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Duan RN, He JZ, Cao LL. "Hot Cross Bun" Sign in a Patient with Glutamic Acid Decarboxylase 65-KDa Isoform Associated Cerebellar Ataxia: Case Report and Review of the Literature. CEREBELLUM (LONDON, ENGLAND) 2024; 23:1204-1210. [PMID: 37948023 DOI: 10.1007/s12311-023-01631-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 11/12/2023]
Abstract
The "hot cross bun" sign (HCBs) is a cruciform hyperintensity on T2-weighted imaging within the pons initially found in patients diagnosed as multiple system atrophy. However, recent findings have broadened the disease spectrum presented with HCBs. Here is a case report at an academic medical center. Cerebral magnetic resonance imaging (MRI), electroneuromyography, serum, and CSF analysis were performed. Literature is comprehensively reviewed. We investigated a woman presented with blurred speech and cerebellar ataxia. Her MRI showed the vertical line of HCBs 2 weeks after disease onset and gradually enhanced, presenting as an intact HCBs in a year. Glutamic acid decarboxylase 65-kDa isoform (GAD65) antibody IgG was detected in serum and CSF. The patient was diagnosed as GAD65 associated cerebellar ataxia and treated with corticosteroid and rituximab. We found 6 previously reported autoimmune cerebellar ataxia patients with HCBs. Anti-KLHL-11, anti-Homer-3, anti-Ri, and anti-Amphiphysin were associated. All patients had cerebellar ataxia with other neurological symptoms. Five patients were diagnosed with tumor. First-line immunotherapy including corticosteroid, intravenous immunoglobulin, and plasma exchange for most patients was unsatisfied. This case highlights the importance of considering GAD65 IgG evaluation in patients with progressive cerebellar syndrome and HCBs. Early diagnosis and therapy are challenging but imperative. Further studies are required in regard to therapeutic management.
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Affiliation(s)
- Ruo-Nan Duan
- Department of Neurology, Cheeloo College of Medicine, Qilu Hospital of Shandong Univeristy, Jinan, 250012, Shandong, China
| | - Jing-Zhen He
- Department of Radiology, Qilu Hospital of Shandong Univeristy, Jinan, Shandong, China
| | - Li-Li Cao
- Department of Neurology, Cheeloo College of Medicine, Qilu Hospital of Shandong Univeristy, Jinan, 250012, Shandong, China.
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2
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Segal Y, Zekeridou A. Interest of rare autoantibodies in autoimmune encephalitis and paraneoplastic neurological syndromes: the utility (or futility) of rare antibody discovery. Curr Opin Neurol 2024; 37:295-304. [PMID: 38533672 DOI: 10.1097/wco.0000000000001261] [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: 03/28/2024]
Abstract
PURPOSE OF REVIEW The increasing recognition and diagnosis of autoimmune encephalitis (AE) and paraneoplastic neurological syndromes (PNS) is partly due to neural autoantibody testing and discovery. The past two decades witnessed an exponential growth in the number of identified neural antibodies. This review aims to summarize recent rare antibody discoveries in the context of central nervous system (CNS) autoimmunity and evaluate the ongoing debate about their utility. RECENT FINDINGS In the last 5 years alone 15 novel neural autoantibody specificities were identified. These include rare neural antibody biomarkers of autoimmune encephalitis, cerebellar ataxia or other movement disorders, including multifocal presentations. SUMMARY Although the clinical applications of these rare antibody discoveries may be limited by the low number of positive cases, they still provide important diagnostic, prognostic, and therapeutic insights.
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Affiliation(s)
- Yahel Segal
- Department of Laboratory Medicine and Pathology
| | - Anastasia Zekeridou
- Department of Laboratory Medicine and Pathology
- Department of Neurology
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
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3
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Muñiz-Castrillo S, Honnorat J. Genetic predisposition to autoimmune encephalitis and paraneoplastic neurological syndromes. Curr Opin Neurol 2024; 37:329-337. [PMID: 38483154 DOI: 10.1097/wco.0000000000001263] [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: 04/30/2024]
Abstract
PURPOSE OF REVIEW We summarize the recent discoveries on genetic predisposition to autoimmune encephalitis and paraneoplastic neurological syndromes (PNS), emphasizing clinical and pathophysiological implications. RECENT FINDINGS The human leukocyte antigen (HLA) is the most studied genetic factor in autoimmune encephalitis and PNS. The HLA haplotype 8.1, which is widely known to be related to systemic autoimmunity, has been only weakly associated with a few types of autoimmune encephalitis and PNS. However, the strongest and most specific associations have been reported in a subgroup of autoimmune encephalitis that comprises antileucine-rich glioma-inactivated 1 (LGI1) limbic encephalitis, associated with DRB1∗07 : 01 , anticontactin-associated protein-like 2 (CASPR2) limbic encephalitis, associated with DRB1∗11 : 01 , and anti-IgLON5 disease, associated with DRB1∗10 : 01∼DQA1∗01∼DQB1∗05 . Non-HLA genes have been poorly investigated so far in autoimmune encephalitis, mainly in those lacking HLA associations such as anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis, with only a few genome-wide association studies (GWAS) reporting equivocal results principally limited by small sample size. SUMMARY Genetic predisposition seems to be driven mostly by HLA in a group of autoimmune encephalitis characterized by being nonparaneoplastic and having predominantly IgG4 autoantibodies. The contribution of non-HLA genes, especially in those diseases lacking known or strong HLA associations, will require large cohorts enabling GWAS to be powerful enough to render meaningful results.
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Affiliation(s)
- Sergio Muñiz-Castrillo
- Stanford Center for Sleep Sciences and Medicine, Stanford University, Palo Alto, California, USA
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon
| | - Jérôme Honnorat
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon
- MeLiS Institute - UCBL-CNRS UMR 5284 - INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
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4
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Aboseif A, Vorasoot N, Pinto MV, Guo Y, Hasan S, Zekeridou A, Chen JJ, Dubey D. Immune Checkpoint Inhibitor-Associated Kelch-Like Protein-11 IgG Brainstem Encephalitis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200218. [PMID: 38484218 DOI: 10.1212/nxi.0000000000200218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/19/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVES Kelch-like protein-11 (KLHL11)-IgG is associated with rhombencephalitis and seminoma. It has not previously been described as a neurologic immune checkpoint inhibitor (ICI)-related adverse event (nirAE) or in association with esophageal adenocarcinoma. METHODS We describe a 61-year-old man with metastatic esophageal adenocarcinoma treated with folinic acid, fluorouracil, oxaliplatin (FOLFOX), and nivolumab, who subsequently developed diplopia, vertigo, and progressive gait ataxia after 8 weeks of treatment. RESULTS Owing to a concern for ICI-associated myasthenia gravis, nivolumab was held and he was treated with prednisone and pyridostigmine. EMG showed no neuromuscular junction dysfunction, and acetylcholine-receptor antibodies were negative. Brain MRI was unrevealing. Murine brain tissue immunofluorescence assay revealed KLHL11-IgG in both serum and CSF, confirmed by cell-based assay. Tumor histopathology demonstrated poorly differentiated, highly proliferative adenocarcinoma with increased mitotic figures and cytoplasmic KLHL11 immunoreactivity. He was initiated on 6 months of cyclophosphamide in addition to FOLFOX for post-ICI-associated KLHL11-IgG rhombencephalitis. DISCUSSION We report KLHL11-IgG rhombencephalitis associated with poorly differentiated esophageal cancer as a novel nirAE. Tumor staining revealed KLHL11 immunoreactivity, supporting a cancer-antigen-driven ICI-associated paraneoplastic syndrome. Recognition of novel nirAEs can expedite treatment and potentially prevent progressive neurologic disability.
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Affiliation(s)
- Albert Aboseif
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - Nisa Vorasoot
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - Marcus V Pinto
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - Yong Guo
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - Shemonti Hasan
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - Anastasia Zekeridou
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - John J Chen
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
| | - Divyanshu Dubey
- From the Center for Multiple Sclerosis and Autoimmune Neurology (A.A., N.V., Y.G., S.H., A.Z., J.J.C., D.D.), Department of Neurology; Department of Laboratory Medicine and Pathology (N.V., Y.G., A.Z., D.D.); Department of Neurology (N.V.), Mayo Clinic College of Medicine, Rochester, MN; Division of Neurology (M.V.P.), Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand; and Department of Ophthalmology (J.J.C.), Mayo Clinic College of Medicine, Rochester, MN
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5
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Sanvito F, Pichiecchio A, Paoletti M, Rebella G, Resaz M, Benedetti L, Massa F, Morbelli S, Caverzasi E, Asteggiano C, Businaro P, Masciocchi S, Castellan L, Franciotta D, Gastaldi M, Roccatagliata L. Autoimmune encephalitis: what the radiologist needs to know. Neuroradiology 2024; 66:653-675. [PMID: 38507081 PMCID: PMC11031487 DOI: 10.1007/s00234-024-03318-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/20/2024] [Indexed: 03/22/2024]
Abstract
Autoimmune encephalitis is a relatively novel nosological entity characterized by an immune-mediated damage of the central nervous system. While originally described as a paraneoplastic inflammatory phenomenon affecting limbic structures, numerous instances of non-paraneoplastic pathogenesis, as well as extra-limbic involvement, have been characterized. Given the wide spectrum of insidious clinical presentations ranging from cognitive impairment to psychiatric symptoms or seizures, it is crucial to raise awareness about this disease category. In fact, an early diagnosis can be dramatically beneficial for the prognosis both to achieve an early therapeutic intervention and to detect a potential underlying malignancy. In this scenario, the radiologist can be the first to pose the hypothesis of autoimmune encephalitis and refer the patient to a comprehensive diagnostic work-up - including clinical, serological, and neurophysiological assessments.In this article, we illustrate the main radiological characteristics of autoimmune encephalitis and its subtypes, including the typical limbic presentation, the features of extra-limbic involvement, and also peculiar imaging findings. In addition, we review the most relevant alternative diagnoses that should be considered, ranging from other encephalitides to neoplasms, vascular conditions, and post-seizure alterations. Finally, we discuss the most appropriate imaging diagnostic work-up, also proposing a suggested MRI protocol.
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Affiliation(s)
- Francesco Sanvito
- Unit of Radiology, Department of Clinical, Surgical, Diagnostic, and Paediatric Sciences, University of Pavia, Viale Camillo Golgi, 19, 27100, Pavia, Italy.
- UCLA Brain Tumor Imaging Laboratory (BTIL), Center for Computer Vision and Imaging Biomarkers, University of California Los Angeles, Los Angeles, CA, USA.
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | - Anna Pichiecchio
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Matteo Paoletti
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Giacomo Rebella
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Martina Resaz
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Luana Benedetti
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Federico Massa
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Largo Daneo 3, 16132, Genoa, Italy
| | - Silvia Morbelli
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Via Antonio Pastore 1, 16132, Genoa, Italy
| | - Eduardo Caverzasi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Carlo Asteggiano
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Pietro Businaro
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Stefano Masciocchi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Lucio Castellan
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Diego Franciotta
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Luca Roccatagliata
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Via Antonio Pastore 1, 16132, Genoa, Italy
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6
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Agyei P, Chen M, Guo Y, Pérez CA, Dubey D, Gupta RK. Pearls & Oy-sters: KLHL11 IgG Paraneoplastic-Associated Hearing Loss and Rhombencephalitis in a Woman With Metastatic Müllerian Tumor. Neurology 2024; 102:e209187. [PMID: 38484225 DOI: 10.1212/wnl.0000000000209187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 01/02/2024] [Indexed: 03/19/2024] Open
Abstract
Kelch-like protein-11 (KLHL11) immunoglobulin G (IgG) is a recently reported paraneoplastic autoantibody associated with rhombencephalitis, which commonly presents with ataxia, diplopia, vertigo, hearing loss, tinnitus, and gaze palsies. The association of this high-risk paraneoplastic autoantibody with testicular germ cell tumors is widely accepted, but it has not been associated with Müllerian tumors. In this study, we report a woman without a known germ cell tumor presenting with signs and symptoms suggesting autoimmune encephalitis. She was found to have metastatic ovarian serous carcinoma with KLHL11 immunoreactivity on histopathology. This case demonstrates a rare cancer association of KLHL11 IgG-seropositive rhombencephalitis with Müllerian tumor and highlights that this autoantibody can also be detected in female patients. Thus, this case expands on the current knowledge of KLHL11-related autoimmune encephalitis including the paraneoplastic presentation, associated tumor types, and management of this syndrome in women.
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Affiliation(s)
- Paunel Agyei
- From the Department of Neurology (P.A., R.K.G., M.C.), University of Texas Health Science Center at Houston, TX; Departments of Neurology (Y.G., D.D.) and Laboratory Medicine and Pathology (D.D.), Mayo Clinic, Rochester, MN; and Department of Neurology (C.A.P.), Baylor College of Medicine, Houston, TX
| | - Michelle Chen
- From the Department of Neurology (P.A., R.K.G., M.C.), University of Texas Health Science Center at Houston, TX; Departments of Neurology (Y.G., D.D.) and Laboratory Medicine and Pathology (D.D.), Mayo Clinic, Rochester, MN; and Department of Neurology (C.A.P.), Baylor College of Medicine, Houston, TX
| | - Yong Guo
- From the Department of Neurology (P.A., R.K.G., M.C.), University of Texas Health Science Center at Houston, TX; Departments of Neurology (Y.G., D.D.) and Laboratory Medicine and Pathology (D.D.), Mayo Clinic, Rochester, MN; and Department of Neurology (C.A.P.), Baylor College of Medicine, Houston, TX
| | - Carlos A Pérez
- From the Department of Neurology (P.A., R.K.G., M.C.), University of Texas Health Science Center at Houston, TX; Departments of Neurology (Y.G., D.D.) and Laboratory Medicine and Pathology (D.D.), Mayo Clinic, Rochester, MN; and Department of Neurology (C.A.P.), Baylor College of Medicine, Houston, TX
| | - Divyanshu Dubey
- From the Department of Neurology (P.A., R.K.G., M.C.), University of Texas Health Science Center at Houston, TX; Departments of Neurology (Y.G., D.D.) and Laboratory Medicine and Pathology (D.D.), Mayo Clinic, Rochester, MN; and Department of Neurology (C.A.P.), Baylor College of Medicine, Houston, TX
| | - Rajesh K Gupta
- From the Department of Neurology (P.A., R.K.G., M.C.), University of Texas Health Science Center at Houston, TX; Departments of Neurology (Y.G., D.D.) and Laboratory Medicine and Pathology (D.D.), Mayo Clinic, Rochester, MN; and Department of Neurology (C.A.P.), Baylor College of Medicine, Houston, TX
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7
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Manto M, Hadjivassiliou M, Baizabal-Carvallo JF, Hampe CS, Honnorat J, Joubert B, Mitoma H, Muñiz-Castrillo S, Shaikh AG, Vogrig A. Consensus Paper: Latent Autoimmune Cerebellar Ataxia (LACA). CEREBELLUM (LONDON, ENGLAND) 2024; 23:838-855. [PMID: 36991252 PMCID: PMC10060034 DOI: 10.1007/s12311-023-01550-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 06/01/2023]
Abstract
Immune-mediated cerebellar ataxias (IMCAs) have diverse etiologies. Patients with IMCAs develop cerebellar symptoms, characterized mainly by gait ataxia, showing an acute or subacute clinical course. We present a novel concept of latent autoimmune cerebellar ataxia (LACA), analogous to latent autoimmune diabetes in adults (LADA). LADA is a slowly progressive form of autoimmune diabetes where patients are often initially diagnosed with type 2 diabetes. The sole biomarker (serum anti-GAD antibody) is not always present or can fluctuate. However, the disease progresses to pancreatic beta-cell failure and insulin dependency within about 5 years. Due to the unclear autoimmune profile, clinicians often struggle to reach an early diagnosis during the period when insulin production is not severely compromised. LACA is also characterized by a slowly progressive course, lack of obvious autoimmune background, and difficulties in reaching a diagnosis in the absence of clear markers for IMCAs. The authors discuss two aspects of LACA: (1) the not manifestly evident autoimmunity and (2) the prodromal stage of IMCA's characterized by a period of partial neuronal dysfunction where non-specific symptoms may occur. In order to achieve an early intervention and prevent cell death in the cerebellum, identification of the time-window before irreversible neuronal loss is critical. LACA occurs during this time-window when possible preservation of neural plasticity exists. Efforts should be devoted to the early identification of biological, neurophysiological, neuropsychological, morphological (brain morphometry), and multimodal biomarkers allowing early diagnosis and therapeutic intervention and to avoid irreversible neuronal loss.
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Affiliation(s)
- Mario Manto
- Service de Neurologie, Médiathèque Jean Jacquy, CHU-Charleroi, Charleroi, Belgium
- Service des Neurosciences, University of Mons, Mons, Belgium
| | | | | | | | - Jerome Honnorat
- French Reference Center on Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Institut NeuroMyoGene MELIS INSERM U1314/CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Bastien Joubert
- French Reference Center on Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Institut NeuroMyoGene MELIS INSERM U1314/CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, Tokyo, Japan.
| | | | - Aasef G Shaikh
- Louis Stokes Cleveland VA Medical Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Alberto Vogrig
- Clinical Neurology, Udine University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
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8
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Shim YM, Kim SI, Lim SD, Lee K, Kim EE, Won JK, Park SH. An Autopsy-proven Case-based Review of Autoimmune Encephalitis. Exp Neurobiol 2024; 33:1-17. [PMID: 38471800 PMCID: PMC10938074 DOI: 10.5607/en23036] [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: 10/16/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
Autoimmune encephalitis (AIE) is a type of immunoreactive encephalitic disorder and is recognized as the most prevalent noninfectious encephalitis. Nevertheless, the rarity of definitive AIE diagnosis through biopsy or autopsy represents a significant hurdle to understanding and managing the disease. In this article, we present the pathological findings of AIE and review the literature based on a distinct case of AIE presenting as CD8+ T-lymphocyte predominant encephalitis. We describe the clinical progression, diagnostic imaging, laboratory data, and autopsy findings of an 80-year-old deceased male patient. The patient was diagnosed with pulmonary tuberculosis 6 months before death and received appropriate medications. A week before admission to the hospital, the patient manifested symptoms such as a tendency to sleep, decreased appetite, and confusion. Although the patient temporally improved with medication including correction of hyponatremia, the patient progressed rapidly and died in 6 weeks. The brain tissue revealed lymphocytic infiltration in the gray and white matter, leptomeninges, and perivascular infiltration with a predominance of CD8+ T lymphocytes, suggesting a case of AIE. There was no detectable evidence of viral infection or underlying neoplasm. The autopsy revealed that this patient also had Alzheimer's disease, atherosclerosis, arteriolosclerosis, and aging-related tau astrogliopathy. This report emphasizes the pivotal role of pathological examination in the diagnosis of AIE, especially when serological autoantibody testing is not available or when a patient is suspected of having multiple diseases.
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Affiliation(s)
- Yu-Mi Shim
- Department of Pathology, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Seong-Ik Kim
- Department of Pathology, Seoul National University College of Medicine, Seoul 03080, Korea
| | - So Dug Lim
- Department of Pathology, KonKuk University School of Medicine, Seoul 05029, Korea
| | - Kwanghoon Lee
- Department of Pathology, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Eric Eunshik Kim
- Department of Pathology, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Jae Kyung Won
- Department of Pathology, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Sung-Hye Park
- Department of Pathology, Seoul National University College of Medicine, Seoul 03080, Korea
- Institute of Neuroscience, Seoul National University College of Medicine, Seoul 03080, Korea
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9
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Bhatia K, Balint B. Autoimmunity Panels: Needs and Implementation in the Underdeveloped Regions and how to Approach the Disparities. Mov Disord Clin Pract 2024; 11:119-122. [PMID: 38386486 PMCID: PMC10883400 DOI: 10.1002/mdc3.13946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/15/2023] [Accepted: 11/15/2023] [Indexed: 02/24/2024] Open
Affiliation(s)
- Kailash Bhatia
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology University College LondonLondonUnited Kingdom
| | - Bettina Balint
- Department of NeurologyUniversity Hospital Zurich, University of ZurichSwitzerland
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10
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Hoshina Y, Gradin C, Germaine S, Wold J. Kelch-like Protein-11 Encephalitis Associated With Squamous Cell Carcinoma of Unknown Origin: A Case Report. Neurol Clin Pract 2024; 14:e200219. [PMID: 37982047 PMCID: PMC10656177 DOI: 10.1212/cpj.0000000000200219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/26/2023] [Indexed: 11/21/2023]
Abstract
Objectives We report a case of Kelch-like protein-11 (KLHL11) encephalitis associated with squamous cell carcinoma (SCC) of unknown origin in the neck. Methods A 70-year-old man, diagnosed with prurigo nodularis 4 months prior, presented with subacute-onset progressive dysarthria, imbalance, and diplopia. Neurologic examination revealed horizontal and downbeating nystagmus with lateral gaze, dysarthria, dysmetria, and hearing difficulties. Skin examination showed localized pruritus with excoriated ulcerations on the neck and proximal upper extremities. MRI of the brain revealed T2 hyperintensities in the pons and left cerebellum, and CT of the neck showed a right neck mass. Results Extensive workup for acquired brainstem syndromes revealed KLHL11 antibodies in both the serum and CSF, together with superimposed unclassified antibodies. The patient was diagnosed with KLHL11 encephalitis and was treated with intravenous immunoglobulin, intravenous methylprednisolone, and plasmapheresis. He underwent right neck dissection, with pathology revealing SCC of unknown origin. Subsequently, the patient received monthly IV cyclophosphamide and adjuvant radiation therapy. His clinical symptoms, including the excoriated ulcerations, improved remarkably with treatment. Discussion Our patient represents the first case of KLHL11 encephalitis associated with SCC of unknown origin in the neck, and our observations delineate a potentially novel correlation between the 2 diseases.
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Affiliation(s)
- Yoji Hoshina
- Department of Neurology, University of Utah, Salt Lake City
| | - Collin Gradin
- Department of Neurology, University of Utah, Salt Lake City
| | - Sarah Germaine
- Department of Neurology, University of Utah, Salt Lake City
| | - Jana Wold
- Department of Neurology, University of Utah, Salt Lake City
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Farina A, Villagrán-García M, Vogrig A, Zekeridou A, Muñiz-Castrillo S, Velasco R, Guidon AC, Joubert B, Honnorat J. Neurological adverse events of immune checkpoint inhibitors and the development of paraneoplastic neurological syndromes. Lancet Neurol 2024; 23:81-94. [PMID: 38101905 DOI: 10.1016/s1474-4422(23)00369-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 09/14/2023] [Accepted: 09/20/2023] [Indexed: 12/17/2023]
Abstract
Immune checkpoint inhibitors, a class of oncological treatments that enhance antitumour immunity, can trigger neurological adverse events closely resembling paraneoplastic neurological syndromes. Unlike other neurological adverse events caused by these drugs, post-immune checkpoint inhibitor paraneoplastic neurological syndromes predominantly affect the CNS and are associated with neural antibodies and cancer types commonly found also in spontaneous paraneoplastic neurological syndromes. Furthermore, post-immune checkpoint inhibitor paraneoplastic neurological syndromes have poorer neurological outcomes than other neurological adverse events of immune checkpoint inhibitors. Early diagnosis and initiation of immunosuppressive therapy are likely to be crucial in preventing the accumulation of neurological disability. Importantly, the neural antibodies found in patients with post-immune checkpoint inhibitor paraneoplastic neurological syndromes are sometimes detected before treatment, indicating that these antibodies might help to predict the development of neurological adverse events. Experimental and clinical evidence suggests that post-immune checkpoint inhibitor paraneoplastic neurological syndromes probably share immunological features with spontaneous paraneoplastic syndromes. Hence, the study of post-immune checkpoint inhibitor paraneoplastic neurological syndromes can help in deciphering the immunopathogenesis of paraneoplastic neurological syndromes and in identifying novel therapeutic targets.
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Affiliation(s)
- Antonio Farina
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France; Department of Neuroscience, Psychology, Pharmacology and Child Health, University of Florence, Florence, Italy
| | - Macarena Villagrán-García
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Alberto Vogrig
- Clinical Neurology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy; Department of Medicine (DAME), University of Udine Medical School, Udine, Italy
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Sergio Muñiz-Castrillo
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France; Stanford Center for Sleep Sciences and Medicine, Palo Alto, CA, USA
| | - Roser Velasco
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-Institut Català d Oncologia L'Hospitalet, Institut d'Investigació Biomèdica de Bellvitge, l'Hospitalet de Llobregat, Barcelona, Spain; Institute of Neurosciences and Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Amanda C Guidon
- Harvard Medical School, Boston, MA, USA; Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Bastien Joubert
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France; Department of Neurology, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Jérôme Honnorat
- Reference Centre for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Neurological Hospital, Bron, France; MeLiS, UCBL-CNRS UMR 5284, INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France.
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12
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Kvam KA, Stahl JP, Chow FC, Soldatos A, Tattevin P, Sejvar J, Mailles A. Outcome and Sequelae of Autoimmune Encephalitis. J Clin Neurol 2024; 20:3-22. [PMID: 38179628 PMCID: PMC10782092 DOI: 10.3988/jcn.2023.0242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 01/06/2024] Open
Abstract
Autoimmune etiologies are a common cause for encephalitis. The clinical syndromes consistent with autoimmune encephalitis are both distinct and increasingly recognized, but less is known about persisting sequelae or outcomes. We searched PubMed for reports on outcomes after autoimmune encephalitis. Studies assessing validated, quantitative outcomes were included. We performed a narrative review of the published literature of outcomes after autoimmune encephalitis. We found 146 studies that produced outcomes data. The mortality rates were 6%-19% and the relapse risks were 10%-62%. Most patients achieved a good outcome based on a score on the modified Rankin Scale (mRS) of ≤2. Forty-nine studies evaluated outcomes beyond mRS; these studies investigated cognitive outcome, psychiatric sequelae, neurological deficits, global function, and quality-of-life/patient-reported outcomes using various tools at varying time points after the index hospital discharge. These more-detailed assessments revealed that most patients had persistent impairments, with frequent deficits in cognitive function, especially memory and attention. Depression and anxiety were also common. Many of these sequelae continued to improve over months or even years after the acute illness. While we found that lasting impairments were common among survivors of autoimmune encephalitis, additional research is needed to better understand the nature and impact of these sequelae. Standardized evaluation protocols are needed to improve the ability to compare outcomes across studies, guide rehabilitation strategies, and inform outcomes of interest in treatment trials as the field advances.
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Affiliation(s)
- Kathryn A Kvam
- Department of Neurology & Neurological Sciences, Center for Academic Medicine, Stanford University, Stanford, CA, USA.
| | | | - Felicia C Chow
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, CA, USA
| | - Ariane Soldatos
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - James Sejvar
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alexandra Mailles
- Department of Infectious Diseases, Santé publique France, Saint-Maurice, France
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13
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Alkhayat D, Khawaji ZY, Sunyur AM, Sanyour OA, Badawi AS. Overview of Paraneoplastic Autoantibody-Mediated Cognitive Impairment and Behavioral Changes: A Narrative Review. Cureus 2024; 16:e51787. [PMID: 38322089 PMCID: PMC10846349 DOI: 10.7759/cureus.51787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2024] [Indexed: 02/08/2024] Open
Abstract
Cognitive dysfunction and behavioral change can be some of the manifestations of cancer, occurring as a part of paraneoplastic neurological syndrome, most commonly in small cell lung cancer. Paraneoplastic limbic encephalitis is the leading cause of cognitive disturbance and abnormal behavior in paraneoplastic syndromes, which is usually autoantibody-mediated. Autoantibodies are the main contributors to the development of cognitive dysfunction and behavioral change in cancer patients, with studies suggesting a higher liability for antibody-positive cancer patients to be affected. Anti-NMDAR and anti-AMPAR are antibodies targeted against surface antigens, manifesting predominantly as memory disturbance, abnormal behavior, psychiatric symptoms, and seizures. Other surface antigen-targeted antibodies include anti-GABA, anti-CASPR2, and anti-LGI1, which were shown to have cognitive function impairment and abnormal behavior as some of the main presentations, predominantly affecting memory. Cognitive deterioration and changes in behavior were also relatively common with some of the intracellular antigen-targeted antibodies, including anti-Hu, anti-SOX1, anti-PCA2, and anti-Zic2. Affected behavior and cognition, however, were reported less commonly in other paraneoplastic antibodies against intracellular antigens (anti-Yo, anti-GAD, anti-Ma2, anti-Ri, anti-CV2, and anti-KLHL11). Our article will provide a comprehensive review of the clinical manifestations of cognitive impairment and behavioral changes among cancer patients who develop paraneoplastic syndrome. Additionally, this review will discuss the role of specific paraneoplastic autoantibodies and the clinical spectrum linked to each separately.
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Affiliation(s)
| | | | - Amal M Sunyur
- Medicine and Surgery, Taibah University, Medina, SAU
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14
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McKeon A, Tracy J. Paraneoplastic movement disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:211-227. [PMID: 38494279 DOI: 10.1016/b978-0-12-823912-4.00004-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic movement disorders are diverse autoimmune neurological illnesses occurring in the context of systemic cancer, either in isolation or as part of a multifocal neurological disease. Movement phenomena may be ataxic, hypokinetic (parkinsonian), or hyperkinetic (myoclonus, chorea, or other dyskinetic disorders). Some disorders mimic neurodegenerative or hereditary illnesses. The subacute onset and coexisting nonclassic features of paraneoplastic disorders aid distinction. Paraneoplastic autoantibodies provide further information regarding differentiating cancer association, disease course, and treatment responses. A woman with cerebellar ataxia could have metabotropic glutamate receptor 1 autoimmunity, in the setting of Hodgkin lymphoma, a mild neurological phenotype and response to immunotherapy. A different woman, also with cerebellar ataxia, could have Purkinje cytoplasmic antibody type 1 (anti-Yo), accompanying ovarian adenocarcinoma, a rapidly progressive phenotype and persistent disabling deficits despite immune therapy. The list of antibody biomarkers is growing year-on-year, each with its own ideal specimen type for detection (serum or CSF), accompanying neurological manifestations, cancer association, treatment response, and prognosis. Therefore, a profile-based approach to screening both serum and CSF is recommended. Immune therapy trials are generally undertaken, and include one or more of corticosteroids, IVIg, plasma exchange, rituximab, or cyclophosphamide. Symptomatic therapies can also be employed for hyperkinetic disorders.
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Affiliation(s)
- Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
| | - Jennifer Tracy
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
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15
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Wagner B, Irani S. Autoimmune and paraneoplastic seizures. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:151-172. [PMID: 38494275 DOI: 10.1016/b978-0-12-823912-4.00009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Seizures are a common feature of autoimmune encephalitis and are especially prevalent in patients with the commonest autoantibodies, against LGI1, CASPR2 and the NMDA, GABAB, and GABAA receptors. In this chapter, we discuss the classification, clinical, investigation, and treatment aspects of patients with these, and other autoantibody-mediated and -associated, illnesses. We highlight distinctive and common seizure semiologies which, often alongside other features we outline, can help the clinical diagnosis of an autoantibody-associated syndrome. Next, we classify these syndromes by either focusing on whether they represent underlying causative autoantibodies or T-cell-mediated syndromes and on the distinction between acute symptomatic seizures and a more enduring tendency to autoimmune-associated epilepsy, a practical and valuable distinction for both patients and clinicians which relates to the pathogenesis. We emphasize the more effective immunotherapy response in patients with causative autoantibodies, and discuss the emerging evidence for various first-, second-, and third-line immunotherapies. Finally, we highlight available clinical rating scales which can guide autoantibody testing and immunotherapy in patients with seizures of unknown etiology. Throughout, we relate the clinical and therapeutic observations to the immunobiology and neuroscience which drive these seizures.
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Affiliation(s)
- Barbara Wagner
- Neuroscience Department, NDCN, University of Oxford and Oxford University Hospitals, Oxford, United Kingdom; Kantonsspital Aarau Switzerland, Tellstrasse, Aarau, Switzerland
| | - Sarosh Irani
- Neuroscience Department, NDCN, University of Oxford and Oxford University Hospitals, Oxford, United Kingdom.
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16
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Graus F. Clinical approach to diagnosis of paraneoplastic neurologic syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:79-96. [PMID: 38494298 DOI: 10.1016/b978-0-12-823912-4.00007-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
The correct diagnosis of a paraneoplastic neurologic syndrome (PNS) first requires the identification of the syndrome as one of those defined as high-risk (previously called classical) or intermediate-risk for cancer in the 2021 PNS diagnostic criteria. Testing for neuronal antibodies should be restricted to these syndromes as indiscriminate request decreases the diagnostic value of the antibodies. Identifying onconeural (high-risk for cancer) or intermediate-risk for cancer antibodies supports the paraneoplastic diagnosis and mandates the search for an underlying cancer. Tumor screening must follow the published guidelines. Repeated screening is indicated in neurologic syndromes with onconeural antibodies and patients with high-risk for cancer neurologic syndromes unless they present neuronal antibodies which are not associated with cancer. Neuronal antibodies should be screened by immunohistochemistry and confirmed by immunoblot (intracellular antigens) or cell-based assay (CBA) (surface antigens). Positive results only by immunoblot or CBA should be taken with caution. Although the 2021 diagnostic criteria for PNS do not capture all PNS, as they do not allow to diagnose definite PNS neurologic syndromes without neuronal antibodies, the updated criteria represent a step forward to differentiate true PNS from neurologic syndromes that coincide in time with cancer diagnosis without having a pathogenic link.
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Affiliation(s)
- Francesc Graus
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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17
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Shelly S, Dubey D, Mills JR, Klein CJ. Paraneoplastic neuropathies and peripheral nerve hyperexcitability disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:239-273. [PMID: 38494281 DOI: 10.1016/b978-0-12-823912-4.00020-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Peripheral neuropathy is a common referral for patients to the neurologic clinics. Paraneoplastic neuropathies account for a small but high morbidity and mortality subgroup. Symptoms include weakness, sensory loss, sweating irregularity, blood pressure instability, severe constipation, and neuropathic pain. Neuropathy is the first presenting symptom of malignancy among many patients. The molecular and cellular oncogenic immune targets reside within cell bodies, axons, cytoplasms, or surface membranes of neural tissues. A more favorable immune treatment outcome occurs in those where the targets reside on the cell surface. Patients with antibodies binding cell surface antigens commonly have neural hyperexcitability with pain, cramps, fasciculations, and hyperhidrotic attacks (CASPR2, LGI1, and others). The antigenic targets are also commonly expressed in the central nervous system, with presenting symptoms being myelopathy, encephalopathy, and seizures with neuropathy, often masked. Pain and autonomic components typically relate to small nerve fiber involvement (nociceptive, adrenergic, enteric, and sudomotor), sometimes without nerve fiber loss but rather hyperexcitability. The specific antibodies discovered help direct cancer investigations. Among the primary axonal paraneoplastic neuropathies, pathognomonic clinical features do not exist, and testing for multiple antibodies simultaneously provides the best sensitivity in testing (AGNA1-SOX1; amphiphysin; ANNA-1-HU; ANNA-3-DACH1; CASPR2; CRMP5; LGI1; PCA2-MAP1B, and others). Performing confirmatory antibody testing using adjunct methods improves specificity. Antibody-mediated demyelinating paraneoplastic neuropathies are limited to MAG-IgM (IgM-MGUS, Waldenström's, and myeloma), with the others associated with cytokine elevations (VEGF, IL6) caused by osteosclerotic myeloma, plasmacytoma (POEMS), and rarely angiofollicular lymphoma (Castleman's). Paraneoplastic disorders have clinical overlap with other idiopathic antibody disorders, including IgG4 demyelinating nodopathies (NF155 and Contactin-1). This review summarizes the paraneoplastic neuropathies, including those with peripheral nerve hyperexcitability.
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Affiliation(s)
- Shahar Shelly
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Neurology, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Christopher J Klein
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
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18
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Budhram A, Flanagan EP. Optimizing the diagnostic performance of neural antibody testing for paraneoplastic and autoimmune encephalitis in clinical practice. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:365-382. [PMID: 38494290 DOI: 10.1016/b978-0-12-823912-4.00002-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
The detection of neural antibodies in patients with paraneoplastic and autoimmune encephalitis has majorly advanced the diagnosis and management of neural antibody-associated diseases. Although testing for these antibodies has historically been restricted to specialized centers, assay commercialization has made this testing available to clinical chemistry laboratories worldwide. This improved test accessibility has led to reduced turnaround time and expedited diagnosis, which are beneficial to patient care. However, as the utilization of these assays has increased, so too has the need to evaluate how they perform in the clinical setting. In this chapter, we discuss assays for neural antibody detection that are in routine use, draw attention to their limitations and provide strategies to help clinicians and laboratorians overcome them, all with the aim of optimizing neural antibody testing for paraneoplastic and autoimmune encephalitis in clinical practice.
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Affiliation(s)
- Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, ON, Canada; Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada.
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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19
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Kadish R, Clardy SL. Epidemiology of paraneoplastic neurologic syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:57-77. [PMID: 38494297 DOI: 10.1016/b978-0-12-823912-4.00011-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes (PNS), initially depicted as seemingly cryptic remote manifestations of malignancy, were first described clinically in the early 20th century, with pathophysiologic correlates becoming better elucidated in the latter half of the century. There remain many questions not only about the pathophysiology but also regarding the epidemiology of these conditions. The continuous discovery of novel autoantigens and related neurologic disease has broadened the association in classical PNS to include conditions such as paraneoplastic cerebellar degeneration. It has also brought into focus several other neurologic syndromes with a putative neoplastic association. These conditions are overall rare, making it difficult to capture large numbers of patients to study, and raising the question of whether incidence is increasing over time or improved identification is driving the increased numbers of cases. With the rise and increasing use of immunotherapy for cancer treatment, the incidence of these conditions is additionally expected to rise and may present with various clinical symptoms. As we enter an era of clinical trial intervention in these conditions, much work is needed to capture more granular data on population groups defined by socioeconomic characteristics such as age, ethnicity, economic resources, and gender to optimize care and clinical trial planning.
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Affiliation(s)
- Robert Kadish
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Stacey L Clardy
- Department of Neurology, University of Utah, Salt Lake City, UT, United States; George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States.
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20
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Tzartos J, Pechlivanidou M, Bosveli D, Ninou E, Yuceer H, Yalcin B, Kucukali CI, Tuzun E, Tzartos S, Turkdogan D. Kelch-like Protein 11 (KLHL11) Antibodies in Children With Seizures of Undetermined Cause. In Vivo 2024; 38:351-357. [PMID: 38148071 PMCID: PMC10756464 DOI: 10.21873/invivo.13445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND/AIM Kelch-like protein 11 (KLHL11)-antibody may be found in paraneoplastic neurological disorders presenting with epileptic seizures. The aim of this study was to investigate the prevalence and clinical significance of KLHL11-antibody in epilepsy. PATIENTS AND METHODS Sera of 42 pediatric and 59 adult patients with seizures of undetermined cause were screened using a cell-based assay. RESULTS KLHL11-antibody was found in three of 168 control patients with paraneoplastic neurological disorders and four pediatric patients (4-8-year-old, 2 boys/2 girls) with seizures of unknown cause presenting with myoclonic-atonic epilepsy, generalized epilepsy or childhood epilepsy with centrotemporal spikes. In these four cases, seizures continued for 2-7 months, responded promptly and favorably to conventional anti-seizure drugs and did not recur in follow-up durations ranging between 2-5 years. Patients had normal brain MRI findings and motor-mental development before and after seizures. KLHL11-antibody was not detected in adult epilepsy patients with undetermined cause, MOG antibody-positive patients and healthy controls. CONCLUSION KLHL11-antibody may be detected in pediatric epilepsy patients with a relatively benign disease course.
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Affiliation(s)
- John Tzartos
- 2 Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece
| | | | | | | | - Hande Yuceer
- Department of Neuroscience, Aziz Sancar Institute for Experimental Medical Research, Istanbul University, Istanbul, Turkey
| | - Beyzanur Yalcin
- Department of Neuroscience, Aziz Sancar Institute for Experimental Medical Research, Istanbul University, Istanbul, Turkey
| | - Cem Ismail Kucukali
- Department of Neuroscience, Aziz Sancar Institute for Experimental Medical Research, Istanbul University, Istanbul, Turkey
| | - Erdem Tuzun
- Department of Neuroscience, Aziz Sancar Institute for Experimental Medical Research, Istanbul University, Istanbul, Turkey;
| | - Socrates Tzartos
- Tzartos NeuroDiagnostics, Athens, Greece
- Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece
- Department of Pharmacy, University of Patras, Patras, Greece
| | - Dilsad Turkdogan
- Division of Child Neurology, Department of Pediatrics, Faculty of Medicine, Marmara University, Istanbul, Turkey
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21
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Abbatemarco JR, Vedeler CA, Greenlee JE. Paraneoplastic cerebellar and brainstem disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:173-191. [PMID: 38494276 DOI: 10.1016/b978-0-12-823912-4.00030-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic cerebellar and brainstem disorders are a heterogeneous group that requires prompt recognition and treatment to help prevent irreversible neurologic injury. Paraneoplastic cerebellar degeneration is best characterized by Yo antibodies in patients with breast or ovarian cancer. Tr (DNER) antibodies in patients with Hodgkin lymphoma can also present with a pure cerebellar syndrome and is one of the few paraneoplastic syndromes found with hematological malignancy. Opsoclonus-myoclonus-ataxia syndrome presents in both pediatric and adult patients with characteristic clinical findings. Other paraneoplastic brainstem syndromes are associated with Ma2 and Hu antibodies, which can cause widespread neurologic dysfunction. The differential for these disorders is broad and also includes pharmacological side effects, infection or postinfectious processes, and neurodegenerative diseases. Although these immune-mediated disorders have been known for many years, mechanisms of pathogenesis are still unclear, and optimal treatment has not been established.
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Affiliation(s)
- Justin R Abbatemarco
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, United States.
| | - Christian A Vedeler
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, University of Bergen, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - John E Greenlee
- Neurology Service, George E. Wahlen Veterans Affairs Health Care System, Salt Lake City, UT, United States; Department of Neurology, University of Utah, Salt Lake City, UT, United States
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22
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Jean MJ, Samkoff L, Mohile N. Management of Paraneoplastic Syndromes in the Era of Immune Checkpoint Inhibitors. Curr Treat Options Oncol 2024; 25:42-65. [PMID: 38198120 DOI: 10.1007/s11864-023-01157-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 01/11/2024]
Abstract
OPINION STATEMENT Our understanding of paraneoplastic neurologic syndromes (PNS) has blossomed over the past few decades. Clinicians have access to more robust diagnostic criteria and have a heightened index of suspicion for these disorders. Nonetheless, treatment, which typically includes immunosuppression, and response to treatment, varies. Due to persistent difficulty in making a definitive diagnosis, we favor empiric treatment when a possible diagnosis of PNS is suspected, and other alternative causes have substantially been excluded (e.g., infections, toxic-metabolic derangements, metastasis, or leptomeningeal disease). Treatment of the underlying cancer, if identified, is the first therapeutic step and can prevent disease worsening and in rare cases, can reverse neurologic symptoms. In addition to anti-cancer treatment, first line immunotherapies, which include corticosteroids, intravenous immunoglobulins (IVIG), or plasma exchange (PLEX) are typically used. If partial or no benefit is seen, second line immunotherapeutic agents such as rituximab are considered. Additionally, the severity of the initial presentation and possible risk for relapse influences the use of the latter agents. Symptomatic management is also an important component in our practice and will depend on the syndrome being treated. One of the more novel entities we are facing currently is the management of immune checkpoint (ICI)-induced PNS. In those cases, current American Society of Clinical Oncology (ASCO) guidelines are followed.
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Affiliation(s)
- Maxime Junior Jean
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Lawrence Samkoff
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Nimish Mohile
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA.
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Hammami MB, Rezk M, Dubey D. Paraneoplastic neurologic syndrome and autoantibody accompaniments of germ cell tumors. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:431-445. [PMID: 38494295 DOI: 10.1016/b978-0-12-823912-4.00001-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes (PNSs) are a group of diseases affecting the central and/or peripheral nervous system caused by immune-mediated processes directed toward antigens with shared expression in tumor and neural tissue. Germ cell tumors (GCTs) are associated with PNSs with varied clinical phenotypes. Early diagnosis of PNS is vital to potentially uncover and treat underlying tumors, improving the chances of recovery, and preventing permanent neurologic complications. In this chapter, we outline the pathophysiology and epidemiology of PNS. We briefly provide a summary of GCTs in males and females. We review the neural-specific autoantibodies and PNSs associated with GCTs and their clinical and radiologic accompaniments. We also provide an overview of the treatment and prognosis of these disorders.
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Affiliation(s)
- M Bakri Hammami
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States
| | - Mohamed Rezk
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Divyanshu Dubey
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Neurology, Mayo Clinic, Rochester, MN, United States.
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24
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Linnoila JJ. Paraneoplastic antibodies targeting intracellular antigens. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:335-346. [PMID: 38494288 DOI: 10.1016/b978-0-12-823912-4.00021-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Although they are relatively rare, the diagnosis of paraneoplastic neurologic syndromes (PNS) can be aided by the identification of neural autoantibodies in patients' serum and cerebrospinal fluid (CSF). They often clinically manifest as characteristic syndromes, including limbic encephalitis, opsoclonus-myoclonus syndrome, paraneoplastic cerebellar degeneration, and paraneoplastic encephalomyelitis. The antibodies are directed either toward intracellular targets, or epitopes on the cell surface. As compared to cell surface antibodies, intracellular paraneoplastic autoantibodies are more classically associated with cancer, most often lung, breast, thymoma, gynecologic, testicular, and/or neuroendocrine cancers. The malignancies themselves tend to be small and regionally contained, attesting to the strength of the immune system in cancer immunosurveillance. Typically, the intracellular antibodies are not directly pathogenic and tend to be associated with PNS that are poorly responsive to treatment. With some notable exceptions, including patients with PNS associated with testicular cancer, patients with intracellular antibodies are typically older individuals, in their 7th decade of life and beyond. Many of them are current or former smokers. Treatment strategies include tumor removal as well as immunotherapy to treat the concomitant PNS. Newer technologies and the ever-broadening use of cancer immunotherapies are contributing to the continued identification of novel intracellularly targeted autoantibodies.
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Affiliation(s)
- Jenny J Linnoila
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States.
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Quinot V, Höftberger R. Pathogenesis and immunopathology of paraneoplastic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:33-54. [PMID: 38494287 DOI: 10.1016/b978-0-12-823912-4.00027-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes (PNS) represent a rare group of immune-mediated complications associated with an underlying tumor. Ectopic protein expression in neoplastic cells or an aberrant immune regulation in the course of hematooncologic diseases or thymomas trigger an autoimmune response that may affect any part of the central and/or peripheral nervous system. Recent advances in drug therapies as well as novel animal models and neuropathologic studies have led to further insights on the immune pathomechanisms of PNS. Although the syndromes share common paths in pathogenesis, they may differ in the disease course, prognosis, and therapy targets, depending on the localization and type of antibody epitope. Neuropathologic hallmarks of PNS associated with antibodies directed against intracellular epitopes are characterized by T cell-dominated inflammation, reactive gliosis including microglial nodules, and neuronal degeneration. By contrast, the neuropathology of cell surface antibody-mediated PNS strongly depends on the targeted antigen and varies from B cell/plasma cell-dominated inflammation and well-preserved neurons together with a reduced expression of the target antigen in anti-NMDAR encephalitis to irreversible Purkinje cell loss in anti-P/Q-type VGCC antibody-associated paraneoplastic cerebellar degeneration. The understanding of different pathomechanisms in PNS is important because they strongly correspond with therapy response and prognosis, and should guide treatment decisions.
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Affiliation(s)
- Valérie Quinot
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria.
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26
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Waters P, Mills JR, Fox H. Evolution of methods to detect paraneoplastic antibodies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:113-130. [PMID: 38494273 DOI: 10.1016/b978-0-12-823912-4.00010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
An adaptive immune response in less than 1% of people who develop cancer produces antibodies against neuronal proteins. These antibodies can be associated with paraneoplastic syndromes, and their accurate detection should instigate a search for a specific cancer. Over the years, multiple systems, from indirect immunofluorescence to live cell-based assays, have been developed to identify these antibodies. As the specific antigens were identified, high throughput, multi-antigen substrates such as line blots and ELISAs were developed for clinical laboratories. However, the evolution of assays required to identify antibodies to membrane targets has shone a light on the importance of antigen conformation for antibody detection. This chapter discusses the early antibody assays used to detect antibodies to nuclear and cytosolic targets and how new approaches are required to detect antibodies to membrane targets. The chapter presents recent data that support international recommendations against the sole use of line blots for antibody detection and highlights a new antigen-specific approach that appears promising for the detection of submembrane targets.
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Affiliation(s)
- Patrick Waters
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Hannah Fox
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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Li EC, Lai QL, Cai MT, Fang GL, Shen CH, Ding MP, Zhang YX. Anti-adenylate kinase 5 encephalitis: Clinical characteristics, diagnosis, and management of this rare entity. J Transl Autoimmun 2023; 7:100218. [PMID: 37859804 PMCID: PMC10582738 DOI: 10.1016/j.jtauto.2023.100218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/08/2023] [Accepted: 10/06/2023] [Indexed: 10/21/2023] Open
Abstract
The spectrum and understanding of antibody-positive autoimmune encephalitis (AE) have expanded over the past few decades. In 2007, a rare subtype of AE known as anti-adenylate kinase 5 (AK5) encephalitis, was first reported. This disease is more common in elderly males, with limbic encephalitis as the core phenotype (characterized by subacute anterograde amnesia, sometimes with psychiatric symptoms, and rarely with seizures). Brain magnetic resonance imaging typically demonstrated initial temporal lobe T2/fluid-attenuated inversion recovery hyperintensities, and subsequent atrophy. No concomitant tumors have been found yet. AK5 antibody, targeting the intracellular antigen, is a biomarker for a non-paraneoplastic T-cell autoimmunity response, and can be detected in serum and cerebrospinal fluid using tissue-based and cell-based assays. Cytotoxic T-cell-mediating neuronal injury and loss play a pivotal role in the immunopathogenesis of anti-AK5 encephalitis. Patients mostly show poor response to immunotherapy and thus a poor prognosis in the long run. Herein, we review the literature and provide updated knowledge of this less-known entity, focusing on clinical characteristics, paraclinical findings, diagnosis process, and therapeutic approaches.
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Affiliation(s)
- Er-Chuang Li
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
- Department of Neurology, Taikang Ningbo Hospital, Ningbo, 315042, China
| | - Qi-Lun Lai
- Department of Neurology, Zhejiang Hospital, Hangzhou, 310013, China
| | - Meng-Ting Cai
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Gao-Li Fang
- Department of Neurology, Zhejiang Chinese Medicine and Western Medicine Integrated Hospital, Hangzhou, 310003, China
| | - Chun-Hong Shen
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Mei-Ping Ding
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Yin-Xi Zhang
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
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28
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Akkus S, Elkhooly M, Amatya S, Shrestha K, Sharma K, Kagzi Y, Khan E, Gupta R, Piquet AL, Jaiswal S, Wen S, Tapia M, Samant R, Sista SR, Sriwastava S. Autoimmune and paraneoplastic neurological disorders: A review of relevant neuroimaging findings. J Neurol Sci 2023; 454:120830. [PMID: 37856996 DOI: 10.1016/j.jns.2023.120830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/28/2023] [Accepted: 10/04/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Paraneoplastic neurologic syndromes (PNS) and autoimmune encephalitis (AIE) are immune-mediated disorders. PNS is linked to cancer, while AIE may not Their clinical manifestations and imaging patterns need further elucidation. OBJECTIVE/AIMS To investigate the clinical profiles, antibody associations, neuroimaging patterns, treatments, and outcomes of PNS and AIE. METHODS A systematic review of 379 articles published between 2014 and 2023 was conducted. Of the 55 studies screened, 333 patients were diagnosed with either PNS or AIE and tested positive for novel antibodies. Data on demographics, symptoms, imaging, antibodies, cancer associations, treatment, and outcomes were extracted. RESULTS The study included 333 patients (mean age 54 years, 67% males) with PNS and AIE positive for various novel antibodies. 84% had central nervous system issues like cognitive impairment (53%), rhombencephalitis (17%), and cerebellar disorders (24%). Neuroimaging revealed distinct patterns with high-risk antibodies associated with brainstem lesions in 98%, cerebellar in 91%, hippocampal in 98%, basal ganglia in 75%, and spinal cord in 91%, while low/intermediate-risk antibodies were associated with medial temporal lobe lesions in 71% and other cortical/subcortical lesions in 55%. High-risk antibodies were associated with younger males, deep brain lesions, and increased mortality of 61%, while low/intermediate-risk antibodies were associated with females, cortical/subcortical lesions, and better outcomes with 39% mortality. Associated cancers included seminomas (23%), lung (19%), ovarian (2%), and breast (2%). Treatments included IVIG, chemotherapy, and plasmapheresis. Overall mortality was 25% in this cohort. CONCLUSION PNS and AIE have distinct clinical and radiological patterns based on antibody profiles. High-risk antibodies are associated with increased mortality while low/intermediate-risk antibodies are associated with improved outcomes. Appropriate imaging and antibody testing are critical for accurate diagnosis.
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Affiliation(s)
- Sema Akkus
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mahmoud Elkhooly
- Department of Neurology, Wayne state University, Detroit, MI, USA; Department of Neurology, Southern Illinois university, Springfield, IL, USA; Department of Neuropsychiatry, Minia University, Egypt
| | - Suban Amatya
- Department of Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Kriti Shrestha
- Department of Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Kanika Sharma
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA
| | - Yusuf Kagzi
- Mahatma Gandhi Memorial Medical College, Indore, India
| | - Erum Khan
- Department of Neurology, University of Alabama at Birmingham, Al, USA
| | - Rajesh Gupta
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA
| | - Amanda L Piquet
- Neuroimmunology, Neuroinfectious Disease and Neurohospitalist Sections, University of Colorado School of Medicine, CO, USA
| | - Shruti Jaiswal
- Department of Neuro-oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Sijin Wen
- West Virginia Clinical Transitional Science, Morgantown, WV, USA
| | - Michaela Tapia
- West Virginia Clinical Transitional Science, Morgantown, WV, USA
| | - Rohan Samant
- Department of Neuroradiology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sri Raghav Sista
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA
| | - Shitiz Sriwastava
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA.
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29
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Song Y, Hu Q, Zhang Q. Anti-Kelch-like protein 11 antibody encephalitis: a case report and literature review. Front Neurol 2023; 14:1273051. [PMID: 37954647 PMCID: PMC10637383 DOI: 10.3389/fneur.2023.1273051] [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: 08/05/2023] [Accepted: 10/02/2023] [Indexed: 11/14/2023] Open
Abstract
Anti-Kelch-like protein 11 (KLHL11) antibody encephalitis is a rare clinical condition characterized by autoimmune-mediated encephalomyelitis associated with the presence of KLHL11 antibodies. Diagnosis requires the detection of serum and cerebrospinal fluid anti-KLHL11 antibodies, while immunotherapy serves as the principal treatment approach. This paper presents a case report highlighting the emergence of anti-KLHL11 antibody encephalitis. A 66-year-old male patient presented with seizures, impaired cognitive function, disturbance of consciousness, apathy, hypologia, dysphoria, and ataxia. Serum and cerebrospinal fluid (CSF) were identified as positive for anti-KLHL11 antibodies, leading to a diagnosis of autoimmune encephalitis associated with KLHL11 antibodies. After treatment with glucocorticoid, the patient did not experience further convulsions and recovered consciousness, with improved cognitive function. Tumor screening suggested the presence of an underlying malignancy. The clinical manifestations of anti-KLHL11 antibody encephalitis vary widely, and timely identification and treatment can improve prognosis.
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Affiliation(s)
- Yanling Song
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, Ningxia, China
| | - Quanzhong Hu
- Department of Neurology, Qinghai Provincial People’s Hospital, Xining, Qinghai, China
| | - Qing Zhang
- Department of Neurology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
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30
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Yang W, Yang J, Zhang J, Wei N, Xuan T, Wang Z, Li H. KLHL11 antibody-associated autoimmune encephalomyelitis in a middle-aged female patient: a case report and literature review. Int J Neurosci 2023:1-6. [PMID: 37881832 DOI: 10.1080/00207454.2023.2269306] [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: 06/06/2023] [Accepted: 10/05/2023] [Indexed: 10/27/2023]
Abstract
HEADINGS Kelch-like protein 11antibody is a recently identified biomarker for paraneoplastic neurological syndromes associated with germ-cell tumors that was first described as an onconeural antibody causing autoimmune encephalitis associated with seminoma in 2019. Ataxia is the most prevalent presenting symptom, with other neurological symptoms including vertigo, double vision, hearing loss, tinnitus and dysarthria. Magnetic resonance imaging scans reveal that the lesions are mostly located in the cerebellum and brainstem, particularly in the pontine region, and may also exhibit cerebellar atrophy. AIM OF THE STUDY In this study, we report the clinical features of Kelch-like protein 11 antibody-associated paraneoplastic neurological syndrome. MATERIALS AND METHODS We present a middle-aged female patient who presented with vertigo, cognitive decline, ataxia and limb weakness. A cell-based assay (CBA) showed positive IgG Kelch-like protein 11 in both her serum and CSF, as well as positive oligoclonal bands in her CSF. She was diagnosed with KLHL11 antibody-associated autoimmune encephalomyelitis and received high-dose intravenous methylprednisolone pulse therapy. RESULT AND CONCLUSIONS Clinical outcomes suggest that patients with Kelch-like protein 11 antibody mostly have poor prognoses, excepting our case. We propose that early and appropriate treatments are critical for timely diagnosis and rapid improvement.
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Affiliation(s)
- Wanqiu Yang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia, Yinchuan, China
- Diagnosis and Treatment Engineering Technology Research Center of Nervous System Diseases of Ningxia Hui Autonomous Region, Ningxia, Yinchuan, China
- Clinical College of Ningxia Medical University, Ningxia, Yinchuan, China
| | - Juan Yang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia, Yinchuan, China
- Diagnosis and Treatment Engineering Technology Research Center of Nervous System Diseases of Ningxia Hui Autonomous Region, Ningxia, Yinchuan, China
| | - Junmei Zhang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia, Yinchuan, China
- Diagnosis and Treatment Engineering Technology Research Center of Nervous System Diseases of Ningxia Hui Autonomous Region, Ningxia, Yinchuan, China
- Clinical College of Ningxia Medical University, Ningxia, Yinchuan, China
| | - Na Wei
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia, Yinchuan, China
- Diagnosis and Treatment Engineering Technology Research Center of Nervous System Diseases of Ningxia Hui Autonomous Region, Ningxia, Yinchuan, China
- Clinical College of Ningxia Medical University, Ningxia, Yinchuan, China
| | - Tingting Xuan
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia, Yinchuan, China
- Diagnosis and Treatment Engineering Technology Research Center of Nervous System Diseases of Ningxia Hui Autonomous Region, Ningxia, Yinchuan, China
- Clinical College of Ningxia Medical University, Ningxia, Yinchuan, China
| | - Zhenhai Wang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia, Yinchuan, China
- Diagnosis and Treatment Engineering Technology Research Center of Nervous System Diseases of Ningxia Hui Autonomous Region, Ningxia, Yinchuan, China
| | - Haining Li
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia, Yinchuan, China
- Diagnosis and Treatment Engineering Technology Research Center of Nervous System Diseases of Ningxia Hui Autonomous Region, Ningxia, Yinchuan, China
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Rezk M, Pittock SJ, Kapadia RK, Knight AM, Guo Y, Gupta P, LaFrance-Corey RG, Zekeridou A, McKeon A, Dasari S, Mills JR, Dubey D. Identification of SKOR2 IgG as a novel biomarker of paraneoplastic neurologic syndrome. Front Immunol 2023; 14:1243946. [PMID: 37795104 PMCID: PMC10546397 DOI: 10.3389/fimmu.2023.1243946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 08/22/2023] [Indexed: 10/06/2023] Open
Abstract
Introduction The development of new autoantigen discovery techniques, like programmable phage immunoprecipitation sequencing (PhIP-Seq), has accelerated the discovery of neural-specific autoantibodies. Herein, we report the identification of a novel biomarker for paraneoplastic neurologic syndrome (PNS), Sloan-Kettering-Virus-Family-Transcriptional-Corepressor-2 (SKOR2)-IgG, utilizing PhIP-Seq. We have also performed a thorough clinical validation using normal, healthy, and disease/cancer control samples. Methods Stored samples with unclassified staining at the junction of the Purkinje cell and the granule cell layers were analyzed by PhIP-Seq for putative autoantigen identification. The autoantigen was confirmed by recombinant antigen-expressing cell-based assay (CBA), Western blotting, and tissue immunofluorescence assay colocalization. Results PhIP-Seq data revealed SKOR2 as the candidate autoantigen. The target antigen was confirmed by a recombinant SKOR-2-expressing, and cell lysate Western blot. Furthermore, IgG from both patient samples colocalized with a commercial SKOR2-specific IgG on cryosections of the mouse brain. Both SKOR2 IgG-positive patients had central nervous system involvement, one presenting with encephalitis and seizures (Patient 1) and the other with cognitive dysfunction, spastic ataxia, dysarthria, dysphagia, and pseudobulbar affect (Patient 2). They had a refractory progressive course and were diagnosed with adenocarcinoma (Patient 1: lung, Patient 2: gallbladder). Sera from adenocarcinoma patients without PNS (n=30) tested for SKOR2-IgG were negative. Discussion SKOR2 IgG represents a novel biomarker for PNS associated with adenocarcinoma. Identification of additional SKOR2 IgG-positive cases will help categorize the associated neurological phenotype and the risk of underlying malignancy.
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Affiliation(s)
- Mohamed Rezk
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Sean J. Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States
| | - Ronak K. Kapadia
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrew M. Knight
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Yong Guo
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Pranjal Gupta
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | | | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States
| | - Surendra Dasari
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - John R. Mills
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States
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32
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Yang B, Brown A, McKeon A, Ahlskog JE, Tipton P, Guo Y, Lucchinetti C, Pittock SJ, Zekeridou A. Tenascin-R Autoimmunity: Isolated Tremor Reversed with Immunotherapy. Ann Neurol 2023; 94:502-507. [PMID: 37370243 PMCID: PMC10527205 DOI: 10.1002/ana.26730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 05/10/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023]
Abstract
Autoimmune movement disorders are increasingly recognized, but isolated tremor is extremely rare. We describe a 70-year-old male with rapidly progressive, severe postural and intention tremor and weight loss. His cerebrospinal fluid was inflammatory and harbored a neural tissue-restricted antibody. The autoantigen was identified by immunoprecipitation and mass spectrometry and confirmed by antigen-specific assays to be specific for tenascin-R. He was investigated for cancer and diagnosed with follicular lymphoma that expressed tenascin-R suggesting a paraneoplastic origin; cancer treatment and immunotherapy led to complete recovery. With this individualized patient approach and antibody discovery, we expand the spectrum of antibodies accompanying autoimmune hyperkinetic movement disorders. ANN NEUROL 2023;94:502-507.
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Affiliation(s)
- Binxia Yang
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Andrew Brown
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Andrew McKeon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | - J Eric Ahlskog
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Philip Tipton
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Yong Guo
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | - Claudia Lucchinetti
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | - Sean J Pittock
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | - Anastasia Zekeridou
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
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Smith KM, Britton JW, Thakolwiboon S, Chia NH, Gupta P, Flanagan EP, Zekeridou A, Lopez Chiriboga AS, Valencia Sanchez C, McKeon A, Pittock SJ, Dubey D. Seizure characteristics and outcomes in patients with neurological conditions related to high-risk paraneoplastic antibodies. Epilepsia 2023; 64:2385-2398. [PMID: 37366270 DOI: 10.1111/epi.17695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/21/2023] [Accepted: 06/21/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVE Seizures are a common manifestation of paraneoplastic neurologic syndromes. The objective of this study was to describe the seizure characteristics and outcomes in patients with high-risk paraneoplastic autoantibodies (>70% cancer association) and to determine factors associated with ongoing seizures. METHODS Patients from 2000 to 2020 with seizures and high-risk paraneoplastic autoantibodies were retrospectively identified. Factors associated with ongoing seizures at last follow-up were evaluated. RESULTS Sixty patients were identified (34 males, median age at presentation = 52 years). ANNA1-IgG (Hu; n = 24, 39%), Ma2-IgG (n = 14, 23%), and CRMP5-IgG (CV2; n = 11, 18%) were the most common underlying antibodies. Seizures were the initial presenting symptom in 26 (43%), and malignancy was present in 38 (63%). Seizures persisted for >1 month in 83%, and 60% had ongoing seizures, with almost all patients (55/60, 92%) still being on antiseizure medications at last follow-up a median of 25 months after seizure onset. Ongoing seizures at last follow-up were associated with Ma2-IgG or ANNA1-IgG compared to other antibodies (p = .04), highest seizure frequency being at least daily (p = .0002), seizures on electroencephalogram (EEG; p = .03), and imaging evidence of limbic encephalitis (LE; p = .03). Death occurred in 48% throughout the course of follow-up, with a higher mortality in patients with LE than in those without LE (p = .04). Of 31 surviving patients at last follow-up, 55% continued to have intermittent seizures. SIGNIFICANCE Seizures in the setting of high-risk paraneoplastic antibodies are frequently resistant to treatment. Ongoing seizures are associated with ANNA1-IgG and Ma2-IgG, high seizure frequency, and EEG and imaging abnormalities. Although a subset of patients may respond to immunotherapy and achieve seizure freedom, poor outcomes are frequently encountered. Death was more common among patients with LE.
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Affiliation(s)
- Kelsey M Smith
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Nicholas H Chia
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Pranjal Gupta
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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Varley JA, Strippel C, Handel A, Irani SR. Autoimmune encephalitis: recent clinical and biological advances. J Neurol 2023; 270:4118-4131. [PMID: 37115360 PMCID: PMC10345035 DOI: 10.1007/s00415-023-11685-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 04/29/2023]
Abstract
In 2015, we wrote a review in The Journal of Neurology summarizing the field of autoantibody-associated neurological diseases. Now, in 2023, we present an update of the subject which reflects the rapid expansion and refinement of associated clinical phenotypes, further autoantibody discoveries, and a more detailed understanding of immunological and neurobiological pathophysiological pathways which mediate these diseases. Increasing awareness around distinctive aspects of their clinical phenotypes has been a key driver in providing clinicians with a better understanding as to how these diseases are best recognized. In clinical practice, this recognition supports the administration of often effective immunotherapies, making these diseases 'not to miss' conditions. In parallel, there is a need to accurately assess patient responses to these drugs, another area of growing interest. Feeding into clinical care are the basic biological underpinnings of the diseases, which offer clear pathways to improved therapies toward enhanced patient outcomes. In this update, we aim to integrate the clinical diagnostic pathway with advances in patient management and biology to provide a cohesive view on how to care for these patients in 2023, and the future.
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Affiliation(s)
- James A Varley
- Department of Brain Sciences, Charing Cross Hospital, Imperial College London, Fulham Palace Road, London, W6 8RF, UK
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Oxford, OX3 9DS, UK
| | - Christine Strippel
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Oxford, OX3 9DS, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
| | - Adam Handel
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Oxford, OX3 9DS, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Oxford, OX3 9DS, UK.
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK.
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Orozco E, Valencia-Sanchez C, Britton J, Dubey D, Flanagan EP, Lopez-Chiriboga AS, Zalewski N, Zekeridou A, Pittock SJ, McKeon A. Autoimmune Encephalitis Criteria in Clinical Practice. Neurol Clin Pract 2023; 13:e200151. [PMID: 37124463 PMCID: PMC10132262 DOI: 10.1212/cpj.0000000000200151] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/13/2023] [Indexed: 05/02/2023]
Abstract
Background and Objectives To assess the clinical practice applicability of autoimmune encephalitis (AE) criteria (2016). Methods Medical records of 538 adults diagnosed with AE or related autoimmune encephalopathy at Mayo Clinic (not including pure movement disorders) were reviewed and AE guideline criteria applied. Results Of 538 patients, 288 were male (52%). The median symptom onset age was 55 years (range, 11-97 years; 16 had onset as children). All had other non-AE diagnoses reasonably excluded. Of 538 patients, 361 (67%) met at least possible criteria, having all 3 of subacute onset; memory deficits, altered mental status or psychiatric symptoms, and ≥1 supportive feature (new focal objective CNS finding, N = 285; new-onset seizures, N = 283; supportive MRI findings, N = 251; or CSF pleocytosis, N = 160). Of 361 patients, AE subgroups were as follows: definite AE (N = 221, 61%, [87% AE-specific IgG positive]), probable seronegative AE (N = 18, 5%), Hashimoto encephalopathy (N = 20, 6%), or possible AE not otherwise categorizable (N = 102, 28%). The 221 patients with definite AE had limbic encephalitis (N = 127, 57%), anti-NMDA-R encephalitis (N = 32, 15%), ADEM (N = 8, 4%), or other AE-specific IgG defined (N = 54, 24%). The 3 most common definite AE-IgGs detected were as follows: LGI1 (76, 34%), NMDA-R (32, 16%), and high-titer GAD65 (23, 12%). The remaining 177 patients (33%) not meeting possible AE criteria had the following: seizures only (65, 12% of all 538 patients), brainstem encephalitis without supratentorial findings (55, 10%; none had Bickerstaff encephalitis), or other (57, 11%). Those 57 "others" lacked sufficient supportive clinical, radiologic, or CSF findings (N = 26), had insidious or initially episodic onset of otherwise typical disorders (N = 21), or had atypical syndromes without clearcut memory deficits, altered mental status, or psychiatric symptoms (N = 10). Fifteen of 57 were AE-specific IgG positive (26%). Among the remaining 42, evidence of other organ-specific autoimmunity (mostly thyroid) was encountered in 31 (74%, ≥1 coexisting autoimmune disease [21, 50%] or ≥1 non-AE-specific antibodies detected [23, 53%]), and all but 1 had an objective immunotherapy response (97%). Discussion The 2016 AE guidelines permit autoimmune causation assessment in subacute encephalopathy and are highly specific. Inclusion could be improved by incorporating AE-IgG-positive patients with isolated seizures or brainstem disorders. Some patients with atypical presentations but with findings supportive of autoimmunity may be immune therapy responsive.
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Affiliation(s)
- Emma Orozco
- Department of Laboratory Medicine and Pathology (EO, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; Department of Neurology (CV-S, NZ), Mayo Clinic, AZ; Department of Neurology (JB, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; and Department of Neurology (ASL-C), Mayo Clinic, FL
| | - Cristina Valencia-Sanchez
- Department of Laboratory Medicine and Pathology (EO, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; Department of Neurology (CV-S, NZ), Mayo Clinic, AZ; Department of Neurology (JB, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; and Department of Neurology (ASL-C), Mayo Clinic, FL
| | - Jeffrey Britton
- Department of Laboratory Medicine and Pathology (EO, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; Department of Neurology (CV-S, NZ), Mayo Clinic, AZ; Department of Neurology (JB, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; and Department of Neurology (ASL-C), Mayo Clinic, FL
| | - Divyanshu Dubey
- Department of Laboratory Medicine and Pathology (EO, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; Department of Neurology (CV-S, NZ), Mayo Clinic, AZ; Department of Neurology (JB, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; and Department of Neurology (ASL-C), Mayo Clinic, FL
| | - Eoin P Flanagan
- Department of Laboratory Medicine and Pathology (EO, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; Department of Neurology (CV-S, NZ), Mayo Clinic, AZ; Department of Neurology (JB, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; and Department of Neurology (ASL-C), Mayo Clinic, FL
| | - A Sebastian Lopez-Chiriboga
- Department of Laboratory Medicine and Pathology (EO, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; Department of Neurology (CV-S, NZ), Mayo Clinic, AZ; Department of Neurology (JB, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; and Department of Neurology (ASL-C), Mayo Clinic, FL
| | - Nicholas Zalewski
- Department of Laboratory Medicine and Pathology (EO, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; Department of Neurology (CV-S, NZ), Mayo Clinic, AZ; Department of Neurology (JB, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; and Department of Neurology (ASL-C), Mayo Clinic, FL
| | - Anastasia Zekeridou
- Department of Laboratory Medicine and Pathology (EO, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; Department of Neurology (CV-S, NZ), Mayo Clinic, AZ; Department of Neurology (JB, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; and Department of Neurology (ASL-C), Mayo Clinic, FL
| | - Sean J Pittock
- Department of Laboratory Medicine and Pathology (EO, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; Department of Neurology (CV-S, NZ), Mayo Clinic, AZ; Department of Neurology (JB, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; and Department of Neurology (ASL-C), Mayo Clinic, FL
| | - Andrew McKeon
- Department of Laboratory Medicine and Pathology (EO, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; Department of Neurology (CV-S, NZ), Mayo Clinic, AZ; Department of Neurology (JB, DD, EPF, AZ, SJP, AM), Mayo Clinic, Rochester, MN; and Department of Neurology (ASL-C), Mayo Clinic, FL
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Marsili L, Marcucci S, LaPorta J, Chirra M, Espay AJ, Colosimo C. Paraneoplastic Neurological Syndromes of the Central Nervous System: Pathophysiology, Diagnosis, and Treatment. Biomedicines 2023; 11:biomedicines11051406. [PMID: 37239077 DOI: 10.3390/biomedicines11051406] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/04/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023] Open
Abstract
Paraneoplastic neurological syndromes (PNS) include any symptomatic and non-metastatic neurological manifestations associated with a neoplasm. PNS associated with antibodies against intracellular antigens, known as "high-risk" antibodies, show frequent association with underlying cancer. PNS associated with antibodies against neural surface antigens, known as "intermediate- or low-risk" antibodies, are less frequently associated with cancer. In this narrative review, we will focus on PNS of the central nervous system (CNS). Clinicians should have a high index of suspicion with acute/subacute encephalopathies to achieve a prompt diagnosis and treatment. PNS of the CNS exhibit a range of overlapping "high-risk" clinical syndromes, including but not limited to latent and overt rapidly progressive cerebellar syndrome, opsoclonus-myoclonus-ataxia syndrome, paraneoplastic (and limbic) encephalitis/encephalomyelitis, and stiff-person spectrum disorders. Some of these phenotypes may also arise from recent anti-cancer treatments, namely immune-checkpoint inhibitors and CAR T-cell therapies, as a consequence of boosting of the immune system against cancer cells. Here, we highlight the clinical features of PNS of the CNS, their associated tumors and antibodies, and the diagnostic and therapeutic strategies. The potential and the advance of this review consists on a broad description on how the field of PNS of the CNS is constantly expanding with newly discovered antibodies and syndromes. Standardized diagnostic criteria and disease biomarkers are fundamental to quickly recognize PNS to allow prompt treatment initiation, thus improving the long-term outcome of these conditions.
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Affiliation(s)
- Luca Marsili
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Samuel Marcucci
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Joseph LaPorta
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Martina Chirra
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Alberto J Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Carlo Colosimo
- Department of Neurology, Santa Maria University Hospital, 05100 Terni, Italy
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Gyongyosi B, Magyar-Stang R, Takacs T, Szekely E, Illes Z, Nilsson C, Gyorke T, Barsi P, Juhasz D, Banky B, Bereczki D, Honnorat J, Gunda B. Paraneoplastic Kelch-like protein 11 antibody-associated cerebellar and limbic encephalitis caused by metastatic “burned-out” seminoma – A scar(r)y phenomenon. J Neuroimmunol 2023; 378:578073. [PMID: 36989702 DOI: 10.1016/j.jneuroim.2023.578073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/09/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023]
Abstract
INTRODUCTION The diagnosis of paraneoplastic neurologic syndromes is challenging when the primary tumor masquerades as scar tissue (i.e. "burned-out"). METHODS Case report. RESULTS A 45-year-old male patient presented with progressive cerebellar symptoms and hearing loss. Initial screening for malignancy and extensive testing of paraneoplastic and autoimmune neuronal antibodies gave negative results. Repeated whole-body FDG-PET CT revealed a single paraaortic lymphadenopathy, metastasis of a regressed testicular seminoma. Anti-Kelch-like protein-11 (KLHL11) encephalitis was finally diagnosed. CONCLUSION Our case highlights the importance of continued efforts to find an often burned-out testicular cancer in patients with a highly unique clinical presentation of KLHL11 encephalitis.
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Affiliation(s)
- Benedek Gyongyosi
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Budapest, Hungary
| | - Rita Magyar-Stang
- Department of Neurology, Semmelweis University, Budapest, Hungary; János Szentágothai Doctoral School of Neurosciences, Semmelweis University, Budapest, Hungary.
| | - Timea Takacs
- Department of Neurology, Semmelweis University, Budapest, Hungary; János Szentágothai Doctoral School of Neurosciences, Semmelweis University, Budapest, Hungary
| | - Eszter Szekely
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Budapest, Hungary
| | - Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Christine Nilsson
- Laboratory of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - Tamas Gyorke
- Department of Nuclear Medicine, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Peter Barsi
- Department of Neuroradiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Daniel Juhasz
- Department of Urology, Semmelweis University, Budapest, Hungary
| | - Balazs Banky
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Daniel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Jerome Honnorat
- French Reference Center on Paraneoplastic Neurological Diseases and Autoimmune Encephalitis, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France
| | - Bence Gunda
- Department of Neurology, Semmelweis University, Budapest, Hungary
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Abstract
PURPOSE OF REVIEW To provide an overview and highlight recent updates in the field of paraneoplastic neurologic disorders. RECENT FINDINGS The prevalence of paraneoplastic neurologic disorders is greater than previously reported and the incidence has been rising over time, due to improved recognition in the era of antibody biomarkers. Updated diagnostic criteria that are broadly inclusive and also contain diagnostic risk for clinical presentations (high and intermediate) and diagnostic antibodies (high, intermediate, and low) have replaced the original 2004 criteria. Antibody biomarkers continue to be characterized (e.g., KLHL-11 associated with seminoma in men with brainstem encephalitis). Some paraneoplastic antibodies also provide insight into likely immunotherapy response and prognosis. The rise of immune checkpoint inhibitors as cancer therapeutics has been associated with newly observed immune-mediated adverse effects including paraneoplastic neurological disorders. The therapeutic approach to paraneoplastic neurologic disorders is centered around cancer care and trials of immune therapy. The field of paraneoplastic neurologic disorders continues to be advanced by the identification of novel antibody biomarkers which have diagnostic utility, and give insight into likely treatment responses and outcomes.
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Affiliation(s)
- Michael Gilligan
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, St Vincent's University Hospital, Dublin, Ireland
| | | | - Andrew McKeon
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN, USA.
- Department of Neurology, College of Medicine, Mayo Clinic, 200 1st ST SW, Rochester, MN, 55905, USA.
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Ramanathan S, Brilot F, Irani SR, Dale RC. Origins and immunopathogenesis of autoimmune central nervous system disorders. Nat Rev Neurol 2023; 19:172-190. [PMID: 36788293 DOI: 10.1038/s41582-023-00776-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 02/16/2023]
Abstract
The field of autoimmune neurology is rapidly evolving, and recent discoveries have advanced our understanding of disease aetiologies. In this article, we review the key pathogenic mechanisms underlying the development of CNS autoimmunity. First, we review non-modifiable risk factors, such as age, sex and ethnicity, as well as genetic factors such as monogenic variants, common variants in vulnerability genes and emerging HLA associations. Second, we highlight how interactions between environmental factors and epigenetics can modify disease onset and severity. Third, we review possible disease mechanisms underlying triggers that are associated with the loss of immune tolerance with consequent recognition of self-antigens; these triggers include infections, tumours and immune-checkpoint inhibitor therapies. Fourth, we outline how advances in our understanding of the anatomy of lymphatic drainage and neuroimmune interfaces are challenging long-held notions of CNS immune privilege, with direct relevance to CNS autoimmunity, and how disruption of B cell and T cell tolerance and the passage of immune cells between the peripheral and intrathecal compartments have key roles in initiating disease activity. Last, we consider novel therapeutic approaches based on our knowledge of the immunopathogenesis of autoimmune CNS disorders.
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Affiliation(s)
- Sudarshini Ramanathan
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead, Sydney, New South Wales, Australia
- Sydney Medical School, Faculty of Medicine and Health and Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Concord Hospital, Sydney, New South Wales, Australia
| | - Fabienne Brilot
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead, Sydney, New South Wales, Australia
- School of Medical Science, Faculty of Medicine and Health and Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Russell C Dale
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead, Sydney, New South Wales, Australia.
- Sydney Medical School, Faculty of Medicine and Health and Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia.
- TY Nelson Department of Paediatric Neurology, Children's Hospital Westmead, Sydney, New South Wales, Australia.
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León Betancourt A, Schwarzwald A, Millonig A, Oberholzer M, Sabater L, Hammer H, Kamber N, Diem L, Chan A, Hoepner R, Salmen A, Friedli C. Anti-kelchlike protein 11 antibody-associated encephalitis: Two case reports and review of the literature. Eur J Neurol 2023; 30:1801-1814. [PMID: 36815561 DOI: 10.1111/ene.15758] [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: 11/21/2022] [Revised: 01/19/2023] [Accepted: 02/20/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND AND PURPOSE Kelchlike protein 11 antibodies (KLHL11-IgGs) were first described in 2019 as a marker of paraneoplastic neurological syndromes (PNSs). They have mostly been associated with testicular germ cell tumors (tGCTs). METHODS Two patients with KLHL11-IgG encephalitis are reported, and the literature is comprehensively reviewed. RESULTS Patient 1 had been in remission from a tGCT 10 years prior. He developed episodic vertigo and diplopia progressing over a few days. Treatment with corticosteroids (CSs) was started a few days after symptom onset. Patient 2 had transient diplopia, which resolved spontaneously. Visual problems persisted for 7 months, when he additionally developed a progressive cerebellar syndrome. One year after onset, CS treatment was started. Initial magnetic resonance imaging was unremarkable in both patients, but analysis of cerebrospinal fluid (CSF) revealed chronic inflammation. KLHL11-IgG was positive in both patients (Patient 1 only in CSF, Patient 2 in serum). Neoplastic screening has so far not revealed any signs of active underlying malignancy. We found 15 publications of 112 patients in total with KLHL11-IgG encephalitis. Most patients (n = 82) had a cerebellar syndrome with or without signs of rhombencephalitis. The most common symptoms were ataxia (n = 82) and vertigo (n = 47), followed by oculomotor disturbances (n = 35) and hearing disorders (n = 31). Eighty of 84 patients had a GCT as an underlying tumor. CONCLUSIONS Our cases demonstrate classical symptoms of KLHL11-IgG encephalitis. Early diagnosis and therapy are imperative. As with other PNSs, clinical awareness is needed and further studies are required especially in regard to therapeutic management.
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Affiliation(s)
- Alejandro León Betancourt
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Anina Schwarzwald
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Alban Millonig
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Michael Oberholzer
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Lidia Sabater
- Neuroimmunology Unit, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Fundació Clínic per a la Recerca Biomèdica, University Hospital Barcelona, Barcelona, Spain
| | - Helly Hammer
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Nicole Kamber
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Lara Diem
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Andrew Chan
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Robert Hoepner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Anke Salmen
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Christoph Friedli
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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41
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Hammami MB, Rezk M, Dubey D. Validation of MATCH score: a predictive tool for identification of patients with kelch-like protein-11 autoantibodies. J Neurol Neurosurg Psychiatry 2023; 94:171-172. [PMID: 36150843 DOI: 10.1136/jnnp-2022-329584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/31/2022] [Indexed: 01/14/2023]
Affiliation(s)
- M Bakri Hammami
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Medicine, Jacobi Medical Center, Bronx, New York, USA
| | - Mohamed Rezk
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Divyanshu Dubey
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA .,Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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Krivitski D, Alcalay Y, Peer M, Paran Y, Eisenstein O, Davidson T, Gadoth A. Bilateral hearing loss preceding rhomboencephalitis - a hint for Kelch-like 11 syndrome. Neurol Sci 2023; 44:369-372. [PMID: 36112277 DOI: 10.1007/s10072-022-06369-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 08/23/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Paraneoplastic neurological syndromes have diverse clinical presentations and offer an opportunity for early diagnosis of malignancy and treatment. Recently, a new paraneoplastic syndrome associated with seminoma was described, consisting of rhombencephalitis with antibodies targeting the Kelch-like protein 11 (KLHL11). Questions were raised as to the spectrum of clinical symptoms and strength of association to seminoma. METHODS We present a 45-year-old man with bilateral sensorineural hearing loss, vertigo, and progressive ataxia. An extensive diagnostic workup led to the diagnosis of anti-KLHL11 paraneoplastic syndrome based on an immunofluorescence assay showing a typical pattern and a confirmatory serological assay. As a result, the patient underwent a meticulous search for an underlying seminoma. RESULTS Although initially, all images were interpreted as negative, a revision of the positron emission tomography-CT (PET-CT) examination identified a small mediastinal suspicious mass. The mass was resected, and pathological examination confirmed it to be an extra-testicular seminoma. CONCLUSIONS Patients presenting with progressive sensorineural hearing loss, vertigo, and ataxia should be evaluated for KLHL11 paraneoplastic syndrome. Furthermore, we support a strong association between anti-KLH11 rhombencephalitis and an underlying seminoma and recommend a thorough search for an undiagnosed germ cell tumor in these patients.
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Affiliation(s)
- David Krivitski
- Department of Neurology, Tel Aviv Medical Center, Tel Aviv, 6243906, Israel.
| | - Yifat Alcalay
- Department of Neurology, Tel Aviv Medical Center, Tel Aviv, 6243906, Israel.,Immunology Laboratory, Epilepsy Service Imaging Unit, Tel Aviv Medical Center, 6243906, Tel Aviv, Israel.,Encephalitis Center, Epilepsy Service Imaging Unit, Tel Aviv Medical Center, 6243906, Tel Aviv, Israel
| | - Michael Peer
- Department of Thoracic Surgery, Epilepsy Service Imaging Unit, Tel Aviv Medical Center, 6243906, Tel Aviv, Israel
| | - Yael Paran
- Encephalitis Center, Epilepsy Service Imaging Unit, Tel Aviv Medical Center, 6243906, Tel Aviv, Israel.,Infectious Disease Unit, Epilepsy Service Imaging Unit, Tel Aviv Medical Center, 6243906, Tel Aviv, Israel
| | - Orna Eisenstein
- Encephalitis Center, Epilepsy Service Imaging Unit, Tel Aviv Medical Center, 6243906, Tel Aviv, Israel.,Imaging Division, Epilepsy Service Imaging Unit, Tel Aviv Medical Center, 6243906, Tel Aviv, Israel
| | - Tima Davidson
- Department of Nuclear Medicine, Sheba Medical Center, Tel Hashomer, Israel
| | - Avi Gadoth
- Department of Neurology, Tel Aviv Medical Center, Tel Aviv, 6243906, Israel.,Encephalitis Center, Epilepsy Service Imaging Unit, Tel Aviv Medical Center, 6243906, Tel Aviv, Israel
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Binks S, Lamquet S, Crawford AH, Meurs A, Irani SR, Pakozdy A. Parallel roles of neuroinflammation in feline and human epilepsies. Vet J 2022; 290:105912. [PMID: 36209994 PMCID: PMC10912827 DOI: 10.1016/j.tvjl.2022.105912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
Autoimmune encephalitis refers to a group of disorders characterised by a non-infectious encephalitis, often with prominent seizures and surface neuronal autoantibodies. AE is an important cause of new-onset refractory status epilepticus in humans and is frequently responsive to immunotherapies including corticosteroids, plasma exchange, intravenous immunoglobulin G and rituximab. Recent research suggests that parallel autoantibodies can be detected in non-human mammalian species. The best documented example is leucine-rich glioma-inactivated 1 (LGI1)-antibodies in domestic cats with limbic encephalitis (LE). In this review, we discuss the role of neuroinflammation and autoantibodies in human and feline epilepsy and LE.
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Affiliation(s)
- Sophie Binks
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, OX3 9DU, UK; Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals Foundation Trust, Oxford OX3 9DU, UK.
| | - Simon Lamquet
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Abbe H Crawford
- Clinical Science and Services, The Royal Veterinary College, Hertfordshire AL9 7TA, UK
| | - Alfred Meurs
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, OX3 9DU, UK; Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals Foundation Trust, Oxford OX3 9DU, UK
| | - Akos Pakozdy
- University Clinic for Small Animals, University of Veterinary Medicine Vienna, Austria
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Wang L, Yin J, Wang Q, Wang B, Song Y. The diagnostic challenge of small cell lung cancer with anti-gamma-aminobutyric-acid B receptor encephalitis: a case report. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:1412. [PMID: 36660653 PMCID: PMC9843415 DOI: 10.21037/atm-22-6162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/19/2022] [Indexed: 01/01/2023]
Abstract
Background Anti-gamma-aminobutyric-acid B receptor (anti-GABABR) encephalitis is a rare type of encephalitis, with an incidence of only 5% in all autoimmune encephalitis (AE). A third of patients had pathologically confirmed small-cell lung cancer (SCLC). Early identification and treatment of tumors can improve the poor prognosis. Most patients attend hospital for the treatment of neurological disorders and rarely present with any respiratory symptoms, but suffer from an underlying tumor. Thus, early proper diagnosis is very important. In this article, we report a special case of a patient with anti-GABABR encephalitis with delayed SCLC pulmonary behavior, whose diagnosis prosses was tortuous and complicated. Case Description A 62-year-old man with a history of anti-GABABR encephalitis presented with respiratory symptoms. His chest computed tomography (CT) scan showed significant progression of right superior lobe consolidation. A bronchoscopy was performed with no histopathological result, but the microbiological examination of the bronchial lavage fluid showed Aspergillus niger infection. With antifungal therapy, the patient's respiratory symptoms were significantly relieved. Given the close relationship between SCLC and anti-GABABR encephalitis, we insisted to clarify the pulmonary lesions. The other three biopsies were performed successively, including lung biopsy, endobronchial ultrasonography (EBUS), and transbronchial needle aspiration (TBNA). SCLC was finally proven by pathology, and the patient received systemic chemotherapy. Conclusions SCLC is the most common pulmonary neuroendocrine tumor. It secretes onconeural antibodies and is closely associated with paraneoplastic neurologic syndromes (PNSs). Lung tumors, especially SCLC, should be a concern in patients presenting with AE or neurological symptoms, even if they have not any abnormal sign in respiratory system. The early diagnosis and intervention for underlying tumors will improve the clinical outcomes of patients significantly. Thus, the close follow-up is helpful and it is imperative to select and combine the most appropriate examinations for proper diagnosis.
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Affiliation(s)
- Liming Wang
- Department of Respiratory and Critical Care Medicine, Shanghai Xuhui Central Hospital, Shanghai, China
| | - Jun Yin
- Department of Thoracic Surgery, Zhongshan Hospital of Fudan University, Shanghai, China
| | - Qiong Wang
- Department of Respiratory and Critical Care Medicine, Shanghai Xuhui Central Hospital, Shanghai, China
| | - Baoqing Wang
- Department of Respiratory and Critical Care Medicine, Shanghai Xuhui Central Hospital, Shanghai, China;,Department of Respiratory and Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, China
| | - Yuanlin Song
- Department of Respiratory and Critical Care Medicine, Shanghai Xuhui Central Hospital, Shanghai, China;,Department of Respiratory and Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, China
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Clarkson BDS, Johnson RK, Bingel C, Lothaller C, Howe CL. Preservation of antigen-specific responses in cryopreserved CD4 + and CD8 + T cells expanded with IL-2 and IL-7. J Transl Autoimmun 2022; 5:100173. [PMID: 36467614 PMCID: PMC9713293 DOI: 10.1016/j.jtauto.2022.100173] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/31/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022] Open
Abstract
Objectives We sought to develop medium throughput standard operating procedures for screening cryopreserved human peripheral blood mononuclear cells (PBMCs) for CD4+ and CD8+ T cell responses to potential autoantigens. Methods Dendritic cells were loaded with a peptide cocktail from ubiquitous viruses or full-length viral protein antigens and cocultured with autologous T cells. We measured expression of surface activation markers on T cells by flow cytometry and cytometry by time of flight 24-72 h later. We tested responses among T cells freshly isolated from healthy control PBMCs, cryopreserved T cells, and T cells derived from a variety of T cell expansion protocols. We also compared the transcriptional profile of CD8+ T cells rested with interleukin (IL)7 for 48 h after 1) initial thawing, 2) expansion, and 3) secondary cryopreservation/thawing of expanded cells. To generate competent antigen presenting cells from PBMCs, we promoted differentiation of PBMCs into dendritic cells with granulocyte macrophage colony stimulating factor and IL-4. Results We observed robust dendritic cell differentiation from human PBMCs treated with 50 ng/mL GM-CSF and 20 ng/mL IL-4 in as little as 3 days. Dendritic cell purity was substantially increased by magnetically enriching for CD14+ monocytes prior to differentiation. We also measured antigen-dependent T cell activation in DC-T cell cocultures. However, polyclonal expansion of T cells with anti-CD3/antiCD28 abolished antigen-dependent upregulation of CD69 in our assay despite minimal transcriptional differences between rested CD8+ T cells before and after expansion. Furthermore, resting these expanded T cells in IL-2, IL-7 or IL-15 did not restore the antigen dependent responses. In contrast, T cells that were initially expanded with IL-2 + IL-7 rather than plate bound anti-CD3 + anti-CD28 retained responsiveness to antigen stimulation and these responses strongly correlated with responses measured at initial thawing. Significance While screening techniques for potential pathological autoantibodies have come a long way, comparable full-length protein target assays for screening patient T cells at medium throughput are noticeably lacking due to technical hurdles. Here we advance techniques that should have broad applicability to translational studies investigating cell mediated immunity in infectious or autoimmune diseases. Future studies are aimed at investigating possible CD8+ T cell autoantigens in MS and other CNS autoimmune diseases.
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Affiliation(s)
- Benjamin DS. Clarkson
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, 55905, USA,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA,Corresponding author. Mayo Clinic, Guggenheim 1521C, 200 First Street SW, Rochester, MN, 55905.
| | | | - Corinna Bingel
- Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center, Heidelberg, Germany
| | | | - Charles L. Howe
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, 55905, USA,Division of Experimental Neurology, Mayo Clinic, Rochester, MN, 55905, USA,Department of Immunology, Mayo Clinic, Rochester, MN, 55905, USA
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Zapata-García JA, Riveros-Magaña AR, Ortiz-Lazareno PC, Hernández-Flores G, Jave-Suárez LF, Aguilar-Lemarroy A. Comparative Genomic Hybridization and Transcriptome Sequencing Reveal Genes with Gain in Acute Lymphoblastic Leukemia: JUP Expression Emerges as a Survival-Related Gene. Diagnostics (Basel) 2022; 12:diagnostics12112788. [PMID: 36428851 PMCID: PMC9689318 DOI: 10.3390/diagnostics12112788] [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: 09/29/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Acute lymphoblastic leukemia (ALL) in children or adults is characterized by structural and numeric aberrations in chromosomes; these anomalies strongly correlate with prognosis and clinical outcome. Therefore, this work aimed to identify the genes present in chromosomal gain regions found more frequently in patients with acute lymphoblastic leukemia (ALL) and ALL-derived cell lines using comparative genomic hybridization (CGH). In addition, validation of the genes found in these regions was performed utilizing RNAseq from JURKAT, CEM, and SUP-B15 cell lines, as well as expression microarrays derived from a MILE study. Chromosomes with common gain zones that were maintained in six or more samples were 14, 17, and 22, in which a total of 22 genes were identified. From them, NT5C3B, CNP, ACLY, and GNB1L maintained overexpression at the mRNA level in the cell lines and in patients with ALL. It is noteworthy that SALL2 showed very high expression in T-ALL, while JUP was highly expressed in B-ALL lineages. Interestingly, the latter correlated with worse survival in patients. This provided evidence that the measurement of these genes has high potential for clinical utility; however, their expressions should first be evaluated with a sensitive test in a more significant number of patients.
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Affiliation(s)
- Jessica Alejandra Zapata-García
- Programa de Doctorado en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara C.P. 44340, Mexico
- División de Inmunología, Centro de Investigación Biomédica de Occidente (CIBO), Instituto Mexicano del Seguro Social (IMSS), Guadalajara C.P. 44340, Mexico
| | - Alma Rocío Riveros-Magaña
- Centro Universitario del Sur, Universidad de Guadalajara, Ciudad Guzmán C.P. 49000, Mexico
- Hospital General Zona 9, Ciudad Guzmán C.P. 49000, Mexico
| | - Pablo Cesar Ortiz-Lazareno
- División de Inmunología, Centro de Investigación Biomédica de Occidente (CIBO), Instituto Mexicano del Seguro Social (IMSS), Guadalajara C.P. 44340, Mexico
| | - Georgina Hernández-Flores
- División de Inmunología, Centro de Investigación Biomédica de Occidente (CIBO), Instituto Mexicano del Seguro Social (IMSS), Guadalajara C.P. 44340, Mexico
| | - Luis Felipe Jave-Suárez
- Programa de Doctorado en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara C.P. 44340, Mexico
- División de Inmunología, Centro de Investigación Biomédica de Occidente (CIBO), Instituto Mexicano del Seguro Social (IMSS), Guadalajara C.P. 44340, Mexico
| | - Adriana Aguilar-Lemarroy
- Programa de Doctorado en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara C.P. 44340, Mexico
- División de Inmunología, Centro de Investigación Biomédica de Occidente (CIBO), Instituto Mexicano del Seguro Social (IMSS), Guadalajara C.P. 44340, Mexico
- Correspondence: ; Tel.: +52-331-520-7625
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Daneshmand A, Borhani-Haghighi A, Monabati A, Karimi M, Ostovan VR. Bilateral Hypertrophic Olivary Degeneration as a Paraneoplastic Syndrome of a Poorly Differentiated Carcinoma of the Upper Gastrointestinal Tract: A Case Report and Literature Review. Neurologist 2022; 27:357-360. [PMID: 35051964 DOI: 10.1097/nrl.0000000000000414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Hypertrophic olivary degeneration (HOD) is a unique form of trans-synaptic neuronal degeneration within the dentato-rubro-olivary pathway which is manifested by the enlargement and hyperintensities of the inferior olivary nucleus in the brain magnetic resonance imaging. CASE REPORT We report a 53-year-old man admitted to our emergency department with a history of progressive ataxia and vertigo for 6 months before admission. Neurological examination revealed cerebellar dysfunction, and the brain magnetic resonance imaging showed bilateral HOD without an identifiable causative lesion within the brain or abnormal meningeal enhancement. Cerebrospinal fluid analysis showed mild lymphocytic pleocytosis, elevated protein, and negative cytology. Malignancy and paraneoplastic workup exhibited marked elevation of carbohydrate antigen 19-9 level and para-aortic lymphadenopathy. A histologic examination demonstrated the infiltration of lymph nodes by a malignant, poorly differentiated carcinomatous tumor that arises from the upper gastrointestinal tract. Considering the primary site of the tumor and HOD as a paraneoplastic effect of carcinoma, a FOLFIRINOX regimen, intravenous immunoglobulin, and pulse methylprednisolone were started. A follow-up imaging after 3 months depicted a significant resolution of HOD but the neurological status only mildly improved. The patient developed liver and adrenal metastasis over the following 6 months, culminating in his death. CONCLUSION This study strengthens a relationship between HOD and malignancy as a paraneoplastic syndrome and provides a new incentive for further researches to confirm this association.
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Affiliation(s)
| | | | | | - Mojtaba Karimi
- Hematology Research Center, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Korsmo M, Seeberger LC. Subacute Progressive Imbalance and Jaw Movements Due to Kelch-Like Protein-11 Rhombencephalitis. Mov Disord Clin Pract 2022; 9:S26-S28. [PMID: 36118513 PMCID: PMC9464999 DOI: 10.1002/mdc3.13540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 04/04/2022] [Accepted: 04/09/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Michael Korsmo
- University of Colorado Movement Disorders Center, CAMC NeurologyCharlestonWest VirginiaUSA
| | - Lauren C. Seeberger
- University of Colorado Movement Disorders Center, CAMC NeurologyCharlestonWest VirginiaUSA
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Kherallah B, Samaha E, Bach SE, Guede C, Kattah JC. Case report: Acute vestibular syndrome and cerebellitis in anti-Yo paraneoplastic syndrome. Front Neurol 2022; 13:960584. [PMID: 36090885 PMCID: PMC9462393 DOI: 10.3389/fneur.2022.960584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/03/2022] [Indexed: 11/18/2022] Open
Abstract
Background We define acute vestibular syndrome (AVS) as a sudden onset vertigo, nausea, vomiting, and head motion intolerance, more frequently associated with an acute peripheral and unilateral vestibulopathy. About 10–20% of all cases with central vestibulopathy are secondary to stroke. We report three patients evaluated over the past decade with an acute AVS along with subtle downbeat nystagmus (DBN), followed by dysarthria and progressive truncal and limb ataxia, as well as increasing DBN intensity. Methods All patients underwent neurologic examination, video-oculography, MRI, serum cancer markers, spinal fluid examination, paraneoplastic panel testing, and oncologic workup. With a consolidated diagnosis of cancer/paraneoplastic syndrome, we treated with plasma exchange (PLEX), high-dose steroids, surgery, and oncologic investigation. We additionally provided oncotherapy in one out of three patients. Results All three patients had an acute AVS, downbeat nystagmus DBN, and inability to perform tandem gait. Two of three patients had a normal head impulse test (HIT). As acute vertigo, nausea, and vomiting subsided, a progressive cerebellar syndrome ensued characterized by persistent DBN, impaired horizontal and vertical pursuit, impaired VOR suppression, truncal and limb ataxia, and dysarthria. All patients had normal MRI brain studies excluding stroke. CSF studies demonstrated lymphocytic pleocytosis and elevated protein. One patient had confirmed ovarian cancer with high CA-125 serum levels; another had undifferentiated cancer of unknown primary with high CA-125 and one patient with esophageal cancer. All had a positive PCA-1 antibody titer, also known as anti-Yo antibody. In one patient with expeditious immunosuppression, the ataxia progression slowed for 18 months, whereas the other two patients with delayed initiation of treatment had more rapidly progressive ataxia. Discussion Paraneoplastic encephalitis related to PCA-1 antibody (Anti-Yo) targets Purkinje cells and cells in the granular layer of the cerebellar cortex. Clinically, our patients had a central AVS characterized by DBN and followed with progressive ataxia and unremarkable neuroimaging studies. Rapid initiation of treatment may offer a greater chance to prevent further neurologic decline. Any patient with an AVS as well as DBN and normal MRI should have an expeditious workup to rule out metabolic, toxic, and infectious causes just prior to considering prompt treatment with high-dose steroids and plasma exchange (PLEX) to mitigate the risk of rapidly progressive and irreversible neurologic decline.
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Affiliation(s)
- Bassil Kherallah
- Department of Neurology, University of Illinois College of Medicine, Peoria, IL, United States
| | - Elias Samaha
- Department of Neurology, University of Illinois College of Medicine, Peoria, IL, United States
| | - Sarah E. Bach
- Department of Pathology, University of Illinois College of Medicine, Peoria, IL, United States
| | - Cindy Guede
- Department of Neurology, University of Illinois College of Medicine, Peoria, IL, United States
| | - Jorge C. Kattah
- Department of Neurology, University of Illinois College of Medicine, Peoria, IL, United States
- *Correspondence: Jorge C. Kattah
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Muñiz-Castrillo S, Vogrig A, Ciano-Petersen NL, Villagrán-García M, Joubert B, Honnorat J. Novelties in Autoimmune and Paraneoplastic Cerebellar Ataxias: Twenty Years of Progresses. CEREBELLUM (LONDON, ENGLAND) 2022; 21:573-591. [PMID: 35020135 DOI: 10.1007/s12311-021-01363-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/23/2021] [Indexed: 06/14/2023]
Abstract
Major advances in our knowledge concerning autoimmune and paraneoplastic cerebellar ataxias have occurred in the last 20 years. The discovery of several neural antibodies represents an undeniable contribution to this field, especially those serving as good biomarkers of paraneoplastic neurological syndromes and those showing direct pathogenic effects. Yet, many patients still lack detectable or known antibodies, and also many antibodies have only been reported in few patients, which makes it difficult to define in detail their clinical value. Nevertheless, a notable progress has additionally been made in the clinical characterization of patients with the main neural antibodies, which, although typically present with a subacute pancerebellar syndrome, may also show either hyperacute or chronic onsets that complicate the differential diagnoses. However, prodromal and transient features could be useful clues for an early recognition, and extracerebellar involvement may also be highly indicative of the associated antibody. Moreover, important advances in our understanding of the pathogenesis of cerebellar ataxias include the description of antibody effects, especially those targeting cell-surface antigens, and first attempts to isolate antigen-specific T-cells. Furthermore, genetic predisposition seems relevant, although differently involved according to cancer association, with particular HLA observed in non-paraneoplastic cases and genetic abnormalities in the tumor cells in paraneoplastic ones. Finally, immune checkpoint inhibitors used as cancer immunotherapy may rarely induce cerebellar ataxias, but even this undesirable effect may in turn serve to shed some light on their physiopathology. Herein, we review the principal novelties of the last 20 years regarding autoimmune and paraneoplastic cerebellar ataxias.
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Affiliation(s)
- Sergio Muñiz-Castrillo
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France
- SynatAc Team, Institut NeuroMyoGène, INSERM U1217, CNRS, UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Alberto Vogrig
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France
- SynatAc Team, Institut NeuroMyoGène, INSERM U1217, CNRS, UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Nicolás Lundahl Ciano-Petersen
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France
- SynatAc Team, Institut NeuroMyoGène, INSERM U1217, CNRS, UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Macarena Villagrán-García
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France
- SynatAc Team, Institut NeuroMyoGène, INSERM U1217, CNRS, UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Bastien Joubert
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France
- SynatAc Team, Institut NeuroMyoGène, INSERM U1217, CNRS, UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Jérôme Honnorat
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France.
- SynatAc Team, Institut NeuroMyoGène, INSERM U1217, CNRS, UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France.
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