine receptor antibodies are strongly associated with spinal and brainstem disorders, and the majority of patients have progressive encephalomyelitis with rigidity and myoclonus. The antibodies demonstrate in vitro evidence of pathogenicity and the patients respond well to immunotherapies, contrasting with earlier studies of this syndrome, which indicated a poor prognosis. The presence of glycine receptor antibodies should help to identify a disease that responds to immunotherapies, but these treatments may need to be sustained, relapses can occur and maintenance immunosuppression may be required.
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Affiliation(s)
| | - M Isabel Leite
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Patrick Waters
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Mark Woodhall
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Ester Coutinho
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Bettina Balint
- 2 Department of Neurology, INF 400, 69120 Heidelberg, Germany
| | - Bethan Lang
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Philippa Pettingill
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Aisling Carr
- 3 Department of Clinical Neurology, Royal Victoria Hospital, Belfast, Northern Ireland, BT12 6BA
| | - Una-Marie Sheerin
- 4 Department of Clinical Neurosciences, Charing Cross Hospital, Imperial College, London UK
| | | | - Raomand Press
- 5 Clinical Neuroscience, Karolinska Institute, Department of Neurology, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Michael P Lunn
- 6 Centre for Neuromuscular Disease, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Ming Lim
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Paul Maddison
- 7 Department of Clinical Neurology, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - H-M Meinck
- 2 Department of Neurology, INF 400, 69120 Heidelberg, Germany
| | - Wim Vandenberghe
- 8 Department of Neurology, University Hospitals Leuven; Department of Neurosciences, KU Leuven, Leuven, Belgium
| | - Angela Vincent
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
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Alexopoulos H, Dalakas MC. Immunology of stiff person syndrome and other GAD-associated neurological disorders. Expert Rev Clin Immunol 2014; 9:1043-53. [DOI: 10.1586/1744666x.2013.845527] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Planche V, Marques A, Ulla M, Ruivard M, Durif F. Intravenous Immunoglobulin and Rituximab for Cerebellar Ataxia with Glutamic Acid Decarboxylase Autoantibodies. THE CEREBELLUM 2013; 13:318-22. [DOI: 10.1007/s12311-013-0534-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Chang T, Alexopoulos H, Pettingill P, McMenamin M, Deacon R, Erdelyi F, Szabó G, Buckley CJ, Vincent A. Immunization against GAD induces antibody binding to GAD-independent antigens and brainstem GABAergic neuronal loss. PLoS One 2013; 8:e72921. [PMID: 24058450 PMCID: PMC3776810 DOI: 10.1371/journal.pone.0072921] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 07/15/2013] [Indexed: 11/18/2022] Open
Abstract
Stiff person syndrome (SPS) is a highly-disabling neurological disorder of the CNS characterized by progressive muscular rigidity and spasms. In approximately 60–80% of patients there are autoantibodies to glutamic acid decarboxylase (GAD), the enzyme that synthesizes gamma-amino butyric acid (GABA), the predominant inhibitory neurotransmitter of the CNS. Although GAD is intracellular, it is thought that autoimmunity to GAD65 may play a role in the development of SPS. To test this hypothesis, we immunized mice, that expressed enhanced green fluorescent protein (EGFP) under the GAD65 promoter, with either GAD65 (n = 13) or phosphate buffered saline (PBS) (n = 13). Immunization with GAD65 resulted in autoantibodies that immunoprecipitated GAD, bound to CNS tissue in a highly characteristic pattern, and surprisingly bound not only to GAD intracellularly but also to the surface of cerebellar neurons in culture. Moreover, immunization resulted in immunoglobulin diffusion into the brainstem, and a partial loss of GAD-EGFP expressing cells in the brainstem. Although immunization with GAD65 did not produce any behavioral abnormality in the mice, the induction of neuronal-surface antibodies and the trend towards loss of GABAergic neurons in the brainstem, supports a role for humoral autoimmunity in the pathogenesis of SPS and suggests that the mechanisms may involve spread to antigens expressed on the surface of these neurons.
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Affiliation(s)
- Thashi Chang
- Neuroimmunology Group, Weatherall Institute of Molecular Medicine and Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
- Department of Clinical Medicine, University of Colombo, Colombo, Sri Lanka
| | - Harry Alexopoulos
- Neuroimmunology Group, Weatherall Institute of Molecular Medicine and Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Philippa Pettingill
- Neuroimmunology Group, Weatherall Institute of Molecular Medicine and Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Mary McMenamin
- Department of Physiology Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Robert Deacon
- Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom
| | - Ferenc Erdelyi
- Department of Gene Technology and Developmental Neurobiology, Institute of Experimental Medicine, Budapest, Hungary
| | - Gabor Szabó
- Department of Gene Technology and Developmental Neurobiology, Institute of Experimental Medicine, Budapest, Hungary
| | - Camilla J. Buckley
- Neuroimmunology Group, Weatherall Institute of Molecular Medicine and Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Angela Vincent
- Neuroimmunology Group, Weatherall Institute of Molecular Medicine and Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
- * E-mail:
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